Background The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and
treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national
health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for
pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the
pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in
the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context
the expected need for investment in pandemic preparedness.
Methods In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we
estimated four sources of health spending: development assistance for health (DAH), government spending, out-ofpocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for
Economic Co-operation and Development (OECD)’s Creditor Reporting System (CRS) and the WHO Global Health
Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health,
COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates
were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future
health spending patterns, relative to need.
Findings In 2019, at the onset of the COVID-19 pandemic, US9⋅2trillion(95spentonhealthworldwide.Wefoundgreatdisparitiesintheamountofresourcesdevotedtohealth,withhigh−incomecountriesspending7·3 trillion (95% UI 7·2–7·4) in 2019; 293·7 times the 24⋅8billion(95low−incomecountriesin2019.Thatsameyear,43·1 billion in development assistance was provided to maintain or
improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in
2020 and 2021, 1⋅8billioninDAHcontributionswasprovidedtowardspandemicpreparednessinLMICs,and37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness
is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the healthrelated COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest
that between 2022 and 2026, governments in 17 (95% UI 11–21) of the 137 LMICs will observe an increase in national
government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP.
Interpretation There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this
time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical
patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is
maintained