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Out-of-pocket health spending vs. PISA science

Fades after adjusting for income

Across 84 countries, Out-of-pocket health spending and PISA science 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 -0.18, which could easily be chance (q = 0.43, 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 science, 403 to 489 PISA points, out-of-pocket health spending is better by 13.4% of health spending at the top of that range than the bottom. Comparing only countries with similar national income, the gap is 4.31% of health spending.

Link before adjusting (r)-0.607p = 9.4e-10 · 84 countries
After adjusting for national income-0.175p = 0.114 · likely range [-0.38, +0.04]
p, allowing for regions0.200standard error 0.114 · 5 regions
Check for luck (q)0.431across 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 science · PISA pointslink with income +0.78 · 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 science · PISA points →7.41%64.1%347561Albania: 48.3% of health spending, 376 PISA pointsUnited Arab Emirates: 9.67% of health spending, 432 PISA pointsArgentina: 24.5% of health spending, 406 PISA pointsAustralia: 15.8% of health spending, 507 PISA pointsAustria: 16.5% of health spending, 491 PISA pointsBelgium: 21.5% of health spending, 491 PISA pointsBulgaria: 35.5% of health spending, 421 PISA pointsBosnia and Herzegovina: 31% of health spending, 398 PISA pointsBelarus: 28.5% of health spending, 471 PISA pointsBrazil: 26.2% of health spending, 403 PISA pointsBrunei Darussalam: 7.41% of health spending, 446 PISA pointsCanada: 15.3% of health spending, 515 PISA pointsSwitzerland: 22% of health spending, 503 PISA pointsChile: 39.1% of health spending, 444 PISA pointsColombia: 14.7% of health spending, 411 PISA pointsCosta Rica: 24.1% of health spending, 411 PISA pointsCyprus: 17.9% of health spending, 411 PISA pointsCzechia: 14.1% of health spending, 498 PISA pointsGermany: 10.7% of health spending, 492 PISA pointsDenmark: 13.9% of health spending, 494 PISA pointsDominican Republic: 25.1% of health spending, 360 PISA pointsAlgeria: 45% of health spending, 376 PISA pointsSpain: 20.9% of health spending, 485 PISA pointsEstonia: 21.4% of health spending, 526 PISA pointsFinland: 14.1% of health spending, 511 PISA pointsFrance: 9.23% of health spending, 487 PISA pointsUnited Kingdom: 14.6% of health spending, 500 PISA pointsGeorgia: 58.8% of health spending, 384 PISA pointsGreece: 34.3% of health spending, 441 PISA pointsGuatemala: 57.2% of health spending, 373 PISA pointsCroatia: 9.38% of health spending, 483 PISA pointsHungary: 23.1% of health spending, 486 PISA pointsIndonesia: 31.1% of health spending, 383 PISA pointsIreland: 10.6% of health spending, 504 PISA pointsIceland: 14.9% of health spending, 447 PISA pointsIsrael: 20.5% of health spending, 465 PISA pointsItaly: 22.3% of health spending, 477 PISA pointsJamaica: 20.2% of health spending, 403 PISA pointsJordan: 34.5% of health spending, 375 PISA pointsJapan: 12.2% of health spending, 547 PISA pointsKazakhstan: 27.6% of health spending, 423 PISA pointsCambodia: 60.6% of health spending, 347 PISA pointsKorea, Rep.: 33.7% of health spending, 528 PISA pointsLebanon: 29.7% of health spending, 384 PISA pointsLithuania: 31.4% of health spending, 484 PISA pointsLuxembourg: 8.5% of health spending, 477 PISA pointsLatvia: 35.1% of health spending, 494 PISA pointsMorocco: 37.3% of health spending, 365 PISA pointsMoldova: 27.5% of health spending, 417 PISA pointsMexico: 41.2% of health spending, 410 PISA pointsNorth Macedonia: 39.6% of health spending, 380 PISA pointsMalta: 30.9% of health spending, 466 PISA pointsMontenegro: 26.3% of health spending, 403 PISA pointsMongolia: 48.8% of health spending, 412 PISA pointsMalaysia: 37.1% of health spending, 416 PISA pointsNetherlands: 11.8% of health spending, 488 PISA pointsNorway: 13.7% of health spending, 478 PISA pointsNew Zealand: 12.7% of health spending, 504 PISA pointsPanama: 40.5% of health spending, 388 PISA pointsPeru: 27% of health spending, 408 PISA pointsPhilippines: 44.4% of health spending, 356 PISA pointsPoland: 16.2% of health spending, 499 PISA pointsPortugal: 28.2% of health spending, 484 PISA pointsParaguay: 36.3% of health spending, 368 PISA pointsWest Bank and Gaza: 42.1% of health spending, 369 PISA pointsQatar: 7.43% of health spending, 432 PISA pointsRomania: 23% of health spending, 428 PISA pointsRussian Federation: 28.4% of health spending, 478 PISA pointsSaudi Arabia: 14.1% of health spending, 390 PISA pointsSingapore: 25.4% of health spending, 561 PISA pointsEl Salvador: 32.5% of health spending, 373 PISA pointsSerbia: 32.1% of health spending, 447 PISA pointsSlovak Republic: 20.2% of health spending, 462 PISA pointsSlovenia: 11.7% of health spending, 500 PISA pointsSweden: 13.4% of health spending, 494 PISA pointsThailand: 9.93% of health spending, 409 PISA pointsTrinidad and Tobago: 45.3% of health spending, 425 PISA pointsTunisia: 37.9% of health spending, 386 PISA pointsTurkiye: 19% of health spending, 476 PISA pointsUkraine: 45.3% of health spending, 450 PISA pointsUruguay: 17.1% of health spending, 435 PISA pointsUnited States: 10.9% of health spending, 499 PISA pointsUzbekistan: 64.1% of health spending, 355 PISA pointsViet Nam: 39.2% of health spending, 472 PISA pointsDOMGTMIRLJPNKHMKORLVASAUSGPTHAUZB

