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, Krycia Cowling, Angela E. Micah, Abigail Chapin, Catherine S. Chen, Gloria Ikilezi, Nafis Sadat, Golsum Tsakalos, Junjie Wu, Theodore Younker, Yingxi Zhao, Bianca S. Zlavog, Cristiana Abbafati, Anwar E. Ahmed, Khurshid Alam, Vahid Alipour, Syed Mohamed Aljunid, Mohammed J. Almalki, Nelson Alvis-Guzman, Walid Ammar & 186 others Catalina Liliana Andrei, Mina Anjomshoa, Carl Abelardo T. Antonio, Jalal Arabloo, Olatunde Aremu, Marcel Ausloos, Leticia Avila-Burgos, Ashish Awasthi, Martin Amogre Ayanore, Samad Azari, Natasha Azzopardi-Muscat, Mojtaba Bagherzadeh, Till Winfried Bärnighausen, Bernhard T. Baune, Mohsen Bayati, Yared Belete Belay, Yihalem Abebe Belay, Habte Belete, Dessalegn Ajema Berbada, Adam Eric Berman, Mircea Beuran, Ali Bijani, Reinhard Busse, Lucero Cahuana-Hurtado, Luis Alberto Cámera, Ferrán Catalá-López, Bal Govind Chauhan, Maria Magdalena Constantin, Christopher Stephen Crowe, Alexandra Cucu, Koustuv Dalal, Jan Walter De Neve, Selina Deiparine, Feleke Mekonnen Demeke, Huyen Phuc Do, Manisha Dubey, Maha El Tantawi, Sharareh Eskandarieh, Reza Esmaeili, Mahdi Fakhar, Ali Akbar Fazaeli, Florian Fischer, Nataliya A. Foigt, Takeshi Fukumoto, Nancy Fullman, Adriana Galan, Amiran Gamkrelidze, Kebede Embaye Gezae, Alireza Ghajar, Ahmad Ghashghaee, Ketevan Goginashvili, Annie Haakenstad, Hassan Haghparast Bidgoli, Samer Hamidi, Hilda L. Harb, Edris Hasanpoor, Hamid Yimam Hassen, Simon I. Hay, Delia Hendrie, Andualem Henok, Ileana Heredia-Pi, Claudiu Herteliu, Chi Linh Hoang, Michael K. Hole, Enayatollah Homaie Rad, Naznin Hossain, Mehdi Hosseinzadeh, Sorin Hostiuc, Olayinka Stephen Ilesanmi, Seyed Sina Naghibi Irvani, Mihajlo Jakovljevic, Amir Jalali, Spencer L. James, Jost B. Jonas, Mikk Jürisson, Rajendra Kadel, Behzad Karami Matin, Amir Kasaeian, Habtamu Kebebe Kasaye, Mesfin Wudu Kassaw, Ali Kazemi Karyani, Roghayeh Khabiri, Junaid Khan, Md Nuruzzaman Khan, Young Ho Khang, Adnan Kisa, Katarzyna Kissimova-Skarbek, Stefan Kohler, Ai Koyanagi, Kristopher J. Krohn, Ricky Leung, Lee Ling Lim, Stefan Lorkowski, Azeem Majeed, Reza Malekzadeh, Morteza Mansourian, Lorenzo Giovanni Mantovani, Benjamin Ballard Massenburg, Martin McKee, Varshil Mehta, Atte Meretoja, Tuomo J. Meretoja, Neda Milevska Kostova, Ted R. Miller, Erkin M. Mirrakhimov, Bahram Mohajer, Aso Mohammad Darwesh, Shafiu Mohammed, Farnam Mohebi, Ali H. Mokdad, Shane Douglas Morrison, Seyyed Meysam Mousavi, Saravanan Muthupandian, Ahamarshan Jayaraman Nagarajan, Vinay Nangia, Ionut Negoi, Cuong Tat Nguyen, Huong Lan Thi Nguyen, Son Hoang Nguyen, Shirin Nosratnejad, Olanrewaju Oladimeji, Stefano Olgiati, Jacob Olusegun Olusanya, Obinna E. Onwujekwe, Stanislav S. Otstavnov, Adrian Pana, David M. Pereira, Bakhtiar Piroozi, Sergio I. Prada, Mostafa Qorbani, Mohammad Rabiee, Navid Rabiee, Alireza Rafiei, Fakher Rahim, Vafa Rahimi-Movaghar, Usha Ram, Chhabi Lal Ranabhat, Anna Ranta, David Laith Rawaf, Salman Rawaf, Satar Rezaei, Elias Merdassa Roro, Ali Rostami, Salvatore Rubino, Mohamadreza Salahshoor, Abdallah M. Samy, Juan Sanabria, João Vasco Santos, Milena M. Santric Milicevic, Bruno Piassi Sao Jose, Miloje Savic, Falk Schwendicke, Sadaf G. Sepanlou, Masood Sepehrimanesh, Aziz Sheikh, Mark G. Shrime, Solomon Sisay, Shahin Soltani, Moslem Soofi, Vinay Srinivasan, Rafael Tabarés-Seisdedos, Anna Torre, Marcos Roberto Tovani-Palone, Bach Xuan Tran, Khanh Bao Tran, Eduardo A. Undurraga, Pascual R. Valdez, Job F.M. van Boven, Veronica Vargas, Yousef Veisani, Francesco S. Violante, Sergey Konstantinovitch Vladimirov, Vasily Vlassov, Sebastian Vollmer, Giang Thu Vu, Charles D.A. Wolfe, Naohiro Yonemoto, Mustafa Z. Younis, Mahmoud Yousefifard, Sojib Bin Zaman, Alireza Zangeneh, Elias Asfaw Zegeye, Arash Ziapour, Adrienne Chew, Christopher J.L. Murray, Joseph L. Dieleman

