Future and potential spending on health 2015–40: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries

Background The amount of resources, particularly prepaid resources, available for health can affect access to health care and health outcomes. Although health spending tends to increase with economic development, tremendous variation exists among health financing systems. Estimates of future spending can be beneficial for policy makers and planners, and can identify financing gaps. In this study, we estimate future gross domestic product (GDP), all-sector government spending, and health spending disaggregated by source, and we compare expected future spending to potential future spending. Methods We extracted GDP, government spending in 184 countries from 1980–2015, and health spend data from 1995–2014. We used a series of ensemble models to estimate future GDP, all-sector government spending, development assistance for health, and government, out-of-pocket, and prepaid private health spending through 2040. We used frontier analyses to identify patterns exhibited by the countries that dedicate the most funding to health, and used these frontiers to estimate potential health spending for each low-income or middle-income country. All estimates are inflation and purchasing power adjusted. Findings We estimated that global spending on health will increase from US$9·21 trillion in 2014 to $24·24 trillion (uncertainty interval [UI] 20·47–29·72) in 2040. We expect per capita health spending to increase fastest in uppermiddle-income countries, at 5·3% (UI 4·1–6·8) per year. This growth is driven by continued growth in GDP, government spending, and government health spending. Lower-middle income countries are expected to grow at 4·2% (3·8–4·9). High-income countries are expected to grow at 2·1% (UI 1·8–2·4) and low-income countries are expected to grow at 1·8% (1·0–2·8). Despite this growth, health spending per capita in low-income countries is expected to remain low, at $154 (UI 133–181) per capita in 2030 and $195 (157–258) per capita in 2040. Increases in national health spending to reach the level of the countries who spend the most on health, relative to their level of economic development, would mean $321 (157–258) per capita was available for health in 2040 in low-income countries. Interpretation Health spending is associated with economic development but past trends and relationships suggest that spending will remain variable, and low in some low-resource settings. Policy change could lead to increased health spending, although for the poorest countries external support might remain essential. Funding Bill & Melinda Gates Foundation. Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Introduction Anticipation of future health spending and the source of that funding is vital for effective health policy. With reliable spending forecasts, decision makers can adjust long-term planning and processes. Investments can be made strategically to counter shortfalls or enhance growth in coming years. Because dependence on out-of-pocket health payments has been shown to reduce access to health services and increase medical impoverishment in some settings, understanding how funds will be collected, and if they will be prepaid and pooled across groups, is also of crucial importance. The source of health funding often dictates the types of services and supplies procured and how efficiently those resources are deployed. Without careful planning, limited resources for health can translate into insufficient access to health services and an over-reliance on out-of-pocket payments. The health financing transition describes how health financing changes, on average, as countries develop economically: per capita health spending increases and out-of-pocket expenses comprise a smaller share of total health expenditure than previously. However, tremendous variation in health financing systems and the associated levels of financing underpins these trends. In 2014, spending per capita in low-income countries varied from US$33 to $347, and per capita spending in high-income countries varied from $853 to $9237. The health financing transition is not guaranteed to continue as new countries progress through various stages of development. Prospective health spending estimates Published Online April 19, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)30873-5 See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(17)31001-2 *Collaborators listed at the end of the Article Correspondence to: Dr Joseph L Dieleman, 2301 5th Avenue, Suite 600, Seattle, WA 98121, USA [email protected]