best-fit line line after adjusting

Four ways to measure the link

MethodrpCountries
Standard (Pearson), not adjusted-0.6079.4e-1084
By rank (Spearman), not adjusted-0.5952.4e-984
Standard (Pearson), adjusted for national income-0.1750.11484
By rank (Spearman), adjusted for national income-0.0880.43284

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: +0.432 (a minus sign means it grew).

How solid is it?

Leaving out one country at a time, r ranges from -0.210 (without KOR) to -0.140 (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 (+0.035).

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+0.06
Europe & Central Asia43-0.42
Latin America & Caribbean15-0.24

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 third28-0.27
Middle third28-0.35
Richest third28+0.37

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
Christians55-0.27
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
Spain14-0.24
United Kingdom14+0.05

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 = -0.175 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.

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Over time, within countries

Everything above compares countries with each other at one moment. This section compares each country only with itself over 17years. 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 = -0.207, 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 science move with it.

Across countries (adjusted)-0.175for comparison
Within countries-0.105each country vs itself
…and vs the same year elsewhere-0.207q = 0.128 · 52 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.

306 country-years (one country in one year), 52 countries, 2006–2022, about 6 years each on average. Share of the variation that happens within countries over time: 5% for Out-of-pocket health spending, 7% for PISA science. 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

0.40−0.4-50+9years PISA science trails Out-of-pocket health spending →lag -5: r = -0.097 (n = 245)lag -4: r = -0.046 (n = 240)lag -3: r = -0.127 (n = 240)lag -2: r = -0.165 (n = 261)lag -1: r = -0.191 (n = 306)lag +0: r = -0.207 (n = 306)lag +1: r = -0.315 (n = 306)lag +2: r = -0.314 (n = 306)lag +3: r = -0.207 (n = 306)lag +4: r = -0.242 (n = 306)lag +5: r = -0.246 (n = 306)lag +6: r = -0.285 (n = 306)lag +7: r = -0.219 (n = 250)lag +8: r = -0.135 (n = 250)lag +9: r = -0.150 (n = 250)

Same year (lag 0): -0.207. 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 (-0.31 at lag +1) is higher than the same-year one by 0.11. That gap is not a finding. It is the largest of 15 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%3552023, 2022
Cambodia KHM60.6%3472023, 2022
Georgia GEO58.8%3842023, 2022
Guatemala GTM57.2%3732023, 2022
Mongolia MNG48.8%4122023, 2022
Albania ALB48.3%3762023, 2022
Ukraine UKR45.3%4502021, 2022
Trinidad and Tobago TTO45.3%4252023, 2015
Algeria DZA45%3762023, 2015
Philippines PHL44.4%3562023, 2022
West Bank and Gaza PSE42.1%3692023, 2022
Mexico MEX41.2%4102023, 2022
Panama PAN40.5%3882023, 2022
North Macedonia MKD39.6%3802023, 2022
Viet Nam VNM39.2%4722023, 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 science

PISA mean science 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 science

This page shows that two measures go together. It does not show that Out-of-pocket health spending changes PISA science, 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 science