Research output: Contribution to journalArticle

5 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)2233-2260
Number of pages28
JournalThe Lancet
Volume393
Issue number10187
DOIs
StatePublished - Jun 1 2019

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

In: The Lancet, Vol. 393, No. 10187, 01.06.2019, p. 2233-2260.

Research output: Contribution to journalArticle

Chang, AY, Cowling, K, Micah, AE, Chapin, A, Chen, CS, Ikilezi, G, Sadat, N, Tsakalos, G, Wu, J, Younker, T, Zhao, Y, Zlavog, BS, Abbafati, C, Ahmed, AE, Alam, K, Alipour, V, Aljunid, SM, Almalki, MJ, Alvis-Guzman, N, Ammar, W, Andrei, CL, Anjomshoa, M, Antonio, CAT, Arabloo, J, Aremu, O, Ausloos, M, Avila-Burgos, L, Awasthi, A, Ayanore, MA, Azari, S, Azzopardi-Muscat, N, Bagherzadeh, M, Bärnighausen, TW, Baune, BT, Bayati, M, Belay, YB, Belay, YA, Belete, H, Berbada, DA, Berman, AE, Beuran, M, Bijani, A, Busse, R, Cahuana-Hurtado, L, Cámera, LA, Catalá-López, F, Chauhan, BG, Constantin, MM, Crowe, CS, Cucu, A, Dalal, K, De Neve, JW, Deiparine, S, Demeke, FM, Do, HP, Dubey, M, El Tantawi, M, Eskandarieh, S, Esmaeili, R, Fakhar, M, Fazaeli, AA, Fischer, F, Foigt, NA, Fukumoto, T, Fullman, N, Galan, A, Gamkrelidze, A, Gezae, KE, Ghajar, A, Ghashghaee, A, Goginashvili, K, Haakenstad, A, Haghparast Bidgoli, H, Hamidi, S, Harb, HL, Hasanpoor, E, Hassen, HY, Hay, SI, Hendrie, D, Henok, A, Heredia-Pi, I, Herteliu, C, Hoang, CL, Hole, MK, Homaie Rad, E, Hossain, N, Hosseinzadeh, M, Hostiuc, S, Ilesanmi, OS, Irvani, SSN, Jakovljevic, M, Jalali, A, James, SL, Jonas, JB, Jürisson, M, Kadel, R, Karami Matin, B, Kasaeian, A, Kasaye, HK, Kassaw, MW, Kazemi Karyani, A, Khabiri, R, Khan, J, Khan, MN, Khang, YH, Kisa, A, Kissimova-Skarbek, K, Kohler, S, Koyanagi, A, Krohn, KJ, Leung, R, Lim, LL, Lorkowski, S, Majeed, A, Malekzadeh, R, Mansourian, M, Mantovani, LG, Massenburg, BB, McKee, M, Mehta, V, Meretoja, A, Meretoja, TJ, Milevska Kostova, N, Miller, TR, Mirrakhimov, EM, Mohajer, B, Mohammad Darwesh, A, Mohammed, S, Mohebi, F, Mokdad, AH, Morrison, SD, Mousavi, SM, Muthupandian, S, Nagarajan, AJ, Nangia, V, Negoi, I, Nguyen, CT, Nguyen, HLT, Nguyen, SH, Nosratnejad, S, Oladimeji, O, Olgiati, S, Olusanya, JO, Onwujekwe, OE, Otstavnov, SS, Pana, A, Pereira, DM, Piroozi, B, Prada, SI, Qorbani, M, Rabiee, M, Rabiee, N, Rafiei, A, Rahim, F, Rahimi-Movaghar, V, Ram, U, Ranabhat, CL, Ranta, A, Rawaf, DL, Rawaf, S, Rezaei, S, Roro, EM, Rostami, A, Rubino, S, Salahshoor, M, Samy, AM, Sanabria, J, Santos, JV, Santric Milicevic, MM, Sao