Pi Is 0140673619308414

Articles
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
Global Burden of Disease Health Financing Collaborator Network*
Summary
Background Comprehensive and comparable estimates of health spending in each country are a key input for health Lancet 2019; 393: 2233–60
policy and planning, and are necessary to support the achievement of national and international health goals. Previous Published Online
studies have tracked past and projected future health spending until 2040 and shown that, with economic development, April 25, 2019
http://dx.doi.org/10.1016/
countries tend to spend more on health per capita, with a decreasing share of spending from development assistance
S0140-6736(19)30841-4
and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending,
This online publication has been
with an emphasis on equity in spending across countries. corrected. The corrected version
first appeared at thelancet.com
Methods We estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three on September 9, 2021
categories—government, out-of-pocket, and prepaid private health spending—and estimated development assistance *Collaborators are listed at the
for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear end of the Article
mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050 Correspondence to:
Dr Joseph L Dieleman, Institute for
and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and Health Metrics and Evaluation,
revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data Seattle, WA 98121, USA
were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, dieleman@uw.edu
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.
www.thelancet.com Vol 393 June 1, 2019 2233

Articles
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.
Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.
Introduction that promotes equity.2 Health systems funded according to

Financial resources are an essential input to health one’s ability to pay, such as those based on income taxes,
systems—at a minimum, these are necessary to purchase promote both financial equity and better health.3 Over-
medicines and supplies, build health facilities, and pay reliance on out-of-pocket spending diminishes access to
health workers. However, limited financial resources are care for those who are uninsured or underinsured, and
a universal constraint faced by all health systems. WHO risks exacerbating the burden of ill health and increasing
has identified health financing as one of the six key poverty due to the high cost of care.4 The recognised
building blocks of health systems and adequate financing importance of financial protection has led to its inclusion
is essential to the other five blocks.1 Health financing as one of two pillars of universal health coverage, alongside
For more on Sustainable systems are tasked not only with raising sufficient financial coverage of core health services, as outlined in Sustainable
Development Goal 3 see resources to fund the health system, but doing so in a way Development Goal 3.
https://www.who.int/sdg/
targets/en/
Research in context
Evidence before this study increases in government health spending across countries,
Understanding past trends and anticipating future trends in showing that increased prioritisation of the health sector and
health financing is important for planning and allocating economic development are associated with the largest increases
resources required to achieve universal health coverage and in government health spending globally. These time trends in
other health goals. Previous studies, including work by the Global health spending also reveal persistent disparities across income
Burden of Disease Health Financing Collaborator Network, groups, with per capita health spending in high-income
have tracked past and projected future health spending and countries 130·2 times (95% uncertainty interval 122·9–136·9)
spending disaggregated by funding source (ie, government, that in low-income countries in 2016, and projected to remain
prepaid private, out-of-pocket, and development assistance for stable at 125·9 times (113·7–138·1) greater in 2050. Within
health) up to 2040. A 2018 report from WHO documents the low-income and middle-income country groups, the gaps
global pattern of declining external financing and increasing between countries with the highest and lowest government
domestic public funding, supporting key findings from other health spending per capita are projected to widen between
existing studies. Research focusing on the global health financing now and the future. Furthermore, consistently high rates of
transition by this team and others has shown that with economic out-of-pocket spending in low-income and middle-income
development, countries tend to spend more money on health countries suggest ongoing within-country inequities. Although
per capita and that a declining share of this spending tends to these trends also provide evidence of the global health financing
come from development assistance and out-of-pocket sources. transition, many countries’ trends run counter to global norms.
Added value of this study Implications of all the available evidence
This study is, to our knowledge, the first analysis of global health Development assistance for health has plateaued; moreover,
financing to generate past trends, characterise present patterns, projected future spending suggests that low levels of domestic
and predict future scenarios for 195 countries over a period health spending and high out-of-pocket spending will persist in
spanning 56 years, with an emphasis on equity across countries many low-income countries. Increasing prioritisation of health
over time, providing a holistic assessment of the state of global and economic development should be supported as key
health financing. This analysis provides new estimates of total, mechanisms to increase government health spending and
government, prepaid private, and out-of-pocket health spending address persistent global inequities in health spending.
and development assistance for health for 195 countries Given the limited financial resources for health in all countries
spanning from 1995 to 2050. The relationship between and persistently low levels of health financing in some, it is
economic development and the distribution of these sources of important to identify and implement policies to generate
financing provides further support for the theory of the global additional resources and improve the efficiency of health
health financing transition. The decomposition analysis shows, spending to maximise health outcomes in the future.
for the first time, key factors that have been associated with
2234 www.thelancet.com Vol 393 June 1, 2019

Articles
Empirical studies have shown that reducing government spending disaggregated by new programme areas, such
health spending per capita can lead to increased child, as antimicrobial resistance.
adult, and maternal mortality.5–8 Other research has The objective of this analysis is to provide comprehensive
found that countries with lower levels of health spending and comparable national health spending estimates, by
coming from pooled financing mechanisms, such as four major sources of funding, from 1995 to 2016 and into
insurance-based or tax-based financing, have lower 2050, emphasising equity in spending across countries
performance on universal health coverage.9 These over time. We also characterise health spending patterns
benefits and the established risks of high out-of-pocket associated with economic development to assess support
spending have led to a focus on the composition of for the theory of the health financing transition, analyse
sources of health financing across countries. The health factors associated with increases in government health
financing transition is a theory developed to characterise spending, and report expected future spending under
the gradual shift in the level and source of health two alternative government spending scenarios.
financing observed in countries over time. Generally,
countries start this transition with a low initial level of Methods
health spending per capita that is largely out of pocket or Overview
from donors, and progressively transition to higher per The methods presented here summarise the various
capita spending relying more on government financing. components of the estimation process; the appendix See Online for appendix
Tracking financial resources for health is a prerequisite for provides further details about data sources, methods, and
assessing the performance of health financing systems additional results presented in alternative units. We
and financial protection, characterising progress along defined health spending as money spent on services,
the health financing transition, evaluating health-system supplies, and basic infrastructure to deliver health care,
efficiency and productivity, or advocating for health- using the same definition used by the System of Health
system policy change. Moreover, developing future Accounts 2011 and the WHO Global Health Expenditure
health financing scenarios enables policy makers and Database (GHED).12,13
donors to predict the amount of services that can be We estimated health spending from four main
provided and identify gaps where expected funding is funding sources—government, out-of-pocket, prepaid
insufficient. Established frameworks and examples from private, and DAH—for 195 countries and territories.
a range of countries underscore the important role of “Countries and territories” are referred to only as
timely, comprehensive health financing estimates in “countries”, which are categorised into four World Bank
decision making and analysis.10,11 As countries work income groups and seven Global Burden of Disease
towards global commitments to universal health coverage (GBD) super-regions. Data tracking government, out-
and the other health-related targets enshrined in the UN of-pocket, and prepaid private health spending, which For more on the UN Sustainable
Sustainable Development Goals, the expected resources together comprise total domestic health spending, were Development Goals see
https://www.un.org/
available for health can be used to assess expected available from 1995 through 2016. Government health sustainabledevelopment/
progress. In the absence of comprehensive and spending includes social health insurance and man sustainable-development-goals/
comparable health financing estimates, policy makers dated private health insurance, as well as government
and planners cannot clearly measure how much has public health programmes. Out-of-pocket health
been spent on health, where funding has come from, or spending includes health-care spending by the patient
what are reasonable expectations for future spending. or their household, excluding insurance premiums
This study incorporates several important methodo paid in advance of care. Prepaid private health spending
logical advancements and novel analyses. The health includes voluntary private insurance and non-govern
financing estimation methods are continuously im mental agency spending on health.
proving and forecasting is particularly enhanced by DAH was defined as the financial and in-kind
advances in the underlying approach to project gross contributions from major development agencies to low-
domestic product (GDP). The time horizon for spending income and middle-income countries for maintaining or
forecasts is 10 years longer than previously available improving population health. The total amount of DAH,
and alternative future scenarios are based, for the first by source, was estimated through 2018, but was not
time, on a new understanding of factors associated allocated by recipient country for 2018. The sum of
with increased government spending, as identified from domestic health spending and DAH, net of administrative
the decomposition analysis, also new to this study. costs needed to run development agencies, form the
Additionally, these estimates include seven additional envelope of total health spending for each country and
countries or territories not previously included. There year.
are also several advances specific to the development Domestic health spending from each of the three sources
assistance for health (DAH) estimates, including the was projected for each country from 2017 to 2050, and
addition of China as a donor, inclusion of the Coalition for DAH was projected from 2018 to 2050, by modelling
Epidemic Preparedness Innovations and the European rates of change across time. These models incorporate
Economic Area as channels of disbursements, and country-specific time trends that attenuate across time

Articles
and converge to the global average, consider a broad set as well as private foundations and non-governmental
of covariates and time-series modelling techniques, agencies for whom we have data. DAH excludes
and propagate four types of uncertainty: model, data, spending on basic bench science. Detailed descriptions
parameter, and fundamental uncertainty. of the methodology used for tracking DAH and these
improvements, including data sources and keywords
Estimating domestic health spending for 1995–2016 used to isolate relevant projects, are included in the
We extracted data on GDP per capita from five leading appendix.
sources of these estimates.14–18 Building from methods
described by James and colleagues,19 we generated a Factors associated with changes in government health
single series of GDP per capita using Gaussian processes, spending for 1995–2016
incorporating data from all five GDP series from We completed a decomposition analysis to understand
1970 to 2017.19 the relationship between changes in per capita govern
We extracted data from the WHO’s GHED on ment health spending between 1995 and 2016 and the
government domestic revenue transfers allocated for underlying contributing factors. A standard demographic
health, compulsory prepayment, voluntary prepayment, decomposition technique popularised by Das Gupta was
social insurance contributions, and other domestic applied; this approach yields estimates of how changes in
revenue from households, corporations, and non-profit each of a set of prespecified factors are associated with
institutions serving households.12 Data from GHED changes in the outcome (government health spending per
exclude spending on major investments (eg, hospital capita).26 The three factors examined were economic
construction, health worker education and training, and development, measured as GDP per person (GDP/Pop);
research and development). Health spending estimates increased total government spending, measured as
were extracted in current national currency units, the proportion of GDP that is government spending
deflated to 2018 national currency units, and exchanged (Gov/GDP); and greater government prioritisation of
to 2018 US dollars. Deflator series and exchanges rates the health sector, measured as the proportion of total
were taken from the IMF World Economic Outlook.16 government spending spent on the health sector
To generate domestic health spending estimates in (Gov Health/Gov). The product of these three factors is
purchasing-power parity-adjusted dollars, we divided government health spending per capita (Gov Health/Pop):
health spending in 2018 US dollars by GDP in 2018 US
dollars, and then multiplied health spending fractions Gov Health = GDP × Gov × Gov Health
by GDP per capita measured in 2018 purchasing-power Pop Pop GDP Gov
parity-adjusted dollars.
The extracted data were assessed for quality using These three factors form a comprehensive set, as all
point-specific metadata provided in the GHED, and other factors that influence government health spending
weighted according to estimation methods and whether must operate through one or more of those factors. For
they were tied to an underlying data source. We then example, if demand for health services increases or a
used a spatiotemporal Gaussian process regression population ages and requires additional health services
model to estimate health spending across time, country, from the government, this must lead to an increase in total
and spending category.20 We based weights on metadata government spending or a reprioritisation of existing
completeness, documented source information, and government spending towards health. This decomposition
documented methods for estimation. approach measures the relative contribution of each factor
to changes in per capita government health spending
Estimating development assistance for health for during the time period examined.
1990–2018
Although most of the methods used for tracking DAH Estimating health spending in the future, for 2017–50
have been described previously, we incorporated several Future health spending scenarios were estimated with an
major improvements.21–25 These include the addition of ensemble modelling framework and key covariates. A
China as a source of funding; the inclusion of the process diagram in the appendix displays the flow of
Coalition for Epidemic Preparedness Innovations as a input data and models for each step of the forecasting
channel; and the addition of antimicrobial resistance as process. Ensemble modelling estimates a set of future
a programme area. The estimate we generated for scenarios using a large number of distinct sub-models
antimicrobial resistance is restricted to funds that and then takes the average across all sub-models that
were disbursed through development agencies. These pass a predetermined inclusion criterion.27 Each sub-
improvements expand the scope of our DAH resource model has a distinct specification or set of covariates;
tracking to capture some of the emerging areas of primary covariates considered were GDP per capita, total
importance in the current global health financing government spending, total fertility rate, and fraction of
landscape. For all DAH tracking, we include funds that the population older than 65 years, as well as country-
were transferred through major development agencies, specific time trends. Total fertility rates and age-specific

Articles
A 1995
Health spending per capita (US$)

5 to <118
118 to <389
389 to <892
892 to <2406
2406 to <15 826
ATG VCT Barbados Comoros Marshall Isl Kiribati

West Africa Eastern
Mediterranean
Solomon Isl FSM
Dominica Grenada Maldives Mauritius Malta

Vanuatu Samoa
Caribbean LCA TTO TLS Seychelles Persian Gulf Singapore Balkan Peninsula Fiji Tonga
B 2016

5 to <118
118 to <389
389 to <892
892 to <2406
2406 to <15 826

West Africa Eastern
Mediterranean
Solomon Isl FSM

Vanuatu Samoa
(Figure 1 continues on next page)

Articles
C 2030

5 to <118
118 to <389
389 to <892
892 to <2406
2406 to <15 826

West Africa Eastern
Mediterranean
Solomon Isl FSM

Vanuatu Samoa
D 2050

5 to <118
118 to <389
389 to <892
892 to <2406
2406 to <15 826

West Africa Eastern
Mediterranean
Solomon Isl FSM

Vanuatu Samoa

Articles
population data were extracted from the UN World 1995

Population Prospects, while we generated our own 2016
15 000 2030
estimates of GDP per capita and fraction of GDP from
2050

government spending.28
To project expected GDP per capita for each of the
195 countries from 2018 through 2050, we estimated 10 000
the GDP per working-age adult growth rate (ages
20–64 years). Using out-of-sample validation, we showed
that GDP per capita could be more accurately estimated 5000
(smaller root-mean-squared error) by estimating GDP
per working-age adult growth rates, rather than GDP per
capita growth rates.
0
After estimating GDP per capita, we used the same 100 1000 10 000 50 000 160 000
method to estimate future scenarios of total government Gross domestic product per capita (US$)
spending as a fraction of GDP, government health
spending as a fraction of total government spending, Figure 2: Health spending per capita by gross domestic product per capita, for 1995, 2016, 2030, and 2050
Health spending per capita and gross domestic product per capita are reported in inflation-adjusted 2018 US dollars.
prepaid private health spending as a fraction of GDP,
The lines are the trend lines reflecting model fit for each year. 2030 and 2050 values are reference scenarios. Each dot
and out-of-pocket health spending as a fraction of represents a country-year estimate, with the colours representing different years (1995, 2016, 2030, and 2050).
GDP. We called these our reference future scenarios. The x-axis is presented in natural logarithmic scale. This figure was remade but with health spending measured as a
Additionally, we estimated future scenarios of the share percentage of gross domestic product, and is included in the appendix.
of health spending that was provided as DAH from each
major donor country, which allowed us to estimate total 195 countries. We then set the target levels of the
DAH expected to be disbursed between 2019 and 2050. two fractions as the 90th percentile of the observed
Next, we estimated the fraction of the total amount of fractions’ distributions. Building on the existing GDP
DAH that we expected each low-income and middle- per capita projections, scenario 1 adjusts all countries so
income country to receive. Finally, if a country was that the fraction of government spending on health is at
projected to reach high-income status before 2050, it was least the 90th percentile. Scenario 2 adjusts all countries
deemed ineligible to receive DAH from that year onward so that both the fraction of government spending on
and the DAH it was otherwise expected to receive was health and the fraction of GDP that is based on
reallocated to all other countries eligible to receive DAH. government spending is at least the 90th percentile.
To estimate total health spending for each country and
year, we added DAH received by countries to estimates Reporting and uncertainty analysis
of government, prepaid private, and out-of-pocket health All inflation-adjusted health spending estimates are
spending. reported with 2018 prices. We report health spending
per capita in US dollars and purchasing-power parity-
Alternative future government health spending adjusted dollars and as a fraction of GDP. When not
scenarios other
wise indicated, estimates are reported in 2018
To assess the potential for governments to generate US dollars. We report country spending estimates using
more resources for health, we estimated two alternative 2017 GBD super-regions and 2018 World Bank income
future scenarios associated with higher government groups, regardless of whether a country changed, or is
health spending: one reflects increased prioritisation of projected to change, income groups during the study
the health sector, and the other reflects both increased period.29,30 Rates were calculated to reflect each group,
overall government spending and increased government rather than the average of countries within the group,
prioritisation of health. To generate the two scenarios, such that spending per capita estimates for an income
we assessed the observed 2016 fraction of government group or region more heavily reflect rates in more
spending that was allocated to the health sector populous countries. The uncertainty interval around
(Gov Health/Gov) and the fraction of GDP that is each estimate was computed with the 2·5th and
based on government spending (Gov/GDP) across the 97·5th percentiles of the 1000 draws. All analyses were
done with R (version 3.5.2) and Stata (version 13).
Role of the funding source

Figure 1: Health spending per capita in 1995 (A), 2016 (B), 2030 (C),
and 2050 (D) The funder of this study had no role in study design,
Reported in inflation-adjusted 2018 US dollars. 2030 and 2050 values are data collection, data analysis, data interpretation, or
reference scenarios. This figure was remade but with health spending measured writing of the manuscript. All authors had full access to
as a percentage of gross domestic product, and is included in the appendix.
all the data in the study, and JLD and CJLM had
ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines.
LCA=Saint Lucia. TTO=Trinidad and Tobago. Isl=Islands. FSM=Federated States final responsibility for the decision to submit for
of Micronesia. TLS=Timor-Leste. publication.

