12/11/2023

The launch of the Global Health Expenditure Report 2023, December 11, 2023

Global spending on health: Coping with the pandemic

Time Topic

14:30-14:35 Meeting logistics

Opening
14:35-14:40 Dr Bruce Aylward,
Assistant Director-General of the Universal Health Coverage, Life Course Division. WHO

Global spending on health: A poll survey

14:40-14:50
(WHO Health Accounts Team & participants)

Highlights from the report

14:50-15:15
Ke Xu, Senior Health Financing and Expenditure Analyst. WHO

Panel discussion
Walaiporn Patcharanarumol, Director, Global Health Division of the MOH Thailand.
Ogochukwu Chukwujekwu, Lead, health financing and investment, WHO/AFRO
15:15-15:55
Francesca Colombo, Head, the Health Division, OECD
David Wilson, Senior Program Officer, the Bill and Melinda Gates Foundation
Christoph Kurowski, Global Lead for Health Financing, the World Bank Group

15:55-16:00 Wrap up

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Housekeeping

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Opening Speech
Dr Bruce Aylward,
Assistant Director-General

The Universal Health Coverage, Life Course Division, WHO

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A poll survey

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 12/11/2023

Global spending on health:

Coping with the pandemic

WHO Health Accounts Team

11 December 2023

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Highlights from the report

Higher health spending in 2021- the 2nd year of the global pandemic

Health spending on COVID-19 increased in 2021

Adapting service delivery for pandemic control and sustaining essential services

Health capital investment played an important role in the COVID-19 response

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Higher health spending in 2021-

the 2nd year of the global pandemic

• Health spending: total current expenditure, capital investment is not included.

• Government spending on health from domestic sources: current expenditure,

including central and local governments spending on health through budget
transfers and compulsory health insurance contributions

• External aid on health: current expenditure, including aid channeled through

governments and nongovernmental organizations.

• All growth rates are in real terms

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Macro-fiscal context in 2021

2021
 GDP rose
 Government
spending with
diverse trends

2020
 GDP decreased
 Government
spending increased

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Year-to-year growth of health spending per capita

varied across income groups in 2020 and 2021
Health spending
per capita, 2021
Average
Income group
(US$)
Low income 45
Lower-middle income 146
Upper-middle income 531
High income 4001

 2020 to 2021:
increased, except
low income countries
 2019 to 2020:
increased in all
Note: Each coloured dot represents one country, and the white circle is the mean. The vertical lines from the bars extend to the maximum and minimum
values. The boxplots show the interquartile range (25th–75th percentile) of values; where the darkness of the bar changes is the median. Liberia, where income groups
health spending nearly doubled in 2020, is excluded from the graph for better visualization. Growth rates are based on per capita values in constant
(2021) national currency units. Country-specific GDP deflators were used to convert current values to constant values.
Data source: WHO Global Health Expenditure Database, 2023.

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Health spending as a share of GDP remained

higher in 2021 than before the COVID-19 pandemic

Health spending as
% of GDP, 2021

Income group Average

Low income 6.9%
Lower-middle income 5.4%
Upper-middle income 7.2%
High income 9.0%
Note: Group averages exclude countries with fewer than 600 000
people in 2021. Population data used in the report are from United
Nations, World Population Prospects, 2022 revision.

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Per capita government spending on health increased

from 2020 to 2021, except low income countries

Government spending
on health, per capita 2021

2020 to 2021:
– further increased, except
low income countries
– The growth was slower
than in 2020
2019 to 2020: increased

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Government health spending (GGHED) is the product of

health priority and total general government spending (GGE)
GGHED=health_priority × GGE

From 2020 to 2021

Low income countries

𝐺𝐺𝐻𝐸𝐷 ↓= ℎ𝑒𝑎𝑙𝑡ℎ_𝑝𝑟𝑖𝑜𝑟𝑖𝑡𝑦 ↓× 𝐺𝐺𝐸 ↓

Lower-middle income countries

𝐺𝐺𝐻𝐸𝐷 ↑= ℎ𝑒𝑎𝑙𝑡ℎ_𝑝𝑟𝑖𝑜𝑟𝑖𝑡𝑦 ±× 𝐺𝐺𝐸 ↑

High & upper-middle income countries

𝐺𝐺𝐻𝐸𝐷 ↑= ℎ𝑒𝑎𝑙𝑡ℎ_𝑝𝑟𝑖𝑜𝑟𝑖𝑡𝑦 ↑× 𝐺𝐺𝐸 ↓
Note: Growth indexes are based on per capita values in constant (2021) national currency units. Country-specific GDP deflators were used to
convert current values to constant values. Health priority refers to government spending on health as a share of general government spending.
Data source: WHO Global Health Expenditure Database, 2023.

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Per capita external aid increased in 2021, more in lower-

middle income countries than in low income countries
 In low income countries, government budgets deprioritized health in 2021 while external
aid for health was increasing
 In lower-middle income countries such pattern is less evident.

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In 2021, out-of-pocket spending on health per capita

generally returned to its pre-pandemic level
 From 2020 to 2021:

 High and upper middle income

countries: OOPs surpassed pre-
pandemic level

 Lower-middle income countries:

returned to pre-pandemic level

 Low income countries: OOPs

decreased

 From 2019 to 2020, OOPs decreased

in all income groups

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Across all income groups, the share of out-of-pocket spending in

total health spending declined during the pandemic (2020 & 2021)
\
 In the meantime, the
share of government
spending rose,
supported by
external spending in
low and lower--
middle income
countries

 Whether this trend

would continue
beyond the
pandemic period is
uncertain

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Health spending on COVID-19 increased in 2021,

accounting for an average of
11% of public spending on health

COVID-19 health spending Spending on other diseases

 48 countries for both 2020 and 2021
– 8 low income countries,
– 6 lower-middle income countries,
– 9 upper-middle income countries
– 25 high income countries.
 18 countries for prepandemic and 2020
– 11 low income countries
– 7 lower-middle income countries

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COVID-19 health spending did not trigger a decrease in

spending on other disease categories from 2019 to 2020
Average health spending per capita, by disease and condition, 2019 and 2020
 Initial results from
18 low and lower-
middle income
countries

 A firm conclusion
requires data from
a larger group of
countries and
through the whole
period of the
pandemic.

