Fertility, mortality, migration, and population scenarios for 195 countries and territories from 2017 to 2100: a forecasting analysis for the Global Burden of Disease Study.

BACKGROUND: Understanding potential patterns in future population levels is crucial for anticipating and planning for changing age structures, resource and health-care needs, and environmental and economic landscapes. Future fertility patterns are a key input to estimation of future population size, but they are surrounded by substantial uncertainty and diverging methodologies of estimation and forecasting, leading to important differences in global population projections. Changing population size and age structure might have profound economic, social, and geopolitical impacts in many countries. In this study, we developed novel methods for forecasting mortality, fertility, migration, and population. We also assessed potential economic and geopolitical effects of future demographic shifts. METHODS: We modelled future population in reference and alternative scenarios as a function of fertility, migration, and mortality rates. We developed statistical models for completed cohort fertility at age 50 years (CCF50). Completed cohort fertility is much more stable over time than the period measure of the total fertility rate (TFR). We modelled CCF50 as a time-series random walk function of educational attainment and contraceptive met need. Age-specific fertility rates were modelled as a function of CCF50 and covariates. We modelled age-specific mortality to 2100 using underlying mortality, a risk factor scalar, and an autoregressive integrated moving average (ARIMA) model. Net migration was modelled as a function of the Socio-demographic Index, crude population growth rate, and deaths from war and natural disasters; and use of an ARIMA model. The model framework was used to develop a reference scenario and alternative scenarios based on the pace of change in educational attainment and contraceptive met need. We estimated the size of gross domestic product for each country and territory in the reference scenario. Forecast uncertainty intervals (UIs) incorporated uncertainty propagated from past data inputs, model estimation, and forecast data distributions. FINDINGS: The global TFR in the reference scenario was forecasted to be 1·66 (95% UI 1·33-2·08) in 2100. In the reference scenario, the global population was projected to peak in 2064 at 9·73 billion (8·84-10·9) people and decline to 8·79 billion (6·83-11·8) in 2100. The reference projections for the five largest countries in 2100 were India (1·09 billion [0·72-1·71], Nigeria (791 million [594-1056]), China (732 million [456-1499]), the USA (336 million [248-456]), and Pakistan (248 million [151-427]). Findings also suggest a shifting age structure in many parts of the world, with 2·37 billion (1·91-2·87) individuals older than 65 years and 1·70 billion (1·11-2·81) individuals younger than 20 years, forecasted globally in 2100. By 2050, 151 countries were forecasted to have a TFR lower than the replacement level (TFR <2·1), and 183 were forecasted to have a TFR lower than replacement by 2100. 23 countries in the reference scenario, including Japan, Thailand, and Spain, were forecasted to have population declines greater than 50% from 2017 to 2100; China's population was forecasted to decline by 48·0% (-6·1 to 68·4). China was forecasted to become the largest economy by 2035 but in the reference scenario, the USA was forecasted to once again become the largest economy in 2098. Our alternative scenarios suggest that meeting the Sustainable Development Goals targets for education and contraceptive met need would result in a global population of 6·29 billion (4·82-8·73) in 2100 and a population of 6·88 billion (5·27-9·51) when assuming 99th percentile rates of change in these drivers. INTERPRETATION: Our findings suggest that continued trends in female educational attainment and access to contraception will hasten declines in fertility and slow population growth. A sustained TFR lower than the replacement level in many countries, including China and India, would have economic, social, environmental, and geopolitical consequences. Policy options to adapt to continued low fertility, while sustaining and enhancing female reproductive health, will be crucial in the years to come. FUNDING: Bill & Melinda Gates Foundation.

The G20 and development assistance for health: historical trends and crucial questions to inform a new era.

