Out-of-pocket health spending vs. Voice and accountability
Fades after adjusting for income
Across 186 countries, Out-of-pocket health spending and Voice and accountability rise and fall together at r = -0.55 (on a scale from −1 to +1, where 0 means no link). Comparing only countries with similar income (GDP per person) leaves r = -0.45, which could easily be chance (q = 0.088, allowing for the many pairs tested, and allowing for countries in the same region being alike).
Comparing countries across the middle half of out-of-pocket health spending, 14.2% to 43.8% of health spending, voice and accountability is worse by 0.873 points at the top of that range than the bottom. Comparing only countries with similar national income, the gap is 0.641 points.
Link before adjusting (r)-0.545p = 8.5e-16 · 186 countries
After adjusting for national income-0.454p = 8.2e-11 · likely range [-0.56, -0.33]
p, allowing for regions0.014standard error 0.133 · 7 regions
Check for luck (q)0.088across 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
Voice and accountability · index (approx. -2.5 to 2.5)link with income +0.58 · moderate
“Link with income” is how closely each measure tracks GDP per person across countries, from −1 to +1.
Every country as a dot
best-fit line line after adjusting
Four ways to measure the link
Method
r
p
Countries
Standard (Pearson), not adjusted
-0.545
8.5e-16
186
By rank (Spearman), not adjusted
-0.525
1.4e-14
186
Standard (Pearson), adjusted for national income
-0.454
8.2e-11
186
By rank (Spearman), adjusted for national income
-0.427
1.3e-9
186
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 186 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: +0.091 (a minus sign means it grew).
How solid is it?
Leaving out one country at a time, r ranges from -0.470 (without SAU) to -0.434 (without TKM). 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: TKM (+0.020).
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.
n
r
East Asia & Pacific
29
-0.73
Europe & Central Asia
50
-0.27
Latin America & Caribbean
31
-0.13
Middle East, North Africa, Afghanistan & Pakistan
22
-0.11
Sub-Saharan Africa
46
-0.35
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.
n
r
Poorest third
62
-0.69
Middle third
62
-0.44
Richest third
62
-0.04
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.
n
r
Christians
108
-0.44
Muslims
49
-0.33
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.
n
r
France
25
-0.43
Never a European colony
21
-0.09
Spain
20
-0.71
United Kingdom
63
-0.40
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 = -0.454 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 25years. 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 = -0.007, 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 voice and accountability move with it.
Across countries (adjusted)-0.454for comparison
Within countries+0.005each country vs itself
…and vs the same year elsewhere-0.007q = 0.933 · 193 countries
Year-on-year changes-0.030q = 0.385
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.
4,378 country-years (one country in one year), 193 countries, 2000–2024, about 23 years each on average. Share of the variation that happens within countries over time: 10% for Out-of-pocket health spending, 4% for Voice and accountability. 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
Same year (lag 0): -0.007. 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 (+0.11 at lag +8) is higher than the same-year one by 0.10. That gap is not a finding. It is the largest of 21 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
index (approx. -2.5 to 2.5)
Years
Armenia ARM
80.5%
0.12
2023, 2024
Bangladesh BGD
79.3%
-1.16
2023, 2024
Turkmenistan TKM
77.4%
-2.04
2023, 2024
Afghanistan AFG
77.1%
-2.15
2023, 2024
Syrian Arab Republic SYR
72.4%
-1.85
2023, 2024
Nigeria NGA
71.9%
-0.727
2023, 2024
Myanmar MMR
71.1%
-2.12
2023, 2024
Cameroon CMR
67.7%
-1.24
2023, 2024
Equatorial Guinea GNQ
66%
-1.73
2023, 2024
Azerbaijan AZE
64.6%
-1.5
2023, 2024
Togo TGO
64.3%
-0.972
2023, 2024
Uzbekistan UZB
64.1%
-1.04
2023, 2024
Liberia LBR
63.2%
-0.112
2023, 2024
Tajikistan TJK
62.4%
-1.64
2023, 2024
Guinea-Bissau GNB
61.6%
-0.779
2023, 2024
World Bank, World Development Indicators Kaufmann, D. and A. Kraay, Worldwide Governance Indicators, World Bank
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.
Data used: most recent value in 2010-2025; values come from 2021–2024. 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 7 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 Voice and accountability
This page shows that two measures go together. It does not show that Out-of-pocket health spending changes Voice and accountability, or the reverse. These figures also describe countries, not individual people. See the ecological fallacy.
More links with Out-of-pocket health spending or Voice and accountability