Articles
Health spending Health spending Health Government Out-of-pocket Development Annualised rate Annualised rate Annualised rate
per capita, 2016 per capita, 2016 spending per health spending per assistance for of change in of change in of change in
(US$) ($PPP) GDP, 2016 spending per total health health per health spending, health spending health spending
total health spending, total health 1995–2016 per capita, per GDP,
spending, 2016 spending, (US$) 1995–2016 1995–2016
2016 2016 (US$) (US$)
Global
Total 1077 1400 8·6% 74·0% 18·6% 0·2% 4·00% 2·72% 1·02%
(1058 to 1096) (1368 to 1432) (8·4 to 8·7) (72·5 to 75·5) (18·0 to 19·4) (0·2 to 0·2) (3·89 to 4·12) (2·61 to 2·84) (0·92 to 1·12)
World Bank income group
High income 5252 5621 10·8% 79·6% 13·8% 0·0% 3·61% 2·92% 1·52%
Upper-middle 491 1009 5·0% 53·9% 35·9% 0·2% 6·37% 5·55% 1·17%
income (461 to 524) (948 to 1072) (4·7 to 5·3) (49·9 to 58·6) (32·0 to 40·0) (0·1 to 0·2) (5·95 to 6·79) (5·18 to 5·95) (0·81 to 1·55)
Lower-middle 81 274 3·2% 32·1% 56·1% 3·2% 5·40% 3·71% 0·00%
income (74 to 89) (247 to 303) (2·9 to 3·5) (28·4 to 36·1) (47·3 to 65·4) (2·9 to 3·6) (4·76 to 6·08) (3·10 to 4·34) (–0·63 to 0·60)
Low income 40 125 5·1% 26·3% 42·4% 25·4% 4·25% 1·46% 0·39%
GBD super-region
Central Europe, 530 1265 4·3% 62·6% 33·5% 0·3% 3·44% 3·41% 0·06%
eastern Europe, (505 to 555) (1200 to 1330) (4·1 to 4·5) (59·4 to 65·9) (31·3 to 35·8) (0·2 to 0·3) (3·10 to 3·81) (3·06 to 3·77) (–0·26 to 0·37)
and central Asia
High income 5874 6107 11·2% 79·9% 13·5% 0·0% 3·57% 2·93% 1·59%
Latin America and 693 1270 6·4% 42·7% 39·5% 0·3% 4·21% 2·84% 1·56%
Caribbean (658 to 728) (1209 to 1333) (6·1 to 6·7) (40·3 to 44·9) (36·0 to 43·2) (0·3 to 0·3) (3·83 to 4·62) (2·48 to 3·22) (1·20 to 1·93)
North Africa and 336 1000 3·7% 61·4% 29·3% 0·5% 6·01% 3·92% 1·87%
Middle East (320 to 352) (949 to 1053) (3·5 to 3·9) (56·9 to 65·9) (27·5 to 31·3) (0·4 to 0·5) (5·66 to 6·42) (3·60 to 4·25) (1·58 to 2·19)
South Asia 59 219 3·0% 25·0% 65·2% 1·9% 5·76% 4·09% –0·73%
(49 to 71) (182 to 265) (2·5 to 3·5) (18·7 to 32·2) (46·7 to 88·1) (1·6 to 2·3) (4·42 to 7·15) (2·81 to 5·44) (–1·96 to 0·59)
Southeast Asia, 350 703 4·7% 57·5% 35·9% 0·2% 9·35% 8·52% 1·72%
east Asia, and (319 to 385) (643 to 769) (4·3 to 5·1) (50·8 to 65·5) (30·0 to 42·8) (0·2 to 0·2) (8·56 to 10·14) (7·69 to 9·33) (0·98 to 2·45)
Oceania
Sub-Saharan Africa 80 199 4·1% 36·8% 31·5% 14·0% 4·31% 1·54% –0·17%
Country
Afghanistan 56 200 7·4% 5·7% 84·3% 9·7% 7·06% 3·41% 1·07%
Albania 330 867 6·0% 42·3% 57·2% 0·5% 4·31% 4·74% –0·04%
Algeria 304 1055 4·7% 69·4% 29·2% 0·0% 6·71% 5·12% 3·18%
American Samoa 692 692 6·4% 90·1% 8·3% 0·0% –0·20% –2·20% –1·65%
(604 to 791) (604 to 791) (5·6 to 7·4) (86·5 to 93·0) (5·8 to 11·7) (0·0 to 0·0) (–1·55 to 1·01) (–3·52 to –1·01) (–2·97 to –0·45)
Andorra 4234 7865 8·2% 48·9% 41·9% 0·0% 2·50% 1·13% –0·07%
Angola 121 201 2·4% 48·3% 31·7% 3·6% 3·24% –0·12% –3·81%
(100 to 143) (167 to 237) (2·0 to 2·8) (39·7 to 56·7) (24·3 to 40·2) (3·0 to 4·3) (1·98 to 4·43) (–1·34 to 1·04) (–4·98 to –2·69)
Antigua and Barbuda 760 1233 4·8% 64·4% 29·1% 0·0% 3·98% 2·48% 1·28%
Argentina 1071 1616 7·9% 76·1% 14·8% 0·7% 1·83% 0·68% –0·69%
(1008 to 1135) (1520 to 1713) (7·5 to 8·4) (73·5 to 78·9) (12·7 to 16·9) (0·6 to 0·7) (1·39 to 2·25) (0·24 to 1·09) (–1·13 to –0·29)
Armenia 365 933 7·8% 15·8% 81·1% 1·9% 10·73% 11·04% 4·25%
Australia 5563 5083 7·1% 68·3% 18·9% 0·0% 4·72% 3·28% 1·47%
Austria 5287 5252 9·2% 72·6% 18·9% 0·0% 2·20% 1·76% 0·43%
Azerbaijan 297 1192 3·6% 20·6% 78·3% 0·3% 10·29% 9·00% 1·27%
(Table 1 continues on next page)

Articles
2016 2016 (US$) (US$)
(Continued from previous page)
Bahrain 1169 2365 4·3% 62·7% 27·1% 0·0% 5·39% 1·00% 0·88%
Bangladesh 37 100 3·1% 19·2% 71·4% 6·7% 5·42% 3·81% –0·41%
Barbados 1188 1244 6·3% 46·9% 45·8% 0·0% 2·21% 1·86% 0·81%
Belarus 354 1170 5·0% 61·1% 35·9% 0·3% 5·60% 5·93% 0·44%
Belgium 5014 5048 9·2% 79·1% 15·1% 0·0% 3·18% 2·61% 1·36%
Belize 283 511 5·6% 66·3% 23·4% 3·5% 6·29% 3·37% 2·16%
Benin 32 83 3·1% 22·3% 44·3% 27·5% 3·76% 0·56% –0·83%
(27 to 38) (70 to 98) (2·6 to 3·6) (16·7 to 28·1) (35·3 to 53·4) (23·0 to 32·3) (2·46 to 5·04) (–0·70 to 1·81) (–2·07 to 0·40)
Bermuda 10 802 6982 11·5% 29·1% 10·2% 0·0% 3·05% 1·93% 0·87%
(9469 to 12 352) (6120 to 7983) (10·1 to 13·2) (25·1 to 33·0) (7·7 to 13·4) (0·0 to 0·0) (1·35 to 4·55) (0·25 to 3·41) (–0·80 to 2·33)
Bhutan 84 258 2·5% 72·7% 20·0% 6·1% 4·75% 2·62% –2·38%
Bolivia 214 486 6·7% 66·7% 28·1% 1·8% 6·83% 4·94% 2·52%
Bosnia and 517 1251 8·0% 68·5% 27·6% 2·0% 8·31% 8·48% 0·42%
Herzegovina (473 to 569) (1144 to 1376) (7·3 to 8·7) (64·1 to 72·6) (23·6 to 32·0) (1·8 to 2·2) (7·40 to 9·21) (7·57 to 9·39) (–0·43 to 1·25)
Botswana 427 1000 4·4% 54·5% 5·3% 8·4% 3·73% 1·82% –0·99%
Brazil 1114 1864 8·0% 33·3% 43·9% 0·1% 4·58% 3·35% 2·21%
Brunei 770 1914 1·7% 90·5% 5·3% 0·0% –0·36% –2·11% –1·20%
Bulgaria 681 1786 6·8% 50·9% 47·4% 0·1% 5·65% 6·38% 2·91%
Burkina Faso 37 103 4·4% 35·9% 35·4% 22·3% 6·61% 3·51% 0·55%
Burundi 28 61 10·3% 26·3% 24·9% 47·2% 3·97% 0·90% 1·51%
(25 to 31) (55 to 69) (9·3 to 11·6) (21·1 to 32·1) (19·2 to 31·9) (42·0 to 52·2) (2·89 to 5·03) (–0·16 to 1·92) (0·45 to 2·54)
Cambodia 76 225 5·9% 23·4% 63·2% 12·8% 5·09% 2·91% –2·56%
Cameroon 58 148 3·2% 15·0% 73·3% 9·2% 4·31% 1·56% –0·08%
Canada 4875 5217 8·0% 73·5% 14·6% 0·0% 3·51% 2·44% 1·03%
Cape Verde 157 330 3·7% 64·8% 27·4% 5·4% 4·98% 3·24% –0·77%
Central African 22 37 5·6% 13·5% 36·3% 49·2% 1·48% –0·55% 1·29%
Republic (19 to 25) (33 to 43) (4·9 to 6·4) (10·1 to 17·3) (28·6 to 44·5) (42·9 to 55·6) (0·37 to 2·65) (–1·64 to 0·60) (0·17 to 2·45)
Chad 36 99 3·1% 21·9% 58·0% 14·8% 3·83% 0·18% –2·73%
Chile 1244 2199 6·8% 58·5% 34·7% 0·0% 5·78% 4·55% 1·57%
China 436 808 5·0% 58·8% 35·3% 0·0% 10·84% 10·25% 1·53%
Colombia 358 853 3·9% 65·1% 20·6% 0·1% 2·06% 0·81% –1·24%
Comoros 80 157 6·3% 12·8% 68·4% 17·7% 0·85% –1·58% –1·56%

Articles
2016 2016 (US$) (US$)
Congo (Brazzaville) 79 235 2·0% 46·9% 44·6% 4·4% 5·76% 3·07% 2·22%
Costa Rica 948 1416 8·1% 72·7% 22·1% 2·5% 5·72% 4·11% 1·53%
Côte d’Ivoire 77 178 4·1% 23·6% 43·3% 14·5% 2·18% –0·19% –0·97%
Croatia 939 1707 5·5% 77·7% 15·2% 1·0% 2·34% 2·78% 0·25%
Cuba 1128 2470 15·0% 83·3% 9·3% 0·1% 8·39% 8·14% 4·05%
(1047 to 1228) (2292 to 2689) (13·9 to 16·3) (77·8 to 87·4) (fv7·4 to 11·4) (0·1 to 0·1) (7·56 to 9·18) (7·31 to 8·93) (3·26 to 4·81)
Cyprus 1226 1712 3·9% 42·8% 45·3% 0·0% 3·62% 2·22% 1·46%
Czech Republic 1515 2511 5·7% 82·0% 14·8% 0·0% 3·38% 3·22% 0·84%
Democratic Republic 19 30 4·0% 14·8% 41·2% 36·0% 5·25% 1·99% 1·92%
of the Congo (17 to 23) (26 to 36) (3·4 to 4·7) (11·1 to 19·2) (32·6 to 50·1) (30·3 to 41·5) (3·66 to 6·87) (0·45 to 3·56) (0·38 to 3·49)
Denmark 6195 5240 8·6% 84·1% 13·7% 0·0% 2·89% 2·45% 1·42%
Djibouti 66 124 3·6% 52·7% 23·5% 22·9% 1·46% –0·17% –1·28%
Dominica 438 638 5·5% 66·4% 31·4% 0·8% 1·45% 1·13% –0·60%
Dominican Republic 420 995 5·1% 45·3% 44·1% 1·5% 6·45% 4·98% 1·05%
Ecuador 536 1015 8·7% 51·1% 41·4% 0·2% 6·50% 4·69% 3·21%
Egypt 125 577 3·7% 31·5% 60·2% 0·5% 3·45% 1·54% –0·86%
El Salvador 313 656 7·2% 64·4% 27·6% 1·9% 2·31% 1·82% 0·29%
Equatorial Guinea 310 797 1·6% 21·5% 71·6% 2·8% 9·04% 5·74% –6·21%
Eritrea 30 46 4·4% 20·3% 63·0% 14·8% 0·24% –2·20% –2·07%
Estonia 1392 2051 6·2% 75·5% 22·7% 0·0% 3·80% 4·28% –0·14%
eSwatini 329 876 6·6% 60·3% 9·8% 22·5% 6·39% 4·63% 2·87%
Ethiopia 31 83 5·4% 22·6% 34·2% 26·3% 8·94% 5·83% 0·55%
Federated States of 130 144 3·9% 84·1% 7·7% 8·1% 1·56% 1·79% 1·54%
Micronesia (109 to 154) (121 to 171) (3·3 to 4·7) (79·9 to 87·5) (5·2 to 11·1) (6·8 to 9·6) (0·33 to 2·77) (0·56 to 3·00) (0·31 to 2·75)
Fiji 200 350 3·6% 61·8% 20·3% 4·5% 3·13% 2·48% 1·06%
Finland 4656 4235 8·4% 77·4% 20·2% 0·0% 3·37% 3·00% 1·24%
France 4945 5148 9·8% 80·6% 9·6% 0·0% 2·45% 1·88% 0·87%
Gabon 281 649 2·2% 62·1% 24·4% 1·1% 1·57% –0·82% –0·01%
Georgia 319 851 6·1% 34·0% 59·2% 1·3% 8·15% 9·29% 2·21%
Germany 5263 5619 9·6% 84·6% 12·4% 0·0% 1·26% 1·20% –0·12%