Jose, BP, Savic, M, Schwendicke, F, Sepanlou, SG, Sepehrimanesh, M, Sheikh, A, Shrime, MG, Sisay, S, Soltani, S, Soofi, M, Srinivasan, V, Tabarés-Seisdedos, R, Torre, A, Tovani-Palone, MR, Tran, BX, Tran, KB, Undurraga, EA, Valdez, PR, van Boven, JFM, Vargas, V, Veisani, Y, Violante, FS, Vladimirov, SK, Vlassov, V, Vollmer, S, Vu, GT, Wolfe, CDA, Yonemoto, N, Younis, MZ, Yousefifard, M, Zaman, SB, Zangeneh, A, Zegeye, EA, Ziapour, A, Chew, A, Murray, CJL & Dieleman, JL 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, 1995–2050', The Lancet, vol. 393, no. 10187, pp. 2233-2260. https://doi.org/10.1016/S0140-6736(19)30841-4
Chang, Angela Y. ; Cowling, Krycia ; Micah, Angela E. ; Chapin, Abigail ; Chen, Catherine S. ; Ikilezi, Gloria ; Sadat, Nafis ; Tsakalos, Golsum ; Wu, Junjie ; Younker, Theodore ; Zhao, Yingxi ; Zlavog, Bianca S. ; Abbafati, Cristiana ; Ahmed, Anwar E. ; Alam, Khurshid ; Alipour, Vahid ; Aljunid, Syed Mohamed ; Almalki, Mohammed J. ; Alvis-Guzman, Nelson ; Ammar, Walid ; Andrei, Catalina Liliana ; Anjomshoa, Mina ; Antonio, Carl Abelardo T. ; Arabloo, Jalal ; Aremu, Olatunde ; Ausloos, Marcel ; Avila-Burgos, Leticia ; Awasthi, Ashish ; Ayanore, Martin Amogre ; Azari, Samad ; Azzopardi-Muscat, Natasha ; Bagherzadeh, Mojtaba ; Bärnighausen, Till Winfried ; Baune, Bernhard T. ; Bayati, Mohsen ; Belay, Yared Belete ; Belay, Yihalem Abebe ; Belete, Habte ; Berbada, Dessalegn Ajema ; Berman, Adam Eric ; Beuran, Mircea ; Bijani, Ali ; Busse, Reinhard ; Cahuana-Hurtado, Lucero ; Cámera, Luis Alberto ; Catalá-López, Ferrán ; Chauhan, Bal Govind ; Constantin, Maria Magdalena ; Crowe, Christopher Stephen ; Cucu, Alexandra ; Dalal, Koustuv ; De Neve, Jan Walter ; Deiparine, Selina ; Demeke, Feleke Mekonnen ; Do, Huyen Phuc ; Dubey, Manisha ; El Tantawi, Maha ; Eskandarieh, Sharareh ; Esmaeili, Reza ; Fakhar, Mahdi ; Fazaeli, Ali Akbar ; Fischer, Florian ; Foigt, Nataliya A. ; Fukumoto, Takeshi ; Fullman, Nancy ; Galan, Adriana ; Gamkrelidze, Amiran ; Gezae, Kebede Embaye ; Ghajar, Alireza ; Ghashghaee, Ahmad ; Goginashvili, Ketevan ; Haakenstad, Annie ; Haghparast Bidgoli, Hassan ; Hamidi, Samer ; Harb, Hilda L. ; Hasanpoor, Edris ; Hassen, Hamid Yimam ; Hay, Simon I. ; Hendrie, Delia ; Henok, Andualem ; Heredia-Pi, Ileana ; Herteliu, Claudiu ; Hoang, Chi Linh ; Hole, Michael K. ; Homaie Rad, Enayatollah ; Hossain, Naznin ; Hosseinzadeh, Mehdi ; Hostiuc, Sorin ; Ilesanmi, Olayinka Stephen ; Irvani, Seyed Sina Naghibi ; Jakovljevic, Mihajlo ; Jalali, Amir ; James, Spencer