Past, present, and future of global health financing : a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995-2050

Background Comprehensive and comparable estimates of health spending in each country are a key input for health policy and planning, and are necessary to support the achievement of national and international health goals. Previous studies have tracked past and projected future health spending until 2040 and shown that, with economic development, countries tend to spend more on health per capita, with a decreasing share of spending from development assistance and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending, with an emphasis on equity in spending across countries. Methods We estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories-government, out-of-pocket, and prepaid private health spending-and estimated development assistance for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. We used demographic decomposition methods to assess a set of factors associated with changes in government health spending between 1995 and 2016 and to examine evidence to support the theory of the health financing transition. We projected two alternative future scenarios based on higher government health spending to assess the potential ability of governments to generate more resources for health. Findings Between 1995 and 2016, health spending grew at a rate of 4.00% (95% uncertainty interval 3.89-4.12) annually, although it grew slower in per capita terms (2.72% [2.61-2.84]) and increased by less than $1 per capita over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed in upper-middle-income countries (5.55$ 8.0 trillion (7.8-8.1) in 2016 (comprising 8.6% [8.4-8.7] of the global economy and $10.3 trillion [10.1-10.6] in purchasing-power parity-adjusted dollars), with a per capita spending of US$ 5252 (5184-5319) in high-income countries, $491 (461-524) in upper-middle-income countries,$ 81 (74-89) in lower-middle-income countries, and $40 (38-43) in low-income countries. In 2016, 0.4$ 9.5 billion, 24.3% of total DAH), although spending on other infectious diseases (excluding tuberculosis and malaria) grew fastest from 2010 to 2018 (6.27% per year). The leading sources of DAH were the USA and private philanthropy (excluding corporate donations and the Bill & Melinda Gates Foundation). For the first time, we included estimates of China's contribution to DAH ($644.7 million in 2018). Globally, health spending is projected to increase to$ 15.0 trillion (14.0-16.0) by 2050 (reaching 9.4% [7.6-11.3] of the global economy and $ 21.3 trillion [19.8-23.1] in purchasing-power parity-adjusted dollars), but at a lower growth rate of 1.84% (1.68-2.02) annually, and with continuing disparities in spending between countries. In 2050, we estimate that 0.6% (0.6-0.7) of health spending will occur in currently low-income countries, despite these countries comprising an estimated 15.7% of the global population by 2050. The ratio between per capita health spending in high-income and low-income countries was 130.2 (122.9-136.9) in 2016 and is projected to remain at similar levels in 2050 (125.9 [113.7-138.1]). The decomposition analysis identified governments' increased prioritisation of the health sector and economic development as the strongest factors associated with increases in government health spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the health sector and increased government spending, health spending per capita could more than double, with greater impacts in countries that currently have the lowest levels of government health spending. Interpretation Financing for global health has increased steadily over the past two decades and is projected to continue increasing in the future, although at a slower pace of growth and with persistent disparities in per-capita health spending between countries. Out-of-pocket spending is projected to remain substantial outside of high-income countries. Many low-income countries are expected to remain dependent on development assistance, although with greater government spending, larger investments in health are feasible. In the absence of sustained new investments in health, increasing efficiency in health spending is essential to meet global health targets.Peer reviewe

Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995–2050

Background: Comprehensive and comparable estimates of health spending in each country are a key input for health policy and planning, and are necessary to support the achievement of national and international health goals. Previous studies have tracked past and projected future health spending until 2040 and shown that, with economic development, countries tend to spend more on health per capita, with a decreasing share of spending from development assistance and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending, with an emphasis on equity in spending across countries. Methods: We estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories—government, out-of-pocket, and prepaid private health spending—and estimated development assistance for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. We used demographic decomposition methods to assess a set of factors associated with changes in government health spending between 1995 and 2016 and to examine evidence to support the theory of the health financing transition. We projected two alternative future scenarios based on higher government health spending to assess the potential ability of governments to generate more resources for health. Findings: Between 1995 and 2016, health spending grew at a rate of 4·00% (95% uncertainty interval 3·89–4·12) annually, although it grew slower in per capita terms (2·72% [2·61–2·84]) and increased by less than $1 per capita over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed in upper-middle-income countries (5·55 in lower-middle-income countries (3·71$8·0 trillion (7·8–8·1) in 2016 (comprising 8·6% [8·4–8·7] of the global economy and $10·3 trillion [10·1–10·6] in purchasing-power parity-adjusted dollars), with a per capita spending of US$5252 (5184–5319) in high-income countries, $491 (461–524) in upper-middle-income countries,$81 (74–89) in lower-middle-income countries, and $40 (38–43) in low-income countries. In 2016, 0·4 countries, despite these countries comprising 10·0 DAH targeted HIV/AIDS ($9·5 billion, 24·3% of total DAH), although spending on other infectious diseases (excluding tuberculosis and malaria) grew fastest from 2010 to 2018 (6·27% per year). The leading sources of DAH were the USA and private philanthropy (excluding corporate donations and the Bill & Melinda Gates Foundation). For the first time, we included estimates of China’s contribution to DAH ($644·7 million in 2018). Globally, health spending is projected to increase to$15·0 trillion (14·0–16·0) by 2050 (reaching 9·4% [7·6–11·3] of the global economy and $21·3 trillion [19·8–23·1] in purchasing-power parity-adjusted dollars), but at a lower growth rate of 1·84% (1·68–2·02) annually, and with continuing disparities in spending between countries. In 2050, we estimate that 0·6% (0·6–0·7) of health spending will occur in currently low-income countries, despite these countries comprising an estimated 15·7% of the global population by 2050. The ratio between per capita health spending in high-income and low-income countries was 130·2 (122·9–136·9) in 2016 and is projected to remain at similar levels in 2050 (125·9 [113·7–138·1]). The decomposition analysis identified governments’ increased prioritisation of the health sector and economic development as the strongest factors associated with increases in government health spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the health sector and increased government spending, health spending per capita could more than double, with greater impacts in countries that currently have the lowest levels of government health spending Interpretation: Financing for global health has increased steadily over the past two decades and is projected to continue increasing in the future, although at a slower pace of growth and with persistent disparities in per-capita health spending between countries. Out-of-pocket spending is projected to remain substantial outside of high-income countries. Many low-income countries are expected to remain dependent on development assistance, although with greater government spending, larger investments in health are feasible. In the absence of sustained new investments in health, increasing efficiency in health spending is essential to meet global health targets. Funding: Bill & Melinda Gates Foundatio

