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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. 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. 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. 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. Bill & Melinda Gates Foundation.

Background Fighting illness and poverty are intertwined objectives in global development. In recent decades, health financing reforms across many nations have enhanced financial protection for low-income populations and promoted health equity for all citizens. However, prior cross-national comparative studies predominantly focused on examining financing structures or social health insurance (SHI) schemes, neglecting financing schemes targeting the poor, such as medical financial assistance (MFA). This study comparatively explores the design of health financing schemes and financial protection outcomes for low-income populations across six societies in East Asia: mainland China, Hong Kong, Taiwan, Japan, South Korea, and Singapore. Methods We assess the design of health financing schemes from the dimensions of income-based eligibility, population coverage, and benefit generosity. Policy information was collected from official websites and policy reports. To compare financial protection outcomes, we derived the data through the “model family approach” and jurisdiction-level statistics and simulated catastrophic health spending of lung cancer for individuals across four income levels: (1) no income; (2) earning minimum wage; (3) earning half the national/regional average wage; and (4) earning the national/regional average wage. Results We find that health financing schemes in Taiwan and Hong Kong are generous and inclusive for general populations, while Japan, South Korea, and Singapore’s financing schemes are protective and offer relatively generous benefits for vulnerable groups. In contrast, mainland China provides limited benefits in SHI and MFA schemes. Health financing schemes reduce the financial burden to varying degrees, with Taiwan, Hong Kong, and South Korea providing financial protection for low-income populations to a higher degree, followed by Japan, Singapore, and mainland China. Notably, our findings highlight inequities for individuals earning half the average wage in Singapore, mainland China, and Japan (and to a lesser extent in Taiwan, Hong Kong and Korea), as these groups face higher risks of catastrophic health spending compared to other income groups. Conclusions Our findings further the understanding of health financing designs in East Asia. We also provide evidence for governments to enhance financial protection for low-income populations, particularly near-poor groups, to achieve more equitable health financing arrangements.

Background Implementing health financing equity plays a determining role in achieving Universal Health Coverage. For this reason, the global health community stated multiple political declarations to guide health financing equity implementation in countries. The aim of this study was to investigate the global strategies for implementing health financing equity that emerged from political declarations made before 2024. Methods Using a state-of-the-art review design, we identified the political declarations from the search of United Nations databases and the snowball search. We used textual and theoretical thematic analysis methods to extract the global strategies of health financing equity implementation that emerged from the political declarations. We grounded the global strategies in the existing practical framework – the Health Financing Progress Matrix of the World Health Organization. We employed a time-based descriptive analysis method to document the results. Quantitative information was used to shape the analysis. Results In total, 40 political declarations were included in the review. From these declarations emerged the strategies of targeted, selective, contributive, universal, claims, proportionate, experimental, united, and aggregated financing to implement health financing equity in countries. Thirty nine of the 40 political declarations that labelled the global health community from 1944 until 2023 placed more efforts on duplicating the prevailing strategies. The declarations, categorised into nine groups (target, unity, universality, selectivity, contribution, aggregation, claims, experience, and proportionality-oriented political declarations), were insistent to press countries effectively implement the strategies. Conclusion The political declarations proved to be the essential markers of the global health community’s efforts to raise the profile of health financing equity in countries. Although some of the global strategies that emerged from the political declarations have been shown promise in different countries, any global strategy is neither effective nor optimal for providing efficient and sustainable UHC in all countries. This lays the groundwork for careful management and adaptation of the global strategies to the diverse needs of the diverse population.

Background One of the major goals of health systems is providing a financing strategy without inequality; this has a significant impact on people’s access to healthcare. The present study aimed to investigate the inequality in households’ financial contribution (HFC) to health expenditure both before and after the implementation of the Iranian Health Transformation Plan (HTP) in 2014. Methods This study is a secondary analysis of two waves of a national survey conducted in Iran. The data were collected from the Households Income and Expenditure Survey in 2013 and 2015. The research sample included 76,195 Iranian households. The inequality in households’ financial contributions to the health system was assessed using the Gini coefficient, and the concentration index (CI). In addition, by using econometric modeling, the relationship between the implementation of the HTP and inequality in HFC was studied. The households’ financial contribution included healthcare and health insurance prepayments. Results The Gini coefficient values were 0.67 and 0.65 in 2013 and 2015, respectively, indicating a medium degree of inequality in HFC in both years. The CI values were 0.54 and 0.56 in 2013 and 2015, respectively, suggesting that inequalities in HFC were in favor of higher income quintiles in the years before and after the implementation of the HTP. Regression analysis showed that households with a female head, with an unemployed head, or with a head having income without a job were contributing more to financing health expenditure. The presence of a household member over the age of 65 was associated with a higher level of HFC. The implementation of the HTP had a negative relationship with the HFC. Conclusion The HTP, aiming to address inequality in the financing system, did not achieve the intended goal as expected. The implementation of the HTP neglected certain factors at the household level, such as the presence of family members older than the age of 65, a female household head, and unemployment. This resulted in a failure to reduce the inequality of the HFC. We suggest that, in the future, policymakers take into account factors at the household level to reduce inequality in the HFC.