Articles
2016 2016 (US$) (US$)
Ghana 75 210 3·6% 39·9% 39·4% 13·7% 6·39% 3·75% 0·57%
Greece 1693 2392 6·4% 59·7% 35·6% 0·0% 1·17% 1·06% 0·47%
Greenland 4457 3516 8·1% 100·0% 0·0% 0·0% 2·51% 2·52% –0·04%
Grenada 486 723 5·0% 40·9% 58·6% 0·5% 0·82% 0·56% –2·31%
Guam 1990 1990 5·5% 87·4% 8·8% 0·0% 2·88% 2·01% 0·97%
Guatemala 262 479 6·8% 36·6% 54·8% 1·2% 5·07% 2·77% 1·46%
Guinea 44 119 6·0% 11·1% 53·4% 25·7% 6·11% 3·49% 1·82%
Guinea-Bissau 49 110 6·1% 34·4% 33·9% 31·7% 1·71% –0·66% –0·70%
Guyana 208 377 4·5% 56·6% 38·5% 4·8% 3·12% 3·02% 0·11%
Haiti 47 113 5·4% 13·1% 35·6% 47·1% 0·55% –1·13% –1·08%
Honduras 193 401 7·2% 43·1% 47·3% 3·2% 5·18% 3·15% 1·54%
Hungary 1029 2133 5·8% 66·1% 29·3% 0·0% 2·34% 2·54% 0·04%
Iceland 6307 4347 10·6% 81·4% 17·0% 0·0% 3·52% 2·47% 0·06%
India 65 247 3·0% 25·4% 64·2% 0·9% 6·07% 4·46% –0·84%
Indonesia 116 388 2·3% 40·3% 40·1% 0·7% 5·94% 4·59% 1·70%
Iran 420 1707 4·8% 50·5% 37·6% 0·0% 7·80% 6·31% 4·27%
Iraq 157 505 2·0% 26·2% 73·5% 0·3% 10·14% 6·70% 1·56%
Ireland 5097 5194 6·2% 71·9% 13·2% 0·0% 6·60% 5·33% 0·92%
Israel 2757 2597 6·7% 63·6% 23·2% 0·0% 3·75% 1·65% 0·03%
Italy 3059 3462 7·4% 74·4% 23·1% 0·0% 1·70% 1·40% 1·15%
Jamaica 314 569 5·4% 60·0% 21·0% 1·7% 1·76% 1·16% 1·33%
Japan 4175 4667 7·2% 83·7% 13·3% 0·0% 3·94% 3·89% 3·07%
Jordan 224 509 5·1% 65·7% 26·2% 2·1% 1·86% –0·93% –2·26%
(198 to 253) (450 to 574) (4·6 to 5·8) (59·8 to 70·7) (21·5 to 31·4) (1·8 to 2·3) (1·06 to 2·67) (–1·70 to –0·14) (–3·03 to –1·48)
Kazakhstan 295 868 2·1% 61·3% 32·6% 0·8% 2·95% 2·43% –2·53%
Kenya 82 168 6·3% 33·9% 27·1% 23·9% 4·09% 1·51% 0·19%
Kiribati 198 233 9·1% 64·6% 13·6% 17·8% 2·45% 0·78% 0·55%
Kuwait 1279 2959 2·7% 83·2% 15·2% 0·0% 3·56% –0·58% –0·02%

Articles
2016 2016 (US$) (US$)
Kyrgyzstan 79 262 5·5% 40·0% 52·4% 7·6% 4·48% 3·14% –0·09%
Laos 52 157 2·4% 33·4% 48·9% 14·3% 4·38% 2·34% –2·81%
Latvia 995 1635 5·4% 55·1% 43·9% 0·0% 4·29% 5·41% 0·25%
Lebanon 486 852 5·3% 51·4% 32·5% 0·5% 1·90% –1·22% –2·11%
(437 to 540) (766 to 946) (4·8 to 5·9) (46·4 to 56·4) (28·3 to 37·1) (0·5 to 0·6) (1·25 to 2·57) (–1·85 to –0·57) (–2·74 to –1·46)
Lesotho 122 323 7·0% 55·8% 15·5% 27·3% 6·96% 5·86% 2·81%
Liberia 81 179 14·7% 9·6% 42·3% 42·2% 14·61% 10·42% 4·22%
Libya 257 467 4·6% 65·8% 29·2% 0·3% –1·18% –2·27% 1·83%
(222 to 294) (404 to 535) (4·0 to 5·3) (58·5 to 72·1) (23·0 to 35·7) (0·2 to 0·3) (–2·01 to –0·35) (–3·10 to –1·45) (0·96 to 2·68)
Lithuania 1121 2044 5·7% 66·1% 32·5% 0·0% 5·50% 6·63% 1·22%
Luxembourg 7027 6677 5·2% 82·4% 11·3% 0·0% 4·75% 3·00% 1·15%
Macedonia 364 949 5·6% 63·5% 34·5% 0·3% 1·14% 0·87% –1·68%
Madagascar 23 81 4·1% 46·6% 27·1% 19·1% 3·45% 0·45% 0·52%
Malawi 39 141 6·6% 23·4% 9·8% 61·0% 8·37% 5·36% 3·88%
Malaysia 407 1151 3·0% 52·2% 36·2% 0·0% 6·96% 4·96% 2·20%
Maldives 974 1539 10·0% 70·5% 20·1% 0·2% 6·60% 4·44% 0·91%
Mali 33 84 3·1% 24·7% 37·1% 36·8% 5·45% 2·34% –0·64%
Malta 2799 4037 8·7% 62·3% 35·5% 0·0% 5·73% 5·12% 2·26%
Marshall Islands 529 518 13·6% 79·3% 14·3% 2·5% 2·29% 0·29% –0·06%
Mauritania 56 191 3·2% 36·9% 50·4% 8·4% 2·92% 0·10% –1·19%
Mauritius 557 1237 4·6% 44·1% 49·3% 0·2% 8·11% 7·48% 3·60%
Mexico 505 1101 4·2% 52·5% 40·0% 0·1% 4·10% 2·64% 1·25%
Moldova 204 498 8·1% 50·2% 45·4% 3·2% 3·19% 3·50% 0·33%
Mongolia 150 506 2·8% 52·2% 35·5% 9·1% 6·11% 4·71% –0·01%
Montenegro 603 1325 6·8% 74·4% 24·6% 0·6% 0·40% 0·35% –3·12%
(554 to 656) (1218 to 1442) (6·2 to 7·4) (70·3 to 78·0) (21·0 to 28·7) (0·6 to 0·7) (–0·16 to 0·99) (–0·21 to 0·94) (–3·66 to –2·55)
Morocco 185 500 4·8% 43·7% 48·6% 3·7% 7·89% 6·81% 3·55%
Mozambique 32 92 4·6% 19·5% 5·5% 73·3% 8·52% 5·40% –0·03%
Myanmar 59 302 3·3% 19·6% 71·0% 9·4% 13·54% 12·46% 3·79%
Namibia 512 1119 7·1% 58·7% 8·0% 6·7% 3·89% 1·89% –0·49%

Articles
2016 2016 (US$) (US$)
Nepal 48 153 5·4% 18·5% 60·1% 8·2% 6·14% 4·42% 1·79%
Netherlands 5329 5603 8·6% 80·7% 11·7% 0·0% 3·11% 2·60% 1·11%
New Zealand 4276 4002 9·2% 78·7% 13·5% 0·0% 3·88% 2·81% 1·10%
Nicaragua 184 502 8·0% 56·2% 32·7% 9·0% 4·76% 3·27% 0·57%
Niger 27 67 5·4% 24·9% 54·7% 15·0% 4·57% 0·75% –0·32%
Nigeria 71 199 2·4% 14·5% 75·2% 8·6% 6·75% 4·01% 0·81%
North Korea 66 44 5·8% 61·9% 36·8% 0·3% 0·92% 0·26% 0·31%
(54 to 80) (35 to 53) (4·7 to 7·1) (51·7 to 72·2) (26·6 to 47·2) (0·3 to 0·4) (–0·45 to 2·37) (–1·10 to 1·70) (–1·06 to 1·75)
Northern Mariana 261 261 1·2% 84·2% 14·6% 0·0% –1·02% –4·24% –3·67%
Islands (208 to 326) (208 to 326) (1·0 to 1·5) (77·6 to 88·8) (10·1 to 21·1) (0·0 to 0·0) (–2·62 to 0·61) (–5·79 to –2·66) (–5·23 to –2·09)
Norway 8269 7708 7·1% 85·2% 14·5% 0·0% 4·03% 3·10% 1·89%
Oman 764 1861 3·4% 89·1% 5·9% 0·0% 4·54% 0·96% 0·69%
Pakistan 41 142 2·7% 26·2% 62·7% 8·3% 3·42% 1·25% –0·57%
Palestine 320 113 10·6% 38·7% 39·1% 1·8% 5·93% 2·44% 1·05%
Panama 1078 1872 8·1% 64·6% 28·6% 0·1% 6·11% 4·23% 0·11%
Papua New Guinea 59 73 1·8% 72·8% 7·4% 18·4% 4·15% 1·70% 0·85%
Paraguay 343 804 6·5% 52·1% 37·0% 0·6% 5·58% 3·91% 2·29%
Peru 337 683 4·5% 62·7% 29·1% 0·3% 5·08% 3·59% 0·40%
Philippines 124 361 3·7% 30·9% 54·4% 1·0% 6·24% 4·28% 1·36%
Poland 908 1857 5·1% 69·9% 23·2% 0·0% 4·98% 4·92% 0·85%
Portugal 1954 2649 7·4% 66·2% 27·8% 0·0% 2·73% 2·53% 1·47%
Puerto Rico 1364 1671 4·5% 64·9% 26·5% 0·0% 1·47% 1·46% 0·24%
Qatar 2064 4145 2·4% 82·8% 7·8% 0·0% 9·14% 1·61% –0·47%
Romania 537 1181 4·3% 78·2% 20·8% 0·1% 4·56% 5·41% 1·88%
Russia 574 1470 3·5% 58·1% 39·2% 0·0% 2·52% 2·54% –0·62%
Rwanda 44 121 5·0% 37·0% 8·1% 43·6% 7·70% 4·46% –0·21%
Saint Lucia 511 800 5·5% 39·1% 47·9% 7·1% 1·61% 0·58% –0·28%
Saint Vincent and 277 453 3·7% 68·3% 18·7% 10·4% 1·52% 1·49% –0·72%
the Grenadines (245 to 310) (400 to 507) (3·3 to 4·2) (62·9 to 73·2) (14·3 to 23·8) (9·3 to 11·7) (0·72 to 2·37) (0·68 to 2·33) (–1·51 to 0·10)
Samoa 232 320 4·9% 76·7% 12·2% 10·1% 3·30% 2·61% 0·42%

Articles
2016 2016 (US$) (US$)
São Tomé and 102 173 6·4% 42·9% 18·2% 37·2% 1·99% –0·18% –1·78%
Príncipe (90 to 114) (154 to 195) (5·7 to 7·2) (37·1 to 48·8) (13·7 to 23·7) (32·9 to 41·8) (1·06 to 2·89) (–1·09 to 0·70) (–2·68 to –0·93)
Saudi Arabia 1257 3200 4·5% 69·5% 14·2% 0·0% 6·77% 4·30% 3·65%
Senegal 69 172 5·1% 30·0% 48·7% 13·4% 4·51% 1·62% 0·13%
Serbia 462 1121 6·1% 58·0% 40·0% 0·5% 4·99% 5·58% 1·95%
Seychelles 534 1002 3·5% 97·8% 2·1% 0·1% 0·65% –0·48% –3·01%
Sierra Leone 82 257 14·9% 9·8% 46·4% 39·0% 5·74% 2·97% 2·33%
Singapore 2580 4240 3·9% 54·1% 31·2% 0·0% 5·37% 4·05% 1·12%
Slovakia 1325 2334 5·7% 79·5% 17·9% 0·0% 4·78% 4·67% 0·79%
Slovenia 2090 2857 7·2% 72·0% 12·2% 0·0% 3·49% 3·30% 0·95%
Solomon Islands 109 114 5·5% 64·7% 4·7% 30·5% 3·36% 0·89% 1·09%
Somalia 15 30 15·6% 20·0% 28·7% 49·8% 3·63% 1·00% 1·41%
South Africa 512 1162 5·6% 53·6% 7·8% 2·3% 3·15% 2·00% 0·53%
South Korea 2150 2833 7·1% 59·1% 33·4% 0·0% 7·67% 7·06% 3·30%
South Sudan 52 248 2·8% 43·8% 36·0% 15·6% 5·26% 1·05% 0·53%
Spain 2687 3419 7·2% 71·2% 23·9% 0·0% 3·39% 2·62% 1·23%
Sri Lanka 159 505 3·5% 43·6% 48·9% 1·4% 3·54% 2·93% –1·61%
Sudan 113 265 5·1% 23·2% 69·2% 3·9% 5·25% 2·70% 0·04%
Suriname 417 939 4·8% 61·1% 22·4% 0·6% 0·96% 0·02% –1·83%
Sweden 6095 5757 8·6% 83·5% 15·3% 0·0% 4·44% 3·87% 1·88%
Switzerland 10 036 7601 9·9% 62·9% 29·5% 0·0% 2·84% 1·98% 0·95%
(9841 to 10 235) (7454 to 7752) (9·7 to 10·1) (62·0 to 63·7) (28·7 to 30·2) (0·0 to 0·0) (2·68 to 3·01) (1·82 to 2·16) (0·78 to 1·12)
Syria 44 773 2·4% 44·7% 50·0% 1·5% –2·10% –3·18% –1·90%
(36 to 53) (631 to 934) (2·0 to 2·9) (35·1 to 53·8) (40·6 to 59·9) (1·3 to 1·9) (–3·30 to –0·81) (–4·37 to –1·91) (–3·11 to –0·62)
Taiwan (province of 1632 3118 6·4% 59·6% 36·9% 0·0% 5·31% 4·76% 1·14%
China) (1538 to 1726) (2938 to 3297) (6·0 to 6·7) (56·7 to 62·4) (34·3 to 39·2) (0·0 to 0·0) (4·93 to 5·70) (4·38 to 5·15) (0·77 to 1·51)
Tajikistan 53 210 4·5% 27·8% 63·1% 8·8% 9·76% 7·65% 3·66%
Tanzania 41 129 4·0% 34·3% 22·8% 41·6% 5·73% 2·81% –0·41%
Thailand 231 654 3·2% 77·3% 12·3% 0·3% 3·80% 3·22% 0·70%
The Bahamas 1938 1976 6·6% 49·9% 27·7% 0·0% 2·64% 0·95% 0·99%
The Gambia 29 104 4·8% 16·2% 18·2% 56·9% 5·24% 2·11% 1·75%

Articles
2016 2016 (US$) (US$)
Timor-Leste 85 209 2·0% 65·2% 10·6% 22·9% 6·79% 5·07% 1·21%
Togo 41 108 5·6% 21·9% 54·8% 14·6% 5·06% 2·31% 2·05%
Tonga 219 322 4·4% 56·2% 10·2% 29·1% 3·48% 3·05% 2·03%
Trinidad and Tobago 1048 2148 5·1% 52·1% 40·7% 0·0% 5·79% 5·47% 1·33%
Tunisia 242 847 4·8% 56·8% 39·1% 0·7% 5·28% 4·27% 1·53%
Turkey 445 1107 2·9% 77·9% 16·8% 0·1% 6·67% 5·17% 1·87%
Turkmenistan 511 1382 5·8% 21·2% 73·6% 0·4% 7·02% 5·63% –1·00%
Uganda 44 153 6·0% 16·0% 38·2% 43·0% 5·66% 2·29% –0·68%
Ukraine 171 567 4·7% 43·3% 52·3% 1·3% 1·28% 1·81% 0·10%
United Arab 1440 2586 2·8% 72·1% 18·1% 0·0% 6·43% –0·29% 1·68%
Emirates (1346 to 1538) (2417 to 2762) (2·6 to 3·0) (68·6 to 75·3) (15·5 to 20·9) (0·0 to 0·0) (5·97 to 6·91) (–0·72 to 0·16) (1·24 to 2·14)
UK 4113 4364 8·3% 80·0% 15·3% 0·0% 4·97% 4·37% 2·82%
Uruguay 1520 2049 8·6% 71·2% 17·2% 0·0% 2·44% 2·10% –0·45%
USA 10 271 10 271 17·1% 81·8% 11·1% 0·0% 4·03% 3·08% 1·61%
(10 054 to 10 498) (10 054 to 10 498) (16·8 to 17·5) (81·2 to 82·5) (10·6 to 11·5) (0·0 to 0·0) (3·84 to 4·23) (2·89 to 3·28) (1·42 to 1·80)
Uzbekistan 76 423 3·2% 47·3% 48·4% 3·9% 5·71% 4·26% –0·53%
Vanuatu 96 84 2·7% 60·3% 10·4% 25·0% 3·06% 0·80% 0·41%
Venezuela 384 636 4·1% 33·2% 33·8% 0·0% –0·28% –1·96% –1·14%
Vietnam 119 347 5·5% 49·6% 46·7% 2·7% 7·97% 6·71% 1·27%
Virgin Islands 2196 1180 6·3% 63·4% 26·1% 0·0% 4·27% 4·31% 2·92%
Yemen 59 126 9·2% 14·1% 79·8% 5·2% 1·96% –1·08% 2·42%
Zambia 64 187 3·2% 38·1% 12·3% 44·0% 3·85% 0·98% –1·81%
Zimbabwe 106 198 9·7% 45·0% 26·5% 18·9% 1·89% 0·36% 0·95%
Estimates in parentheses are 95% uncertainty intervals. PPP=2018 purchasing-power parity-adjusted dollars. GDP=Gross domestic product. GBD=Global Burden of Disease.
Table 1: Health spending by source, 2016
Results played in providing resources for health, especially to

