Government Health Spending Outlook - Projections Through 2029 Diverging Fiscal Pressures, Uneven Constraints Double Shock, Double Recovery Paper Series Christoph Kurowski, Martin Schmidt, David B. Evans, Ajay Tandon, Patrick Hoang-Vu Eozenou, Jewelwayne Salcedo Cain, and Eko Setyo Pambudi November 2024 2 Health, Nutrition and Population Discussion Paper This series is produced by the Health, Nutrition and Population (HNP) Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of materials presented in this series should take into account this provisional character. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. For information regarding the HNP Discussion Paper Series, please contact the Editor, Jung-Hwan Choi at jchoi@worldbank.org. Rights and Permissions The material in this work is subject to copyright. Because the World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522- 2625; e-mail: pubrights@worldbank.org. Cover design: World Bank © 2024 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433. All rights reserved. 3 Government Health Spending Outlook - Projections Through 2029 Diverging Fiscal Pressures, Uneven Constraints Double Shock, Double Recovery Paper Series Christoph Kurowski, Martin Schmidt, David B. Evans, Ajay Tandon, Patrick Hoang-Vu Eozenou, Jewelwayne Salcedo Cain, and Eko Setyo Pambudi. Health, Nutrition and Population Global Practice, World Bank, Washington, DC, USA. Abstract This paper examines the implications of the IMF’s April 2024 macro-fiscal forecast updates on government health expenditure (GHE) across 170 economies through 2029, covering nearly all years remaining to achieve the Sustainable Development Goals (SDGs). The findings reveal wide disparities in governments' capacities to increase health spending, with differences not only observed across income groups but also within them. Primary concerns focus to two groups of low- and lower middle- income countries: the first group is projected to experience a contraction in real per capita GHE from 2019 and 2029, threatening to reverse progress toward the health SDG targets, while the other group faces stagnation in real per capita GHE, greatly limiting advancement. The insights presented are crucial for health policymakers and their external partners to respond to evolving macro-fiscal circumstances and stabilize investment growth in health. While increasing the priority of health in spending is a key policy option, it will not be sufficient on its own. Effective responses also require improving spending efficiency and addressing broader fiscal challenges. Without decisive action, many countries have little chance of achieving the health SDGs. Keywords: COVID-19, macro-economic crisis, inflation, debt distress, government health expenditure, Disclaimer: The findings, interpretations, and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Christoph Kurowski, MC 8-127, 1818 H Street NW, Washington, DC 20433; Tel.: 202-458-4275; email: ckurowski@worldbank.org; website http://worldbank.org 4 ACKNOWLEDGEMENTS The authors are grateful to the World Bank for publishing this report as a Health, Nutrition and Population (HNP) Discussion Paper. This paper was prepared under the overall guidance of Mamta Murthi, Human Development Vice President, and Juan Pablo Uribe, Global Director for HNP. The authors are deeply grateful for the insightful comments and valuable suggestions by the peer reviewers: Francisca Ayodeji Akala, Edson Correia Araujo, Alaka Holla, Marc-Francois Smitz, and Srinivas Gurazada (all from the World Bank). Sincere thanks also to Mauricio Soto and Nick Carroll from the International Monetary Fund (IMF) for their unwavering engagement and support. The authors would like to acknowledge the contributions of people, organizations, and events that supported earlier issues of this report series, which also benefited the current report. The HNP GP Leadership Team also offered valuable feedback. We also appreciate the input from discussions with organizations such as the Bill and Melinda Gates Foundation, the International Health Economics Association, the Joint Learning Network, PAHO, P4H, SEARO, the Sustainable Health Financing Accelerator of the Global Action Plan, WPRO, and the UK's Foreign, Commonwealth & Development Office. Finally, the 7th Annual Health Financing Forum in Washington, DC, in April 2024 contributed valuable perspectives that informed this report series. The authors sincerely appreciate Karunia Silitonga's coordination and administrative support in finalizing the report. Julie Luvisa Bazolana and Alexandra Beith also made valuable contributions to its production. Special thanks to Alexandra Humme for her assistance with external communications, and to Andres de la Roche for designing the cover. The authors gratefully acknowledge the generous financial support of the Bill & Melinda Gates Foundation, Gavi, the Vaccine Alliance, and the Government of Japan’s Policy and Human Resources Development Fund (PHRD) UHC Window, which made this work possible. 5 TABLE OF CONTENTS ACKNOWLEDGEMENTS ................................................................................................................ 5 TABLE OF CONTENTS .................................................................................................................... 6 LIST OF FIGURES, MAPS AND TABLES ............................................................................................ 7 ACRONYMS AND ABBREVIATIONS ................................................................................................ 