The share of a population covered for a core set of health services offers an initial assessment of access to care and financial protection. However, it is only a partial measure of accessibility and coverage, focusing on the number of people covered. Universal health coverage also depends on the range of services covered and the degree of cost sharing for these services. Such services also need to be of sufficient quality. Indicators in this chapter focus on access and different dimensions of coverage, while Chapter 6 provides indicators on quality and outcomes of care.

In addition to the share of the population entitled to core health services, the extent of health care coverage is defined by the range of services included in a publicly defined benefit package and the proportion of costs covered. assesses the extent of overall coverage, as well as coverage for selected health care services, by computing the share of expenditure covered under government schemes or compulsory health insurance. Differences across countries in the extent of coverage can be due to specific goods and services being included or excluded in the publicly defined benefit package (e.g. a particular drug or medical treatment); different cost-sharing arrangements; or some services only being covered for specific population groups in a country (e.g. dental treatment).

Primary care services are the main entry point into health systems. Indicators on the use of such services therefore provide a critical barometer of accessibility, with data disaggregated by income illustrating the degree of inequalities in access.

People should be able to access health services when they need to, irrespective of their socio-economic circumstances. This is a fundamental principle underpinning all health systems across the OECD. Yet a quarter of individuals aged 18 or older report unmet need (defined as forgoing or delaying care) because limited availability or affordability of services compromise access, on average across 23 OECD countries. People may also forgo care because of fear or mistrust of health service providers. Strategies to reduce unmet need, particularly for the less well-off, need to tackle both financial and non-financial barriers to access (OECD, 2019[1]).

Where health systems fail to provide adequate financial protection, people may not have enough money to pay for health care or meet other basic needs. As a result, lack of financial protection can reduce access to health care, undermine health status, deepen poverty and exacerbate health and socio-economic inequalities. On average across OECD countries, just over a fifth of all spending on health care comes directly from patients through out-of-pocket (OOP) payments (see indicator “Financing of health care”). People experience financial hardship when the burden of such OOP payments is large in relation to their ability to pay. Poor households and those who have to pay for long-term treatment such as medicines for chronic illness are particularly vulnerable.

Access to medical care requires an adequate number and equitable distribution of doctors in all parts of the country. Concentration of doctors in one region and shortages in others can lead to inequities in access such as longer travel or waiting times. The uneven distribution of doctors and the difficulties in recruiting and retaining doctors in certain regions is an important policy issue in most OECD countries, especially in countries with remote and sparsely populated areas, and those with deprived rural and urban regions.

Long waiting times for elective (non-emergency) surgery cause dissatisfaction for patients, because they postpone the expected benefits of treatment, and pain and disability remain. Waiting times are the result of a complex interaction between the demand and supply of health services, with doctors playing a critical role on both sides. Demand for health services and elective surgeries is determined by the health status of the population, progress in medical technologies (including the simplification of many procedures, such as cataract surgery), patient preferences, and the burden of cost-sharing for patients. However, doctors play a crucial role in the decision to operate on a patient or not. On the supply side, the availability of surgeons, anaesthetists and other staff in surgical teams, as well as the supply of the required medical equipment, affect surgical activity rates.