A quantitative analysis of sources of changes in government expenditures on health, 2000 to 2015: what can we learn from experience to date?

Background: Achieving universal health coverage (UHC) requires increased domestic financing of health by low-income countries (LICs) and middle-income countries (MICs). It is critical to understand how much governments have devoted to health from their own sources and how much growth might be realistic over time. Methods: Using data from WHO’s Global Health Expenditure Database, we examined how the composition of current health expenditure changed by financing source and the main sources of growth in health expenditures from 2000-2015. We also disaggregated how much growth in government expenditures on health from domestic sources was due to economic growth, growth in the tax base, reallocations in government expenditures towards health, and the interactions of these factors. Results: Lower MICs (LMICs) and upper MICs (UMICs), as a group, saw a significant reduction in out-of-pocket expenditures and a significant growth in government expenditures on health from domestic sources as a share of current health expenditures over the period. This trend indicates likely progress in the pathway to UHC. For LICs, these trends were much more muted. Growth in government expenditure on health from domestic sources was driven primarily by economic growth in LICs, LMICs, and UMICs. Growth in government expenditure on health due to a strengthened tax base was most important in UMICs. For high-income countries, where economic growth was relatively slower and tax bases were already strong, the largest driver of growth in government expenditure on health from domestic sources was reallocation of the government budget towards health. Conclusions: Given these findings from 2000-2015, discussions about a government’s ability to reallocate to health from its overall budget need to be evidence based and pragmatic. Dialogue on domestic resource mobilization needs to emphasize overall economic growth and growth in the tax base as well as the share of health in the government budget.