Overview low-income countries from 1990 to 2018. Third, we
This analysis focuses on the past, present, and future of focus on health spending in 2016, and assess varia
global health financing. First, we present levels of health tions in the composition of financing sources across
spending and trends in health spending for the countries. Fourth, we present future scenarios of
historical period from 1995 to 2016, and the analysis of health spending, assessing levels and growth rates of
factors contributing to increases in government health health spending from 2017 to 2050, with an additional
spending. Second, we highlight the role that DAH has emphasis on 2030, given its significance as the target

Articles
Total health spending per capita Government spending per capita Prepaid private spending per capita Out-of-pocket spending per capita
Development assistance spending per capita
A Global and World bank income groups B GBD super-regions
Central Europe, eastern

Global Europe, and central Asia
High income
High income
Latin America
and Carribbean
North Africa
Upper-middle income
and Middle East
South Asia
Lower-middle income
Southeast Asia, east

Asia and Oceania
Low income
Sub-Saharan Africa
–5 0 5 10 –5 0 5 10
Annualised rate of change, 1995–2016 (%) Annualised rate of change, 1995–2016 (%)
Figure 3: Annualised rate of change in health spending per capita by source, by World Bank income group (A) and GBD super-region (B), 1995–2016
Error bars represent 95% uncertainty intervals. This figure was remade but with health spending measured as a percentage of gross domestic product, and is included in the appendix. GBD=Global
Burden of Disease.
year for achieving the Sustainable Development Goals. Between 1995 and 2016, there was substantive growth in
Finally, we highlight observed and expected trends health spending in many countries, with a global growth
during the entire study period. All estimates made in rate of 4·00% (95% UI 3·89–4·12) annually, although
this Article are available to view in an associated this rate was lower for health spending per capita
For more on the visualisation visualisation, available on Viz Hub. (2·72% [2·61–2·84]; figure 1B, figure 2, table 1). Countries
see https://vizhub.healthdata. with the largest absolute increases in annual per capita
org/fgh/
Past and present health spending during this period were the USA
In 1995, health spending globally was $3·5 trillion ($4843 [4580–5125] increase), Norway ($3913 [3501–4327]
(95% uncertainty interval [UI] 3·4–3·5), $4·3 trillion increase), and Bermuda ($3485 [535–5916] increase),
(4·2–4·4) in purchasing-power parity-adjusted dollars, while spending increased by less than $1 per capita in
and comprised 6·9% (6·8–7·0) of global GDP. That 22 countries. The most populous of these 22 countries
year, 87·6% (87·1–88·1) was spent in countries that are Venezuela, Yemen, and Angola. Figure 3 shows that
are currently high-income, 9·8% (9·4–10·3) in upper- the highest annual growth rates in per capita health
middle-income countries, 2·2% (2·1–2·4) in lower- spending were observed in upper-middle-income (5·55%
middle-income countries, and only 0·3% (0·3–0·4) in [5·18–5·95]) and lower-middle-income countries (3·71%
low-income countries. Health spending per capita [3·10–4·34]). In upper-middle-income countries, the
globally was $612 (603–622), ranging from $5 (4–7) in largest source of this increase was increased govern
Myanmar to $7318 (5490–10 192) in Bermuda (figure 1A). ment health spending (6·85% [6·37–7·34]) and in lower-
In 1995, countries currently classified as high income middle-income countries the fastest growth was in DAH
spent $2871 (2823–2921) per capita on health, whereas (4·34%). These groups of countries also saw rapid annual
those classified as upper-middle income spent $158 growth in out-of-pocket spending: 3·54% (2·57–4·54) in
(150–166) per capita, those classified as lower-middle lower-middle-income countries and 4·60% (4·01–5·22)
income spent $38 (35–41) per capita, and those classified in upper-middle-income countries. Although DAH per
as low income spent $30 (28–31) per capita. Health capita increased rapidly, at 6·74% annually in low-income
spending per capita was the lowest in South Asia, at countries, overall growth in health spending per capita
$26 (21–31) per capita, and in sub-Saharan Africa, at remained low at 1·46% (1·13–1·80) per year in these
$58 (54–62) per capita, and highest in GBD high-income countries. Geographically, southeast Asia, east Asia, and
countries, at $3206 (3151–3264) per capita. Oceania had the highest growth in health spending per

Articles
capita (8·52% [7·69 to 9·33]) annually between 1995 and

A Global
2016, driven mainly by large growth in government health
spending (10·76% [9·94 to 11·57]) and out-of-pocket Global
spending (7·34% [6·15 to 8·59]), whereas sub-Saharan 0 50 100 150 200 250 300 350 400 450 500 550
Africa had the lowest growth in health spending per capita
(1·54% [1·08 to 1·97]), with only modest increases in B GBD and World Bank high-income countries
government health spending (2·00% [1·45 to 2·53]) and GBD high income
out-of-pocket spending (0·65% [–0·12 to 1·44]). The World Bank high income
negative growth (–3·49% [–3·75 to –3·22]) in prepaid
0 500 1000 1500 2000 2500
private spending per capita in high-income countries
(figure 3) is attributable to the enactment in 2014 of the C Low and middle-income countries
insurance mandate in the US Affordable Care Act, which (World Bank income groups and GBD super-regions)
reclassified a large proportion of health spending that was Upper-middle income
originally prepaid private spending as government health
spending because this spending became compulsory.13 Lower-middle income
Governments play an important role in the changing Low income
landscape of health financing and are globally the largest Central Europe, eastern Europe,
source of funds for health. Figure 4 highlights the amount and central Asia
of change in government health spending per capita Latin America and Caribbean
between 1995 and 2016 that is associated with each of North Africa and Middle East
three key factors. Globally, the primary factor driving
South Asia
increases in government health spending was greater
Southeast Asia, east Asia,
prioritisation of the health sector, which was associated and Oceania
with an increase of $299 (95% UI 287–311) in annual
Sub-Saharan Africa
government spending on health per capita between
–20 0 20 40 60 80 100 120 140 160 180 200 220
1995 and 2016. The other key factor driving growth in
Change in government health spending per capita, 1995-2016 (US$)
government health spending per capita globally was
Contributing factors GDP per capita Government spending Government prioritisation of health
economic development, associated with a $185 (165–207)
increase per capita. Across regions and income groups, Figure 4: Factors of change in government health spending per capita, 1995–2016
government prioritisation of health was the leading factor Change in government health spending per capita by global (A), high-income (B), and low-income and
middle-income countries (C), reported in inflation-adjusted 2018 US dollars. Error bars represent uncertainty
of change in high-income countries and in North Africa intervals. Black dots represent the estimated change in government spending per capita. GBD=Global Burden of
and the Middle East, whereas economic development was Diseases, Injuries, and Risk Factors. GDP=gross domestic product.
the key factor in upper-middle-income, lower-middle-
income, and low-income countries; in central Europe, Health spending per capita increased to $1077 (1058–1096),
eastern Europe, and central Asia; in south Asia; in despite significant variation across regions and income
southeast Asia, east Asia, and Oceania; and in sub-Saharan groups (figure 1B, table 1). Per capita health spending in
Africa. Increases in total government spending also led to high-income countries was $5252 (5184–5319), ranging
substantial increases in government health spending in from $261 (208–326) in the Northern Mariana Islands to
upper-middle-income countries, particularly in southeast $10 802 (9469–12 352) in Bermuda; and $40 (38–43) in
Asia, east Asia, and Oceania and in Latin America and the low-income countries, ranging from $15 (13–17) in
Caribbean. The smallest increase in government health Somalia to $106 (91–124) in Zimbabwe. Disparities
spending per capita was in low-income countries, persist across geographical regions, with per capita
especially in south Asia and sub-Saharan Africa; in these spending ranging from $37 (29–48) in Bangladesh to
regions, economic development was the leading factor $84 (69–100) in Bhutan in south Asia, where health
contributing to this growth. spending is the lowest of all regions (table 1).
Globally, health spending reached $8·0 trillion Figure 2 and figure 5A collectively highlight the
(95% UI 7·8–8·1) in 2016, $10·3 trillion (10·1–10·6) in hypotheses made in the health financing transition.31
purchasing-power parity-adjusted dollars, and comprised Figure 2 shows that the exponential relationship between
8·6% (8·4–8·7) of global GDP in 2016. 81·0% (80·0–81·9) GDP and health spending has persisted from 1995 to 2016.
was spent in high-income countries, 15·7% (14·9–16·6) Figure 5A explores how the sources of health spending
in upper-middle-income countries, 3·0% (2·7–3·3) in tend to evolve with economic development (similar figures
lower-middle-income countries, and 0·4% (0·3–0·4) in showing this relationship in past and future years are
low-income countries, despite low-income countries com provided in the appendix). Countries at a lower income
prising 10·0% of the global population. 41·7% (40·9–42·5) level tend to have a higher proportion of out-of-pocket
of total health spending worldwide was in the USA alone, spending and DAH to finance the health sector; as
while the countries of sub-Saharan Africa collectively countries get wealthier, less of their health spending is
comprised 1·0% (0·9–1·0) of total health spending. financed by DAH. As the proportion of health spending

Articles
pocket spending (56·1% [95% UI 47·3–65·4]), even higher

A Composition of health spending by source
Government spending Prepaid private spending
than that of low-income countries (42·4% [38·3–47·0]),
Out-of-pocket spending Development assistance for health because low-income countries also had a large share of
100 spending from DAH (25·4% [23·9–26·8]; table 1). Despite
this global pattern, figure 5B and table 1 highlight the wide
Modelled proportion of total health spending (%)
80
variation in the proportion of health spending that came
from the government: 79·6% (78·2–81·1) of all spending
in high-income countries in 2016 came from government
60 health spending, as did 53·9% (49·9–58·6) in upper-
middle-income countries, 32·1% (28·4–36·1) in lower-
40
middle-income countries, and 26·3% (23·3–29·5) in
low-income countries. Wide variation exists even for
countries at similar levels of GDP per capita. In 2016,
20 among low-income countries the proportion of health
spending from the government ranged from 5·7% (3·9–
7·9) in Afghanistan to 61·9% (51·7–72·2) in North Korea;
0
0 100 1000 10 000 50 000 100 000 among lower-middle-income countries it ranged from
Gross domestic product per capita (US$) 14·5% (10·6–19·2) in Nigeria to 84·1% (79·9–87·5) in the
Federated States of Micronesia; among upper-middle-
B Government health spending, total health spending, and economic development
income countries it ranged from 15·8% (12·5–19·7) in
Income groups Greenland
Seychelles
Armenia to 90·1% (86·5–93·0) in American Samoa; and
100 High income
Upper-middle income among high-income countries it ranged from 29·1%
Lower-middle income American Samoa (25·1–33·0) in Bermuda to 100·0% (100·0–100·0) in
Low income
Federated States of Micronesia Norway Greenland (table 1).
Health spending per capita Cuba
Proportion of health spending from the government (%)
USA
$ 100 Marshall Islands Luxembourg
Samoa Development assistance for health
$ 1000
75 Bhutan Although government health spending did not grow
$ 10 000 substantially in countries that are currently classified
Solomon Islands
North Korea Switzerland as low-income, DAH had the fastest growth in health
spending per capita in these countries (figure 3).
Singapore
Figure 6 (A–C) shows that in 1990, total DAH disbursed to
The Bahamas
50 Madagascar Barbados Andorra low-income and middle-income countries was $7·7 billion.
Syria
Cyprus Between 1990 and 2000, DAH increased at 5·69% annu
Zimbabwe
ally, whereas between 2000 and 2010 it increased at
10·03% annually. More recently, DAH disbursement has
Bermuda levelled, with annual growth from 2010 through 2018
Burundi Iraq
25 Sudan estimated to be 1·33%.
Bangladesh Azerbaijan
Somalia Myanmar In 2018, total DAH reached $38·9 billion, with the USA
Armenia Equatorial Guinea
Cameroon as the largest single source of contributions in terms of
GuineaComoros
Liberia Nigeria volume, providing $13·2 billion (33·8% of total DAH);
Afghanistan the UK as the second largest single contributing source,
0
providing $3·3 billion (8·4%); and the Bill & Melinda
100 1000 10 000 50 000 100 000 Gates Foundation as the third largest single contributing
Gross domestic product per capita (US$) source, providing $3·2 billion (8·3%; figure 6A). Despite
Figure 5: Economic development and the composition of health spending by source and proportion of health
having a lower income per capita than all other national
spending from the government in 2016 contributors, China provided $644·7 million of DAH in
Composition by source (A) and proportion of health spending from the government (B). Each dot represents a 2018. Figure 6B shows the annual total DAH by disbursing
country colour-coded by World Bank income group. Gross domestic product per capita reported in agency. The largest multilateral and public–private partner
inflation-adjusted 2018 US dollars. The x-axes are presented in natural logarithmic scale.
ships that disbursed DAH in 2018 included the Global
that is DAH subsides, countries tend to fill the gap by Fund ($3·2 billion; 8·2% of the total disbursed), WHO
further increasing out-of-pocket and government health ($2·6 billion, 6·6%), and UNICEF ($1·9 billion, 4·9%).
spending, with an increasing proportion from government The Coalition for Epidemic Preparedness Innovation
health spending as economic development increases. This disbursed $71·0 million.
trend is seen by comparing the proportion of total spending Figure 6C highlights the annual total DAH targeted to
from out-of-pocket spending in low-income and lower- different health focus areas over time. Although all
middle-income countries: in 2016, lower-middle-income health focus areas tracked in this study have more DAH
countries had the highest share of spending from out-of- targeting them now than in 1990, this growth has

Articles
A Development assistance for health by source of funding, 1990–2018 B Development assistance for health by channel of assistance, 1990–2018
Unallocable Canada Regional development banks UNICEF, UNFPA, UNAIDS, Unitaid, PAHO
Other Japan World Bank Other bilateral development agencies
40 Debt repayments (IBRD) Netherlands US foundations China bilateral
38 Other private philanthropy Norway International NGOs Australia bilateral
36 Corporate donations Spain US NGOs Canada bilateral
34 Gates foundation France Gates Foundation France bilateral
32 Other governments Germany CEPI Germany bilateral
30 China UK Global Fund UK bilateral
28 Australia USA Gavi USA bilateral
Billions of 2018 US$
26 WHO
24
22
20
18
16
14
12
10
8
6
4
2
0 *
*
19 6
19 8
20 9
19 6
19 8
20 9
19 4
20 6
20 8
20 9
19 4
20 6
20 8
20 9
20 4
20 4
19 0
19 0
20 0
20 0
19 2
19 3
19 5
19 2
20 6
19 3
19 5
20 2
20 2
20 6
20 3
20 5
20 3
20 5
19 7
20 4
19 7
20 4
19 1
20 7
20 0
19 1
20 7
20 0
20 1
20 1
20 2
20 3
20 5
20 2
20 3
20 5
20 17
20 17
20 1
20 1
18
18
9
9
0
0
9
9
9
9
9
0
0
0
0
0
9
1
9
0
9
9
9
9
0
0
0
0
1
1
0
0
1
1
1
1
1
1
1
1
1
19
19
Year
C Development assistance for health by health focus area, 1990–2018 D Annualised rate of change of development assistance for health disbursed
by health focus area
40 Unallocable
38 Other health focus areas HIV/AIDS
36 Sector-wide approaches and health sector support
34 Other infectious diseases Tuberculosis
32 Non-communicable diseases
30 Reproductive and maternal health Malaria
28
Billions of 2018 US$
Newborn and child health

Health focus area
26 Malaria Newborn
24 Tuberculosis and child health
22 HIV/AIDS Reproductive
20 and maternal health
18
16 Non-communicable
14 diseases
12 Other infectious diseases
10
8 Sector-wide approaches
6 and health sector support 1990–2000
4 2000–10
2 Other health focus areas 2010–18
0
0 10 20 30
*
19 6
19 8
20 9
19 4
20 6
20 8
20 9
20 4
19 0
20 0
19 2
19 3
19 5
20 2
20 6
20 3
20 5
19 7
20 4
19 1
20 7
20 0
20 1
20 2
20 3
20 5
20 17
20 1
18
9
0
9
9
0
0
0
9
1
9
0
9
9
0
0
1
1
1
1
1
19
Year Annualised rate of change (%)
Figure 6: Changes in development assistance for health disbursements, 1990–2018