L. ; Jonas, Jost B. ; Jürisson, Mikk ; Kadel, Rajendra ; Karami Matin, Behzad ; Kasaeian, Amir ; Kasaye, Habtamu Kebebe ; Kassaw, Mesfin Wudu ; Kazemi Karyani, Ali ; Khabiri, Roghayeh ; Khan, Junaid ; Khan, Md Nuruzzaman ; Khang, Young Ho ; Kisa, Adnan ; Kissimova-Skarbek, Katarzyna ; Kohler, Stefan ; Koyanagi, Ai ; Krohn, Kristopher J. ; Leung, Ricky ; Lim, Lee Ling ; Lorkowski, Stefan ; Majeed, Azeem ; Malekzadeh, Reza ; Mansourian, Morteza ; Mantovani, Lorenzo Giovanni ; Massenburg, Benjamin Ballard ; McKee, Martin ; Mehta, Varshil ; Meretoja, Atte ; Meretoja, Tuomo J. ; Milevska Kostova, Neda ; Miller, Ted R. ; Mirrakhimov, Erkin M. ; Mohajer, Bahram ; Mohammad Darwesh, Aso ; Mohammed, Shafiu ; Mohebi, Farnam ; Mokdad, Ali H. ; Morrison, Shane Douglas ; Mousavi, Seyyed Meysam ; Muthupandian, Saravanan ; Nagarajan, Ahamarshan Jayaraman ; Nangia, Vinay ; Negoi, Ionut ; Nguyen, Cuong Tat ; Nguyen, Huong Lan Thi ; Nguyen, Son Hoang ; Nosratnejad, Shirin ; Oladimeji, Olanrewaju ; Olgiati, Stefano ; Olusanya, Jacob Olusegun ; Onwujekwe, Obinna E. ; Otstavnov, Stanislav S. ; Pana, Adrian ; Pereira, David M. ; Piroozi, Bakhtiar ; Prada, Sergio I. ; Qorbani, Mostafa ; Rabiee, Mohammad ; Rabiee, Navid ; Rafiei, Alireza ; Rahim, Fakher ; Rahimi-Movaghar, Vafa ; Ram, Usha ; Ranabhat, Chhabi Lal ; Ranta, Anna ; Rawaf, David Laith ; Rawaf, Salman ; Rezaei, Satar ; Roro, Elias Merdassa ; Rostami, Ali ; Rubino, Salvatore ; Salahshoor, Mohamadreza ; Samy, Abdallah M. ; Sanabria, Juan ; Santos, João Vasco ; Santric Milicevic, Milena M. ; Sao Jose, Bruno Piassi ; Savic, Miloje ; Schwendicke, Falk ; Sepanlou, Sadaf G. ; Sepehrimanesh, Masood ; Sheikh, Aziz ; Shrime, Mark G. ; Sisay, Solomon ; Soltani, Shahin ; Soofi, Moslem ; Srinivasan, Vinay ; Tabarés-Seisdedos, Rafael ; Torre, Anna ; Tovani-Palone, Marcos Roberto ; Tran, Bach Xuan ; Tran, Khanh Bao ; Undurraga, Eduardo A. ; Valdez, Pascual R. ; van Boven, Job F.M. ; Vargas, Veronica ; Veisani, Yousef ; Violante, Francesco S. ; Vladimirov, Sergey Konstantinovitch ; Vlassov, Vasily ; Vollmer, Sebastian ; Vu, Giang Thu ; Wolfe, Charles D.A. ; Yonemoto, Naohiro ; Younis, Mustafa Z. ; Yousefifard, Mahmoud ; Zaman, Sojib Bin ; Zangeneh, Alireza ; Zegeye, Elias Asfaw ; Ziapour, Arash ; Chew, Adrienne ; Murray, Christopher J.L. ; Dieleman, Joseph L. / 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. In: The Lancet. 2019 ; Vol. 393, No. 10187. pp. 2233-2260.
@article{951810bc01b245d0b87db88630020549,
title = "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",
