In 31 of 192 economies, households paid more than half of all health costs out of their own pockets in 2022 — and the two heaviest burdens fell on upper-middle-income states, not the poorest

The World Bank publishes out-of-pocket health spending as a share of each economy's current health expenditure — indicator SH.XPD.OOPC.CH.ZS — compiled from the World Health Organization's Global Health Expenditure Database, itself built from national health accounts. It measures the portion of total health financing paid directly by patients at the point of care, rather than pooled through governments, social insurance or prepaid schemes. For nearly all economies the yearly value is a health-accounts estimate, not a count from a complete billing record; the figures below are those estimates ^mmodeled. The series was last updated 2026-07-13 and its latest year is 2022. This run pulled the full 2022 panel, joined it to the World Bank's country-metadata endpoint to drop regional and income aggregates, and joined GNI per capita and health spending per capita for the same year. That left 192 economies with a 2022 value. Across those 192 economies the out-of-pocket share ranges from 0.0% (Tuvalu) to 79.2% (Turkmenistan) — a spread that runs the full width of the scale. The median economy financed 27.8% of its health spending out of pocket and the mean 30.2%. The spending-weighted world aggregate, by contrast, is 17.2%, because the high-spending rich economies that dominate the global total sit well below the typical country ^mmodeled. In 31 of the 192 economies, the out-of-pocket share exceeds 50% — households paid the majority of all health costs directly [verified as a count on the published series; several cases sit within a point or two of the 50% line and, because the underlying figures are estimates, the exact count could move by a few on revision — see Room for Disagreement]. The highest shares are Turkmenistan 79.2%, Armenia 79.1%, Bangladesh 78.3%, Afghanistan 77.9%, Nigeria 75.7% and Yemen 71.4% ^mmodeled. The two at the top — Turkmenistan and Armenia — are both classified upper-middle-income, and neither is among the world's poorest economies; Bangladesh and Afghanistan, next in line, are lower-middle and low income respectively. Six of the 31 are former Soviet republics: Armenia, Azerbaijan, Georgia, Tajikistan, Turkmenistan and Uzbekistan ^mmodeled. The burden falls as national income rises, but loosely. By World Bank income group the mean out-of-pocket share runs 42.9% (low income, n=24), 36.1% (lower-middle, n=47), 31.7% (upper-middle, n=57) and 19.7% (high income, n=64) — a monotonic decline. Yet the Pearson correlation between the out-of-pocket share and GNI per capita is −0.42 across the 186 economies with both figures, and −0.46 against log GNI per capita — a real but far-from-tight association. The looseness shows in the group composition: of the 31 economies above 50%, 9 are low income, 13 lower-middle, 9 upper-middle, and none is high income. The upper-middle-income band alone spans from Tuvalu at 0.0% to Turkmenistan at 79.2% ^mmodeled. Absolute spending compounds it at the bottom: Bangladesh's 78.3% out-of-pocket share sits atop total health spending of about $57 per person for 2022, Afghanistan's 77.9% atop roughly $81, and Yemen's 71.4% atop about $54 — high shares of very small totals ^mmodeled. For reference, the United States financed 11.0% of its health spending out of pocket in 2022, the United Kingdom 14.4%, Germany 10.4%, France 9.2%, Japan 11.1%, China 31.6%, India 44.5%, Brazil 27.3% and the Russian Federation 27.6% ^mmodeled. Above the WHO's flagged threshold of 20% — the level the WHO associates with rising rates of catastrophic and impoverishing health spending — sit 126 of the 192 economies; 87 exceed 30%.

