Reeves Aaron, Gourtsoyannis Yannis, Basu Sanjay, McCoy David, McKee Martin, Stuckler David
Department of Sociology, University of Oxford, Oxford, UK.
London School of Hygiene & Tropical Medicine, London, UK.
Lancet. 2015 Jul 18;386(9990):274-80. doi: 10.1016/S0140-6736(15)60574-8. Epub 2015 May 14.
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.
如何为低收入和中等收入国家实现全民健康覆盖的进展筹集资金是一个激烈辩论的话题。我们研究了不同的税收制度如何影响卫生系统覆盖的广度、深度和高度。
我们使用跨国纵向固定效应模型来评估1995年至2011年期间89个低收入和中等收入国家的总税收及不同类型税收收入、卫生系统覆盖情况以及相关的儿童和孕产妇健康结果之间的关系。
税收收入是全民健康覆盖进展的一个主要统计学决定因素。人均每年额外增加100美元税收收入，对应政府卫生支出每年增加9.86美元（95%置信区间3.92 - 15.8），并根据人均国内生产总值进行了调整。这种关联在资本利得税、利润税和所得税方面很强（16.7美元，9.16至24.3），但在商品和服务消费税方面则不然（-4.37美元，-12.9至4.11）。在税收收入较低的国家（人均每年低于1000美元），每年额外增加100美元税收收入会使有熟练医护人员接生的分娩比例大幅提高6.74个百分点（95%置信区间0.87 - 12.6），财务覆盖范围扩大11.4个百分点（5.51 - 17.2）。消费税是一种更具累退性的税收形式，可能会降低穷人购买基本商品的能力，它与新生儿后期死亡率、婴儿死亡率和5岁以下儿童死亡率上升有关。我们未发现资本利得税、利润税和所得税存在这些不良关联，这些税种往往更具累进性。
增加国内税收收入对于实现全民健康覆盖至关重要，尤其是在税基较低的国家。对利润和资本利得征收的扶贫税似乎有助于扩大卫生覆盖范围，且不会像较高消费税那样对健康结果产生不良关联。在扶贫框架内的累进税收政策可能会加速实现主要国际卫生目标的进程。
欧洲共同体委员会（FP7 - DEMETRIQ）、欧盟的HRES资助以及惠康信托基金会。
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