9 EXECUTIVE SUMMARY ............................................................................................................... 10 Diverging fiscal pressures.................................................................................................................. 10 Uneven constraints ........................................................................................................................... 10 Navigating difficult choices ............................................................................................................... 10 Time for a rethink ............................................................................................................................. 11 INTRODUCTION ......................................................................................................................... 12 Purpose ............................................................................................................................................. 12 Timeframe and coverage .................................................................................................................. 13 Methods ............................................................................................................................................ 13 Notes to the Reader .......................................................................................................................... 13 General Government Expenditure .............................................................................................. 14 General government per capita expenditure: From increases to declines to modest growth ........ 14 Country-specific trends: Diverging trajectories ................................................................................ 15 Contraction countries ....................................................................................................................... 16 Stagnation countries ......................................................................................................................... 16 Expansion countries .......................................................................................................................... 17 Distribution of countries across GGE growth categories .................................................................. 17 Government health expenditure ................................................................................................ 19 Possible pathways for government health spending........................................................................ 19 Contraction countries ....................................................................................................................... 20 Stagnation countries ......................................................................................................................... 22 Expansion countries .......................................................................................................................... 24 Interest payments on public debt ..................................................................................................... 26 CONCLUSIONS ........................................................................................................................... 28 Diverging fiscal pressures.................................................................................................................. 28 Facing severe funding shortfalls ....................................................................................................... 28 Navigating difficult choices ............................................................................................................... 29 Time for a rethink ............................................................................................................................. 29 BIBLIOGRAPHY........................................................................................................................... 31 ANNEX 1. MACRO-FISCAL FORECASTS ......................................................................................... 33 ANNEX 2. IMPLICATIONS OF THE GOVERNMENT HEALTH SPENDING SCENARIOS BY COUNTRY .... 37 6 LIST OF FIGURES, MAPS AND TABLES Figure 1: Average per capita general government expenditure (GGE), by income group, 170 countries, 2000-2029. (Constant 2021US$) ........................................................................................................... 14 Figure 2: Per capita general government expenditure (GGE), by income group, 29 countries, 2010- 2029. (Constant 2021 US$) ................................................................................................................... 16 Figure 3: Per capita general government expenditure (GGE), by income group, 67 countries, 2000- 2029. (Constant 2021 US$) ................................................................................................................... 16 Figure 4: Per capita general government expenditure (GGE), by income group, 74 countries, 2000- 2029. (Constant 2021 US$) ................................................................................................................... 17 Figure 5: Per capita government health expenditure (GHE), by income group, 29 countries, 2015-2029. (Constant 2021 US$) ............................................................................................................................. 