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, 1995–2050

Angela Y. Chang(University of Washington), Krycia Cowling(University of Washington), Angela E Micah(University of Washington), Abigail Chapin(University of Washington), Catherine S Chen(University of Washington), Gloria Ikilezi(University of Washington), Nafis Sadat(University of Washington), Golsum Tsakalos(University of Washington), Junjie Wu(University of Washington), Theodore Patrick Younker(University of Washington), Yingxi Zhao(University of Washington), Bianca S Zlavog(University of Washington), Cristiana Abbafati(University of Washington), Anwar E Ahmed(University of Washington), Khurshid Alam(University of Washington), Vahid Alipour(University of Washington), Syed Mohamed Aljunid(University of Washington), Mohammed Almalki(University of Washington), Nelson Alvis‐Guzmán(University of Washington), Walid Ammar(University of Washington), Cătălina Liliana Andrei(University of Washington), Mina Anjomshoa(University of Washington), Carl Abelardo T. Antonio(University of Washington), Jalal Arabloo(University of Washington), Olatunde Aremu(University of Washington), Marcel Ausloos(University of Washington), Leticia Ávila‐Burgos(University of Washington), Ashish Awasthi(University of Washington), Martin Amogre Ayanore(University of Washington), Samad Azari(University of Washington), Natasha Azzopardi‐Muscat(University of Washington), Mojtaba Bagherzadeh(University of Washington), Till Bärnighausen(University of Washington), Bernhard T. Baune(University of Washington), Mohsen Bayati(University of Washington), Yared Belete Belay(University of Washington), Yihalem Abebe Belay(University of Washington), Habte Belete(University of Washington), Dessalegn Ajema Berbada(University of Washington), Adam E. Berman(University of Washington), Mircea Beuran(University of Washington), Ali Bijani(University of Washington), Reinhard Busse(University of Washington), Lucero Cahuana-Hurtado(University of Washington), Luis Alberto Cámera(University of Washington), Ferrán Catalá-López(University of Washington), Bal Govind Chauhan(University of Washington), María Magdalena Constantin(University of Washington), Christopher S. Crowe(Saudi Electronic University), Alexandra Cucu(University of Washington), Koustuv Dalal(University of Washington), Jan‐Walter De Neve(University of Washington), Selina Deiparine(University of Washington), Feleke Mekonnen Demeke(University of Washington), Huyen Phuc(University of Washington), Manisha Dubey(University of Washington), Maha El Tantawi(University of Washington), Sharareh Eskandarieh(University of Washington), Reza Esmaeili(University of Washington), Mahdi Fakhar(University of Washington), Ali Akbar Fazaeli(University of Washington), Florian Fischer(University of Washington), Nataliya A Foigt(University of Washington), Takeshi Fukumoto(University of Washington), Nancy Fullman(University of Washington), Adriana Galan(University of Washington), Amiran Gamkrelidze(University of Washington), Kebede Embaye Gezae(University of Washington), Alireza Ghajar(University of Washington), Ahmad Ghashghaee(University of Washington), Ketevan Goginashvili(University of Washington), Annie Haakenstad(University of Washington), Hassan Haghparast‐Bidgoli(University of Washington), Samer Hamidi(University of Washington), Hilda L Harb(University of Washington), Edris Hasanpoor(University of Washington), Hamid Yimam Hassen(University of Washington), Simon I Hay(University of Washington), Delia Hendrie(University of Washington), Andualem Henok(University of Washington), Ileana Heredia-Pi(University of Washington), Claudiu Herţeliu(University of Washington), Chi Linh Hoang(University of Washington), Michael K. Hole(University of Washington), Enayatollah Homaie Rad, Naznin Hossain(University of Washington), Mehdi Hosseinzadeh(University of Washington), Sorin Hostiuc(University of Washington), Olayinka Stephen Ilesanmi(University of Washington), Seyed Sina Naghibi Irvani(University of Washington), Mihajlo Jakovljević(University of Washington), Amir Jalali(University of Washington), Spencer L James(University of Washington), Jost B. Jonas, Mikk Jürisson(University of Washington), Rajendra Kadel(University of Washington), Behzad Karami Matin(University of Washington), Amir Kasaeian(University of Washington), Habtamu Kebebe Kasaye(University of Washington), Mesfin Wudu Kassaw(University of Washington), Ali Kazemi Karyani(University of Washington), Roghayeh Khabiri(University of Washington), Junaid Khan(University of Washington), Md Nuruzzaman Khan(University of Washington), Young‐Ho Khang(University of Washington), Adnan Kısa(University of