placestats

Out-of-pocket health spending vs. PISA reading

Fades after adjusting for income

Across 84 countries, Out-of-pocket health spending and PISA reading rise and fall together at r = -0.61 (on a scale from −1 to +1, where 0 means no link). Comparing only countries with similar income (GDP per person) shrinks it to -0.17, which could easily be chance (q = 0.45, allowing for the many pairs tested, and allowing for countries in the same region being alike). So the first figure mostly shows richer countries differing from poorer ones, not a link between these two things. Caution: direction is not consistent across regions.

Comparing countries across the middle half of pisa reading, 385 to 477 PISA points, out-of-pocket health spending is better by 13.8% of health spending at the top of that range than the bottom. Comparing only countries with similar national income, the gap is 4.36% of health spending.

Link before adjusting (r)-0.606p = 9.8e-10 · 84 countries
After adjusting for national income-0.171p = 0.123 · likely range [-0.37, +0.05]
p, allowing for regions0.211standard error 0.115 · 5 regions
Check for luck (q)0.447across 12,497 pairs

How to read these.r runs from −1 (one goes up as the other goes down) to +1 (they rise together), and 0 means no link. Adjusting for national income means comparing countries with the same GDP per person, so differences in wealth can’t explain the link. Income is used in percentage terms, since an extra $1,000 means more to a poor country than to a rich one. p is how likely a link this strong would be if there were really none. Below 0.05 means it is unlikely to be chance. Very small values are written in short form: 1.1e-32 means a decimal point followed by 31 zeros and then 11, so very close to zero. The likely range is where the true figure probably lies, and a range that crosses zero means the link could easily be chance. Countries in the same region tend to resemble each other, so the third figure allows for that, which gives a fairer p. The standard error is the typical size of the error in r. Finally, testing this many pairs means some will look strong by luck alone. A q below 0.05 means this link is unlikely to be one of those.

Out-of-pocket health spending · % of health spendinglink with income -0.34 · moderate
PISA reading · PISA pointslink with income +0.77 · high

“Link with income” is how closely each measure tracks GDP per person across countries, from −1 to +1.

Every country as a dot

Out-of-pocket health spending · % of health spending →PISA reading · PISA points →7.41%64.1%329543Albania: 48.3% of health spending, 358 PISA pointsUnited Arab Emirates: 9.67% of health spending, 417 PISA pointsArgentina: 24.5% of health spending, 401 PISA pointsAustralia: 15.8% of health spending, 498 PISA pointsAustria: 16.5% of health spending, 480 PISA pointsBelgium: 21.5% of health spending, 479 PISA pointsBulgaria: 35.5% of health spending, 404 PISA pointsBosnia and Herzegovina: 31% of health spending, 403 PISA pointsBelarus: 28.5% of health spending, 474 PISA pointsBrazil: 26.2% of health spending, 410 PISA pointsBrunei Darussalam: 7.41% of health spending, 429 PISA pointsCanada: 15.3% of health spending, 507 PISA pointsSwitzerland: 22% of health spending, 483 PISA pointsChile: 39.1% of health spending, 448 PISA pointsColombia: 14.7% of health spending, 409 PISA pointsCosta Rica: 24.1% of health spending, 415 PISA pointsCyprus: 17.9% of health spending, 381 PISA pointsCzechia: 14.1% of health spending, 489 PISA pointsGermany: 10.7% of health spending, 480 PISA pointsDenmark: 13.9% of health spending, 489 PISA pointsDominican Republic: 25.1% of health spending, 351 PISA pointsAlgeria: 45% of health spending, 350 PISA pointsSpain: 20.9% of health spending, 474 PISA pointsEstonia: 21.4% of health spending, 511 PISA pointsFinland: 14.1% of health spending, 490 PISA pointsFrance: 9.23% of health spending, 474 PISA pointsUnited Kingdom: 14.6% of health spending, 494 PISA pointsGeorgia: 58.8% of health spending, 374 PISA pointsGreece: 34.3% of health spending, 438 PISA pointsGuatemala: 57.2% of health spending, 374 PISA pointsCroatia: 9.38% of health spending, 475 PISA pointsHungary: 23.1% of health spending, 473 PISA pointsIndonesia: 31.1% of health spending, 359 PISA pointsIreland: 10.6% of health spending, 516 PISA pointsIceland: 14.9% of health spending, 436 PISA pointsIsrael: 20.5% of health spending, 474 PISA pointsItaly: 22.3% of health spending, 482 PISA pointsJamaica: 20.2% of health spending, 410 PISA pointsJordan: 34.5% of health spending, 342 PISA pointsJapan: 12.2% of health spending, 516 PISA pointsKazakhstan: 27.6% of health spending, 386 PISA pointsCambodia: 60.6% of health spending, 329 PISA pointsKorea, Rep.: 33.7% of health spending, 515 PISA pointsLebanon: 29.7% of health spending, 353 PISA pointsLithuania: 31.4% of health spending, 472 PISA pointsLuxembourg: 8.5% of health spending, 470 PISA pointsLatvia: 35.1% of health spending, 475 PISA pointsMorocco: 37.3% of health spending, 339 PISA pointsMoldova: 27.5% of health spending, 411 PISA pointsMexico: 41.2% of health spending, 415 PISA pointsNorth Macedonia: 39.6% of health spending, 359 PISA pointsMalta: 30.9% of health spending, 445 PISA pointsMontenegro: 26.3% of health spending, 405 PISA pointsMongolia: 48.8% of health spending, 378 PISA pointsMalaysia: 37.1% of health spending, 388 PISA pointsNetherlands: 11.8% of health spending, 459 PISA pointsNorway: 13.7% of health spending, 477 PISA pointsNew Zealand: 12.7% of health spending, 501 PISA pointsPanama: 40.5% of health spending, 392 PISA pointsPeru: 27% of health spending, 408 PISA pointsPhilippines: 44.4% of health spending, 347 PISA pointsPoland: 16.2% of health spending, 489 PISA pointsPortugal: 28.2% of health spending, 477 PISA pointsParaguay: 36.3% of health spending, 373 PISA pointsWest Bank and Gaza: 42.1% of health spending, 349 PISA pointsQatar: 7.43% of health spending, 419 PISA pointsRomania: 23% of health spending, 428 PISA pointsRussian Federation: 28.4% of health spending, 479 PISA pointsSaudi Arabia: 14.1% of health spending, 383 PISA pointsSingapore: 25.4% of health spending, 543 PISA pointsEl Salvador: 32.5% of health spending, 365 PISA pointsSerbia: 32.1% of health spending, 440 PISA pointsSlovak Republic: 20.2% of health spending, 447 PISA pointsSlovenia: 11.7% of health spending, 469 PISA pointsSweden: 13.4% of health spending, 487 PISA pointsThailand: 9.93% of health spending, 379 PISA pointsTrinidad and Tobago: 45.3% of health spending, 427 PISA pointsTunisia: 37.9% of health spending, 361 PISA pointsTurkiye: 19% of health spending, 456 PISA pointsUkraine: 45.3% of health spending, 428 PISA pointsUruguay: 17.1% of health spending, 430 PISA pointsUnited States: 10.9% of health spending, 504 PISA pointsUzbekistan: 64.1% of health spending, 336 PISA pointsViet Nam: 39.2% of health spending, 462 PISA pointsGEOIRLJPNKHMKORQATSAUSGPTHAUSAUZBVNM

