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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)


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          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.


          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.


          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.


          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.


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

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          Most cited references 30

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              Does progress towards universal health coverage improve population health?

              Many commentators, including WHO, have advocated progress towards universal health coverage on the grounds that it leads to improvements in population health. In this report we review the most robust cross-country empirical evidence on the links between expansions in coverage and population health outcomes, with a focus on the health effects of extended risk pooling and prepayment as key indicators of progress towards universal coverage across health systems. The evidence suggests that broader health coverage generally leads to better access to necessary care and improved population health, particularly for poor people. However, the available evidence base is limited by data and methodological constraints, and further research is needed to understand better the ways in which the effectiveness of extended health coverage can be maximised, including the effects of factors such as the quality of institutions and governance. Copyright © 2012 Elsevier Ltd. All rights reserved.

                Author and article information

                Lancet (London, England)
                14 May 2015
                18 July 2015
                14 May 2015
                : 386
                : 9990
                : 274-280
                [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@
                © 2015 Reeves et al. Open Access article distributed under the terms of CC BY

                This document may be redistributed and reused, subject to certain conditions.




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