One of the most important gatherings of the world's economic leaders, the G20 Summit and ministerial meetings, takes place in June, 2019. The Summit presents a valuable opportunity to reflect on the provision and receipt of development assistance for health (DAH) and the role the G20 can have in shaping the future of health financing. The participants at the G20 Summit (ie, the world's largest providers of DAH, emerging donors, and DAH recipients) and this Summit's particular focus on global health and the Sustainable Development Goals offers a unique forum to consider the changing DAH context and its pressing questions. In this Health Policy perspective, we examined trends in DAH and its evolution over time, with a particular focus on G20 countries; pointed to persistent and emerging challenges for discussion at the G20 Summit; and highlighted key questions for G20 leaders to address to put the future of DAH on course to meet the expansive Sustainable Development Goals. Key questions include how to best focus DAH for equitable health gains, how to deliver DAH to strengthen health systems, and how to support domestic resource mobilisation and transformative partnerships for sustainable impact. These issues are discussed in the context of the growing effects of climate change, demographic and epidemiological transitions, and a global political shift towards increasing prioritisation of national interests. Although not all these questions are new, novel approaches to allocating DAH that prioritise equity, efficiency, and sustainability, particularly through domestic resource use and mobilisation are needed. Wrestling with difficult questions in a changing landscape is essential to develop a DAH financing system capable of supporting and sustaining crucial global health goals.

Donor financing of human resources for health, 1990-2016: an examination of trends, sources of funds, and recipients.

BACKGROUND: Skilled health professionals are a critical component of the effective delivery of lifesaving health interventions. The inadequate number of skilled health professionals in many low- and middle-income countries has been identified as a constraint to the achievement of improvements in health outcomes. In response, more international development agencies have provided funds toward broader health system initiatives and health workforce activities in particular. Nonetheless, estimates of the amount of donor funding targeting investments in human resources for health activities are few. METHODS: We utilize data from the Institute for Health Metrics and Evaluation's annual database on development assistance for health. The estimates in the database are generated using data from publicly available databases that track development assistance. To estimate development assistance for human resources for health, we use keywords to identify projects targeted toward human resource processes. We track development for human resources for health from 1990 through 2016. We categorize the types of human-resources-related projects funded and examine the availability of human resources, development assistance for human resources for health, and disease burden. RESULTS: We find that the amount of donor funding directed toward human resources for health has increased from only $34 million in 1990 to $1.5 billion in 2016 (in 2017 US dollars). Overall, $18.5 billion in 2017 US dollars was targeted toward human resources for health between 1990 and 2016. The primary regions receiving these resources were sub-Saharan Africa and Southeast Asia, East Asia, and Oceania. The main donor countries were the United States, Canada, Australia and the United Kingdom. The main agencies through which these resources were disbursed are non-governmental organizations (NGOs), US bilateral agencies, and UN agencies. CONCLUSION: In 2016, less than 4% of development assistance for health could be tied to funding for human resources. Given the central role skilled health workers play in health systems, in order to make credible progress in reducing disparities in health and attaining the goal of universal health coverage for all by 2030, it may be appropriate for more resources to be mobilized in order to guarantee adequate manpower to deliver key health interventions.

Health expenditures by services and providers for 195 countries, 2000-2017.

INTRODUCTION: National Health Accounts are a significant source of health expenditure data, designed to be comprehensive and comparable across countries. However, there is currently no single repository of this data and even when compiled major gaps persist. This research aims to provide policymakers and researchers with a single repository of available national health expenditures by healthcare functions (ie, services) and providers of such services. Leveraging these data within statistical methods, a complete set of detailed health expenditures is estimated. METHODS: A methodical compilation and synthesis of all available national health expenditure reports including disaggregation by healthcare functions and providers was conducted. Using these data, a Bayesian multivariate regression analysis was implemented to estimate national-level health expenditures by the cross-classification of functions and providers for 195 countries, from 2000 to 2017. RESULTS: This research used 1662 country-years and 110 070 data points of health expenditures from existing National Health Accounts. The most detailed country-year had 52% of the categories of interest reported. Of all health functions, curative care and medical goods were estimated to make up 51.4% (uncertainty interval (UI) 33.2% to 59.4%) and 17.5% (UI 13.0% to 26.9%) of total global health expenditures in 2017, respectively. Three-quarters of the global health expenditures are allocated to three categories of providers: hospital providers (35.4%, UI 30.3% to 38.9%), providers of ambulatory care (25.5%, UI 21.1% to 28.8%) and retailers of medical goods (14.4%, UI 12.4% to 16.3%). As gross domestic product increases, countries spend more on long-term care and less on preventive care. CONCLUSION: Disaggregated estimates of health expenditures are often unavailable and unable to provide policymakers and researchers a holistic understanding of how expenditures are used. This research aggregates reported data and provides a complete time-series of estimates, with uncertainty, of health expenditures by health functions and providers between 2000 and 2017 for 195 countries.