best-fit line line after adjusting

Four ways to measure the link

MethodrpCountries
Standard (Pearson), not adjusted-0.6069.8e-1084
By rank (Spearman), not adjusted-0.5893.9e-984
Standard (Pearson), adjusted for national income-0.1710.12384
By rank (Spearman), adjusted for national income-0.0920.41084

The rank version uses only each country’s place in line, from lowest to highest, so a few extreme countries count for less. The adjusted and unadjusted versions use the same 84 countries: those that report both measures and GDP per person. So the gap between them comes from the adjustment, not from a change in which countries are counted. Drop in the size of r after adjusting: +0.435 (a minus sign means it grew).

How solid is it?

Leaving out one country at a time, r ranges from -0.203 (without KOR) to -0.138 (without GEO). The bar above shows that range on a scale from −1 to +1, with the solid line at the full result. The single country that moves r most: GEO (+0.033).

Fragile: this link may not hold up.
  • direction is not consistent across regions

Within each region

Countries are not separate, unrelated cases, and neighbors share a lot. A link that holds inside each region is far more believable than one that shows up only when comparing regions.

nr
East Asia & Pacific13+0.07
Europe & Central Asia43-0.40
Latin America & Caribbean15-0.15

By income third

If the link shows up only in the richest third of countries, it is a feature of rich countries, not a general pattern.

nr
Poorest third28-0.29
Middle third28-0.31
Richest third28+0.31

By largest religious group

Countries grouped by a label they share, such as main religion, rather than by a number. Groups of fewer than twelve countries are not shown. These groups differ in income, region and history all at once. So a gap between them is a place to start asking questions, not an answer.

nr
Christians55-0.29
Muslims17-0.43

By last european coloniser

Countries grouped by a label they share, such as main religion, rather than by a number. Groups of fewer than twelve countries are not shown. These groups differ in income, region and history all at once. So a gap between them is a place to start asking questions, not an answer.

nr
Spain14-0.09
United Kingdom14-0.02

Without outliers (countries far outside the middle half of countries on either measure, by more than one and a half times the width of that middle half): r = -0.171 after dropping 0 countries.

Two series, one country

Both measures over the years for one country you pick. The two charts are stacked so they share only the years along the bottom.

Loading…

Over time, within countries

Everything above compares countries with each other at one moment. This section compares each country only with itself over 23years. So a link here can’t come from anything about a country that stays the same, such as its history, geography, institutions or culture.