20 Figure 6: Annual average growth rates in real GHE per capita, by country and income group, 29 countries, 2019-2029. ........................................................................................................................... 21 Figure 7: Per capita government health expenditure (GHE), by income group, 67 countries, 2015-2029. (Constant 2021 US$) ............................................................................................................................. 22 Figure 8: Annual average growth rates in real GHE per capita, by country and income group, 67 countries, 2019-2029. ........................................................................................................................... 23 Figure 9: Per capita government health expenditure (GHE), by income-group, 74 countries, 2015-2029. (Constant US$ 2021) ............................................................................................................................. 24 Figure 10: Annual average growth rates in real GHE per capita, by country and income group, 74 countries, 2019-2029. ........................................................................................................................... 26 Figure 11: Countries with more than a five-percentage point change in the share of interest payments in GGE (Panel A) and countries with shares greater than 15 percent in 2029 (Panel B). .................... 27 Figure A1. 1. Real GDP per capita ......................................................................................................... 34 Figure A1. 2. Real general government revenue (GGR) per capita ....................................................... 35 Map 1. Countries covered in study based on per capita GGE growth. ................................................. 15 Table 1: Annual average growth rates of real GGE per capita, by income group, 2000-2029. ............ 14 Table 2. Distribution of countries across contraction, stagnation, and expansion categories, by income group and regional group, 170 countries. ............................................................................................ 18 Table 3: Health shares in government spending required to move from Scenario 1 to Scenario 3 in 2029 and comparison with health share growth during the pandemic response, by income group, 29 countries, 2019-2029. ........................................................................................................................... 21 Table 4: Health shares in government spending required to move from Scenario 1 to Scenario 3 in 2029 and comparison with health share growth during the pandemic response, by income group, 67 countries, 2019-2029. ........................................................................................................................... 23 Table 5: Health shares in government spending required to move from Scenario 1 to Scenario 3 in 2029 and comparison with health share growth during the pandemic response, by income group, 74 countries, 2019-2029. ........................................................................................................................... 25 Table 6: Projected share of interest payments on public debt in GGE, 2019-2029. ............................ 27 Table A1. 1. Average interest payments per capita on public debt in government expenditure (GGE), 2019-2029 (Constant 2021 US$) ........................................................................................................... 35 Table A1. 2. Average share of interest payments on public debt in government expenditure (GGE), 2019-2029 (Percent) ............................................................................................................................. 36 7 Table A2.1. GHE per capita and GHE-to-GGE ratios for 29 contraction countries ............................... 37 Table A2.2. GHE per capita and GHE-to-GGE ratios for 67 stagnation countries ................................. 38 Table A2.3. GHE per capita and GHE-to-GGE ratios for 74 expansion countries.................................. 40 8 ACRONYMS AND ABBREVIATIONS COVID Corona Virus Disease GDP Gross Domestic Product GGE General Government Expenditure GGR General Government Revenue GHE Government Health Expenditure GNI Gross National Income HIC High-Income Country IMF International Monetary Fund LIC Low-Income Country LMIC Lower Middle-Income Country OOP Out-of-Pocket SDG Sustainable Development Goal UHC Universal Health Coverage UMIC Upper-Middle-Income Country WHO World Health Organization WHO GHED WHO Global Health Expenditure Database 9 EXECUTIVE SUMMARY This paper presents projections of government health expenditure (GHE) through 2029, covering 170 countries and representing 95 percent of the world’s population. The analysis places special emphasis on low- and lower middle-income countries (LICs and LMICs), given their profound challenges in financing health as the world approaches the decisive period for the Sustainable Development Goals (SDGs). The paper updates the earlier World Bank Health Spending Outlook, Old Scars, New Wounds (Kurowski et al. 2022). The IMF’s macro-fiscal forecasts released in April 2024 indicate a moderate increase in overall government spending across all income groups from 2023 to 2029. However, this growth is expected to lag significantly behind the marked expansion observed in the pandemic years and the preceding two decades. Diverging fiscal pressures Although average government spending is expected to grow slowly, countries' fiscal capacities vary widely with significant differences in per capita