Development assistance for health by source of funding (A), channel of assistance (B), health focus area (C), and annualised rate of change by health focus area (D). Reported in billions of
inflation-adjusted 2018 US dollars. World Bank includes the International Development Association and the International Bank for Reconstruction and Development (IBRD); and regional
development banks include the Inter-American Development Bank, the African Development Bank, and the Asian Development Bank. CEPI=Coalition for Epidemic Preparedness Innovations.
Gates Foundation=Bill & Melinda Gates Foundation. Gavi=Gavi, the Vaccine Alliance. NGOs=non-governmental organisations. PAHO=Pan American Health Organization. *Data for 2018 are
preliminary estimates based on budget data and estimation.
been especially acute for funding allocated to HIV/AIDS, ($5·6 billion [14·3%]), and reproductive and maternal
malaria, and tuberculosis, all of which increased at more health received the fourth most DAH in 2018 ($4·7 billion
than 20% per year between 2000 and 2010 (figure 6D). [12·1%]). In 2018, we estimated that $48·3 million of
More recently, DAH targeting newborn and child DAH targeted antimicrobial resistance.
health and infectious diseases other than HIV/AIDS,
malaria, and tuberculosis grew most quickly, growing at Future
6·19% and 6·27% annually between 2010 and 2018. Sustained growth in health spending is expected to
During this same period, DAH for HIV/AIDS reduced, continue, with global spending projected to reach
with an annualised decline of 2·05% per year between $10·6 tril lion (95% UI 10·2–10·9) in 2030 and
2010 and 2018, or a reduction of $1·7 billion since the $15·0 trillion (14·0–16·0) in 2050 (table 2, figure 1C, 1D).
2012 peak. Still, in 2018, HIV/AIDS received more DAH In purchasing-power parity-adjusted dollars, these values
than any other health focus area ($9·5 billion [24·3% of are $14·3 trillion (13·7–15·0) in 2030 and $21·3 trillion
the total]). Newborn and child health received the second (19·8–23·1) in 2050. These values are projected to
most DAH ($7·8 billion [20·1%]), sector-wide approaches comprise 8·9% (8·4–9·4) of global GDP in 2030 and
and health sector support received the third most DAH 9·4% (7·6–11·3) of global GDP in 2050. Despite this

2252
Articles
Health Health Health Government Out-of-pocket Development Annualised Annualised Annualised Government Difference Difference
spending per spending per spending per health spending per assistance for rate of rate of rate of change health between between
capita, 2050 capita, 2050 GDP, 2050 spending per total health health per change in change in in health spending per government government
estimates estimates estimates total health spending, total health health health spending per capita ($US) health health
(US$) ($PPP) spending, 2050 spending, spending, spending per GDP 2017–50 spending per spending per
2050 estimates 2050 2017–50 capita, (US$) capita capita
estimates estimates (US$) 2017–50 reference reference
(US$) scenario and scenario and
better better
scenario 1, scenario 2,
2050 (US$) 2050 (US$)
Global
Total 1667 2373 9·4% 72·9% 19·0% 0·3% 1·84% 1·28% 0·25% 1216 229 617
(1567 to 1767) (2222 to 2537) (7·6 to 11·3) (68·4 to 77·5) (17·4 to 20·8) (0·2 to 0·5) (1·68 to 2·02) (1·12 to 1·44) (–0·05 to 0·57) (1071 to 1373) (212 to 267) (605 to 660)
World Bank income group
High income 8286 8812 13·1% 79·8% 12·7% 0·0% 1·38% 1·32% 0·54% 6605 238 1528
(7851 to 8725) (8363 to 9266) (10·2 to 16·3) (74·7 to 85·3) (11·9 to 13·9) (0·0 to 0·0) (1·22 to 1·53) (1·17 to 1·48) (0·38 to 0·69) (5966 to 7270) (211 to 301) (1474 to 1676)
Upper-middle 1435 2858 6·6% 62·4% 29·6% 0·1% 3·25% 3·20% 0·79% 894 410 844
income (1264 to 1632) (2530 to 3233) (4·7 to 9·0) (53·3 to 71·9) (24·0 to 36·5) (0·1 to 0·2) (2·89 to 3·64) (2·84 to 3·58) (0·44 to 1·16) (733 to 1081) (367 to 500) (811 to 910)
Lower-middle 200 675 3·7% 36·4% 51·2% 2·7% 3·34% 2·64% 0·38% 73 172 354
income (176 to 225) (594 to 768) (2·7 to 4·8) (31·6 to 41·4) (41·9 to 62·5) (1·8 to 4·6) (2·97 to 3·73) (2·28 to 3·02) (0·03 to 0·74) (54 to 95) (168 to 180) (349 to 384)
Low income 66 207 5·2% 31·6% 39·2% 21·4% 3·45% 1·41% –0·02% 21 35 79
GBD super-region
Central Europe, 972 2343 5·6% 60·1% 35·8% 0·3% 1·44% 1·76% 0·73% 583 506 791
eastern Europe, and (888 to 1063) (2135 to 2578) (4·2 to 7·3) (55·3 to 65·5) (32·3 to 39·7) (0·2 to 0·6) (1·25 to 1·63) (1·57 to 1·95) (0·59 to 0·87) (495 to 680) (487 to 544) (771 to 863)
central Asia
High income 9224 9547 13·7% 80·0% 12·6% 0·0% 1·38% 1·31% 0·52% 7373 175 1558
(8738 to 9722) (9052 to 10 062) (10·6 to 17·0) (74·8 to 85·7) (11·7 to 13·8) (0·0 to 0·0) (1·22 to 1·54) (1·15 to 1·47) (0·37 to 0·68) (6671 to 8094) (149 to 235) (1492 to 1719)
Latin America and 953 1784 7·3% 48·4% 33·3% 0·3% 1·48% 0·98% 0·39% 462 385 604
Caribbean (889 to 1019) (1668 to 1906) (6·3 to 8·3) (45·0 to 52·6) (29·8 to 37·0) (0·2 to 0·5) (1·29 to 1·68) (0·79 to 1·15) (0·20 to 0·58) (386 to 554) (372 to 410) (592 to 651)
North Africa and 473 1415 4·3% 60·7% 30·1% 0·8% 2·17% 1·11% 0·53% 287 296 567
Middle East (438 to 513) (1312 to 1536) (3·8 to 4·9) (53·1 to 69·9) (27·6 to 33·1) (0·6 to 1·4) (2·00 to 2·40) (0·97 to 1·28) (0·39 to 0·66) (232 to 366) (283 to 320) (557 to 594)
South Asia 180 670 3·5% 32·6% 56·9% 1·2% 3·61% 3·27% 0·37% 58 213 357
Southeast Asia, east 1397 2758 6·6% 64·9% 29·1% 0·1% 4·08% 4·10% 0·92% 905 305 799
Asia, and Oceania (1195 to 1621) (2381 to 3185) (4·5 to 9·5) (53·7 to 76·5) (22·3 to 37·8) (0·1 to 0·2) (3·59 to 4·59) (3·60 to 4·60) (0·44 to 1·43) (737 to 1097) (251 to 407) (762 to 873)
Sub-Saharan Africa 111 283 4·4% 39·0% 32·5% 13·4% 3·07% 0·97% 0·15% 43 61 156
Estimates in parentheses are 95% uncertainty intervals. 2050 scenario 1 reflects the increase in government health spending if all countries met the target proportion of government spending on health. 2050 scenario 2 reflects the increase in
government health spending if all countries met the target proportion of government spending on health and target proportion of GDP that is based on government spending. PPP=2018 purchasing-power parity-adjusted dollars. GDP=gross domestic
product. GBD=Global Burden of Disease.
Table 2: Health spending by source and alternative future scenarios of government health spending, 2050
www.thelancet.com Vol 393 June 1, 2019

Articles
growth, health spending is expected to remain skewed, of health and increased total government spending could
with 69·4% (67·2–71·5) of this spending in countries lead to an additional $617 (605–660) per person. In both
that are currently considered high-income, scenarios, the potential increase in government health
25·1% (23·1–27·1) in upper-middle-income countries, spending per capita is more than double the projection
4·9% (4·4–5·5) in lower-middle-income countries, and in the reference scenario in some countries. Furthermore,
only 0·6% (0·6–0·7) in low-income countries, despite these potential gains are proportionally greater in low-
low-income countries comprising an estimated 15·7% income and lower-middle-income countries and south
of the global population by 2050. In per-capita terms, Asia and sub-Saharan Africa, relative to the low levels of
projected total health spending globally is $1264 government health spending in the reference scenario
(1219–1309) per capita in 2030 and $1667 (1567–1767) per (table 2).
capita in 2050 (table 2). Per capita spending in 2030 is
projected to be $6313 (6135–6499) for high-income Past to the present to the future
groups, $772 (707–847) for upper-middle-income groups, Examining the full set of results spanning 1995 to 2050,
$121 (108–137) for lower-middle-income groups, and $48 we observe three persistent trends. The first trend is an
(44–51) for low-income groups. In 2050, this spending is ongoing increase in health spending over time, as shown
projected to increase to $8286 (7851–8725) for high- by the upward push in the curves in figure 2. Countries
income groups, $1435 (1264–1632) for upper-middle- at the same level of income as other countries in the past
income groups, $200 (176–225) for lower-middle-income tend to spend more on health than those other countries
groups, and $66 (60–73) for low-income groups (table 2). did, especially countries with higher levels of economic
The fastest growth in per capita health spending is development. The second trend, seen across most
predicted among lower-middle-income countries, with regions and income groups, is of positive, albeit slowing,
2·64% (2·28–3·02) annual growth per capita projected growth rates in health spending, as well as declining
between 2017 and 2050, and upper-middle-income population growth rates. Because population growth was
countries, with 3·20% (2·84–3·58) annual growth per generally dropping at the same rate as health spending,
capita projected between 2017 and 2050 (table 2). Health or at a faster rate, health spending per capita growth
spending per capita in 2050 is expected to remain the appears to be flattening or increasing. Sub-Saharan
lowest in sub-Saharan Africa ($111 [102–121]) and South Africa stands out in particular, as population growth is
Asia ($180 [146–220]). noticeably higher than elsewhere in the early 2000s, but
The two regions with the lowest projected growth rate is decreasing over time, leading to a slow increase in
in total health spending between 2017 and 2050 are the health spending per capita growth rate. The third trend is
GBD high-income region, with a growth rate of 1·38% increasing disparities in total and government health
(95% UI 1·22–1·54), and central Europe, eastern Europe, spending, even among countries in the same income
and central Asia, with a growth rate of 1·44% (1·25–1·63; group. As shown in figure 2, despite the fact that the
table 2). Despite this similarity, the growth rates in health majority of countries are moving upwards over time to
spending per capita are actually quite distinct (1·31% higher total health spending per capita, the gap between
[1·15–1·47] for the GBD high-income region and 1·76% the smallest and the largest health spenders per capita
[1·57–1·95] for central Europe, eastern Europe, and central has grown from $7313 (95% UI 6453–10 185) per capita in
Asia), because of differences in population growth. 1995, to $10 787 (9456–12 335) per capita in 2016, to a
Population projections have a large impact on health projected value of $15 806 (14 654–16 913) in 2050.
spending per capita growth rates (table 2); unlike central Between income groups, in 1995, per capita health
Europe, eastern Europe, and central Asia, where population spending in high-income countries was 96·4 times
growth is lower than zero, meaning the population growth (91·3–101·6) greater than the spending in low-income
is well below replacement, population growth is expected countries; this ratio increased to 130·2 (122·9–136·9) in
to remain high in North Africa and the Middle East, and 2016 and is projected to stay at similar levels in the future,
especially in sub-Saharan Africa. In this region, annualised at 133·0 (123·7–142·4) in 2030 and 125·9 (113·7–138·1)
health spending growth between 2017 and 2050 is expected in 2050. Figure 7 shows the changes in the distribution of
to be 3·07% (2·82–3·32), although health spending per government health spending per capita by income group
capita growth is expected to be 0·97% (0·73–1·19; table 2). over time. Although there is clear overall shifting of
Our future scenarios of government health spending distributions towards the upper end during the study
(figure 7) estimate the potential additional funding period, accompanying this trend are the countries that
governments might be able to mobilise if the health are left behind from this positive shift and the large
sector is further prioritised or if governments increase discrepancy in values between high-income and low-
spending overall, or if both are achieved. In scenario 1, in income countries, which are shown on different scales.
2050, increased prioritisation of health by governments Especially in low-income and middle-income groups, the
could lead to an additional $229 (95% UI 212–267) in gap between countries with the highest and lowest
health spending per capita, compared to the reference government health spending per capita is projected to
scenario. In scenario 2, in 2050, increased prioritisation widen between now and the future.

Articles
A Global
50
40
Number of countries
30
20 1995
2016
2030 Reference
10 2050 Reference
2050 Scenario 1
0 2050 Scenario 2
0 1 10 100 500 1000 5000 10 000
Government health spending per capita (US$)
B High income C Upper-middle income

50
Number of countries
40
30
20
10
D Lower-middle income E Low income

50
Nmuber of countries
40
30
20
10
0
1
10
10
0
0
00
00
0
00
00
0
10
10
50
00
50
00
10
50
10
50
10
10
Government health spending per capita (US$) Government health spending per capita (US$)
Figure 7: Distribution of government health spending per capita, globally and by income group, for 1995, 2016, 2030, 2050, and two future scenarios
Reported in inflation-adjusted 2018 US dollars. 2050 scenario 1 reflects the increase in government health spending if all countries met the target proportion of
government spending on health. 2050 scenario 2 reflects the increase in government health spending if all countries met the target proportion of government
spending on health and target proportion of gross domestic product that is based on government spending. The x-axes are presented in a natural logarithmic scale.
This figure was remade with health spending measured as a percentage of gross domestic product, and is included in the appendix.
Discussion (0·2% [0·2–0·2]), and decreased proportions from out-

Overview of-pocket spending (18·6% [18·0–19·4]). However, DAH
Globally, health spending has risen steadily since 1995, has plateaued since 2010, leading to a renewed emphasis
reaching $8·0 trillion (95% UI 7·8–8·1) in 2016 and on domestic resource mobilisation in recent years. By
projected to further increase to a total of $15·0 trillion 2050, we project a problematic shift in this trend,
(14·0–16·0) by 2050, but at a slower rate of growth in with government health spending declining to 72·9%
the majority of countries. Health spending currently (68·4–77·5), and slight increases in out-of-pocket
constitutes 8·6% (8·4–8·7) of the global economy, with spending (19·0% [17·4 to 20·8]).
the largest proportions of this spending financed by Sustaining growth in government health spending is
governments and spent in high-income countries. important because this spending can provide funding
Sub-Saharan Africa and low-income countries currently for essential health services.32 Furthermore, increased
have the lowest levels of spending, with 1·0% (0·9–1·0) government health spending can indirectly affect health
of the global total in sub-Saharan Africa and 0·4% outcomes by increasing household financial resources for
(0·3–0·4) of the global total in low-income countries. other health determinants, such as food and education, as
The composition of health spending by financing source a result of reduced spending on health care.33 Given that
has changed and will continue to evolve in the future. In government spending is a source of pooled spending, it
2016, increased proportions of global health spending could also help spread the risk of financial burden caused
came from government (74·0% [72·5–75·5]) and DAH by health care across the population. This pooling is

