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# Financing universal health coverage—effects of alternative tax structures on public health systems: cross-national modelling in 89 low-income and middle-income countries

, Dr, PhD a , * , , MD b , , PhD b , c , , DrPH d , , Prof, MD b ,   , Prof, PhD a

Lancet (London, England)

Elsevier

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### Summary

##### Background

How to finance progress towards universal health coverage in low-income and middle-income countries is a subject of intense debate. We investigated how alternative tax systems affect the breadth, depth, and height of health system coverage.

##### Methods

We used cross-national longitudinal fixed effects models to assess the relationships between total and different types of tax revenue, health system coverage, and associated child and maternal health outcomes in 89 low-income and middle-income countries from 1995–2011.

##### Findings

Tax revenue was a major statistical determinant of progress towards universal health coverage. Each US$100 per capita per year of additional tax revenues corresponded to a yearly increase in government health spending of$9·86 (95% CI 3·92–15·8), adjusted for GDP per capita. This association was strong for taxes on capital gains, profits, and income ($16·7, 9·16 to 24·3), but not for consumption taxes on goods and services (−$4·37, −12·9 to 4·11). In countries with low tax revenues (<$1000 per capita per year), an additional$100 tax revenue per year substantially increased the proportion of births with a skilled attendant present by 6·74 percentage points (95% CI 0·87–12·6) and the extent of financial coverage by 11·4 percentage points (5·51–17·2). Consumption taxes, a more regressive form of taxation that might reduce the ability of the poor to afford essential goods, were associated with increased rates of post-neonatal mortality, infant mortality, and under-5 mortality rates. We did not detect these adverse associations with taxes on capital gains, profits, and income, which tend to be more progressive.

##### Interpretation

Increasing domestic tax revenues is integral to achieving universal health coverage, particularly in countries with low tax bases. Pro-poor taxes on profits and capital gains seem to support expanding health coverage without the adverse associations with health outcomes observed for higher consumption taxes. Progressive tax policies within a pro-poor framework might accelerate progress toward achieving major international health goals.

##### Funding

Commission of the European Communities (FP7–DEMETRIQ), the European Union's HRES grants, and the Wellcome Trust.

### Most cited references30

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### World Malaria Report 2016

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### Author and article information

###### Journal
Lancet
Lancet
Lancet (London, England)
Elsevier
0140-6736
1474-547X
14 May 2015
18 July 2015
14 May 2015
: 386
: 9990
: 274-280
###### Affiliations
[a ]Department of Sociology, University of Oxford, Oxford, UK
[b ]London School of Hygiene & Tropical Medicine, London, UK
[c ]Department of Medicine, Stanford University, Stanford, CA, USA
[d ]Department of Primary Care and Public Health, Queen Mary University of London, London, UK
###### Author notes
[* ]Correspondence to: Dr Aaron Reeves, Department of Sociology, Manor Road Building, Manor Road, Oxford OX1 3UQ, UK aaron.reeves@ 123456sociology.ox.ac.uk
###### Article
S0140-6736(15)60574-8
10.1016/S0140-6736(15)60574-8
4513966
25982041

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###### Categories
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Medicine