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.",
author = "Chang, {Angela Y.} and Krycia Cowling and Micah, {Angela E.} and Abigail Chapin and Chen, {Catherine S.} and Gloria Ikilezi and Nafis Sadat and Golsum Tsakalos and Junjie Wu and Theodore Younker and Yingxi Zhao and Zlavog, {Bianca S.} and Cristiana Abbafati and Ahmed, {Anwar E.} and Khurshid Alam and Vahid Alipour and Aljunid, {Syed Mohamed} and Almalki, {Mohammed J.} and Nelson Alvis-Guzman and Walid Ammar and Andrei, {Catalina Liliana} and Mina Anjomshoa and Antonio, {Carl Abelardo T.} and Jalal Arabloo and Olatunde Aremu and Marcel Ausloos and Leticia Avila-Burgos and Ashish Awasthi and Ayanore, {Martin Amogre} and Samad Azari and Natasha Azzopardi-Muscat and Mojtaba Bagherzadeh and B{\"a}rnighausen, {Till Winfried} and Baune, {Bernhard T.} and Mohsen Bayati and Belay, {Yared Belete} and Belay, {Yihalem Abebe} and Habte Belete and Berbada, {Dessalegn Ajema} and Berman, {Adam Eric} and Mircea Beuran and Ali Bijani and Reinhard Busse and Lucero Cahuana-Hurtado and C{\'a}mera, {Luis Alberto} and Ferr{\'a}n Catal{\'a}-L{\'o}pez and Chauhan, {Bal Govind} and Constantin, {Maria Magdalena} and Crowe, {Christopher Stephen} and Alexandra Cucu and Koustuv Dalal and {De Neve}, {Jan Walter} and Selina Deiparine and Demeke, {Feleke Mekonnen} and Do, {Huyen Phuc} and Manisha Dubey and {El Tantawi}, Maha and Sharareh Eskandarieh and Reza Esmaeili and Mahdi Fakhar and Fazaeli, {Ali Akbar} and Florian Fischer and Foigt, {Nataliya A.} and Takeshi Fukumoto and Nancy Fullman and Adriana Galan and Amiran Gamkrelidze and Gezae, {Kebede Embaye} and Alireza Ghajar and Ahmad Ghashghaee and Ketevan Goginashvili and Annie Haakenstad and {Haghparast Bidgoli}, Hassan and Samer Hamidi and Harb, {Hilda L.} and Edris Hasanpoor and Hassen, {Hamid Yimam} and Hay, {Simon I.} and Delia Hendrie and Andualem Henok and Ileana Heredia-Pi and Claudiu Herteliu and Hoang, {Chi Linh} and Hole, {Michael K.} and {Homaie Rad}, Enayatollah and Naznin Hossain and Mehdi Hosseinzadeh and Sorin Hostiuc and Ilesanmi, {Olayinka Stephen} and Irvani, {Seyed Sina Naghibi} and Mihajlo Jakovljevic and Amir Jalali and James, {Spencer L.} and Jonas, {Jost B.} and Mikk J{\"u}risson and Rajendra Kadel and {Karami Matin}, Behzad and Amir Kasaeian and Kasaye, {Habtamu Kebebe} and Kassaw, {Mesfin Wudu} and {Kazemi Karyani}, Ali and Roghayeh Khabiri and Junaid Khan and Khan, {Md Nuruzzaman} and Khang, {Young Ho} and Adnan Kisa and Katarzyna Kissimova-Skarbek and Stefan Kohler and Ai Koyanagi and Krohn, {Kristopher J.