Analysis of the off current in nanocrystalline silicon bottom-gate thin-film transistors

The off current in bottom-gate nanocrystalline silicon (nc-Si) thin-film transistor (TFT) is shown to be determined by the conductivity of the channel layer and by the quality of the interface with the passivation nitride. Indeed, the presence of fixed charges at the nc-Sipassivation nitride interface serves to increase the band bending, leading to an increase in the off current by about two orders of magnitude. In contrast, when the nc-Si channel layer is capped with hydrogenated amorphous silicon (a-Si:H), the off current decreases and is determined by the bulk conductivity of nc-Si, as the a-Si:H makes a less defective interface with the passivation nitride. The general effect of the gate and passivation nitride interfaces on band bending and transfer characteristics of the TFT is analyzed by numerical simulations. We find that the band bending due to fixed charges at the gate nitride interface is modulated by a negative gate voltage, while that due to fixed charges at the passivation nitride interface is not, leading to a high off current. © 2008 American Institute of Physics

Nanocrystalline silicon thin film transistors for high performance large area electronics

Nanocrystalline silicon (nc-Si) thin film transistors (TFTs) have potential for high-performance applications in large area electronics, such as next generation of flat panel displays and medical x-ray imagers, for pixel drivers, readout circuits, as well as complementary channel logic circuits for system-on-panel integration. This potential stems from reduced threshold voltage shift and higher transconductance, compared to amorphous silicon counterpart. In this paper, we discuss various TFT structures, their associated design and performance considerations, including leakage current and threshold voltage stability mechanisms. © 2008 World Scientific Publishing Company

Hydrogenated nanocrystalline silicon thin film transistor array for X-ray detector application

Hydrogenated nanocrystalline silicon (nc-Si:H) has strong potential to replace the hydrogenated amorphous silicon (a-Si:H) in thin film transistors (TFTs) due to its compatibility with the current industrial a-Si:H processes, and its better threshold voltage stability [1]. In this paper, we present an experimental TFT array backplane for direct conversion X-ray detector, using inverted staggered bottom gate nc-Si:H TFT as switching element. The TFTs employed a nc-Si:H/a-Si:H bilayer as the channel layer and hydrogenated amorphous silicon nitride (a-SiNx) as the gate dielectric; both layers were deposited by plasma enhanced chemical vapor deposition (PECVD) at 280°C. Each pixel consists of a switching TFT, a charge storage capacitor (Cpx), and a mushroom electrode which serves as the bottom contact for X-ray detector such as amorphous selenium photoconductor. The chemical composition of the a-SiNx was studied by Fourier transform infrared spectroscopy. Current-voltage measurements of the a-SiNx film demonstrate a breakdown field of 4.3 MV/cm. TFTs in the array exhibit a field effect mobility (μEF) of 0.15 cm2/Vs, a threshold voltage (VTh) of 5.71 V, and a subthreshold leakage current (I sub) of 10-10 A. The fabrication sequence and TFT characteristics will be discussed in details. © 2008 Materials Research Society

Blue-light-sensitive phototransistor for indirect X-ray image sensors

A thin-film phototransistor with a peak wavelength sensitivity of 420 nm was fabricated by integrating a bilayer hydrogenated-amorphous-silicon absorber with a nanocrystalline-silicon channel layer. The phototransistor response at λ = 420 nm was about 92 mA/W for an incident power density of 0.16 mW/cm 2. A readout pixel circuit having a single transistor, acting as both the sensing and switching elements, is proposed to demonstrate the device potential for high-resolution pixelated X-ray imaging arrays. Simulation results reveal less than 150 μs to read out the pixel voltage with a storage capacitor of 1 pF. Thus, a frame rate of about 75 ms is predicted for a 500 × 500 pixel imaging array. Transient photocurrent measurements yield on (rise) and off (fall) times of 0.6 and 3 ms, respectively, verifying the requirements for a high frame rate. © 2012 IEEE

Impact of silicon nitride gate dielectric composition on the stability of low temperature nanocrystalline silicon thin film transistors

We report on the stability of nanocrystalline silicon (nc-Si) bottom gate (BG) thin film transistors.(TFTs) with various compositions ([N]/[Si]) of hydrogenated amorphous silicon nitride (a-SiNx:H) gate dielectric, formed at 280°C. The shift in threshold voltage (ΔVT) is larger for gate dielectrics with lower [N]/[Si] content. For example, after 5 hours of stressing at 15 V, the ΔVT is 0.3 V, 1 V, and 12.4 V for [N]/[Si] of 1.3, 1.2, and 1, respectively. Relaxation tests on the stressed TFTs show that the charge trapping in the gate dielectric is the primary instability mechanism in nc-Si BG TFTs. ©The Electrochemical Society