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

Abstract

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 upper-middle-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.

Figure 1

Process diagram for estimating future GDP, all-sector government spending, and health spending by source The process diagram indicates the data used by each ensemble for estimating future GDP, all-sector government spending, government health spending, prepaid private health spending, out-of-pocket health spending, or DAH. The number of models considered is the universe of specific model specifications considered for that ensemble model. Each individual model was tested against three exclusion criteria. The number of models that passed each criterion is also indicated. DAH=development assistance for health. GDP=gross domestic product.

Figure 2

Increases in health spending by source, 2016 World Bank income group, and GBD super region in 2014–40 Per capita spending is measured in 2015 purchasing power parity US$. The left side of each bar marks the 2014 health spending for each group. The right side of the bar represents the expected 2040 health spending. The bar shows the expected increase in health spending between 2014 and 2040, and highlights the source of the spending growth. GBD=global burden of disease.

Figure 3

Expected health spending frontiers in 2040 Per capita spending is measured in 2015 PPP US$. The fitted lines are the estimated spending frontier. GDP=gross domestic product. PPP$=purchasing power parity US$.

Figure 4

Potential government health spending of the six most populated low-income and lower-middle-income countries in 2040 Per capita spending is measured in 2015 PPP US$. The grey fitted lines are the estimated government health spending frontier. The short red lines parallel to the frontier represents the increases possible simply by raising more government spending. The vertical distance between the black and coloured lines represents potential increases in government health spending.

Figure 5

Potential increase in government health spending in 2040 The potential increase is the ratio of potential government health spending over expected government health spending, where potential spending is based on generating all-sector government spending and prioritising health sector at the level indicated by each frontier, based on each country's gross domestic product per capita in 2040. High-income countries and Zimbabwe are grey because we did not complete the potential spend counterfactual for these countries. ATG=Antigua and Barbuda. FSM=Federated States of Micronesia. LCA=Saint Lucia. TLS=Timor-Leste. TTO=Trinidad and Tobago. VCT=Saint Vincent and the Grenadines.

Figure 6

Government health financing expected and potential by global burden of disease super region in 2040 Per capita spending is measured in 2015 purchasing power parity US$. The size of the dot is scaled to reflect the amount of government health spending per capita. Each global burden of disease region has three bubbles. The bubble on the left marks the 2014 amount.