Articles
particularly important given the finding that out-of-pocket of severe global disparities in health spending requires
spending is projected to increase in many low-income and the global community to consider and develop domestic
middle-income countries. Financial protection is a core and international policies that address the causes and
tenet of universal health coverage and these projections effects of these inequities. High-income countries spent
suggest that many countries are not on track to adequately 130·2 times (95% UI 122·9–136·9) more on health per
cover their populations. capita than low-income countries in 2016, and this trend
Our future government health spending scenarios is expected to continue into the future. The strong
suggest that, with greater prioritisation of the health relationship between GDP and health spending suggests
sector or increased total government spending, a drastic that supporting economic development in the poorest
increase in government health spending per capita could countries is an important approach for improving equity
be achieved, especially in countries currently with low in health financing across countries. There are many
levels of government health spending. The two scenarios examples of countries that have substantially increased
assessed how much fiscal space there is and opportunities health spending as their economies have grown. Still,
for expansion, although without considering other there are other important cases where countries have
demands (eg, debt) on government spending. This is increased health spending much faster than their
consistent with findings from recent work by WHO, economic growth. These countries, such as China,
which concluded that low-income countries have been South Korea, and Cuba, highlight what is possible with
lagging in the growth of government health spending.34 political will and investments in health.
The low ratio of tax revenue to GDP in many low-income Although the beginning of the 21st century coincided
countries exemplifies this challenge.35 Furthermore, with a period of substantial increase in resources dedicated
work by the Organisation for Economic Co-operation towards global health goals, growth in overall DAH has
and Development (OECD) points to the difficulty of plateaued more recently. For some health focus areas,
sustaining current patterns of health financing from such as HIV/AIDS and health-systems strengthening,
public sources in the future. which have the potential to promote sustainable health
Patterns of past and projected health spending are systems in recipient countries, funding has reduced. Also
useful for characterising countries’ progress along the of note is the relatively small share of DAH currently
health financing transition.31 This can be described as a targeted at non-communicable diseases, despite these
rise in per capita health spending with a declining diseases accounting for the majority of the global disease
proportion from out-of-pocket and donor assistance. This burden.37 Even so, contributions from emerging donors
is exemplified by the proportion of health spending that such as China have the potential to provide new financing
was out of pocket in 2016, which peaked among lower- streams. Increasingly, China has become an important
middle-income countries (56·1% [47·3–65·4]). The term stakeholder in global health, including contributing
“missing middle” has been used to characterise the substantially to the Ebola containment efforts in 2014 and
problematic situation for countries at a middle level of to the establishment of the Africa Center for Diseases and
income—as they begin to receive less DAH but do not yet Control thereafter.38,39 Globally, other innovative financing
fill the gap in financing with government spending, and mechanisms for pooling additional resources to leverage
instead rely more on additional out-of-pocket spending.36 development assistance efforts have been established. For
In figure 5A, which shows this relationship cross- example, the Global Financing Facility was established in
sectionally in 2016, the “missing middle” phenomenon 2015 as a catalyst to align financing from international
appears to peak for lower-middle-income countries. Key partners, the private sector, and country governments
strategies to help prevent countries from falling into this around country-owned investment cases related to
circumstance include sustaining DAH as countries reach reproductive, maternal, and child health.
middle-income status or development of robust domestic As health spending growth rates decline or sources of
health financing systems early in a country’s economic funding plateau, it is especially important to understand
development. the factors that improve the efficiency of health spending.
These results have important implications for policy, It is important to note that increases in health spending do
both at national and international levels. For countries not necessarily translate into improvements in access to
and regions projected to have the slowest increases in care, quality of care, or health outcomes. Additional
government and prepaid private spending, domestic research is needed to identify policies, such as strength
health financing reforms that increase levels of prepaid ening supply chains, and attributes of health systems and
resources should be a priority as these populations risk governments, such as reduced corruption, that lead to
falling further behind in the global push toward universal more efficient spending and improvements in intermediate
health coverage and in reducing child and adult mortality. outputs and outcomes of health systems. Understanding
Likewise, donors should consider these financing and implementing effective political and policy changes
trajectories when making allocation decisions, possibly that support more efficient use of financial resources for
prioritising countries expected to have the slowest growth health will help countries to better utilise limited resources
in domestic pooled spending. The projected persistence to work toward universal health coverage and improved

Articles
population health. Furthermore, whether increasing country-specific policies. Finally, our prediction models
health spending should be viewed positively or negatively do not capture the dynamic nature of health spending, in
(and therefore promoted or curbed) should be determined that health spending leads to better health, which can also
according to the broader context. While additional health lead to economic growth.
spending in countries with very low health spending is The data going into our modelling were all prepared in
essential to meeting important global health goals, some US dollars. US dollars were seen to be more stable across
high-income countries are concerned about the continuous countries and observed years than purchasing-power
growth in health spending and are searching for policies to parity-adjusted dollars, and more comparable to existing
curb these trends. studies. Each currency has strengths, but neither
US dollars nor purchasing-power parity-adjusted dollars
Limitations are a perfect measure. US dollars value spending most
This study has some limitations. First, although we used accurately for tradable goods, but purchasing-power
estimation methods that account for challenges related to parity-adjusted estimates provide a better reflection of
the reliability and completeness of publicly available domestic spending on non-tradeable goods and are better
historical global health spending data, we acknowledge for cross-country comparisons. Although neither of the
that the input data had some weaknesses. For certain currencies is measured perfectly in the data, having a
countries the extracted data were not tied to an underlying more stable input to our models allowed us to produce
data source or they did not seem to have credible year- more reliable estimates.
over-year trends. In these cases, we modelled domestic
spending ourselves rather than relying on observed Conclusions
data. Additionally, we used the definition of spending Health spending per capita, which has increased steadily
used by the System of Health Accounts and the WHO since 1995, is projected to continue increasing well into
GHED, which excludes investment spending, informal the future, but at a slower rate of growth, and large
payments, and all spending that falls outside of the health existing disparities in per capita spending by country are
system, including cross-sectoral investments. Population projected to persist in the coming decades. Increasing
estimates used to compute per capita values are subject to prioritisation of health and total government spending
similar data limitations, and this is especially true for are key factors to facilitate the health financing transition
countries with civil unrest and large migration patterns. in all countries, whereby additional domestic resources
Second, uncertainty intervals provided throughout this are mobilised for health to gradually replace high out-of-
Article reflect uncertainty in both the retrospective and pocket payments. Sustained increases in the quantity,
prospective data. The widening of uncertainty intervals as equity, and efficiency of health financing are essential
we push further into the future reflects the challenges in to achieving universal health coverage and improving
using trends and relationships from a short time span in health outcomes globally.
the past to project into the future as well as incorporating Global Burden of Disease Health Financing Collaborator Network
unexpected future events and changes. Third, the out-of- Angela Y Chang*, Krycia Cowling*, Angela E Micah*, Abigail Chapin,
sample predictive validity of our models was tested on the Catherine S Chen, Gloria Ikilezi, Nafis Sadat, Golsum Tsakalos,
Junjie Wu, Theodore Younker, Yingxi Zhao, Bianca S Zlavog,
past 10 years of observed data. This process determined Cristiana Abbafati, Anwar E Ahmed, Khurshid Alam, Vahid Alipour,
the models picked for projecting growth rates. Therefore, Syed Mohamed Aljunid, Mohammed J Almalki, Nelson Alvis-Guzman,
our future scenarios are dependent on any observed Walid Ammar, Catalina Liliana Andrei, Mina Anjomshoa,
shocks in the recent past, which would be difficult to Carl Abelardo T Antonio, Jalal Arabloo, Olatunde Aremu, Marcel Ausloos,
Leticia Avila-Burgos, Ashish Awasthi, Martin Amogre Ayanore,
predict out of sample. Similarly, projections are based on Samad Azari, Natasha Azzopardi-Muscat, Mojtaba Bagherzadeh,
past trends and relationships, and our models cannot Maciej Banach, Till Winfried Bärnighausen, Bernhard T Baune,
anticipate events, such as natural disasters or other Mohsen Bayati, Yared Belete Belay, Yihalem Abebe Belay, Habte Belete,
unexpected events, that have never occurred. Fourth, our Dessalegn Ajema Berbada, Adam E Berman, Mircea Beuran, Ali Bijani,
Reinhard Busse, Lucero Cahuana-Hurtado, Luis Alberto Cámera,
projections of available DAH rely primarily on growth Ferrán Catalá-López, Bal Govind Chauhan, Maria-Magdalena Constantin,
in GDP, but we acknowledge that other political and Christopher Stephen Crowe, Alexandra Cucu, Koustuv Dalal,
commercial factors also drive the allocation of DAH from Jan-Walter De Neve, Selina Deiparine, Feleke Mekonnen Demeke,
donors to recipient countries. Fifth, we were not able to Huyen Phuc Do, Manisha Dubey, Maha El Tantawi,
Sharareh Eskandarieh, Reza Esmaeili, Mahdi Fakhar, Ali Akbar Fazaeli,
measure health spending inequities within countries Florian Fischer, Nataliya A Foigt, Sarah Friedman, Takeshi Fukumoto,
(eg, those across subnational regions, income levels, Nancy Fullman, Adriana Galan, Amiran Gamkrelidze,
ethnic groups, and so on). Although some countries are Kebede Embaye Gezae, Alireza Ghajar, Ahmad Ghashghaee,
projected to have large gains in health spending during Ketevan Goginashvili, Annie Haakenstad, Hassan Haghparast Bidgoli,
Samer Hamidi, Hilda L Harb, Edris Hasanpoor, Hamid Yimam Hassen,
the study period, the benefits are not likely to be Simon I Hay, Delia Hendrie, Andualem Henok, Ileana Heredia-Pi,
distributed equally across subgroups. Country-specific Claudiu Herteliu, Chi Linh Hoang, Michael K Hole,
contexts and determinants of health spending, such as Enayatollah Homaie Rad, Naznin Hossain, Mehdi Hosseinzadeh,
Sorin Hostiuc, Olayinka Stephen Ilesanmi, Seyed Sina Naghibi Irvani,
domestic policies and political movements, are not
Mihajlo Jakovljevic, Amir Jalali, Spencer L James, Jost B Jonas,
discussed here but are important when designing

Articles
Mikk Jürisson, Rajendra Kadel, Behzad Karami Matin, Amir Kasaeian, Department of Dermatology (M Constantin MD), Faculty of Dentistry,
Habtamu Kebebe Kasaye, Mesfin Wudu Kassaw, Ali Kazemi Karyani, Department of Legal Medicine and Bioethics (S Hostiuc PhD),
Roghayeh Khabiri, Junaid Khan, Md Nuruzzaman Khan, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
Young-Ho Khang, Adnan Kisa, Katarzyna Kissimova-Skarbek, (C Andrei PhD, A Cucu PhD); Social Determinants of Health Research
Stefan Kohler, Ai Koyanagi, Kristopher J Krohn, Ricky Leung, Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
Lee-Ling Lim, Stefan Lorkowski, Azeem Majeed, Reza Malekzadeh, (M Anjomshoa PhD); Department of Health Policy and Administration,
Morteza Mansourian, Lorenzo Giovanni Mantovani, University of the Philippines Manila, Manila, Philippines
Benjamin Ballard Massenburg, Martin Mckee, Varshil Mehta, (C T Antonio MD); Department of Applied Social Sciences, Hong Kong
Atte Meretoja, Tuomo J Meretoja, Neda Milevska Kostova, Ted R Miller, Polytechnic University, Hong Kong, China (C T Antonio MD); School of
Erkin M Mirrakhimov, Bahram Mohajer, Aso Mohammad Darwesh, Health Sciences, Birmingham City University, Birmingham, UK
Shafiu Mohammed, Farnam Mohebi, Ali H Mokdad, (O Aremu PhD); School of Business, University of Leicester, Leicester,
Shane Douglas Morrison, Seyyed Meysam Mousavi, UK (Prof M Ausloos PhD); Center for Health Systems Research
Saravanan Muthupandian, Ahamarshan Jayaraman Nagarajan, (L Avila-Burgos PhD, L Cahuana-Hurtado PhD,
Vinay Nangia, Ionut Negoi, Cuong Tat Nguyen, Huong Lan Thi Nguyen, Prof I Heredia-Pi Dip Soc Sc), National Centre for Health Promotion
Son Hoang Nguyen, Shirin Nosratnejad, Olanrewaju Oladimeji, and Evaluation (A Cucu PhD, A Galan PhD), National Institute of Public
Stefano Olgiati, Jacob Olusegun Olusanya, Obinna E Onwujekwe, Health, Cuernavaca, Mexico; Indian Institute of Public Health,
Stanislav S Otstavnov, Adrian Pana, David M Pereira, Bakhtiar Piroozi, Gandhinagar, India (A Awasthi PhD); Public Health Foundation of
Sergio I Prada, Mostafa Qorbani, Mohammad Rabiee, Navid Rabiee, India, Gurugram, India (A Awasthi PhD); Department of Family and
Alireza Rafiei, Fakher Rahim, Vafa Rahimi-Movaghar, Usha Ram, Community Health, University of Health and Allied Sciences, Ho,
Chhabi Lal Ranabhat, Anna Ranta, David Laith Rawaf, Salman Rawaf, Ghana (M A Ayanore PhD); Department of Heath Services, University of
Satar Rezaei, Elias Merdassa Roro, Ali Rostami, Salvatore Rubino, Malta, Msida, Malta (N Azzopardi-Muscat PhD); Directorate for Policy,
Mohamadreza Salahshoor, Abdallah M Samy, Juan Sanabria, Directorate for Health Information and Research, Pieta, Malta
João Vasco Santos, Milena M Santric Milicevic, Bruno Piassi Sao Jose, (N Azzopardi-Muscat PhD); Department of Chemistry, Sharif University
Miloje Savic, Falk Schwendicke, Sadaf G Sepanlou, of Technology, Tehran, Iran (Prof M Bagherzadeh PhD, N Rabiee PhD);
Masood Sepehrimanesh, Aziz Sheikh, Mark G Shrime, Solomon Sisay, Department of Hypertension, Medical University of Lodz, Lodz, Poland
Shahin Soltani, Moslem Soofi, Raghavendra Guru Srinivasan, (Prof M Banach PhD); Heidelberg Institute of Global Health, Faculty of
Rafael Tabarés-Seisdedos, Anna Torre, Marcos Roberto Tovani-Palone, Medicine and University Hospital (Prof T W Bärnighausen MD,
Bach Xuan Tran, Khanh Bao Tran, Eduardo A Undurraga, Prof J De Neve MD, S Kohler PhD), Department of Ophthalmology
Pascual R Valdez, Job F M Van Boven, Veronica Vargas, Yousef Veisani, (Prof J B Jonas MD), Institute of Public Health (S Mohammed PhD),
Francesco S Violante, Sergey Konstantinovitch Vladimirov, Vasily Vlassov, Heidelberg University, Heidelberg, Germany; Department of Global
Sebastian Vollmer, Giang Thu Vu, Charles D A Wolfe, Naohiro Yonemoto, Health and Population (Prof T W Bärnighausen MD,
Mustafa Z Younis, Mahmoud Yousefifard, Sojib Bin Zaman, Prof S Vollmer PhD), T.H. Chan School of Public Health
Alireza Zangeneh, Elias Asfaw Zegeye, Arash Ziapour, Adrienne Chew, (A Haakenstad MA), Division of General Internal Medicine and Primary
Christopher J L Murray, Joseph L Dieleman. Care (Prof A Sheikh MD), Davis Rockefeller Center for Latin American
*Joint first authors. Studies (V Vargas PhD), Harvard University, Boston, MA, USA
(M G Shrime MD); Department of Psychiatry, Melbourne Medical
Affiliations
School, Melbourne, VIC, Australia (Prof B T Baune PhD); Health
Institute for Health Metrics and Evaluation (A Y Chang DSc,
Human Resources Research Center, Department of Health Economics,
K Cowling PhD, A E Micah PhD, A Chapin BA, C S Chen BA,
School of Management & Information Sciences (M Bayati PhD), Non-
G Ikilezi MD, N Sadat MA, G Tsakalos MS, J Wu BA, T Younker BS,
communicable Diseases Research Center (Prof R Malekzadeh MD,
Y Zhao MPH, B S Zlavog BS, S Deiparine BA, S Friedman BA,
S G Sepanlou MD), Shiraz University of Medical Sciences, Shiraz, Iran;
N Fullman MPH, A Haakenstad MA, S L James MD, K J Krohn MPH,
Pharmacoepidemiology and Social Pharmacy (Y Belay MSc),
A Torre BS, A Chew ND, Prof C J L Murray DPhil,
Department of Biostatistics (K Gezae MSc), Department of Microbiology
Prof J L Dieleman PhD, Prof S I Hay FMedSci, Prof A H Mokdad PhD),
and Immunology (S Muthupandian PhD), Mekelle University, Mekelle,
Division of Plastic Surgery (C S Crowe MD, B B Massenburg MD),
Ethiopia; AC Environments Foundation, Mexico (Y Belay MSc);
Department of Health Metrics Sciences (Prof S I Hay FMedSci,
Department of Public Health, Debre Markos University, Debre Markos,
Prof A H Mokdad PhD, Prof C J L Murray DPhil,
Ethiopia (Y A Belay MPH); Department of Psychiatry, Bahir Dar
Prof J L Dieleman PhD), Department of Surgery (S D Morrison MD),
University, Bhair Dar, Ethiopia (H Belete MSc); Department of Public
University of Washington, Seattle, WA, USA; Department of Law
Health, Arba Minch University, Arba Minch, Ethiopia
Philosophy and Economic Studies, La Sapienza University, Rome, Italy
(D A Berbada MPH); Department of Medicine, Medical College of
(C Abbafati PhD); College of Public Health and Health Informatics,
Georgia at Augusta University, Augusta, GA, USA (A E Berman MD);
A.T. Still University, Riyadh, Saudi Arabia (A E Ahmed PhD); College of
Social Determinants of Health Research Center (A Bijani PhD),
Arts, Business, Law & Social Sciences, Murdoch University, Murdoch,
Infectious Diseases and Tropical Medicine Research Center
WA, Australia (K Alam PhD); Health Management and Economics
(A Rostami PhD), Babol University of Medical Sciences, Babol, Iran;
Research Center (V Alipour PhD, J Arabloo PhD, S Azari PhD),
Department for Health Care Management, Technical University of
Department of Health Services Management, School of Health
Berlin, Berlin, Germany (Prof R Busse PhD); Medicina Interna, Hospital
Management and Information Sciences (A Ghashghaee BSc), Health
Italiano de Buenos Aires, Caba, Argentina (Prof L A Cámera MD);
Education and Promotion Department (M Mansourian PhD), Physiology
Comisión Directiva (Prof L A Cámera MD), Argentine Society of
Research Center (M Yousefifard PhD), Iran University of Medical
Medicine, Buenos Aires, Argentina (Prof P R Valdez M Ed); National
Sciences, Tehran, Iran; Department of Health Policy and Management,
School of Public Health, Institute of Health Carlos III, Madrid, Spain
Kuwait University, Safat, Kuwait (Prof S M Aljunid PhD); International
(F Catalá-López PhD); Population Research Centre, Gokhale Institute of
Centre for Casemix and Clinical Coding, National University of
Politics and Economics, Pune, India (B Chauhan M Phil); Department of
Malaysia, Bandar Tun Razak, Malaysia (Prof S M Aljunid PhD); Faculty
Population Studies (J Khan M Phil), Department of Public Health &
of Public Health and Tropical Medicine (M J Almalki PhD), Jazan
Mortality Studies (Prof U Ram PhD), International Institute for
University, Jazan, Saudi Arabia (M J Almalki PhD); Research Group in
Population Sciences, Mumbai, India (B Chauhan M Phil); IInd
Health Economics, Universidad de Cartagena, Cartagena, Colombia
Department of Dermatology, Colentina Clinical Hospital, Bucharest,
(Prof N Alvis-Guzman PhD); Research Group in Hospital Management
Romania (M Constantin MD); Higher School of Public Health,
and Health Policies, Universidad de la Costa, Barranquilla, Colombia
Al Farabi Kazakh National University, Almaty, Kazakhstan
(Prof N Alvis-Guzman PhD); Federal Ministry of Health, Beirut,
(Prof K Dalal PhD); School of Health and Education, University of
Lebanon (Prof W Ammar PhD); Faculty of Health Sciences, American
Skövde, Skövde, Sweden (Prof K Dalal PhD); Department of Medical
University of Beirut, Beirut, Lebanon (Prof W Ammar PhD); Emergency
Microbiology, University of Gondar, Gondar, Ethiopia
Hospital of Bucharest (Prof M Beuran PhD, I Negoi PhD), IInd

