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
Open accessAbstract
BACKGROUND: Comprehensive and comparable estimates of health spending in each country are a key input for health policy and planning, and are necessary to support the achievement of national and international health goals. Previous studies have tracked past and projected future health spending until 2040 and shown that, with economic development, countries tend to spend more on health per capita, with a decreasing share of spending from development assistance and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending, with an emphasis on equity in spending across countries. METHODS: We estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories-government, out-of-pocket, and prepaid private health spending-and estimated development assistance for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, 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. 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 disparitie
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Healthcare expenditure has become a significant component of global spending, and many health systems face challenges to improve efficiency and provide sustainable care.
“Healthcare expenditure has become a significant component of global spending14, and many health systems face challenges to improve efficiency and provide sustainable care15,16.”
From Early prediction of diagnostic-related groups and estimation of hospital cost by processing clinical notes (2021) · cites this paper as [15]
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- Authors
- Chang, A. Y., Cowling, K., Micah, A. E., Chapin, A., Chen, C. S., Ikilezi, G., Sadat, N., Tsakalos, G., Wu, J., Younker, T., Zhao, Y., Zlavog, B. S., Abbafati, C., Ahmed, A. E., Alam, K., Alipour, V., Aljunid, S. M., Almalki, M. J., Alvis-Guzman, N., Ammar, W., Andrei, C. L., Anjomshoa, M., Antonio, C. A. T., Arabloo, J., Aremu, O., Ausloos, M., Avila-Burgos, L., Awasthi, A., Ayanore, M. A., Azari, S., Azzopardi-Muscat, N., Bagherzadeh, M., Bärnighausen, T. W., Baune, B. T., Bayati, M., Belay, Y. B., Belay, Y. A., Belete, H., Berbada, D. A., Berman, A. E., Beuran, M., Bijani, A., Busse, R., Cahuana-Hurtado, L., Cámera, L. A., Catalá-López, F., Chauhan, B. G., Constantin, M.-M., Crowe, C. S., Cucu, A., Dalal, K., De Neve, J.-W., Deiparine, S., Demeke, F. M., Do, H. P., Dubey, M., El Tantawi, M., Eskandarieh, S., Esmaeili, R., Fakhar, M., Fazaeli, A. A., Fischer, F., Foigt, N. A., Fukumoto, T., Fullman, N., Galan, A., Gamkrelidze, A., Gezae, K. E., Ghajar, A., Ghashghaee, A., Goginashvili, K., Haakenstad, A., Haghparast Bidgoli, H., Hamidi, S., Harb, H. L., Hasanpoor, E., Hassen, H. Y., Hay, S. I., Hendrie, D., Henok, A., Heredia-Pi, I., Herteliu, C., Hoang, C. L., Hole, M. K., Homaie Rad, E., Hossain, N., Hosseinzadeh, M., Hostiuc, S., Ilesanmi, O. S., Irvani, S. S. N., Jakovljevic, M., Jalali, A., James, S. L., Jonas, J. B., Jürisson, M., Kadel, R., Karami Matin, B., Kasaeian, A., Kasaye, H. K., Kassaw, M. W., Kazemi Karyani, A., Khabiri, R., Khan, J., Khan, M. N., Khang, Y.-H., Kisa, A., Kissimova-Skarbek, K., Kohler, S., Koyanagi, A., Krohn, K. J., Leung, R., Lim, L.-L., Lorkowski, S., Majeed, A., Malekzadeh, R., Mansourian, M., Mantovani, L. G., Massenburg, B. B., McKee, M., Mehta, V., Meretoja, A., Meretoja, T. J., Milevska Kostova, N., Miller, T. R., Mirrakhimov, E. M., Mohajer, B., Mohammad Darwesh, A., Mohammed, S., Mohebi, F., Mokdad, A. H., Morrison, S. D., Mousavi, S. M., Muthupandian, S., Nagarajan, A. J., Nangia, V., Negoi, I., Nguyen, C. T., Nguyen, H. L. T., Nguyen, S. H., Nosratnejad, S., Oladimeji, O., Olgiati, S., Olusanya, J. O., Onwujekwe, O. E., Otstavnov, S. S., Pana, A., Pereira, D. M., Piroozi, B., Prada, S. I., Qorbani, M., Rabiee, M., Rabiee, N., Rafiei, A., Rahim, F., Rahimi-Movaghar, V., Ram, U., Ranabhat, C. L., Ranta, A., Rawaf, D. L., Rawaf, S., Rezaei, S., Roro, E. M., Rostami, A., Rubino, S., Salahshoor, M., Samy, A. M., Sanabria, J., Santos, J. V., Santric Milicevic, M. M., Sao Jose, B. P., Savic, M., Schwendicke, F., Sepanlou, S. G., Sepehrimanesh, M., Sheikh, A., Shrime, M. G., Sisay, S., Soltani, S., Soofi, M., Soofi, M., Srinivasan, V., Tabarés-Seisdedos, R., Torre, A., Tovani-Palone, M. R., Tran, B. X., Tran, K. B., Undurraga, E. A., Valdez, P. R., van Boven, J. F. M., Vargas, V., Veisani, Y., Violante, F. S., Vladimirov, S. K., Vlassov, V., Vollmer, S., Vu, G. T., Wolfe, C. D. A., Yonemoto, N., Younis, M. Z., Yousefifard, M., Zaman, S. B., Zangeneh, A., Zegeye, E. A., Ziapour, A., Chew, A., Murray, C. J. L., & Dieleman, J. L.