Trends and drivers of government health spending in sub-Saharan Africa, 1995-2015.

INTRODUCTION: Government health spending is a primary source of funding in the health sector across the world. However, in sub-Saharan Africa, only about a third of all health spending is sourced from the government. The objectives of this study are to describe the growth in government health spending, examine its determinants and explain the variation in government health spending across sub-Saharan African countries. METHODS: We used panel data on domestic government health spending in 46 countries in sub-Saharan Africa from 1995 to 2015 from the Institute for Health Metrics and Evaluation. A regression model was used to examine the factors associated with government health spending, and Shapley decomposition was used to attribute the contributions of factors to the explained variance in government health spending. RESULTS: While the growth rate in government health spending in sub-Saharan Africa has been positive overall, there are variations across subgroups. Between 1995 and 2015, government health spending in West Africa grew by 6.7% (95% uncertainty intervals [UI]: 6.2% to 7.0%) each year, whereas in Southern Africa it grew by only 4.5% (UI: 4.5% to 4.5%) each year. Furthermore, per-person government health spending ranged from $651 (Namibia) in 2017 purchasing power parity dollars to $4 (Central African Republic) in 2015. Good governance, national income and the share of it that is government spending were positively associated with government health spending. The results from the decomposition, however, showed that individual country characteristics made up the highest percentage of the explained variation in government health spending across sub-Saharan African countries. CONCLUSION: These findings highlight that a country's policy choices are important for how much the health sector receives. As the attention of the global health community focuses on ways to stimulate domestic government health spending, an understanding that individual country sociopolitical context is an important driver for success will be key.

Tracking development assistance for health from China, 2007-2017.

INTRODUCTION: In recent years, China has increased its international engagement in health. Nonetheless, the lack of data on contributions has limited efforts to examine contributions from China. Existing estimates that track development assistance for health (DAH) from China have relied primarily on one dataset. Furthermore, little is known about the disbursing agencies especially the multilaterals through which contributions are disbursed and how these are changing across time. In this study, we generated estimates of DAH from China from 2007 through 2017 and disaggregated those estimates by disbursing agency and health focus area. METHODS: We identified the major government agencies providing DAH. To estimate DAH provided by each agency, we leveraged publicly available development assistance data in government agencies' budgets and financial accounts, as well as revenue statements from key international development agencies such as the WHO. We reported trends in DAH from China, disaggregated contributions by disbursing bilateral and multilateral agencies, and compared DAH from China with other traditional donors. We also compared these estimates with existing estimates. RESULTS: DAH provided by China grew dramatically, from US$323.1 million in 2007 to $652.3 million in 2017. During this period, 91.8% of DAH from China was disbursed through its bilateral agencies, including the Ministry of Commerce ($3.7 billion, 64.1%) and the National Health Commission ($917.1 million, 16.1%); the other 8.2% was disbursed through multilateral agencies including the WHO ($236.5 million, 4.1%) and the World Bank ($123.1 million, 2.2%). Relative to its level of economic development, China provided substantially more DAH than would be expected. However, relative to population size and government spending, China's contributions are modest. CONCLUSION: In the current context of plateauing in the growth rate of DAH contributions, China has the potential to contribute to future global health financing, especially financing for health system strengthening.