Washington), Katarzyna Kissimova‐Skarbek(University of Washington), Stefan Köhler(University of Washington), Ai Koyanagi(University of Washington), Kristopher J Krohn(University of Washington), Ricky Leung(University of Washington), Lee‐Ling Lim(University of Washington), Stefan Lorkowski(University of Washington), Azeem Majeed(University of Washington), Reza Malekzadeh(University of Washington), Morteza Mansourian(University of Washington), LG Mantovani(University of Washington), Benjamin B. Massenburg(University of Washington), Martin McKee(University of Washington), Varshil Mehta(University of Washington), Atte Meretoja(University of Washington), Tuomo J Meretoja(University of Washington), Neda Milevska Kostova(University of Washington), Ted R. Miller(University of Washington), Erkin М Мirrakhimov(University of Washington), Bahram Mohajer(University of Washington), Aso Mohammad Darwesh(University of Washington), Shafiu Mohammed(University of Washington), Farnam Mohebi(University of Washington), Ali H. Mokdad(Saudi Electronic University), Shane D. Morrison(University of Washington), Seyyed Meysam Mousavi(University of Washington), Muthupandian Saravanan(University of Washington), Ahamarshan Jayaraman Nagarajan(University of Washington), Vinay Nangia(University of Washington), Ionuţ Negoi(University of Washington), Cuong Tat Nguyen(University of Washington), Huong Lan Thi Nguyen(University of Washington), Son Hoang Nguyen(University of Washington), Shirin Nosratnejad(University of Washington), Olanrewaju Oladimeji(University of Washington), Stefano Olgiati(University of Washington), Jacob Olusegun Olusanya(University of Washington), Obinna Onwujekwe(University of Washington), Stanislav S Otstavnov(University of Washington), Adrian Pană(University of Washington), David M. Pereira(University of Washington), Bakhtiar Piroozi(University of Washington), Sergio I. Prada(University of Washington), Mostafa Qorbani(University of Washington), Mohammad Rabiee(University of Washington), Navid Rabiee(University of Washington), Alireza Rafiei(University of Washington), Fakher Rahim(University of Washington), Vafa Rahimi‐Movaghar(University of Washington), Usha Ram(University of Washington), Chhabi Lal Ranabhat(University of Washington), Annemarei Ranta(University of Washington), David Laith Rawaf(University of Washington), Salman Rawaf(University of Washington), Satar Rezaei(University of Washington), Elias Merdassa Roro(University of Washington), Ali Rostami(University of Washington), Salvatore Rubino(University of Washington), Mohamadreza Salahshoor(University of Washington), Abdallah M Samy(University of Washington), Juan Sanabria(University of Washington), João Vasco Santos(University of Washington), Milena M Santric-Milicevic(University of Washington), Bruno Piassi Sâo José, Miloje Savic(University of Washington), Falk Schwendicke(University of Washington), Sadaf G Sepanlou(University of Washington), Masood Sepehrimanesh(University of Washington), Aziz Sheikh(University of Washington), Mark G. Shrime(University of Washington), Solomon Sisay(University of Washington), Shahin Soltani(University of Washington), Moslem Soofi(University of Washington), Moslem Soofi(University of Washington), Vinay Srinivasan(University of Washington), Rafael Tabarés‐Seisdedos(University of Washington), Anna E Torre(University of Washington), Marcos Roberto Tovani‐Palone, Bach Xuan Tran(University of Washington), Khanh Bao Tran(University of Washington), Eduardo A. Undurraga(University of Washington), Pascual Valdéz(University of Washington), Job F. M. van Boven(University of Washington), Verónica Vargas(University of Washington), Yousef Veisani(University of Washington), Francesco Saverio Violante(University of Washington), Sergey Konstantinovitch Vladimirov(University of Washington), Vasily Vlassov(University of Washington), Sebastián Vollmer(University of Washington), Giang Thu Vu(University of Washington), Charles Wolfe(University of Washington), Naohiro Yonemoto(University of Washington), Mustafa Z Younis(University of Washington), Mahmoud Yousefifard(University of Washington), Sojib Bin Zaman(University of Washington), Alireza Zangeneh(University of Washington), Elias Asfaw Zegeye(University of Washington), Arash Ziapour(University of Washington), Adrienne Chew(University of Washington), Christopher J L Murray(University of Washington), Joseph L. Dieleman(University of Washington)
The Lancet
April 25, 2019
10.1016/s0140-6736(19)30841-4
Cited by 525Open Access
Full Text

Abstract

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. FUNDING: Bill & Melinda Gates Foundation.

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