Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 2 1995-2050

Aremu, Olatunde (2019) Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 2 1995-2050. THE LANCET.

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Background Comprehensive and comparable estimates of health spending in each country are a key input for health
policy and planning, and are necessary to support the achievement of national and international health goals. Previous
studies have tracked past and projected future health spending until 2040 and shown that, with economic development,
countries tend to spend more on health per capita, with a decreasing share of spending from development assistance
and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending,
with an emphasis on equity in spending across countries.
Methods We estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three
categories—government, out-of-pocket, and prepaid private health spending—and estimated development assistance
for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear
mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050
and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and
revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data
were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private,
and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power
parity-adjusted dollars, and as a percentage of gross domestic product. We used demographic decomposition
methods to assess a set of factors associated with changes in government health spending between 1995 and 2016
and to examine evidence to support the theory of the health financing transition. We projected two alternative future
scenarios based on higher government health spending to assess the potential ability of governments to generate
more resources for health.
Findings Between 1995 and 2016, health spending grew at a rate of 4·00% (95% uncertainty interval 3·89–4·12)
annually, although it grew slower in per capita terms (2·72% [2·61–2·84]) and increased by less than $1 per capita
over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed
in upper-middle-income countries (5·55% [5·18–5·95]), mainly due to growth in government health spending, and
in lower-middle-income countries (3·71% [3·10–4·34]), mainly from DAH. Health spending globally reached
$8·0 trillion (7·8–8·1) in 2016 (comprising 8·6% [8·4–8·7] of the global economy and $10·3 trillion [10·1–10·6] in
purchasing-power parity-adjusted dollars), with a per capita spending of US$5252 (5184–5319) in high-income
countries, $491 (461–524) in upper-middle-income countries, $81 (74–89) in lower-middle-income countries, and
$40 (38–43) in low-income countries. In 2016, 0·4% (0·3–0·4) of health spending globally was in low-income
countries, despite these countries comprising 10·0% of the global population. In 2018, the largest proportion of
DAH targeted HIV/AIDS ($9·5 billion, 24·3% of total DAH), although spending on other infectious diseases
(excluding tuberculosis and malaria) grew fastest from 2010 to 2018 (6·27% per year). The leading sources of DAH
were the USA and private philanthropy (excluding corporate donations and the Bill & Melinda Gates Foundation).
For the first time, we included estimates of China’s contribution to DAH ($644·7 million in 2018). Globally, health
spending is projected to increase to $15·0 trillion (14·0–16·0) by 2050 (reaching 9·4% [7·6–11·3] of the global
economy and $21·3 trillion [19·8–23·1] in purchasing-power parity-adjusted dollars), but at a lower growth rate of
1·84% (1·68–2·02) annually, and with continuing disparities in spending between countries. In 2050, we estimate
that 0·6% (0·6–0·7) of health spending will occur in currently low-income countries, despite these countries
comprising an estimated 15·7% of the global population by 2050. The ratio between per capita health spending in
high-income and low-income countries was 130·2 (122·9–136·9) in 2016 and is projected to remain at similar levels
in 2050 (125·9 [113·7–138·1]). The decomposition analysis identified governments’ increased prioritisation of the
health sector and economic development as the strongest factors associated with increases in government health
spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the
health sector and increased government spending, health spending per capita could more than double, with greater
impacts in countries that currently have the lowest levels of government health spending.

Interpretation Financing for global health has increased steadily over the past two decades and is projected to continue
increasing in the future, although at a slower pace of growth and with persistent disparities in per-capita health
spending between countries. Out-of-pocket spending is projected to remain substantial outside of high-income
countries. Many low-income countries are expected to remain dependent on development assistance, although with
greater government spending, larger investments in health are feasible. In the absence of sustained new investments
in health, increasing efficiency in health spending is essential to meet global health targets.

Item Type: Article
Date: 28 April 2019
Subjects: A900 Others in Medicine and Dentistry
B900 Others in Subjects allied to Medicine
G200 Operational Research
G300 Statistics
L400 Social Policy
Divisions: REF UoA Output Collections > REF2021 UoA 02: Public Health, Health Services and Primary Care
Depositing User: DR Olatunde Aremu
Date Deposited: 07 May 2019 09:38
Last Modified: 07 May 2019 09:38

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