Tandon Ajay, Fleisher Lisa, Li Rong, Yap Wei Aun
Health, Nutrition and Population Global Practice, The World Bank, Washington, DC, USA.
WHO South East Asia J Public Health. 2014 Jul-Dec;3(3):206-212. doi: 10.4103/2224-3151.206742.
Countries vary widely with respect to the share of government spending on health, a metric that can serve as a proxy for the extent to which health is prioritized by governments. World Health Organization (WHO) data estimate that, in 2011, health's share of aggregate government expenditure averaged 12% in the 170 countries for which data were available. However, country differences were striking: ranging from a low of 1% in Myanmar to a high of 28% in Costa Rica. Some of the observed differences in health's share of government spending across countries are unsurprisingly related to differences in national income. However, significant variations exist in health's share of government spending even after controlling for national income. This paper provides a global overview of health's share of government spending and summarizes some of the key theoretical and empirical perspectives on allocation of public resources to health vis-à-vis other sectors from the perspective of reprioritization, one of the modalities for realizing fiscal space for health. The paper argues that theory and cross-country empirical analyses do not provide clear-cut explanations for the observed variations in government prioritization of health. Standard economic theory arguments that are often used to justify public financing for health are equally applicable to many other sectors including defence, education and infrastructure. To date, empirical work on prioritization has been sparse: available cross-country econometric analyses suggest that factors such as democratization, lower levels of corruption, ethnolinguistic homogeneity and more women in public office are correlated with higher shares of public spending on health; however, these findings are not robust and are sensitive to model specification. Evidence from case studies suggests that country-specific political economy considerations are key, and that results-focused reform efforts - in particular efforts to explicitly expand the breadth and depth of health coverage as opposed to efforts focused only on government budgetary benchmarking targets - are more likely to result in sustained and politically feasible prioritization of health from a fiscal space perspective.
各国在政府卫生支出所占份额方面存在很大差异，这一指标可作为衡量政府对卫生重视程度的一个代理变量。世界卫生组织（WHO）的数据估计，2011年，在有数据可查的170个国家中，卫生支出在政府总支出中的平均占比为12%。然而，国家间的差异非常显著：从缅甸的低至1%到哥斯达黎加的高至28%。各国在卫生支出占政府支出份额方面观察到的一些差异不出所料地与国民收入差异有关。然而，即使在控制了国民收入之后，卫生支出在政府支出中的份额仍存在显著差异。本文对卫生支出在政府支出中的份额进行了全球概述，并从重新确定优先次序的角度总结了一些关于相对于其他部门而言将公共资源分配给卫生领域的关键理论和实证观点，重新确定优先次序是实现卫生领域财政空间的方式之一。本文认为，理论和跨国实证分析并未对政府在卫生领域的优先排序中观察到的差异提供明确的解释。常用于为卫生领域公共融资辩护的标准经济理论观点同样适用于包括国防、教育和基础设施在内的许多其他部门。迄今为止，关于优先排序的实证研究很少：现有的跨国计量经济学分析表明，诸如民主化、较低的腐败水平、民族语言同质性以及公职人员中有更多女性等因素与公共卫生支出的较高份额相关；然而，这些发现并不稳健，且对模型设定很敏感。案例研究的证据表明，特定国家的政治经济因素是关键，并且以结果为导向的改革努力——特别是明确扩大卫生覆盖范围的广度和深度的努力（与仅侧重于政府预算基准目标的努力相反）——从财政空间的角度来看，更有可能导致对卫生领域持续且在政治上可行的优先排序。
