even so the most recent health expenditure data shows an increase in outofpocket payments as a percentage of total health expenditure in the majority of european countries however this statement needs qualifying as in several countries the provision of services is determined at the local or provider level subject to resource constraints as budgets are tightened in these countries it is possible that there have been changes in coverage but in a manner difficult to quantify section of this paper defines what is considered as health coverage in the sections that follow