The following is analysis, not fact. Read one country's health system at a time and "people pay a lot for care" is a sentence any national desk can write with a local anecdote. Read all 192 economies' health accounts in a single pull and the first finding has a hard edge: in 31 of them the out-of-pocket share is not a supplement but the majority — patients, not any pooled system, carry more than half the cost of the country's health care [verified as a count on the series]. The second finding is the one that resists intuition. The reflex is that direct payment is a story about the poorest places, and to a degree it is — the low-income group's mean, 42.9%, is more than double the high-income group's 19.7%. But the two heaviest burdens on the planet do not sit in the poorest countries. They sit in Turkmenistan (79.2%) and Armenia (79.1%), both upper-middle-income, ahead of Afghanistan and Yemen ^mmodeled. And the association with income, while real, is loose: a correlation of −0.42 leaves most of the variation unexplained, and the upper-middle-income band alone stretches from 0% to 79%. Income tells you the average; it does not tell you the country. A single-country correspondent, holding one national figure, cannot see that the extreme cases are middle-income, or that the slope from wealth is this shallow ^mmodeled. The third finding is what the share is measuring, and it is a matter of definition, not motive. The out-of-pocket share is the inverse of how much of a country's health financing is pooled — through taxes, social insurance or prepaid schemes — rather than collected at the bedside. Turkmenistan and Armenia are informative precisely because their absolute spending is not trivial (about $579 and $675 per person) yet four-fifths of it still passes through patients' own pockets, which points to a financing architecture that pools little, not merely a poor one ^mmodeled. That is the World Bank/WHO health-accounts framework's own reading of what this indicator captures; the series records the split, not the reason a given government arranged its financing that way. At the other extreme, the pattern is the same in reverse and just as income-blind: among the lowest out-of-pocket shares are South Africa (6.7%) and Botswana (4.4%), middle-income economies that pool heavily, sitting beside high-income Oman (6.9%) ^mmodeled. The fourth finding is a gap between two true numbers. The world's spending-weighted average is 17.2% — a figure a global-health desk might lead with, and one that would leave a reader thinking direct payment is a manageable sixth of the bill ^mmodeled. The median economy is at 27.8%, and 126 of 192 economies clear the WHO's 20% hardship threshold. Both numbers are correct; they answer different questions. The weighted average describes where the world's health dollars are, which is overwhelmingly in the rich systems that pool the most. The count of economies describes where the world's health systems are, which is a very different place. Nearly two-thirds of the world's economies sit in the zone the WHO flags for financial hardship — a fact the single global average hides by construction.

The strongest caution is what the underlying number is. For almost every one of the 192 economies the 2022 value is a national-health-accounts estimate assembled by the WHO, not a tallied billing record, and estimates carry revision risk. That matters most exactly at the line this piece draws. Several economies sit within a point or two of the 50% boundary — Algeria at 50.1%, Mali at 50.8%, Haiti at 51.7% — so the headline count of 31 above 50% should be read as the count on the published series, not an exact and permanent figure; a routine revision could nudge it by a few in either direction ^mmodeled. The direction of the broad pattern — that the burden falls with income but loosely, and that the extremes are middle-income — is robust to that error; the precise membership at the margin is not. A second caution is that the out-of-pocket share is a proportion, not a dollar amount, and the two can diverge sharply. A country can lower its out-of-pocket share by spending more public money without patients paying a cent less, and a very poor country's high share can still be a small absolute sum. This piece reports both the share and, for the heaviest cases, the per-capita total precisely because neither alone describes the burden a household actually feels. A third: the "majority out of pocket" framing counts economies, not people. The 31 economies above 50% include small states as well as Nigeria and Bangladesh, so the count is a statement about health systems in the series, not a population-weighted claim — though because the world's two most populous economies (India 44.5%, China 31.6%) both sit well above the rich-country norm, a population weighting would not soften the picture ^mmodeled. The WHO's 20% figure is its own flagged threshold for financial-hardship risk, offered here as the WHO's benchmark, not a law of nature. Whether a given country's high share reflects deliberate policy, weak revenue, or gaps in insurance coverage is not something this indicator can adjudicate; it records the split, and the reasons belong to each national system.

View from the whole health-accounts record: the vantage here is the one no single ministry occupies — 192 national health accounts read at once, on one screen. From inside any one country, the out-of-pocket share is a domestic budget line. From across all of them, it is a map of which populations were left to self-finance care in 2022, and the map does not follow the income contours a reader would draw from memory. We were never in any clinic and cannot see the household that skipped treatment; we can only see that in 31 economies the pooled system carried a minority of the cost, and that the two heaviest of those burdens fell on countries wealthier than the poorest. That is the pattern the aggregate average is built to erase, and it is visible only from the whole record.

A health correspondent files the local version: patients in one country pay too much at the pharmacy counter, and here is a family that did. Reading all 192 economies' health accounts at once shows what no single-country desk can — that in 31 of them the out-of-pocket share is the majority of health financing, not a supplement; that the two heaviest burdens on Earth fall on Turkmenistan and Armenia, both upper-middle-income, not on the poorest states; that the burden falls with national income but only loosely (correlation −0.42), so the upper-middle band alone runs from 0% to 79%; and that the world's tidy 17.2% average is an artifact of where the rich world's dollars sit, while the median economy is at 27.8% and 126 of 192 clear the WHO's hardship line. The universal fact is that care costs money. The fact you can only see from the whole record is who was left to pay for it directly — and that it is not simply the poor.