} and Ricky Leung and Lim, {Lee Ling} and Stefan Lorkowski and Azeem Majeed and Reza Malekzadeh and Morteza Mansourian and Mantovani, {Lorenzo Giovanni} and Massenburg, {Benjamin Ballard} and Martin McKee and Varshil Mehta and Atte Meretoja and Meretoja, {Tuomo J.} and {Milevska Kostova}, Neda and Miller, {Ted R.} and Mirrakhimov, {Erkin M.} and Bahram Mohajer and {Mohammad Darwesh}, Aso and Shafiu Mohammed and Farnam Mohebi and Mokdad, {Ali H.} and Morrison, {Shane Douglas} and Mousavi, {Seyyed Meysam} and Saravanan Muthupandian and Nagarajan, {Ahamarshan Jayaraman} and Vinay Nangia and Ionut Negoi and Nguyen, {Cuong Tat} and Nguyen, {Huong Lan Thi} and Nguyen, {Son Hoang} and Shirin Nosratnejad and Olanrewaju Oladimeji and Stefano Olgiati and Olusanya, {Jacob Olusegun} and Onwujekwe, {Obinna E.} and Otstavnov, {Stanislav S.} and Adrian Pana and Pereira, {David M.} and Bakhtiar Piroozi and Prada, {Sergio I.} and Mostafa Qorbani and Mohammad Rabiee and Navid Rabiee and Alireza Rafiei and Fakher Rahim and Vafa Rahimi-Movaghar and Usha Ram and Ranabhat, {Chhabi Lal} and Anna Ranta and Rawaf, {David Laith} and Salman Rawaf and Satar Rezaei and Roro, {Elias Merdassa} and Ali Rostami and Salvatore Rubino and Mohamadreza Salahshoor and Samy, {Abdallah M.} and Juan Sanabria and Santos, {Jo{\~a}o Vasco} and {Santric Milicevic}, {Milena M.} and {Sao Jose}, {Bruno Piassi} and Miloje Savic and Falk Schwendicke and Sepanlou, {Sadaf G.} and Masood Sepehrimanesh and Aziz Sheikh and Shrime, {Mark G.} and Solomon Sisay and Shahin Soltani and Moslem Soofi and Vinay Srinivasan and Rafael Tabar{\'e}s-Seisdedos and Anna Torre and Tovani-Palone, {Marcos Roberto} and Tran, {Bach Xuan} and Tran, {Khanh Bao} and Undurraga, {Eduardo A.} and Valdez, {Pascual R.} and {van Boven}, {Job F.M.} and Veronica Vargas and Yousef Veisani and Violante, {Francesco S.} and Vladimirov, {Sergey Konstantinovitch} and Vasily Vlassov and Sebastian Vollmer and Vu, {Giang Thu} and Wolfe, {Charles D.A.} and Naohiro Yonemoto and Younis, {Mustafa Z.} and Mahmoud Yousefifard and Zaman, {Sojib Bin} and Alireza Zangeneh and Zegeye, {Elias Asfaw} and Arash Ziapour and Adrienne Chew and Murray, {Christopher J.L.} and Dieleman, {Joseph L.}",
year = "2019",
month = "6",
day = "1",
doi = "10.1016/S0140-6736(19)30841-4",
language = "English (US)",
volume = "393",
pages = "2233--2260",
journal = "The Lancet",
issn = "0140-6736",
publisher = "Elsevier Limited",
number = "10187",