- Affiliations
- University of Washington (US)
- Corresponding author
- Dieleman, Joseph L
- ORCID
- Chang, Angela Y.
- Cowling, Krycia
- Younker, Theodore
- Zhao, Yingxi
- Abbafati, Cristiana
- Alam, Khurshid
- Alipour, Vahid
- Aljunid, Syed Mohamed
- Almalki, Mohammed J.
- Ammar, Walid
- Antonio, Carl Abelardo T.
- Arabloo, Jalal
- Aremu, Olatunde
- Ausloos, Marcel
- Awasthi, Ashish
- Ayanore, Martin Amogre
- Azari, Samad
- Bagherzadeh, Mojtaba
- Bärnighausen, Till Winfried
- Bayati, Mohsen
- Belay, Yared Belete
- Belay, Yihalem Abebe
- Belete, Habte
- Berman, Adam E.
- Beuran, Mircea
- Bijani, Ali
- Busse, Reinhard
- Cahuana-Hurtado, Lucero
- Cámera, Luis Alberto
- Catalá-López, Ferrán
- Chauhan, Bal Govind
- Crowe, Christopher Stephen
- Cucu, Alexandra
- Dalal, Koustuv
- Deiparine, Selina
- Demeke, Feleke Mekonnen
- Do, Huyen Phuc
- Dubey, Manisha
- Eskandarieh, Sharareh
- Esmaeili, Reza
- Fakhar, Mahdi
- Fazaeli, Ali Akbar
- Fischer, Florian
- Foigt, Nataliya A.
- Fukumoto, Takeshi
- Fullman, Nancy
- Gezae, Kebede Embaye
- Ghajar, Alireza
- Ghashghaee, Ahmad
- Haakenstad, Annie
- Hamidi, Samer
- Harb, Hilda L.
- Hasanpoor, Edris
- Hassen, Hamid Yimam
- Hay, Simon I.
- Hendrie, Delia
- Henok, Andualem
- Heredia-Pi, Ileana
- Hoang, Chi Linh
- Hossain, Naznin
- Hosseinzadeh, Mehdi
- Hostiuc, Sorin
- Ilesanmi, Olayinka Stephen
- Irvani, Seyed Sina Naghibi
- Jalali, Amir
- James, Spencer L.
- Jonas, Jost B.
- Jürisson, Mikk
- Kadel, Rajendra
- Kasaeian, Amir
- Kasaye, Habtamu Kebebe
- Kassaw, Mesfin Wudu
- Khabiri, Roghayeh
- Khan, Junaid
- Khan, Md Nuruzzaman
- Khang, Young-Ho
- Koyanagi, Ai
- Leung, Ricky
- Lim, Lee-Ling
- Majeed, Azeem
- Malekzadeh, Reza
- Mansourian, Morteza
- Mantovani, Lorenzo Giovanni
- Massenburg, Benjamin Ballard
- McKee, Martin
- Mehta, Varshil
- Meretoja, Atte
- Meretoja, Tuomo J
- Miller, Ted R
- Mirrakhimov, Erkin M
- Mohajer, Bahram
- Mohammed, Shafiu
- Mohebi, Farnam
- Mokdad, Ali H
- Morrison, Shane Douglas
- Mousavi, Seyyed Meysam
- Nagarajan, Ahamarshan Jayaraman
- Nguyen, Cuong Tat
- Nguyen, Huong Lan Thi
- Nguyen, Son Hoang
- Nosratnejad, Shirin
- Oladimeji, Olanrewaju
- Olgiati, Stefano
- Olusanya, Jacob Olusegun
- Onwujekwe, Obinna E
- Otstavnov, Stanislav S
- Pereira, David M.
- Piroozi, Bakhtiar
- Prada, Sergio I
- Qorbani, Mostafa
- Rabiee, Mohammad
- Rabiee, Navid
- Rafiei, Alireza
- Rahim, Fakher
- Ram, Usha
- Ranabhat, Chhabi Lal
- Rawaf, David Laith
- Rawaf, Salman
- Rezaei, Satar
- Roro, Elias Merdassa
- Rostami, Ali
- Rubino, Salvatore
- Samy, Abdallah M.