Sanderson et al's realist review of strategic purchasing identifies insights from two strands of theory: the economics of organisation and inter-organisational relationships. Our findings from a programme of research conducted by the RESYST (Resilient and Responsive Health Systems) consortium in seven countries echo these results, and add to them the crucial area of organisational capacity to implement complex reforms. We identify key areas for policy development. These are the need for: (1) a policy design with clearly delineated responsibilities; (2) a task network of organisations to engage in the broad set of functions needed; (3) more effective means of engaging with populations; (4) a range of technical and management capacities; and (5) an awareness of the multiple agency relationships that are created by the broader financing environment and the provider incentives generated by multiple financing flows.

The Global Financing Facility (GFF), launched in 2015, aims to catalyse funding for reproductive, maternal, newborn, child, and adolescent health, and nutrition. Few independent assessments have evaluated its processes and impact. We conducted a multi-layered policy analysis of GFF documents - the Investment Cases (ICs) and the GFF-linked World Bank Project Appraisal Documents (PADs) - examining the content of GFF documents for 28 countries, comparing four tracer themes (maternal and newborn health, adolescent health, community health, and quality), and analysing the policy processes in four country studies (Burkina Faso, Mozambique, Tanzania, and Uganda). From 2015 to 2022, GFF-linked PADs reported US$ 14.5 billion of funding across 26 countries through 30 PADs, with GFF contributing 4% to this value. GFF investments primarily focused on service delivery, governance, and performance-based financing. Countries received more targeted investments for maternal and newborn health and adolescent health linked to their burden of these tracer themes. Attention to community health and quality varied. ICs were broader than PADs and more inclusive in their development. Local contexts shaped policy processes. GFF supported priority-setting and learning; however, translating priorities into resourced actions proved challenging. Power dynamics influenced country ownership, donor coordination and resource mobilisation. The GFF is a significant opportunity to advance health for vulnerable populations. Progress in transparency and data use is evident, but accountability gaps, power imbalances, and limited engagement with civil society and private sector hinder national ownership. Further research is needed to determine GFF's attribution to catalytic resource mobilization.

Background Various attempts to examine health financing mechanisms in Nigeria highlight the fact that there is no single mechanism that fits all contexts and people. This paper sets out findings of an in-depth assessment of different health financing mechanisms in Nigeria. Methods The study was undertaken in the Federal Capital territory of Nigeria and two States (Niger and Kaduna). Data were collected through review of government documents, and in-depth interviews of purposively selected respondents. Data analysis was guided by a conceptual framework which draws from various approaches for assessing health financing mechanisms. Data was examined for current practices, what needs to change and how the change can happen. Results Health financing mechanisms in Nigeria do not operate optimally. Allocation and use of resources are neither evidence-based nor results-driven. Resources are not allocated equitably or in a manner that minimizes wastage and improves efficiency. None of the mechanisms effectively protects individuals/households from catastrophic health expenditure. Issues with social health insurance cut across legal frameworks and use of Health Maintenance Organisations (HMOs) as purchasers. The concomitant effect is that attainment of Universal Health Coverage is greatly compromised. In order to improve efficiency of health financing mechanisms, government needs to allocate more funds for purchasing health services; this spending must be based on evidence (strategic), and appropriately tracked. The legislation that established National Health Insurance Scheme should be amended such that social health insurance becomes mandatory for all citizens. Implementation of the latter should be complemented by revision of benefit package, strict oversight and regulation of HMOs. Conclusion In order to improve health financing in the country, legal and regulatory frameworks need to be revised. Efficient utilization of resources could be improved through strategic purchasing arrangements and strict oversight.

