Summan Amit, Stacey Nicholas, Hofman Karen, Laxminarayan Ramanan
It has been recognized for some time that the primary determinants of population health and health inequalities, particularly in low- and middle-income countries (LMICs), lie outside of the health care system (CSDH 2008). These determinants include individual-level factors—such as access to clean water and sanitation, nutrition, and antenatal care—as well as environmental-level factors—such as pollution, walkability of neighborhoods, rates of open defecation, and tariffs on food imports and exports. Exposure to these hazardous risk factors is the primary contributor to adverse health outcomes, which increase resource demands on health care systems and increase private and public health expenditures. The impetus for universal health coverage (UHC) in countries as diverse as Brazil, India, and South Africa has run up against the barrier of these broader determinants that hinder efforts to improve health. There are three additional challenges to UHC: The economic slowdown has significantly reduced growth rates and government revenues in LMICs. Annual growth rates in Brazil, the Russian Federation, India, China, and South Africa (BRICS) were a population weighted average of nearly two percentage points lower during 2011–15 than during the previous decade (World Bank and IHME 2016). As a result, government expenditures and the ability to increase spending on health care have tightened. The narrow fiscal space for health care, even in countries with relatively high growth rates, is a consequence of a low tax base and constrains health care spending by national and state governments. In India, although government health expenditures as a proportion of total government expenditures are comparable to similar countries, they lag when measured as a proportion of gross domestic product (GDP). Countries seeking to transition to UHC have weak health care systems that are challenged in delivering quality health care coverage even when additional resources are available. India and South Africa are examples of countries where the health care system serves a fairly small proportion of the population; large segments are excluded from even basic health coverage. Despite the recognition that social determinants exercise a significant influence on population health in LMICs as direct interventions in the health sector, there remains a limited understanding of how existing fiscal policy instruments available to governments in LMICs can be leveraged to improve health. This chapter presents the analytic framework for assessing the potential of fiscal instruments to improve population health. We describe the application of this method to specific interventions in India and discuss the implications of these policy changes. The goal is to inform policies at ministries of finance that have an effect on health, either through new policies or by examining existing policies that affect important health risk factors.
一段时间以来，人们已经认识到，影响人群健康及健康不平等的主要因素，尤其是在低收入和中等收入国家（LMICs），存在于医疗保健系统之外（CSDH，2008年）。这些决定因素包括个体层面的因素，如获得清洁水和卫生设施、营养以及产前护理，以及环境层面的因素，如污染、社区的适宜步行性、露天排便率以及食品进出口关税。暴露于这些有害风险因素是导致不良健康结果的主要原因，这增加了对医疗保健系统的资源需求，并增加了私人和公共卫生支出。在巴西、印度和南非等不同国家推动全民健康覆盖（UHC）的努力，遇到了这些更广泛的决定因素的阻碍，这些因素妨碍了改善健康的工作。全民健康覆盖还面临另外三个挑战：经济放缓显著降低了低收入和中等收入国家的增长率和政府收入。2011 - 2015年期间，巴西、俄罗斯联邦、印度、中国和南非（金砖国家）的年增长率，按人口加权平均计算，比前十年低近两个百分点（世界银行和健康指标与评估研究所，2016年）。结果，政府支出以及增加医疗保健支出的能力受到限制。即使在增长率相对较高的国家，医疗保健的财政空间也很狭窄，这是税基较低的结果，限制了国家和州政府的医疗保健支出。在印度，尽管政府卫生支出占政府总支出的比例与类似国家相当，但按国内生产总值（GDP）的比例衡量则滞后。寻求向全民健康覆盖过渡的国家，其医疗保健系统薄弱，即使有额外资源，在提供高质量医疗保健覆盖方面也面临挑战。印度和南非就是这样的例子，在这些国家，医疗保健系统覆盖的人口比例相当小；很大一部分人口甚至被排除在基本医疗覆盖之外。尽管人们认识到社会决定因素作为对卫生部门的直接干预，对低收入和中等收入国家的人群健康有重大影响，但对于低收入和中等收入国家政府现有的财政政策工具如何能够用来改善健康，仍然了解有限。本章介绍了评估财政工具改善人群健康潜力的分析框架。我们描述了该方法在印度特定干预措施中的应用，并讨论了这些政策变化的影响。目的是为财政部的政策提供信息，这些政策通过新政策或审查影响重要健康风险因素的现有政策，对健康产生影响。