- Sanabria, Juan
- Santos, João Vasco
- Savic, Miloje
- Schwendicke, Falk
- Sepanlou, Sadaf G.
- Sepehrimanesh, Masood
- Sheikh, Aziz
- Shrime, Mark G
- Sisay, Solomon
- Soltani, Shahin
- Srinivasan, Vinay
- Tran, Bach Xuan
- Tran, Khanh Bao
- Undurraga, Eduardo A.
- Valdez, Pascual R
- Veisani, Yousef
- Violante, Francesco S
- Vladimirov, Sergey Konstantinovitch
- Vlassov, Vasily
- Vu, Giang Thu
- Wolfe, Charles D A
- Yonemoto, Naohiro
- Younis, Mustafa Z.
- Yousefifard, Mahmoud
- Zaman, Sojib Bin
- Zangeneh, Alireza
- Zegeye, Elias Asfaw
- Ziapour, Arash
- Murray, Christopher J L
- Dieleman, Joseph L
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2019-06
- Volume
- 393
- Issue
- 10187
- Pages
- 2233-2260
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC6548764
- OpenAlex
- W2941926021
- Cited by
- 520
- References
- 27
- Citations by year
- 2026: 32 · 2025: 49 · 2024: 60 · 2023: 101 · 2022: 97 · 2021: 81 · 2020: 80 · 2019: 17 · 2018: 2
- FWCI
- 93.67
- Type
- journal article
- Language
- en
- Update notices
- erratum (2021-09-11)
- Open access
- hybrid
- doi.org
- Licence
- Locations
- The Lancet (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- University of Southern Denmark Research Portal (University of Southern Denmark) (publishedVersion, cc-by)
- BCU Open Access Repository (Birmingham City University) (acceptedVersion)
- Research Open (London South Bank University) (acceptedVersion, cc-by-nc-nd)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- Työväentutkimus Vuosikirja (submittedVersion)
- Minerva Access (University of Melbourne) (submittedVersion, cc-by)
- Murdoch University Research Portal (submittedVersion, cc-by)
- Murdoch University Research Portal (submittedVersion)
- Homo Politicus (Academy of Humanities and Economics in Lodz) (submittedVersion, cc-by-nc-nd)
- Jagiellonian University Repository (Jagiellonian University) (submittedVersion, cc-by-nc-nd)
- Homo Politicus (Academy of Humanities and Economics in Lodz) (submittedVersion)
- Diva portal (Dalarna University Library) (submittedVersion, other-oa)
- BOA (University of Milano-Bicocca) (submittedVersion, other-oa)
- Archivio istituzionale della ricerca (Alma Mater Studiorum Università di Bologna) (submittedVersion)
- LA Referencia (Red Federada de Repositorios Institucionales de Publicaciones Científicas) (submittedVersion, cc-by-nc-nd)
- Research Repository Portal (Ilam University of Medical Sciences) (submittedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Figshare (submittedVersion, cc-by)
- IRIS Research product catalog (Sapienza University of Rome) (submittedVersion)
- Leicester Research Archive (University of Leicester) (submittedVersion, cc-by)
- Publikationen an der Universität Bielefeld (Universität Bielefeld) (submittedVersion)
- GoeScholar The Publication Server of the Georg-August-Universität Göttingen (Georg-August-Universität Göttingen) (submittedVersion, other-oa)
- GoeScholar The Publication Server of the Georg-August-Universität Göttingen (Georg-August-Universität Göttingen) (submittedVersion, cc-by)
- Edinburgh Research Explorer (University of Edinburgh) (submittedVersion, other-oa)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, cc-by)
- Seoul National University Open Repository (Seoul National University) (submittedVersion)
- Spiral (Imperial College London) (submittedVersion, cc-by)
- NOVA (University of Newcastle Australia) (submittedVersion)
- Funders
- Damon Runyon Cancer Research Foundation
- Topics
- Health Sciences › Health Professions › General Health Professions › Global Health Care Issues
- Social Sciences › Economics, Econometrics and Finance › Finance › Healthcare Systems and Reforms
- Social Sciences › Political Science and International Relations › Public health and occupational medicine
- Keywords
- global health financing, health spending, development assistance for health, public health expenditure, out-of-pocket health expenditure, demographic decomposition, health spending growth, health policy planning, low- and middle-income countries, high-income countries
- MeSH terms
- Health Expenditures, Humans, Public Assistance, Global Health, Prepaid Health Plans, Models, Economic, Gross Domestic Product, Healthcare Financing
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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