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Per capita COVID-19 health spending increased in 2021

with vaccination as one of the main factors

Data source: WHO Global Health Expenditure Database, 2023.

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Adapting service delivery for pandemic control

and sustaining essential services
• Health care providers (main categories): hospitals, ambulatory care
providers, pharmacies, preventive care providers (public health
institutions and disease control agencies), health system administration

• The analysis compares spending by different providers in 2019 and

2021, based on data from 50 countries:
• 7 low income, 14 middle income, 29 high income

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The share of spending in preventive care providers as total

health spending increased from 2019 to 2021
The composition of health spending by type of health care provider
 Most health spending occurs
in hospitals, ambulatory care
providers and pharmacies.

 Spending occurred in
preventive care providers is
a small proportion of total
health spending

 The structure of health

spending across providers is
rather stable, except the
increased share in
preventive care providers.

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Delivery of PHC services is context dependent and

requires country specific analysis
 The global measure of PHC spending is
based on health care functions, includes:
prevention, general outpatient care,
medicines result from consultation & self-
treatment, and development &
implementation of health system policies.

 In general health services included in PHC

is mainly provided by the ambulatory care
provider, yet, hospitals also play a role.

 The largest amount of PHC spending

occurs in pharmacies for purchasing
medicines.

 The report cannot answer the question on

which provider should provide PHC
services, but calls for in-depth country
studies.

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Health capital investment played an important

role in the COVID-19 response

• Gross fixed capital formation: infrastructure, machinery and

equipment, computer software and database

• The analysis is based on the most recent year available for each
country before the COVID-19 pandemic (2016–2019) and the
pandemic (2020-2021);
• 64 countries: 12 low income, 14 lower-middle income, 12 upper-middle
income, 26 high income

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The relative level of capital investment in health does not

appear to be linked to a country’s income
Ratio of capital to current health spending Ratio of capital to GDP

Note: Cross-sectional data were matched using the most recent year available for health capital investment (2020 or 2021).
Data source: WHO Global Health Expenditure Database, 2023.

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The structure of investment varies across

country income group
 Per capital health capital investment
increased during the pandemic
– Low income countries: 50%
– Lower middle income countries: 43%
– Upper-middle & high income countries:
8-9%

 Structure of capital investment

– Low income countries: Investment in
machinery and equipment increased
from 52% to 65%
– Middle income countries: database
and software increased and reached
5% during the pandemic
– High income countries: The structure
of health capital investment changed
Note: Prepandemic refers to the most recent year available during 2016–2019, and pandemic refers to the most recent year
available during 2020–2021. The analysis is based on data for 41 countries: 12 low income, 13 middle income and 16 high income. little
Data source: WHO Global Health Expenditure Database, 2023.

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Summary
 Higher health spending in 2021- the second year of the global pandemic, except low income countries
– High & upper-middle income countries: government spending increased, reflecting a higher
prioritization of health within government budgets; out-of-pocket spending (OOPS) rose and
returned to pracademic level
– Lower-middle income countries: government spending increased, reflecting mainly an overall
increase in general government spending; OOPs increased and returned to prepandemic level;
external aid increased
– In low income countries: government spending decreased, reflecting the deprioritization of health
and the overall decline of government spending; OOPs decreased; external aid increased in 2021
and continued to play important role in funding the health system
 Health spending on COVID-19 increased in 2021, accounting for an average of 11% of public spending
on health. A small set of low and lower-middle income countries did not suggest a decrease in other
disease spending in the early pandemic in 2020.
 Health service delivery adapted to the needs for pandemic control and sustaining essential services
 Health capital investment played an important role in the COVID-19 response
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Uncertainty in the future brings opportunities to change

or a lot of things to worry about
2022 data from 19 countries (mostly HIC)
Broader context
Inflation, currency exchange rates; war and conflict; debt
servicing; climate change; and other…
Health
Health security (pandemic preparedness)
Increasing and changing health needs
Evolving concept of health and health care in practice
What the future health system looks like and how to finance it?
• Structural change in service delivery
• Mechanisms for securing recurrent spending and capital
investment for equitable access and financial protection
• Impact of external aid for health (the amount, priorities and
modalities)
• Efficiency gains from digital technology

Data are essential for seizing those opportunities to change

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Thank you!
The report is based on the latest health spending data
which are now online together with country health expenditure profiles,
and relevant methodology documents.
https://apps.who.int/nha/database

Acknowledgement
Country health accounts teams
Technical partners and dedicated technical experts
Policy makers and data users
commitment and financial support from governments and development partners

WHO is committed to work closely with countries and partners

to support this global public good.
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Panel discussion

Walaiporn Patcharanarumol
Director, Global Health Division of the MOH Thailand

Ogochukwu Chukwujekwu
Lead, health financing and investment, WHO/AFRO

Francesca Colombo
Head, the Health Division, OECD

David Wilson
Senior Program Officer, the Bill and Melinda Gates Foundation

Christoph Kurowski
Global Lead for Health Financing, the World Bank Group

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