}

TY - JOUR

T1 - Past, present, and future of global health financing

T2 - a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995–2050

AU - Chang, Angela Y.

AU - Cowling, Krycia

AU - Micah, Angela E.

AU - Chapin, Abigail

AU - Chen, Catherine S.

AU - Ikilezi, Gloria

AU - Sadat, Nafis

AU - Tsakalos, Golsum

AU - Wu, Junjie

AU - Younker, Theodore

AU - Zhao, Yingxi

AU - Zlavog, Bianca S.

AU - Abbafati, Cristiana

AU - Ahmed, Anwar E.

AU - Alam, Khurshid

AU - Alipour, Vahid

AU - Aljunid, Syed Mohamed

AU - Almalki, Mohammed J.

AU - Alvis-Guzman, Nelson

AU - Ammar, Walid

AU - Andrei, Catalina Liliana

AU - Anjomshoa, Mina

AU - Antonio, Carl Abelardo T.

AU - Arabloo, Jalal

AU - Aremu, Olatunde

AU - Ausloos, Marcel

AU - Avila-Burgos, Leticia

AU - Awasthi, Ashish

AU - Ayanore, Martin Amogre

AU - Azari, Samad

AU - Azzopardi-Muscat, Natasha

AU - Bagherzadeh, Mojtaba

AU - Bärnighausen, Till Winfried

AU - Baune, Bernhard T.

AU - Bayati, Mohsen

AU - Belay, Yared Belete

AU - Belay, Yihalem Abebe

AU - Belete, Habte

AU - Berbada, Dessalegn Ajema

AU - Berman, Adam Eric

AU - Beuran, Mircea

AU - Bijani, Ali

AU - Busse, Reinhard

AU - Cahuana-Hurtado, Lucero

AU - Cámera, Luis Alberto

AU - Catalá-López, Ferrán

AU - Chauhan, Bal Govind

AU - Constantin, Maria Magdalena

AU - Crowe, Christopher Stephen

AU - Cucu, Alexandra

AU - Dalal, Koustuv

AU - De Neve, Jan Walter

AU - Deiparine, Selina

AU - Demeke, Feleke Mekonnen

AU - Do, Huyen Phuc

AU - Dubey, Manisha

AU - El Tantawi, Maha

AU - Eskandarieh, Sharareh

AU - Esmaeili, Reza

AU - Fakhar, Mahdi

AU - Fazaeli, Ali Akbar

AU - Fischer, Florian

AU - Foigt, Nataliya A.

AU - Fukumoto, Takeshi

AU - Fullman, Nancy

AU - Galan, Adriana

AU - Gamkrelidze, Amiran

AU - Gezae, Kebede Embaye

AU - Ghajar, Alireza

AU - Ghashghaee, Ahmad

AU - Goginashvili, Ketevan

AU - Haakenstad, Annie

AU - Haghparast Bidgoli, Hassan

AU - Hamidi, Samer

AU - Harb, Hilda L.

AU - Hasanpoor, Edris

AU - Hassen, Hamid Yimam

AU - Hay, Simon I.

AU - Hendrie, Delia

AU - Henok, Andualem

AU - Heredia-Pi, Ileana

AU - Herteliu, Claudiu

AU - Hoang, Chi Linh

AU - Hole, Michael K.

AU - Homaie Rad, Enayatollah

AU - Hossain, Naznin

AU - Hosseinzadeh, Mehdi

AU - Hostiuc, Sorin

AU - Ilesanmi, Olayinka Stephen

AU - Irvani, Seyed Sina Naghibi

AU - Jakovljevic, Mihajlo

AU - Jalali, Amir

AU - James, Spencer L.

AU - Jonas, Jost B.

AU - Jürisson, Mikk

AU - Kadel, Rajendra

AU - Karami Matin, Behzad

AU - Kasaeian, Amir

AU - Kasaye, Habtamu Kebebe

AU - Kassaw, Mesfin Wudu

AU - Kazemi Karyani, Ali

AU - Khabiri, Roghayeh

AU - Khan, Junaid

AU - Khan, Md Nuruzzaman

AU - Khang, Young Ho

AU - Kisa, Adnan

AU - Kissimova-Skarbek, Katarzyna

AU - Kohler, Stefan

AU - Koyanagi, Ai

AU - Krohn, Kristopher J.

