Global discussions on universal health coverage (UHC) have focussed attention on the need for increased government funding for health care in many low- and middle-income countries. The objective of this paper is to explore potential targets for government spending on health to progress towards UHC. An explicit target for government expenditure on health care relative to gross domestic product (GDP) is a potentially powerful tool for holding governments to account in progressing to UHC, particularly in the context of UHC’s inclusion in the Sustainable Development Goals. It is likely to be more influential than the Abuja target, which requires decreases in budget allocations to other sectors and is opposed by finance ministries for undermining their autonomy in making sectoral budget allocation decisions. International Monetary Fund and World Health Organisation data sets were used to analyse the relationship between government health expenditure and proxy indicators for the UHC goals of financial protection and access to quality health care, and triangulated with available country case studies estimating the resource requirements for a universal health system. Our analyses point towards a target of government spending on health of at least 5% of GDP for progressing towards UHC. This can be supplemented by a per capita target of $86 to promote universal access to primary care services in low-income countries.

Since the 2007/2008 financial crisis, the rhetoric in the development assistance dialogue has shifted away from raising more international funding for health, to requesting countries to move toward self-sufficiency. This paper examines the potential of 46 countries identified by an international panel in 2009 as being of high need to raise additional funding for health from domestic sources. Economic growth alone would allow 12 of them to reach a level of health spending where their populations could have access to a very basic set of health services. All of them have the potential to raise additional domestic funds through a range of measures that have been tried successfully in other low- and middle-income countries, but they would all remain well below the eventual objective of universal health coverage without increased and predictable external financial support.

To progress toward universal health coverage and promote inclusive social and economic development, it will be necessary to strengthen domestic resource mobilization for health. In this paper, we examine options for increasing domestic government revenue in low- and middle-income countries. We analyze the relationship between level of economic development and levels of government revenue and expenditure, and show that a country’s level of economic development does not predetermine its spending levels. Government revenue can be increased through improved tax compliance and efficiency in revenue collection, maximizing revenue from mineral and other natural resources, and increasing tax rates where appropriate. The emphasis should be on increasing revenue through the most progressive means possible; the purpose of raising government spending on health would be defeated if that spending were funded by increasing the relative tax burden of those who are meant to benefit. Increasing government revenue through taxation or other sources is first and foremost a fiscal policy choice or political decision and should be supported through concerted global action.

Previous studies have described various associations between tax policy and health. Here we propose a unifying conceptual framework of ‘Five R’s’ to stimulate awareness about the importance of tax to health improvement. First, tax can improve representation and democratic accountability, and help make governments more responsive to the needs of its citizens. Second, tax can create a revenue stream for a universal pool of public finance for health care and other public services. Third, progressive taxation when combined with appropriate public spending can help redistribute wealth and income and mitigate social and health inequalities. Fourth, the re-pricing of harmful products (e.g. tobacco, alcohol and unhealthy food) can help reduce their consumption. Fifth, taxation provides a route by which certain harmful industries can be regulated. The paper also discusses the barriers that hinder the full potential for taxation to be used to improve health, including: weak tax administrations, large ‘shadow economies’, international trade liberalisation, tax avoidance, transfer pricing by transnational corporations and banking secrecy. We suggest that a greater awareness of the manifold associations between tax and health will encourage health practitioners to actively promote fairer and better taxation, thereby helping to improve health and reduce health inequalities.

Since at least the 1990s, there has been growing recognition that societies need global public goods (GPGs) in order to protect and promote public health. While the term GPG is sometimes used loosely to denote that which is ‘good’ for the global public, we restrict our use of the term to its technical definition (goods that are non-excludable and non-rival in consumption) for its useful analytical clarity. Examples of important GPGs for health include standards and guidelines, research on the causes and treatment of disease, and comparative evidence and analysis. While institutions for providing public goods are relatively well developed at the national level – being clearly recognized as a responsibility of sovereign states – institutional arrangements to do so remain fragmented and thin at the global level. For example, the World Health Organization, mandated to provide many GPGs, is not appropriately financed to do so. Three steps are needed to better govern the financing and provision of GPGs for health: first, improved data to develop a clearer picture of how much money is currently going to providing which types of GPGs; second, a legitimate global political process to decide upon priority missing GPGs, followed by estimates of total amounts needed; and third, financing streams for GPGs from governments and private sources, to be channeled through new or existing institutions. Financing should go toward fully financing some GPGs, complementing or supplementing existing national or international financing for others, or deploying funds to make potential GPGs less ‘excludable’ by putting them into the public domain. As globalization deepens the degree of interdependence between countries and as formerly low-income economies advance, there may be less relative need for development assistance to meet basic health care needs, and greater relative need to finance GPGs. Strengthening global arrangements for GPGs today is a worthy investment for improved global health in the years to come.

