Intertemporal Dynamics of Public Financing for Universal Health Coverage : Accounting for Fiscal Space Across Countries
As countries undergo their health financing transitions, moving away from external and out-of-pocket (OOP) financing toward domestically sourced public financing, the issue of fiscal space – that is, of finding ways to increase public financing in...
| Main Authors: | , , , |
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| Format: | Working Paper |
| Language: | English |
| Published: |
World Bank, Washington, DC
2019
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| Subjects: | |
| Online Access: | http://documents.worldbank.org/curated/en/639541545281356938/Intertemporal-Dynamics-of-Public-Financing-for-Universal-Health-Coverage-Accounting-for-Fiscal-Space-Across-Countries http://hdl.handle.net/10986/31211 |
| Summary: | As countries undergo their health
financing transitions, moving away from external and
out-of-pocket (OOP) financing toward domestically sourced
public financing, the issue of fiscal space – that is, of
finding ways to increase public financing in an efficient,
equitable, and sustainable manner -- is front and center in
the policy dialogue around universal health coverage (UHC).
Although how money is expended is just as critical as the
overall resource envelope, we analyze changes in per capita
public financing for health in real terms, a proxy for
realized fiscal space, within and across 151 countries over
time. This allows for an assessment not just of trends in
public financing for health but also of contributions from
three macro-fiscal drivers -- economic growth, changes in
aggregate public spending, and reprioritization for health
-- exploiting a macroeconomic identity that captures the
relationship between these factors. Analysis of data from
2000 to 2015 shows per capita public financing for health in
low- and middle-income countries increased by 5.0 percent
per year on average: up from US$60 (2.2 percent of GDP) in
2000 to US$117 (2.8 percent of gross domestic product [GDP])
in 2015. Some of the largest increases were in countries in
the Europe and Central Asia (ECA) and East Asia and Pacific
(EAP) regions. At 3.1 percent per year, annual growth in
public financing for health was lower among high-income
countries, albeit from a much higher baseline in 2000.
Increases in on-budget external financing comprised most of
the changes among low-income countries, whereas domestic
government revenues dominated changes in composition of
public financing among lower- and upper-middle-income
countries. Public financing increased at a faster rate than
OOP sources for health in most regions except for South
Asia. Although there are important country-specific
differences, it is notable that more than half of the
increase in public financing for health was due to economic
growth alone. For the remainder of the increase, aggregate
public spending contributed more than reprioritization
across low and lower-middle-income countries, whereas the
reverse was true in high-income countries. One key point of
note from the landscaping exercise summarized in the paper
is the diversity of growth trajectories across countries
and, especially, the volatility in trends over time. The
implications are clear: capturing public financing with a
single growth rate is not the best metric to characterize
country experiences, many of which are punctuated by
episodes wherein trends are flat or have varying degrees of
growth rates (positive or negative). Although country
context matters, the importance of economic growth for
public financing for health underscores the critical need to
situate, integrate, leverage, and proactively manage health
financing reforms within a country’s overall macro-fiscal
context and to assess different pillars of fiscal space holistically. |
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