Articles
(F M Demeke MSc); Center for Excellence in Behavioral Health Research Center (S Rezaei PhD, M Soofi PhD), Social Development and
(H P Do PhD), Center of Excellence in Behavioral Medicine Health Promotion Research Center (M Soofi PhD, A Zangeneh MD),
(C L Hoang B Med Sc, S H Nguyen BS, G T Vu BA), Nguyen Tat Thanh Deputy of Research and Technology (A Ziapour PhD), Kermanshah
University, Ho Chi Minh City, Vietnam; United Nations World Food University of Medical Sciences, Kermanshah, Iran; Beijing Institute of
Programme, New Delhi, India (M Dubey PhD); Pediatric Dentistry and Ophthalmology, Beijing Tongren Hospital, Beijing, China
Dental Public Health, Alexandria University, Alexandria, Egypt (Prof J B Jonas MD); Institute of Family Medicine and Public Health,
(Prof M El Tantawi PhD); Preventive Dental Sciences, Imam University of Tartu, Tartu, Estonia (M Jürisson PhD); Personal Social
Abdulrahman Bin Faisal University, Dammam, Saudi Arabia Services Research Unit, London School of Economics and Political
(Prof M El Tantawi PhD); Multiple Sclerosis Research Center Science, London, UK (R Kadel MPH); School of Nursing and Midwifery
(S Eskandarieh PhD, B Mohajer MD), Endocrinology and Metabolism (H K Kasaye MSc), Department of Public Health (E M Roro MPH),
Research Center (EMRC) (A Ghajar MD), Non-communicable Diseases Wollega University, Nekemte, Ethiopia; Department of Nursing,
Research Center (S N Irvani MD, B Mohajer MD, F Mohebi MD), Woldia University, Woldia, Ethiopia (M W Kassaw MSc); Public Health
Hematologic Malignancies Research Center (A Kasaeian PhD), National Department, Amhara Public Health Institute, Bair Dar, Ethiopia
Institute for Health Research (NIHR) (R Khabiri PhD), Digestive (M W Kassaw MSc); Tabriz Health Management Research Center,
Diseases Research Institute (Prof R Malekzadeh MD, Tabriz, Iran (R Khabiri PhD), Health Economics (S Nosratnejad PhD),
S G Sepanlou MD), Iran National Institute of Health Research Tabriz University of Medical Sciences, Tabriz, Iran; Department of
(F Mohebi MD), Department of Health Management and Economics Population Sciences, Jatiya Kabi Kazi Nazrul Islam University,
(S Mousavi PhD), Endocrinology and Metabolism Molecular-Cellular Mymensingh, Bangladesh (M N Khan MSc); Public Health Department,
Sciences Institute, (F Rahim PhD), Sina Trauma and Surgery Research University of Newcastle, Newcastle, NSW, Australia (M N Khan MSc);
Center (Prof V Rahimi-Movaghar MD), Hematology-Oncology and Stem Institute of Health Policy and Management (Prof Y Khang MD),
Cell Transplantation Research Center (A Kasaeian PhD), Tehran Department of Health Policy and Management (Prof Y Khang MD),
University of Medical Sciences, Tehran, Iran; Department of Public Seoul National University, Seoul, South Korea; Department of Health
Health, Gonabad University of Medical Sciences, Gonabad, Iran Management and Health Economics, Kristiania University College,
(R Esmaeili PhD); Molecular and Cell Biology Research Center Oslo, Norway (Prof A Kisa PhD); Department of Health Services Policy
(Prof A Rafiei PhD), Department of Immunology (Prof A Rafiei PhD), and Management, University of South Carolina, Columbia, SC, USA
Mazandaran University of Medical Sciences, Sari, Iran (M Fakhar PhD); (Prof A Kisa PhD); Department of Health Economics and Social Security,
Department of Public Health Medicine, Bielefeld University, Bielefeld, Jagiellonian University Medical College, Krakow, Poland
Germany (F Fischer PhD); Social Determinants of Health Research (K Kissimova-Skarbek PhD); CIBERSAM, San Juan de Dios Sanitary
Center, Hamadan University of Medical Sciences, Hamadan, Iran Park, Sant Boi De Llobregat, Spain (A Koyanagi MD); Catalan Institution
(A Fazaeli PhD); Institute of Gerontology, National Academy of Medical for Research and Advanced Studies (ICREA), Barcelona, Spain
Sciences of Ukraine, Kyiv, Ukraine (N A Foigt PhD); Gene Expression & (A Koyanagi MD); Department of Health Policy, Management and
Regulation Program, Cancer Institute (W.I.A.), Philadelphia, PA, USA Behavior, School of Public Health, University at Albany, Rensselaer, NY,
(T Fukumoto PhD); Department of Dermatology, Kobe University, Kobe, USA (R Leung PhD); Department of Medicine, University of Malaya,
Japan (T Fukumoto PhD); National Centre for Disease Control (NCDC), Kuala Lumpur, Malaysia (L Lim MRCP); Department of Medicine and
Tbilisi, Georgia (Prof A Gamkrelidze PhD); Department of Medicine, Therapeutics, The Chinese University of Hong Kong, Shatin, NT, China
Massachusetts General Hospital, Boston, MA, USA (A Ghajar MD); (L Lim MRCP); Institute of Nutrition, Friedrich Schiller University Jena,
Health Care Department, Ministry of Health, Labour and Social Affairs, Jena, Germany (Prof S Lorkowski PhD); Competence Cluster for
Tbilisi, Georgia (K Goginashvili MPH); Institute for Global Health, Nutrition and Cardiovascular Health (NUTRICARD), Jena, Germany
University College London, London, UK (H Haghparast Bidgoli PhD); (Prof S Lorkowski PhD); Department of Primary Care and Public Health
School of Health and Environmental Studies, Hamdan Bin Mohammed (Prof A Majeed MD, Prof S Rawaf PhD), WHO Collaborating Centre for
Smart University, Dubai, United Arab Emirates (Prof S Hamidi DrPH); Public Health Education and Training (D L Rawaf MD), Imperial College
Department of Vital and Health Statistics, Ministry of Public Health, London, London, UK; School of Medicine and Surgery, University of
Beirut, Lebanon (H L Harb MPH); Healthcare Management, Maragheh Milan Bicocca, Monza, Italy (Prof L G Mantovani DSc); Department of
University of Medical Sciences, Maragheh, Iran (E Hasanpoor PhD); Health Services Research and Policy, London School of Hygiene &
Public Health Department (H Y Hassen MPH), Mizan-tepi University, Tropical Medicine, London, UK (Prof M Mckee DSc); Department of
Teppi, Ethiopia (A Henok MPH); Unit of Epidemiology and Social Internal Medicine, Sevenhills Hospital, Mumbai, India (V Mehta MD);
Medicine, University Hospital Antwerp, Wilrijk, Belgium Neurocenter (A Meretoja MD), Breast Surgery Unit (T J Meretoja MD),
(H Y Hassen MPH); School of Public Health, Curtin University, Bentley, Helsinki University Hospital, Helsinki, Finland; School of Health
WA, Australia (D Hendrie PhD, T R Miller PhD); Department of Sciences, University of Melbourne, Parkville, VIC, Australia
Statistics and Econometrics, Bucharest University of Economic Studies, (A Meretoja MD); University of Helsinki, Helsinki, Finland
Bucharest, Romania (Prof C Herteliu PhD, A Pana MD); University of (T J Meretoja MD); Health Policy and Management, Centre for Regional
Texas Austin, Austin, TX, USA (M K Hole MD); Social Determinants of Policy Research and Cooperation ‘Studiorum’, Skopje, Macedonia
Health Research Center (E Homaie Rad PhD), Guilan University of (N Milevska Kostova PhD); Pacific Institute for Research & Evaluation,
Medical Sciences, Rasht, Iran; Department of Pharmacology and Calverton, MD, USA (T R Miller PhD); Faculty of General Medicine,
Therapeutics, University of Dhaka, Dhaka, Bangladesh Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan
(N Hossain MPH); Health System and Population Studies Division (Prof E M Mirrakhimov MD); Department of Atherosclerosis and
(N Hossain MPH), Maternal and Child Health Division Coronary Heart Disease, National Center of Cardiology and Internal
(S Zaman MPH), International Centre for Diarrhoeal Disease Research, Disease, Bishkek, Kyrgyzstan (Prof E M Mirrakhimov MD); Health
Bangladesh, Dhaka, Bangladesh; Department of Computer Engineering, Systems and Policy Research Unit, Ahmadu Bello University, Zaria,
Science and Research Branch, Islamic Azad University, Tehran, Iran Nigeria (S Mohammed PhD); Founder, Research and Analytics, Initiative
(M Hosseinzadeh PhD); Computer Science (M Hosseinzadeh PhD), for Financing Health and Human Development, Chennai, India
Information Technology Department (A Mohammad Darwesh PhD), (A J Nagarajan D Phil); Founder, Research and Analytics, Bioinsilico
University of Human Development, Sulaimaniyah, Iraq; Department of Technologies, Chennai, India (A J Nagarajan D Phil); Suraj Eye Institute,
Public Health and Community Medicine, University of Liberia, Nagpur, India (V Nangia MD); Institute for Global Health Innovations,
Monrovia, Liberia (O S Ilesanmi PhD); Research Institute for Endocrine Duy Tan University, Hanoi, Vietnam (C T Nguyen MPH,
Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran H L T Nguyen MPH); HAST, Human Sciences Research Council,
(S N Irvani MD); Medical Sciences Department, University of Durban, South Africa (O Oladimeji MD); School of Public Health,
Kragujevac, Kragujevac, Serbia (Prof M Jakovljevic PhD); Psychiatric Faculty of Health Sciences, University of Namibia, Osakhati, Namibia
Department (A Jalali PhD), Research Center for Environmental (O Oladimeji MD); Massachusetts Institute of Technology, Cambridge,
Determinants of Health (Prof B Karami Matin PhD), Faculty of Public MA, USA (S Olgiati PhD); Centre for Healthy Start Initiative, Lagos,
Health (A Kazemi Karyani PhD), Environmental Determinants of Health Nigeria (J O Olusanya MBA); Department of Pharmacology and