AU - Leung, Ricky

AU - Lim, Lee Ling

AU - Lorkowski, Stefan

AU - Majeed, Azeem

AU - Malekzadeh, Reza

AU - Mansourian, Morteza

AU - Mantovani, Lorenzo Giovanni

AU - Massenburg, Benjamin Ballard

AU - McKee, Martin

AU - Mehta, Varshil

AU - Meretoja, Atte

AU - Meretoja, Tuomo J.

AU - Milevska Kostova, Neda

AU - Miller, Ted R.

AU - Mirrakhimov, Erkin M.

AU - Mohajer, Bahram

AU - Mohammad Darwesh, Aso

AU - Mohammed, Shafiu

AU - Mohebi, Farnam

AU - Mokdad, Ali H.

AU - Morrison, Shane Douglas

AU - Mousavi, Seyyed Meysam

AU - Muthupandian, Saravanan

AU - Nagarajan, Ahamarshan Jayaraman

AU - Nangia, Vinay

AU - Negoi, Ionut

AU - Nguyen, Cuong Tat

AU - Nguyen, Huong Lan Thi

AU - Nguyen, Son Hoang

AU - Nosratnejad, Shirin

AU - Oladimeji, Olanrewaju

AU - Olgiati, Stefano

AU - Olusanya, Jacob Olusegun

AU - Onwujekwe, Obinna E.

AU - Otstavnov, Stanislav S.

AU - Pana, Adrian

AU - Pereira, David M.

AU - Piroozi, Bakhtiar

AU - Prada, Sergio I.

AU - Qorbani, Mostafa

AU - Rabiee, Mohammad

AU - Rabiee, Navid

AU - Rafiei, Alireza

AU - Rahim, Fakher

AU - Rahimi-Movaghar, Vafa

AU - Ram, Usha

AU - Ranabhat, Chhabi Lal

AU - Ranta, Anna

AU - Rawaf, David Laith

AU - Rawaf, Salman

AU - Rezaei, Satar

AU - Roro, Elias Merdassa

AU - Rostami, Ali

AU - Rubino, Salvatore

AU - Salahshoor, Mohamadreza

AU - Samy, Abdallah M.

AU - Sanabria, Juan

AU - Santos, João Vasco

AU - Santric Milicevic, Milena M.

AU - Sao Jose, Bruno Piassi

AU - Savic, Miloje

AU - Schwendicke, Falk

AU - Sepanlou, Sadaf G.

AU - Sepehrimanesh, Masood

AU - Sheikh, Aziz

AU - Shrime, Mark G.

AU - Sisay, Solomon

AU - Soltani, Shahin

AU - Soofi, Moslem

AU - Srinivasan, Vinay

AU - Tabarés-Seisdedos, Rafael

AU - Torre, Anna

AU - Tovani-Palone, Marcos Roberto

AU - Tran, Bach Xuan

AU - Tran, Khanh Bao

AU - Undurraga, Eduardo A.

AU - Valdez, Pascual R.

AU - van Boven, Job F.M.

AU - Vargas, Veronica

AU - Veisani, Yousef

AU - Violante, Francesco S.

AU - Vladimirov, Sergey Konstantinovitch

AU - Vlassov, Vasily

AU - Vollmer, Sebastian

AU - Vu, Giang Thu

AU - Wolfe, Charles D.A.

AU - Yonemoto, Naohiro

AU - Younis, Mustafa Z.

AU - Yousefifard, Mahmoud

AU - Zaman, Sojib Bin

AU - Zangeneh, Alireza

AU - Zegeye, Elias Asfaw

AU - Ziapour, Arash

AU - Chew, Adrienne

AU - Murray, Christopher J.L.

AU - Dieleman, Joseph L.

PY - 2019/6/1

Y1 - 2019/6/1

N2 - 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.

AB - 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.

UR - http://www.scopus.com/inward/record.url?scp=85065127995&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85065127995&partnerID=8YFLogxK

U2 - 10.1016/S0140-6736(19)30841-4

DO - 10.1016/S0140-6736(19)30841-4

M3 - Article

VL - 393

SP - 2233

EP - 2260

JO - The Lancet

JF - The Lancet

SN - 0140-6736

IS - 10187

ER -