Although performance-based financing (PBF) receives increasing attention in the literature, a lot remains unknown about the exact mechanisms triggered by PBF arrangements. This article aims to summarize current knowledge on how PBF works, set out what still needs to be investigated and formulate recommendations for researchers and policymakers from donor and recipient countries alike. Drawing on an extensive systematic literature review of peer-reviewed journals, we analysed 35 relevant articles. To guide us through this variety of studies, point out relevant issues and structure findings, we use a comprehensive analytical framework based on eight dimensions. The review inter alia indicates that PBF is generally welcomed by the main actors (patients, health workers and health managers), yet what PBF actually entails is less straightforward. More research is needed on the exact mechanisms through which not only incentives but also ancillary components operate. This knowledge is essential if we really want to appreciate the effectiveness, desirability and appropriate format of PBF as one of the possible answers to the challenges in the health sector of low-and lower middle-income countries. A clear definition of the research constructs is a primordial starting point for such research. Même si le financement basé sur les résultats (PBF) bénéficie d’une attention croissante dans la littérature, il reste encore beaucoup à découvrir sur les mécanismes exacts déclenchés par des accords PBF. Le présent article vise à résumer les connaissances actuelles relatives au fonctionnement des accords PBF, déterminer ce qui doit encore être étudié et formuler des recommandations pour les chercheurs et les décideurs aussi bien des pays donateurs que des pays bénéficiaires. Partant d’un examen approfondi systématique des revues à comité de lecture, nous avons analysé 35 articles pertinents. Pour nous guider à travers cette série d’études, relever les questions pertinentes et structurer les conclusions, nous utilisons un cadre analytique complet basé sur huit dimensions. L’examen indique entre autres, que l’accord PBF est généralement bien accueilli par les principaux acteurs (patients, professionnels de la santé et gestionnaires de la santé), mais la véritable implication de l’accord PBF n’est pas aussi facilement perceptible. Il faut faire davantage de recherches sur les mécanismes exacts de fonctionnement, non seulement des mesures incitatives mais aussi des composants périphériques. Cette connaissance est essentielle si nous voulons vraiment apprécier l’efficacité, l’opportunité et la spécificité du format de l’accord PBF en tant qu’une des réponses possibles aux défis du secteur de la santé dans les pays à revenu faible ou intermédiaire de la tranche inférieure. Une définition claire des éléments de la recherche est un point de départ essentiel pour de telles recherches. Aunque el financiamiento basado en el rendimiento (FBR) recibe creciente atención en la literatura, poco se sabe sobre los mecanismos exactos que son desencadenados por la organización del FBR. Este articulo tiene como objetivo resumir el conocimiento actual sobre cómo funciona el FBR, describir que necesita ser investigado y formular recomendaciones para los investigadores y creadores de políticas por parte de los donantes y países receptores. Utilizando un resumen extensivo de la literatura de las revistas evaluadas por pares, analizamos 35 artículos relevantes. Para guiarnos a través de esta variedad de artículos, destacar los temas relevantes y estructurar los hallazgos relevantes, usamos un marco analítico amplio basado en ocho dimensiones. El resumen, entre otras cosas, indica que el FBR es generalmente bienvenido por los actores principales (pacientes, trabajadores de salud y gerentes de salud), pero lo que el FBR conlleva no es claro. Se necesita más investigación sobre los mecanismos exactos a través de los cuales operan los objetivos y los componentes complementarios. Este conocimiento es esencial si queremos realmente entender la efectividad, el atractivo y el formato apropiado para el FBR como una de las posibles respuestas a los retos en el sector de salud en los países de ingresos bajos y medios. Una definición clara de la construcción de la investigación es un punto de partida primordial para este tipo de investigación. 尽管绩效融资得到文献研究的日益关注, 但是现有研究对绩效 融资安排产生的具体的机制知之甚少。本文旨在总结现有关于 绩效融资运作方式的知识, 设置仍需被调查的方面, 为来自类似 的投资国和融资国研究者和政策制定者提出建议。根据对相关 回顾性期刊的扩展系统性文献综述, 我们分析了35篇相关文 章。为了指导我们了解这一系列的研究, 指出相关问题和结构 性结论, 我们使用了一个基于8个层面的综合性分析结构。本研 究综述特别指出绩效融资受到关键行为主体 （病人、医疗工作 者和医疗主管） 的广泛欢迎, 但是绩效融资赋予的东西并没有 那么直接。需要更多的研究探讨具体机制, 通过该机制激励和 辅助部分同时运转。如果我们真的想要理解绩效融资作为中低 收入国家医疗部门面对挑战潜在解决方案的有效性、受欢迎程 度和合适的形式, 那么该知识是关键。对于这样的研究来说首 要的入手点在于一个明确的研究结构定义。