expenditure within and across income groups. Of the 170 countries, 74 are expected to experience substantial growth in real per capita general government expenditure (GGE) between 2019 and 2029. Meanwhile, 67 countries are projected to experience sluggish growth, while 29 countries are anticipated to see a contraction in per capita spending over the same period. Uneven constraints Differences in government spending projections create distinct fiscal pressures on funding for health. To examine these challenges, the analysis considers three possible pathways for future real per capita government health expenditure (GHE). The first two scenarios use the IMF projections of general government expenditure (GGE) per capita to assess how these trends shape future GHE per capita, applying two different fixed shares of GHE within GGE: the pre-pandemic share and the elevated pandemic-era share. In contrast, the third scenario assumes that GHE per capita continues growing according to historical trends observed in the two decades leading up to the pandemic, independent of GGE per capita projections. The scenarios highlight uneven constraints in growing per capita government health spending under longer-term fiscal pressures. If the health share in GGE reverts to pre-pandemic levels—or even if it remains at the higher shares seen during the pandemic—real GHE per capita in countries with contracting GGE is projected to decline between 2019 and 2029. For countries with stagnating GGE, per capita GHE is projected to grow only modestly by 2029. In both cases, spending remains well below the levels in scenario 3, where GHE per capita is projected to grow at the historical rates observed from 2000 to 2019. The situation is especially precarious for the LIC and LMICs in the groups with contracting and stagnating general government expenditure. The concurrently published Health Spending Review shows that many LICs and LMICs did not maintain the higher shares of GHE in GGE observed during the crisis, instead experiencing negative growth in the share of GHE between 2019 and 2023 (Kurowski et al. 2024). Additionally, in many of these countries, rising or high interest payments on public debt limit their capacity to allocate larger shares of government spending to health. Navigating difficult choices The current spending trajectories in LICs and LMICs are, with few exceptions and regardless of the macro-fiscal outlook, insufficient to meet the per capita government health spending levels needed to achieve the global health goals by 2030. Without decisive policy action, especially in low-income 10 countries with contracting or stagnating fiscal space, government health spending will continue falling far short of the necessary minimum levels. To counter these financing shortfalls, one critical option for governments is to increase the priority of health in spending decisions. Other domestic policies will also be crucial, including fiscal reforms to boost government revenues and measures to improve spending efficiency, such as eliminating ineffective subsidies and combating corruption. As the macro-fiscal landscape shifts, insights from this report provide policymakers with critical information to adapt domestic policies to anticipated declines in GGE or to expand ambitions if trends improve. Regular updates of this analysis can also help external partners anticipate requests for additional Development Assistance for Health (DAH) and refine targeting criteria to better support countries facing significant challenges in expanding health spending through domestic resources. Time for a rethink The current spending outlook does not bode well for achieving global health goals. If the expected funding shortfalls are not addressed, the consequences will be profound. Ministries of Health and other sector agencies will face rapidly increasing unmet health needs with inadequate, stagnant budgets, limiting their ability to strengthen health systems, improve population health, and enhance financial protection. Insufficient health investments will also undermine human capital development and weaken the foundation for long-term growth and revenue generation (World Bank 2019). Meanwhile, development partners risk seeing gains from past Development Assistance for Health (DAH) diminish and progress on global priorities, including pandemic prevention and preparedness, stall. While the SDG era has been envisioned as a transformative decade for global health, the current government health spending outlook threatens to make this period one of missed progress for many countries. This outlook calls for a critical reassessment of financing strategies to achieve the health- related SDGs amid fiscal headwinds and multiplying development challenges. The stakes extend beyond the health sector to include Ministries of Finance and development partners, who risk missing vital opportunities without collaboration to forge new paths. Encouragingly, the analyses also show that some countries are pursuing strategies to sustainably expand health investments, proving that progress is possible. 