title: Financing universal health coverage--effects of alternative tax structures on public health systems: cross-national modelling in 89 low-income and middle-income countries.
abstract: 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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  Commission of the European Communities (FP7-DEMETRIQ), the European Union's HRES grants, and the Wellcome Trust.
authors.affiliation: Department of Sociology, University of Oxford, Oxford, UK. Electronic address: aaron.reeves@sociology.ox.ac.uk.
authors.forename: Aaron
authors.initials: A
authors.lastname: Reeves
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Yannis
authors.initials: Y
authors.lastname: Gourtsoyannis
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK; Department of Medicine, Stanford University, Stanford, CA, USA.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Basu
authors.affiliation: Department of Primary Care and Public Health, Queen Mary University of London, London, UK.
authors.forename: David
authors.initials: D
authors.lastname: McCoy
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: McKee
authors.affiliation: Department of Sociology, University of Oxford, Oxford, UK.
authors.forename: David
authors.initials: D
authors.lastname: Stuckler
mesh_terms: D003906:Developing Countries / Q000191:economics*; D014943:Global Health / Q000191:economics; D006078:Government Programs / Q000191:economics; D005102:Health Expenditures; D006296:Health Services / Q000191:economics*; D061889:Healthcare Financing; D006801:Humans; D013660:Taxes / Q000191:economics*; D019472:Universal Health Insurance / Q000191:economics*