Articles
Therapeutics, University of Nigeria Nsukka, Enugu, Nigeria (Y Veisani PhD); Department of Medical and Surgical Sciences,
(Prof O E Onwujekwe PhD); Analytical Center, Moscow Institute of University of Bologna, Bologna, Italy (Prof F S Violante MD); Federal
Physics and Technology, Dolgoprudny, Russia (S S Otstavnov PhD); Research Institute for Health Organization and Informatics of the
Health Outcomes, Center for Health Outcomes & Evaluation, Bucharest, Ministry of Health (FRIHOI), Moscow, Russia (S K Vladimirov PhD);
Romania (A Pana MD); REQUIMTE/LAQV (Prof D M Pereira PhD), Department of Information and Internet Technologies, I.M. Sechenov
Department of Community Medicine (J V Santos MD), University of First Moscow State Medical University, Moscow, Russia
Porto, Oporto, Portugal; Cartagena University, Cartagena, Colombia (S K Vladimirov PhD); Department of Health Care Administration and
(Prof D M Pereira PhD); Social Determinants of Health Research Center, Economy, National Research University Higher School of Economics,
Research Institute for Health Development, Kurdistan University of Moscow, Russia (Prof V Vlassov MD); Department of Economics,
Medical Sciences, Sanandaj, Iran (B Piroozi PhD); Centro Proesa, University of Goettingen, Göttingen, Germany (Prof S Vollmer PhD);
Icesi University, Cali, Colombia (S I Prada PhD); Non-communicable School of Population Health & Environmental Sciences, King’s College
Diseases Research Center, Alborz University of Medical Sciences, Karaj, London, London, UK (Prof C D A Wolfe MD); Biomedical Research
Iran (M Qorbani PhD); Biomedical Engineering, Amirkabir University Council, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
of Technology, Tehran, Iran (Prof M Rabiee PhD); Division of Chemistry (Prof C D A Wolfe MD); Department of Psychopharmacology, National
and Division of Diseases, Advanced Technologies Research Group, Center of Neurology and Psychiatry, Tokyo, Japan (N Yonemoto MPH);
Tehran, Iran (N Rabiee PhD); Thalassemia and Hemoglobinopathy Department of Health Policy and Management, Jackson State University,
Research Center, Ahvaz Jundishapur University of Medical Sciences, Jackson, MS, USA (Prof M Z Younis DrPH); Department of Public
Ahvaz, Iran (F Rahim PhD); Institute for Poverty Alleviation and Health, Tsinghua University, Beijing, China (Prof M Z Younis DrPH);
International Development, Yonsei University, Wonju, South Korea and Health Care Financing Program, Clinton Health Access Initiative,
(C L Ranabhat PhD); Policy Research Institute, Kathmandu, Nepal Addis Ababa, Ethiopia (E A Zegeye PhD).
(C L Ranabhat PhD); Department of Medicine, University of Otago,
Contributors
Wellington, New Zealand (A Ranta PhD); Department of Neurology,
A Chapin, J L Dieleman, and G Tsakalos were responsible for managing
Capital & Coast District Health Board, Wellington, New Zealand
the estimation process. A Y Chang, K Cowling, J L Dieleman,
(A Ranta PhD); University College London Hospitals, London, UK
and A E Micah were responsible for writing the first draft of the
(D L Rawaf MD); Public Health England, London, UK
manuscript. C S Chen, J L Dieleman, G Ikilezi, N Sadat, T Younker,
(Prof S Rawaf PhD); Department of Public Health, Addis Ababa
Y Zhao, and B S Zlavog were responsible for developing methods or
University, Addis Ababa, Ethiopia (E M Roro MPH); Department of
computational machinery. C S Chen, G Ikilezi, N Sadat, T Younker,
Biomedical Sciences, University of Sassari, Sassari, Italy
Y Zhao, and B S Zlavog were responsible for applying analytical methods
(Prof S Rubino PhD); A.C.S. Medical College and Hospital, Tehran, Iran
to produce estimates. A Y Chang, A Chew, K Cowling, J L Dieleman,
(M Salahshoor PhD); Department of Entomology, Ain Shams University,
and A E Micah and were responsible for drafting the work or revising
Cairo, Egypt (A M Samy PhD); Department of Surgery, Marshall
critically for important intellectual content. C S Chen, G Ikilezi, N Sadat,
University, Huntington, WV, USA (Prof J Sanabria MD); Department of
J Wu, T Younker, Y Zhao, B S Zlavog were responsible for extracting,
Nutrition and Preventive Medicine, Case Western Reserve University,
cleaning, or cataloguing data; and designing or coding figures and tables.
Cleveland, OH, USA (Prof J Sanabria MD); Department of Public
A Chapin, J L Dieleman, C J L Murray, and G Tsakalos were responsible
Health, Regional Health Administration Do Norte I.P.,
for managing the overall research enterprise. All other authors provided
Vila Nova De Gaia, Portugal (J V Santos MD); Centre School of Public
important feedback on the methods, results, or data sources.
Health and Health Management, University of Belgrade, Belgrade,
Serbia (Prof M M Santric Milicevic PhD); Post-Graduate Program in Declaration of interests
Infectious Diseases and Tropical Medicine, Federal University of Minas C A Antonio reports personal fees from Johnson & Johnson (Philippines),
Gerais, Belo Horizonte, Brazil (B P Sao Jose PhD); GSK Biologicals, Inc, outside the submitted work. S Lorkowski reports personal fees from
Wavre, Belgium (M Savic PhD); Department of Operative and Preventive Amgen, Berlin-Chemie, Daiichi Sankyo, MSD Sharp & Dohme, Novo
Dentistry, Charité University Medical Center Berlin, Berlin, Germany Nordisk, Sanofi-Aventis, Synlab, Unilever, and Upfield; non-financial
(Prof F Schwendicke PhD); New Iberia Research Center, University of support from Preventicus outside the submitted work; and is a member of
Louisiana at Lafayette, Lafayette, LA, USA (M Sepehrimanesh PhD); the scientific board of the German Nutrition Society and coauthor of the
Usher Institute of Population Health Sciences and Informatics, evidence-based guideline on fat intake and prevention of nutrition-related
University of Edinburgh, Edinburgh, UK (Prof A Sheikh MD); Medical diseases published by the German Nutrition Society. M Savic reports
Department, German Leprosy and TB Relief Association Ethiopia, Addis employment by the GSK group of companies and holds restricted shares in
Ababa, Ethiopia (S Sisay MPH); Research Center for Environmental the GSK group of companies. M Shrime reports grants from Mercy Ships
Determinants of Health, Academy of Medical Science, Kermanshah, and from Damon Runyon Cancer Research Foundation outside the
Iran (S Soltani PhD); The Institute of Chartered Accountants of India, submitted work. All other authors declare no competing interests.
Chennai, India (R G Srinivasan BComm); Department of Medicine,
References
University of Valencia, Valencia, Spain (Prof R Tabarés-Seisdedos PhD); 1 WHO. World Health Report 2010—health systems financing:
Carlos III Health Institute, Biomedical Research Networking Center for the path to universal coverage. WHO, 2010. https://www.who.int/
Mental Health Network (CIBERSAM), Madrid, Spain whr/2010/en/ (accessed Dec 21, 2018).
(Prof R Tabarés-Seisdedos PhD); Department of Pathology and Legal 2 Gottret P, Schieber G. Health financing revisited: a practioner’s
Medicine, University of São Paulo, Ribeirão Preto, Brazil guide. Washington, DC: The International Bank for Reconstruction
(M R Tovani-Palone MSc); Department of Health Economics, Hanoi and Development/The World Bank, 2006. https://openknowledge.
Medical University, Hanoi, Vietnam (B X Tran PhD); Molecular worldbank.org/handle/10986/7094 (accessed March 6, 2019).
Medicine and Pathology, University of Auckland, Auckland, 3 Reeves A, Gourtsoyannis Y, Basu S, McCoy D, McKee M, Stuckler D.
New Zealand (K B Tran MD); Clinical Hematology and Toxicology, Financing universal health coverage—effects of alternative tax
Military Medical University, Hanoi, Vietnam (K B Tran MD); School of structures on public health systems: cross-national modelling in
Government, Pontifical Catholic University of Chile, Santiago, Chile 89 low-income and middle-income countries. Lancet 2015;
(E A Undurraga PhD); Schneider Institutes for Health Policy, Brandeis 386: 274–80.
University, Waltham, MA, USA (E A Undurraga PhD); Velez Sarsfield 4 Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ.
Hospital, Buenos Aires, Argentina (Prof P R Valdez M Ed); University Household catastrophic health expenditure: a multicountry
Medical Center Groningen, University of Groningen, Groningen, analysis. Lancet 2003; 362: 111–17.
Netherlands (J F M Van Boven PhD); Department of General Practice, 5 Bokhari FAS, Gai Y, Gottret P. Government health expenditures and
University Medical Center Groningen, Groningen, Netherlands health outcomes. Health Econ 2007; 16: 257–73.
(J F M Van Boven PhD); Department of Economics, Alberto Hurtado 6 Moreno-Serra R, Smith PC. Broader health coverage is good for the
University, Santiago, Chile (V Vargas PhD); Psychosocial Injuries nation’s health: evidence from country level panel data.
J R Stat Soc Ser A Stat Soc 2015; 178: 101–24.
Research Center, Ilam University of Medical Sciences, Ilam, Iran

Articles
7 Nixon J, Ulmann P. The relationship between health care 23 Dieleman JL, Graves C, Johnson E, et al. Sources and focus of
expenditure and health outcomes. Evidence and caveats for a causal health development assistance, 1990–2014. JAMA 2015;
link. Eur J Health Econ 2006; 7: 7–18. 313: 2359–68.
8 Budhdeo S, Watkins J, Atun R, Williams C, Zeltner T, 24 Dieleman JL, Graves CM, Templin T, et al. Global health development
Maruthappu M. Changes in government spending on healthcare assistance remained steady in 2013 but did not align with recipients’
and population mortality in the European union, 1995–2010: disease burden. Health Aff 2014; 33: 878–86.
a cross-sectional ecological study. J R Soc Med 2015; 108: 490–98. 25 Dieleman JL, Templin T, Sadat N, et al. National spending on health
9 Dieleman JL, Sadat N, Chang AY, et al. Trends in future health by source for 184 countries between 2013 and 2040. Lancet 2016;
financing and coverage: future health spending and universal 387: 2521–35.
health coverage in 188 countries, 2016–40. Lancet 2018; 391: 1783–98. 26 Das Gupta P. Standardization and decompostion of rates: a user’s
10 Cashin C. Health financing policy: the macroeconomic, fiscal, manual. US Bureau of the Census, 1993. https://www.census.gov/
and public finance context. Washington, DC: International Bank for content/dam/Census/library/publications/1993/demo/p23-186.pdf
Reconstruction and Development/The World Bank, 2016. (accessed Dec 21, 2018).
11 Mann C, Ng C, Akseer N, et al. Countdown to 2015 country case 27 Foreman KJ, Lozano R, Lopez AD, Murray CJ. Modeling causes
studies: what can analysis of national health financing contribute of death: an integrated approach using CODEm.
to understanding MDG 4 and 5 progress? BMC Public Health 2016; Population Health Metrics 2012; 10: 1.
16 (suppl 2): 792. 28 UN Department of Economic and Social Affairs. World Population
12 WHO. Global health expenditure database. Last updated Prospects: the 2017 revision. June 21, 2017. https://www.un.org/
March 22, 2019. http://www.who.int/health-accounts/ghed/en/ development/desa/publications/world-population-prospects-the-
(accessed Dec 21, 2018). 2017-revision.html (accessed Dec 21, 2018).
13 OECD, Eurostat, WHO. A system of health accounts 2011: 29 The World Bank. World Bank Country and Lending Groups—
revised edition. Paris: OECD Publishing, 2017. https://read.oecd- World Bank Data Help Desk. https://datahelpdesk.worldbank.org/
ilibrary.org/social-issues-migration-health/a-system-of-health- knowledgebase/articles/906519-world-bank-country-and-lending-
accounts-2011_9789264270985-en (accessed March 7, 2019). groups (accessed Dec 21, 2018).
14 Feenstra RC, Inklaar R, Marcel P. The next generation of the Penn 30 Abate KH, Abay SM, Abbafati C, et al. Global, regional, and national
World Table. Am Econ Rev 2015; 105: 3150–82. Available for age-sex-specific mortality and life expectancy, 1950–2017:
download at: https://www.rug.nl/ggdc/productivity/pwt/ (accessed a systematic analysis for the Global Burden of Disease Study 2017.
Dec 21, 2018). Lancet 2018; 392: 1684–735.
15 World Bank. World Bank country and lending groups—World Bank 31 Fan VY, Savedoff WD. The health financing transition: a conceptual
data help desk. https://datahelpdesk.worldbank.org/knowledgebase/ framework and empirical evidence. Soc Sci Med 2014; 105: 112–21.
articles/906519-world-bank-country-and-lending-groups (accessed 32 Evans DB, Etienne C. Health systems financing and the path to
Dec 21, 2018). universal coverage. Bull World Health Organ 2010; 88: 402–03.
16 International Monetary Fund. World economic outlook, October 2018: 33 Leive A, Xu K. Coping with out-of-pocket health payments:
challenges to steady growth. https://www.imf.org/en/Publications/ empirical evidence from 15 African countries.
WEO/Issues/2018/09/24/world-economic-outlook-october-2018 Bull World Health Organ 2008; 86: 849–56C.
(accessed Dec 21, 2018). 34 Xu K, Soucat A, Kutzin J, et al. Public spending on health: a closer
17 Jutta B, Inklaar R, de Jong H, van Zanden JL. Maddison Project look at global trends. 2018. https://www.who.int/health_financing/
Database, version 2018. Rebasing ‘Maddison’: new income documents/health-expenditure-report-2018/en/ (accessed
comparisons and the shape of long-run economic development. Dec 22, 2018).
Maddison Project Working paper 10. January, 2018. https://www.rug. 35 Reeves A, Gourtsoyannis Y, Basu S, McCoy D, McKee M,
nl/ggdc/historicaldevelopment/maddison/releases/maddison- Stuckler D. Financing universal health coverage—effects of
project-database-2018 (accessed Dec 21, 2018). alternative tax structures on public health systems: cross-national
18 UN Statistics Division. National Accounts Main Aggregates modelling in 89 low-income and middle-income countries. Lancet
Database. —National Health Accounts. https://unstats.un.org/ 2015; 386: 274–80.
unsd/snaama/Introduction.asp (accessed Dec 21, 2018). 36 Dercon S, Lea N. The missing middle—or is there an obvious
19 James SL, Gubbins P, Murray CJ, Gakidou E. Developing a resource gap for LMICs? May, 2015. https://studylib.net/
comprehensive time series of GDP per capita for 210 countries doc/13003145/the-missing-middle (accessed Dec 21, 2018).
from 1950 to 2015. Pop Health Metrics 2012; 10: 12. 37 GBD 2017 Causes of Death Collaborators. Global, regional,
20 GBD 2015 Risk Factors Collaborators. Global, regional, and national and national age-sex-specific mortality for 282 causes of death in
comparative risk assessment of 79 behavioural, environmental and 195 countries and territories, 1980–2017: a systematic analysis for
occupational, and metabolic risks or clusters of risks, 1990–2015: the Global Burden of Disease Study 2017. Lancet 2018; 392: 1736–88.
a systematic analysis for the Global Burden of Disease Study 2015. 38 Huang Y. China’s response to the 2014 Ebola outbreak in
Lancet 2016; 388: 1659–724. West Africa. Global Challenges 2017; published online Jan 30.
21 Ravishankar N, Gubbins P, Cooley RJ, et al. Financing of global DOI:10.1002/gch2.201600001.
health: tracking development assistance for health from 1990 to 2007. 39 Alcorn T. New orientation for China’s health assistance to Africa.
Lancet 2009; 373: 2113–24. Lancet 2015; 386: 2379–80.
22 Leach-Kemon K, Chou DP, Schneider MT, et al. The global financial
crisis has led to a slowdown in growth of funding to improve health
in many developing countries. Health Aff 2012; 31: 228–35.

Pi Is 0140673619308414

Uploaded by

Copyright:

Available Formats

Pi Is 0140673619308414

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Pi Is 0140673619308414

Uploaded by

Copyright:

Available Formats

Articles

Past, present, and future of global health financing: a review

www.thelancet.com Vol 393 June 1, 2019 2233

Funding Bill & Melinda Gates Foundation.

Introduction that promotes equity.2 Health systems funded according to

2234 www.thelancet.com Vol 393 June 1, 2019

www.thelancet.com Vol 393 June 1, 2019 2235

2236 www.thelancet.com Vol 393 June 1, 2019

Health spending per capita (US$)

ATG VCT Barbados Comoros Marshall Isl Kiribati

Dominica Grenada Maldives Mauritius Malta

Health spending per capita (US$)

ATG VCT Barbados Comoros Marshall Isl Kiribati

Dominica Grenada Maldives Mauritius Malta

(Figure 1 continues on next page)

www.thelancet.com Vol 393 June 1, 2019 2237

Health spending per capita (US$)

ATG VCT Barbados Comoros Marshall Isl Kiribati

Dominica Grenada Maldives Mauritius Malta

Health spending per capita (US$)

ATG VCT Barbados Comoros Marshall Isl Kiribati

Dominica Grenada Maldives Mauritius Malta

2238 www.thelancet.com Vol 393 June 1, 2019

population data were extracted from the UN World 1995

Health spending per capita (US$)

Role of the funding source

www.thelancet.com Vol 393 June 1, 2019 2239

2240 www.thelancet.com Vol 393 June 1, 2019

www.thelancet.com Vol 393 June 1, 2019 2241

2242 www.thelancet.com Vol 393 June 1, 2019

www.thelancet.com Vol 393 June 1, 2019 2243

2244 www.thelancet.com Vol 393 June 1, 2019

www.thelancet.com Vol 393 June 1, 2019 2245

2246 www.thelancet.com Vol 393 June 1, 2019

Table 1: Health spending by source, 2016

Results played in providing resources for health, especially to

www.thelancet.com Vol 393 June 1, 2019 2247

Central Europe, eastern

Southeast Asia, east

2248 www.thelancet.com Vol 393 June 1, 2019

capita (8·52% [7·69 to 9·33]) annually between 1995 and

www.thelancet.com Vol 393 June 1, 2019 2249

pocket spending (56·1% [95% UI 47·3–65·4]), even higher

2250 www.thelancet.com Vol 393 June 1, 2019

Newborn and child health

Year Annualised rate of change (%)

Figure 6: Changes in development assistance for health disbursements, 1990–2018

www.thelancet.com Vol 393 June 1, 2019 2251

www.thelancet.com Vol 393 June 1, 2019

www.thelancet.com Vol 393 June 1, 2019 2253

B High income C Upper-middle income

D Lower-middle income E Low income

Discussion (0·2% [0·2–0·2]), and decreased proportions from out-

2254 www.thelancet.com Vol 393 June 1, 2019

www.thelancet.com Vol 393 June 1, 2019 2255

2256 www.thelancet.com Vol 393 June 1, 2019

www.thelancet.com Vol 393 June 1, 2019 2257

2258 www.thelancet.com Vol 393 June 1, 2019

www.thelancet.com Vol 393 June 1, 2019 2259