Commentary: Growth of Global Health Spending Share in Low and Middle Income Countries

The paper by Jakovljevic and Getzen highlighted the fact that low-and middle-income countries have been grabbing an ever larger share of global health spending over the last couple of decades (1). Share of global health spending of low-and middle-income countries as of 1995 expressed in million current PPP international $US grew from 26. and Vietnam) with a joint contribution to the global total health expenditure several times below the one of BRICS (1–5). Low-and middle-income countries, which represent an immense range of health system contexts, are likely to have more significant contribution in the global health-care market in the future as it is estimated that per-capita health spending will increase annually by 2.4, 3.0, and 3.4% in low-, lower-middle-, and upper-middle-income countries by 2040, respectively (1, 6). For high-income countries this rate is estimated at 2.7% (6). One interesting question can be raised. What is happening with population health outcomes in low-and middle-income countries as health expenditure is increasing? The authors mentioned that " substantial gains in overall welfare are reflected in the expansion of health insurance coverage and diversity of medical services provided " (1). Some other aspects would also be valuable for discussion. First, determining the impact of health expenditure on health outcomes is a challenging and complex issue as health outcomes are determined by a vast number of socioeconomic and environmental factors (7–9). Solely increasing public health expenditure, may not significantly affect health outcomes if its efficiency is inadequate (8, 9). It has been suggested that, on average, inefficiency of allocating health expenditures in emerging and developing economies is highest in Africa, while Western Hemisphere and Asian economies are relatively more efficient, with significant variations within the aforementioned regions (8). One systematic review has shown that private health-care system sectors in low-and middle-income countries appear to have lower efficiency compared to public sector as a result of weak regulation, higher costs of drugs, improper incentives for unnecessary testing, and treatment, but that, on the other hand, public sector tends to be less responsive to patients and susceptible to the lack of availability of supplies (10). Higher public health expenditure is generally associated with better health outcomes, but still there are substantial differences within the emerging and developing economies groups (8). The relationship between public health expenditure and health-adjusted life expectancy, as well as immunization rates, is generally found to be positive and significant, whereas it is negative …