11 INTRODUCTION Countries are entering a critical phase in achieving the health Sustainable Development Goals (SDGs), with Universal Health Coverage (UHC)—ensuring that all people have access to essential health services without financial hardship—at the core of these efforts. Only six years remain to meet these goals, yet global progress toward UHC has been slow, and the COVID-19 pandemic has caused significant setback (WHO and World Bank 2023). The current rate of progress is now estimated to be only a quarter of the pace necessary to achieve the health-related SDGs (WHO 2022). Accelerating progress is particularly challenging in low- and lower middle-income countries. Many of these countries face diverse disease burdens, including maternal and child mortality, major epidemics such as HIV/AIDS, tuberculosis, and malaria, as well as the growing impact of non-communicable diseases, injuries, and environmental threats. Strengthening pandemic preparedness and building climate-resilient health systems also remain critical to safeguarding future gains. Multiple expert bodies have suggested minimum spending levels to meet global health goals, and when these estimates are disaggregated and adjusted to reflect only the government health expenditure component1, they consistently point to, in terms of current 2023-dollar values, about US$80 per person on health in low-income countries (LICs) and at least US$100 in lower middle- income countries (Commission on Macroeconomics and Health, 2001; HLTF, 2009; McIntyre, Meheus, & Røttingen, 2017; Stenberg et al., 2017; Jamison et al., 2024). These estimates reflect only recurrent spending, excluding the capital investments required to expand service delivery infrastructure and reach the entire population, and assume that resources are spent efficiently. Yet, in 2019, government health expenditure was far below these thresholds, averaging, again in 2023-dollar values, US$12 in LICs and US$80 in LMICs, with spending growth over the previous two decades insufficient to even approach the minimum levels needed by 2030, especially in LICs. Closing these shortfalls in government health spending by 2030 presents considerable financing challenges. On the one hand, the IMF’s macro-fiscal projections released in April 2024 indicate better- than-expected economic growth for the next five years, creating opportunities for increased government revenue (IMF 2024a). On the other hand, public debt remains at record levels globally, and rising interest payments may divert resources away from essential priorities like health. Purpose In light of these recent dynamics, this paper has two main objectives: first, to summarize the implications of the IMF’s April 2024 macro-fiscal projections for real per capita general government expenditure, and second, to explore how these projections are likely to shape the future trajectory of government health expenditure (GHE) under various scenarios, with a focus on low-income and lower middle-income countries (LICs and LMICs). As in the previous health spending outlook, the analysis centers on government health expenditure. This component of health expenditures sets the limits of what countries can achieve in providing their populations with essential health services and financial protection. As the primary source of prepaid funding for health systems, GHE enables individuals—especially those less well-off—to access necessary health services without facing financial distress. It is also critical for maintaining public health functions and fostering health system resilience, thereby making it a central consideration in fiscal planning. To ensure timely insights on government health expenditure trends for decision-makers, the study excludes analyses of non-governmental spending sources, such as out-of-pocket payments and off- 1 As defined in the system of health accounts (OECD 2011). 12 budget donor contributions. It also does not assess how changes in government spending levels impact progress toward Universal Health Coverage (UHC) or other global health goals. Timeframe and coverage The analysis focuses on the period from 2019 to 2029, with an emphasis on the outlook from 2023 to 2029. The earlier years of the decade, including the pandemic response and recovery years from 2019 to 2023, provide essential context for understanding the trends in government health expenditure (GHE). The study includes 170 countries, representing 95 of the world’s population. It encompasses all World Bank regions and includes fragile and conflict-affected countries (FCV) as well as small island developing states (SIDS). Special emphasis is placed on low-income and lower middle-income countries (LICs and LMICs), which face the most significant in sustainably financing health. Methods This paper builds on the methodology used in previous health spending outlooks, with a focus on categorizing countries into those with contracting, stagnating, or expanding fiscal space (Kurowski et al. 2021a, 2021b, 2022). However, several modifications have been introduced. First, the analysis emphasizes average annual growth rates across different periods, moving away from simple comparisons of start and end points. Additionally, the scenarios have been streamlined to focus on three pathways for future government health expenditure (GHE) per capita: two driven by macro- fiscal trends and one based on historical growth rates prior to the pandemic. Notes to the Reader Following this introduction, the report moves to an overview of trends in general government per capita expenditure, distinguishing countries by their fiscal outlook—contracting, stagnating, or expanding resource envelopes. Annex 1 provides complementary summaries of trends in economic growth and general government revenue. The subsequent section explores how these fiscal trends affect government per capita health expenditure under different scenarios for each country category, as well as the impact of changes in interest payments on public debt. The