Spending on health and HIV/AIDS: domestic health spending and development assistance in 188 countries, 1995-2015

Abstract

Background: Comparable estimates of health spending are crucial for the assessment of health systems and to optimally deploy health resources. The methods used to track health spending continue to evolve, but little is known about the distribution of spending across diseases. We developed improved estimates of health spending by source, including development assistance for health, and, for the first time, estimated HIV/AIDS spending on prevention and treatment and by source of funding, for 188 countries.

Methods: We collected published data on domestic health spending, from 1995 to 2015, from a diverse set of international agencies. We tracked development assistance for health from 1990 to 2017. We also extracted 5385 datapoints about HIV/AIDS spending, between 2000 and 2015, from online databases, country reports, and proposals submitted to multilateral organisations. We used spatiotemporal Gaussian process regression to generate complete and comparable estimates for health and HIV/AIDS spending. We report most estimates in 2017 purchasing-power parity-adjusted dollars and adjust all estimates for the effect of inflation.

Findings: Between 1995 and 2015, global health spending per capita grew at an annualised rate of 3·1% (95% uncertainty interval [UI] 3·1 to 3·2), with growth being largest in upper-middle-income countries (5·4% per capita [UI 5·3-5·5]) and lower-middle-income countries (4·2% per capita [4·2-4·3]). In 2015, $9·7 trillion (9·7 trillion to 9·8 trillion) was spent on health worldwide. High-income countries spent $6·5 trillion (6·4 trillion to 6·5 trillion) or 66·3% (66·0 to 66·5) of the total in 2015, whereas low-income countries spent $70·3 billion (69·3 billion to 71·3 billion) or 0·7% (0·7 to 0·7). Between 1990 and 2017, development assistance for health increased by 394·7% ($29·9 billion), with an estimated $37·4 billion of development assistance being disbursed for health in 2017, of which $9·1 billion (24·2%) targeted HIV/AIDS. Between 2000 and 2015, $562·6 billion (531·1 billion to 621·9 billion) was spent on HIV/AIDS worldwide. Governments financed 57·6% (52·0 to 60·8) of that total. Global HIV/AIDS spending peaked at 49·7 billion (46·2-54·7) in 2013, decreasing to $48·9 billion (45·2 billion to 54·2 billion) in 2015. That year, low-income and lower-middle-income countries represented 74·6% of all HIV/AIDS disability-adjusted life-years, but just 36·6% (34·4 to 38·7) of total HIV/AIDS spending. In 2015, $9·3 billion (8·5 billion to 10·4 billion) or 19·0% (17·6 to 20·6) of HIV/AIDS financing was spent on prevention, and $27·3 billion (24·5 billion to 31·1 billion) or 55·8% (53·3 to 57·9) was dedicated to care and treatment.

Interpretation: From 1995 to 2015, total health spending increased worldwide, with the fastest per capita growth in middle-income countries. While these national disparities are relatively well known, low-income countries spent less per person on health and HIV/AIDS than did high-income and middle-income countries. Furthermore, declines in development assistance for health continue, including for HIV/AIDS. Additional cuts to development assistance could hasten this decline, and risk slowing progress towards global and national goals.

Funding: The Bill & Melinda Gates Foundation.

Figure 1

Annualised rate of change of health spending and population, 1995–2015 Annualised rate of change of health spending and population by income groups (A,B) and Global Burden of Disease super-regions (C,D). Income groups are 2017 World Bank income groups and held constant across time. Diamonds represent population growth rates. Error bars represent uncertainty intervals for rate of change of health spending.

Figure 2

Development assistance for health by channel and health focus area, 1990–2017 Development assistance for health annual estimates and annualised growth rates, disaggregated by channel (A, B) and health focus area (C, D). Estimates are shown from 1990 to 2017, in billions of 2017 US$. Growth rates are shown for 2000–10, and 2010–17. Gavi channel annualised growth rates were excluded from panel B because of high annualised growth rates between 2000 and 2010, resulting from large increases in funding from the organisation's inception (in 2000) to 2010. World Bank includes the International Development Association and the International Bank for Reconstruction and Development; and regional development banks include the Inter-American Development Bank, the African Development Bank, and the Asian Development Bank. NGOs=non-governmental organisations. Global Fund=The Global Fund to Fight AIDS, Tuberculosis and Malaria. Gavi=Gavi, the Vaccine Alliance. UNFPA=United Nations Population Fund. UNAIDS=Joint United Nations Programme on HIV/AIDS. PAHO=Pan American Health Organization. SWAP/HSS=sector-wide approaches/health system strengthening. *Data for 2017 are preliminary estimates based on budget data and estimation.

Figure 3

Development assistance for HIV/AIDS and pandemic preparedness, 1990–2017 Development assistance for HIV/AIDS by (A) source and (B) programme area, and for pandemic preparedness by channel (C). Spending is reported in 2017 US$. OECD=Organisation for Economic Co-operation and Development. DAC=Development Assistance Committee. PMTCT=prevention of mother-to-child transmission. NGOs=non-governmental organisations. *Data for 2017 are preliminary estimates based on budget data and estimation.

Figure 4

HIV/AIDS spending, 2000–15 HIV/AIDS spending by (A) income group, (B) source, (C) function, and (D) prevalence group. Spending is reported in 2017 purchasing-power parity-adjusted dollars. Income groups are based on 2017 World Bank income groups. Income group specifies where the resources were spent, not the source of the funds. HIV/AIDS prevalence data are from the Global Burden of Disease Study 2016.

Figure 5

Annualised rate of change of HIV/AIDS spending per prevalent case, 2000–10 (A), and 2010–15 (B), by source and prevalence group Annualised rate of change of government and out-of-pocket spending on HIV/AIDS, and development assistance for HIV/AIDS. Number of prevalent cases date to 2015 and are sourced from the Global Burden of Disease Study 2016. Error bars represent 95% uncertainty intervals.

Figure 6

Domestic HIV/AIDS spending, development assistance for HIV/AIDS, and number of people living with HIV/AIDS, 2015 The size of each pie represents the number of people living with HIV/AIDS in 2015, in each specified Global Burden of Disease super-region. Domestic spending includes out-of-pocket, government, and prepaid private spending. Number of prevalent cases date to 2015, and are sourced from the Global Burden of Disease Study 2016.

Figure 7

Spending, population size, and disability-adjusted life -years overall and for HIV/AIDS, by income group, 2015 Income groups are 2017 World Bank income groups.