Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries
Authors: Joseph Dieleman, Madeline Campbell, Abigail Chapin, Erika Eldrenkamp, Victoria Y Fan, Annie Haakenstad, Jennifer Kates, Yingying Liu, Taylor Matyasz, Angela Micah, Alex Reynolds, Nafis Sadat, Matthew T Schneider, Reed Sorensen, Tim Evans, David Evans, Christoph Kurowski, Ajay Tandon, Kaja M Abbas, Semaw Ferede Abera, Aliasghar Ahmad Kiadaliri, Kedir Yimam Ahmed, Muktar Beshir Ahmed, Khurshid Alam, Reza Alizadeh-Navaei, Ala'a Alkerwi, Erfan Amini, Walid Ammar, Stephen Marc Amrock, Carl Abelardo T Antonio, Tesfay Mehari Atey, Leticia Avila-Burgos, Ashish Awasthi, Aleksandra Barac, Oscar Alberto Bernal, Addisu Shunu Beyene, Tariku Jibat Beyene, Charles Birungi, Habtamu Mellie Bizuayehu, Nicholas J K Breitborde, Lucero Cahuana-Hurtado, Ruben Estanislao Castro, Ferran Catalia-Lopez, Koustuv Dalal, Lalit Dandona, Rakhi Dandona, Pieter de Jager, Samath D Dharmaratne, Manisha Dubey, Carla Sofia e Sa Farinha, Andre Faro, Andrea B Feigl, Florian Fischer, Joseph Robert Anderson Fitchett, Nataliya Foigt, Ababi Zergaw Giref, Rahul Gupta, Samer Hamidi, Hilda L Harb, Simon I Hay, Delia Hendrie, Masako Horino, Mikk Jürisson, Mihajlo B Jakovljevic, Mehdi Javanbakht, Denny John, Jost B Jonas, Seyed M. Karimi, Young-Ho Khang, Jagdish Khubchandani, Yun Jin Kim, Jonas M Kinge, Kristopher J Krohn, G Anil Kumar, Hassan Magdy Abd El Razek, Mohammed Magdy Abd El Razek, Azeem Majeed, Reza Malekzadeh, Felix Masiye, Toni Meier, Atte Meretoja, Ted R Miller, Erkin M Mirrakhimov, Shafiu Mohammed, Vinay Nangia, Stefano Olgiati, Abdalla Sidahmed Osman, Mayowa O Owolabi, Tejas Patel, Angel J Paternina Caicedo, David M Pereira, Julian Perelman, Suzanne Polinder, Anwar Rafay, Vafa Rahimi-Movaghar, Rajesh Kumar Rai, Usha Ram, Chhabi Lal Ranabhat, Hirbo Shore Roba, Joseph Salama, Miloje Savic, Sadaf G Sepanlou, Mark G Shrime, Roberto Tchio Talongwa, Braden J Te Ao, Fabrizio Tediosi, Azeb Gebresilassie Tesema, Alan J Thomson, Ruoyan Tobe-Gai, Roman Topor-Madry, Eduardo A Undurraga, Tommi Vasankari, Francesco S Violante, Andrea Werdecker, Tissa Wijeratne, Gelin Xu, Naohiro Yonemoto, Mustafa Z Younis, Chuanhua Yu, Zoubida Zaidi, Maysaa El Sayed Zaki, Christopher J L Murray
Journal: The Lancet (2017)

<h2>Summary</h2><h3>Background</h3> An adequate amount of prepaid resources for health is important to ensure access to health services and for the pursuit of universal health coverage. Previous studies on global health financing have described the relationship between economic development and health financing. In this study, we further explore global health financing trends and examine how the sources of funds used, types of services purchased, and development assistance for health disbursed change with economic development. We also identify countries that deviate from the trends. <h3>Methods</h3> We estimated national health spending by type of care and by source, including development assistance for health, based on a diverse set of data including programme reports, budget data, national estimates, and 964 National Health Accounts. These data represent health spending for 184 countries from 1995 through 2014. We converted these data into a common inflation-adjusted and purchasing power-adjusted currency, and used non-linear regression methods to model the relationship between health financing, time, and economic development. <h3>Findings</h3> Between 1995 and 2014, economic development was positively associated with total health spending and a shift away from a reliance on development assistance and out-of-pocket (OOP) towards government spending. The largest absolute increase in spending was in high-income countries, which increased to purchasing power-adjusted $5221 per capita based on an annual growth rate of 3·0%. The largest health spending growth rates were in upper-middle-income (5·9) and lower-middle-income groups (5·0), which both increased spending at more than 5% per year, and spent $914 and $267 per capita in 2014, respectively. Spending in low-income countries grew nearly as fast, at 4·6%, and health spending increased from $51 to $120 per capita. In 2014, 59·2% of all health spending was financed by the government, although in low-income and lower-middle-income countries, 29·1% and 58·0% of spending was OOP spending and 35·7% and 3·0% of spending was development assistance. Recent growth in development assistance for health has been tepid; between 2010 and 2016, it grew annually at 1·8%, and reached US$37·6 billion in 2016. Nonetheless, there is a great deal of variation revolving around these averages. 29 countries spend at least 50% more than expected per capita, based on their level of economic development alone, whereas 11 countries spend less than 50% their expected amount. <h3>Interpretation</h3> Health spending remains disparate, with low-income and lower-middle-income countries increasing spending in absolute terms the least, and relying heavily on OOP spending and development assistance. Moreover, tremendous variation shows that neither time nor economic development guarantee adequate prepaid health resources, which are vital for the pursuit of universal health coverage. <h3>Funding</h3> The Bill & Melinda Gates Foundation.