After a ‘golden age’ of extraordinary growth in the level of development assistance for health (DAH) since 1990, funding seems to have reached a plateau. With the launch of the Sustainable Development Goals, debate has intensified regarding what international financing for health should look like in the post-2015 era. In this review paper, we offer a systematic overview of problems and proposals for change. Major critiques of the current DAH system include: that the total volume of financing is inadequate; financial flows are volatile and uncertain; DAH may not result in additional resources for health; too small a proportion of DAH is transferred to recipient countries; inappropriate priority setting; inadequate coordination; weak mechanisms for accountability; and disagreement on the rationale for DAH. Proposals to address these critiques include: financing-oriented proposals to address insufficient levels and high volatility of DAH; governance-oriented proposals to address concerns regarding additionality, proportions reaching countries, priority setting, coordination and accountability; and proposals that reach beyond the existing DAH system. We conclude with a discussion of prospects for change.

After years of unprecedented growth in development assistance for health (DAH), the system is challenged on several fronts: by the economic downturn and stagnation of DAH, by the epidemiological transition and increase in non-communicable diseases, and by the economic transition and rise of the middle-income countries. This raises questions about which countries should receive DAH and how much, and, fundamentally, what criteria that promote fair and effective allocation. Yet, no broad comparative assessment exists of the criteria used today. We reviewed the allocation criteria stated by five multilateral and nine bilateral funders of DAH. We found that several funders had only limited information about concrete criteria publicly available. Moreover, many funders not devoted to health lacked specific criteria for DAH or criteria directly related to health, and no funder had criteria directly related to inequality. National income per capita was emphasised by many funders, but the associated eligibility thresholds varied considerably. These findings and the broad overview of criteria can assist funders in critically examining and revising the criteria they use, and inform the wider debate about what the optimal criteria are.

After years of unprecedented growth in development assistance for health (DAH), the DAH system is challenged on several fronts: by the economic downturn and stagnation of DAH, by the epidemiological transition and increase in non-communicable diseases and by the economic transition and rise of the middle-income countries. Central to any potent response is a fair and effective allocation of DAH across countries. A myriad of criteria has been proposed or is currently used, but there have been no comprehensive assessment of their distributional implications. We simulated the implications of 11 quantitative allocation criteria across countries and country categories. We found that the distributions varied profoundly. The group of low-income countries received most DAH from needs-based criteria linked to domestic capacity, while the group of upper-middle-income countries was most favoured by an income-inequality criterion. Compared to a baseline distribution guided by gross national income per capita, low-income countries received less DAH by almost all criteria. The findings can inform funders when examining and revising the criteria they use, and provide input to the broader debate about what criteria should be used.

Recent developments have transformed the role and characteristics of middle-income countries (MICs). Many stakeholders now question the appropriate role of MICs in the system of development assistance for health (DAH), and key funders have already recast their approach to these countries. The pressing question is whether MICs should be recipients, funders, both or neither. The answer has deep implications for individual countries and their citizens, and for the DAH system as a whole. We clarify the fundamental issues involved and emphasise a special feature of many MICs: mid-level gross national income per capita (GNIpc) combined with substantial health needs and large inequalities. We discuss the trade-off between concerns for capacity and need, and illustrate a capacity-based approach to setting the level of a GNIpc eligibility threshold. We also discuss how needs-based exceptions and incentive-preserving instruments can complement such a threshold. Against this background, we outline options for the future roles of MICs in various circumstances. We conclude that major players in the DAH system have reason to reconsider the criteria for allocating DAH among countries and the norms for which countries should contribute and how much.

The articles in this special issue have demonstrated how unprecedented transitions have come with both challenges and opportunities for health financing. Against the background of these challenges and opportunities, the Working Group on Health Financing at the Chatham House Centre on Global Health Security laid out, in 2014, a set of policy responses encapsulated in 20 recommendations for how to make progress towards a coherent global framework for health financing. These recommendations pertain to domestic financing of national health systems, global public goods for health, external financing for national health systems and the cross-cutting issues of accountability and agreement on a new global framework. Since the Working Group concluded its work, multiple events have reinforced the group’s recommendations. Among these are the agreement on the Addis Ababa Action Agenda, the adoption of the Sustainable Development Goals, the outbreak of Ebola in West Africa and the release of the Panama Papers. These events also represent new stepping stones towards a new global framework.