Within countries over time, there is no link that is clearly more than chance (r = -0.042, comparing each country only with itself over the years, and each year only with the same year elsewhere). Whatever the cross-country picture shows, countries whose out-of-pocket health spending moved did not tend to see their pisa reading move with it.

Across countries (adjusted)-0.171for comparison
Within countries-0.000each country vs itself
…and vs the same year elsewhere-0.042q = 0.812 · 53 countries
Year-on-year changes—q = —
Read with care.
  • Almost all of this indicator's variation is between countries, not within them, so the within-country estimate rests on a small part of the data.

384 country-years (one country in one year), 53 countries, 2000–2022, about 7 years each on average. Share of the variation that happens within countries over time: 8% for Out-of-pocket health spending, 9% for PISA reading. The margins of error allow for each country appearing many times, and for each year’s value being close to the year before.

Year-to-year changes are a cautious test, not a final answer. Looking only at changes from one year to the next removes each country’s own trends. But it also makes measurement mistakes louder, which pulls the results toward zero. A near-zero result here is weak evidence of no link, not proof.

With one measure years behind the other

0.20−0.2-80+9years PISA reading trails Out-of-pocket health spending →lag -8: r = -0.144 (n = 241)lag -7: r = -0.095 (n = 241)lag -6: r = -0.098 (n = 279)lag -5: r = -0.094 (n = 331)lag -4: r = -0.030 (n = 326)lag -3: r = -0.058 (n = 326)lag -2: r = -0.047 (n = 347)lag -1: r = -0.020 (n = 384)lag +0: r = -0.042 (n = 384)lag +1: r = -0.061 (n = 345)lag +2: r = -0.086 (n = 345)lag +3: r = -0.030 (n = 345)lag +4: r = -0.125 (n = 304)lag +5: r = -0.164 (n = 304)lag +6: r = -0.158 (n = 304)lag +7: r = -0.145 (n = 245)lag +8: r = -0.107 (n = 245)lag +9: r = -0.073 (n = 245)

Same year (lag 0): -0.042. A peak away from zero does not show which comes first. These series change slowly — this year’s value is close to last year’s. That makes the curve smooth and nearly symmetric, whatever produced the data. Even a sharp peak at one lag (a gap of some years) would not prove that one measure changes the other.

The largest value on this curve (-0.16 at lag +5) is higher than the same-year one by 0.12. That gap is not a finding. It is the largest of 18 closely related estimates, and picking the biggest of many tests always makes it look bigger. That is exactly why nothing on this site is ranked or chosen by lag.

The data


% of health spending
PISA points		Years
Uzbekistan UZB64.1%3362023, 2022
Cambodia KHM60.6%3292023, 2022
Georgia GEO58.8%3742023, 2022
Guatemala GTM57.2%3742023, 2022
Mongolia MNG48.8%3782023, 2022
Albania ALB48.3%3582023, 2022
Ukraine UKR45.3%4282021, 2022
Trinidad and Tobago TTO45.3%4272023, 2015
Algeria DZA45%3502023, 2015
Philippines PHL44.4%3472023, 2022
West Bank and Gaza PSE42.1%3492023, 2022
Mexico MEX41.2%4152023, 2022
Panama PAN40.5%3922023, 2022
North Macedonia MKD39.6%3592023, 2022
Viet Nam VNM39.2%4622023, 2022

World Bank, World Development Indicators
OECD databases as named on each indicator: PISA, Social Expenditure Database (SOCX), Income Distribution Database, Development Assistance Committee statistics, Family Database, Government at a Glance, Corporate Tax Statistics, employment and environment statistics

Sources

Out-of-pocket health spending

Out-of-pocket expenditure (% of current health expenditure)

World Health Organization Global Health Expenditure Database · CC BY 4.0 · updated quarterly

The share of a country's health spending paid by patients themselves when they get care. Health spending as a share of GDP is already on the site and shows how much is spent. This shows who pays.

PISA reading

PISA mean reading score

OECD · via Our World in Data · CC BY 4.0 (OECD terms and conditions) · updated annual, except the snapshots noted per indicator

How this was computed

Data used: most recent value in 2010-2025; values come from 2015–2024. To adjust for income, each measure is first predicted from GDP per person (in percentage terms, on a log scale) with a straight-line fit. Only what is left over is then compared. This is called a partial correlation. The line is drawn the standard way (ordinary least squares), which picks the line that comes closest to all the countries at once. The error margins allow for countries in the same region resembling each other, using 5 World Bank regions. The q-value corrects for testing all 12,497 pairs at once, using the Benjamini–Hochberg method. Underlying data last updated DYB 2024. How the country data works · explore Out-of-pocket health spending and PISA reading

This page shows that two measures go together. It does not show that Out-of-pocket health spending changes PISA reading, or the reverse. These figures also describe countries, not individual people. See the ecological fallacy.

More links with Out-of-pocket health spending or PISA reading