report concludes with final insights. The findings section is intentionally concise, allowing readers to quickly grasp the main trends and shifts. Whether scrolling through the text or navigating through maps, tables, or figures, readers can easily explore the data. The figures have been designed to clearly highlight individual country performances, making it simple to identify both overarching patterns and country-specific details at a glance. Finally, readers should bear in mind that unless stated otherwise, all dollar values in the paper are expressed in constant 2023 US$. This ensures that the analysis accounts for inflation, providing a clearer view of real changes in spending over time. 13 GENERAL GOVERNMENT EXPENDITURE This section explores past trends and future projections for general government per capita expenditure. Understanding these trends is essential, as they are central to assessing the implications of the macro-fiscal trends on government health spending. The analysis considers real general government expenditure (GGE) per capita to account for changes in both prices and population numbers. As a brief reminder, general government expenditure (GGE) derives from revenues generated through taxes, social security contributions (including social health insurance), other levies and charges, on-budget external assistance2, and public borrowing. General government per capita expenditure: From increases to declines to modest growth Across all income groups, average real GGE per capita is projected to grow between 2019 and 2029. Initially, spending increased in response to the COVID-19 health and economic crisis, followed by a temporary decline (Figure 1). In LICs and MICs, this pattern is subdued, while in HICs, it is pronounced. From 2025 onward, all income groups are expected to return to steady growth through 2029. Figure 1: Average per capita general government expenditure (GGE), by income group, 170 countries, 2000-2029. (Constant 2021US$) Source: Data from IMF, World Economic Outlook, April 2024 Table 1: Annual average growth rates of real Despite the general upward trend, average GGE per capita, by income group, 2000-2029. growth in GGE per capita between 2019 and 2029 is expected to be more modest than in the Income 2000- 2009- 2019- 2019- 2023- previous two decades, with high income countries Group 2009 2019 2029 2023 2029 as the exception (Table 1). Additionally, from 2023 LICs 6.4 3.5 2.4 4.0 1.4 LMICs 6.1 2.7 2.1 1.7 2.3 onward, annual growth rates are projected to UMICs 5.9 2.4 2.2 2.7 1.9 slow further, falling below the decade’s average in HICs 3.2 1.0 1.9 2.9 1.3 all income groups. Source: Data from IMF, World Economic Outlook, April 2024 2 This means either being channeled through the government’s financial system or being part of the budget process but distributed in parallel by the external partner. 14 Country-specific trends: Diverging trajectories While average real per capita GGE is set to increase across all income groups from 2019 to 2029, many nations are expected to follow different pathways. Based on their per capita GGE growth between 2019 and 2029, countries fall into three categories: Contraction: Countries projected to experience a decline in real GGE per capita (29 countries);3 Stagnation: Countries expected to see sluggish, albeit positive, growth in real GGE per capita (67 countries);45 Expansion: Countries forecast to record strong growth in real GGE per capita (74 countries)67 Map 1. Countries covered in study based on per capita GGE growth. 3 Countries projected to experience a decline in real GGE per capita: LICs: Burundi, Liberia; LMICs: Algeria, Angola, Bolivia, Comoros, Congo, Rep., Haiti, Lesotho, Papua New Guinea, Solomon Islands, Timor-Leste, Vanuatu; UMICs: Argentina, Belize, Botswana, Equatorial Guinea, Namibia, South Africa, Suriname; HICs: Australia, Bahrain, Brunei Darussalam, Kuwait, Norway, Oman, Qatar, Saudi Arabia, Trinidad and Tobago 4 Countries expected to see sluggish, albeit positive, growth in real GGE per capita: LICs: Central African Republic, Ethiopia, The Gambia, Guinea-Bissau, Madagascar, Malawi, Mali, Mozambique, Niger, Sierra Leone; LMICs Cabo Verde, Cambodia, Cameroon, Djibouti, Egypt, Arab Rep., Eswatini, Ghana, Honduras, Jordan, Kenya, Kiribati, Lao PDR, Micronesia, Fed. Sts., Morocco, Myanmar, Nepal, Nicaragua, Pakistan, Sao Tome and Principe, Tunisia, Ukraine, Zambia; UMICs: Azerbaijan, Belarus, Brazil, Colombia, Costa Rica, Dominica, Fiji, Iraq, Jamaica, Kazakhstan, Malaysia, Maldives, Marshall Islands, Mauritius, Mexico, Paraguay, Peru, St. Lucia, St. Vincent and the Grenadines, Tonga, Tuvalu; HICs Antigua and Barbuda, Austria, Canada, Chile, Finland, France, Germany, Greece, Iceland, New Zealand, San Marino, Spain, Sweden, Switzerland 5 A country falls into the stagnation group, if its average annual growth rate of GGE per capita from 2019-2029 is projected to be below the average annual growth rate of countries in its income group during the decade before COVID-19 (2010 – 2019). In other words, these countries will not achieve their respective income group's pre-COVID growth path. The average annual growth rate during 2010-2019 was 3.0 percent for LICs, 2.7 percent for LMICs, 2.4 percent for UMICs, and 1.3 percent for HICs. 6 Countries forecast to record strong growth in real GGE per capita: LICs: Burkina Faso, Chad, Congo, Dem. Rep., Rwanda, Togo, Uganda; LMICs: Bangladesh, Benin, Bhutan, Cote d'Ivoire, Guinea, India, Iran, Islamic Rep., Kyrgyz Republic, Mauritania, Mongolia, Nigeria, Philippines, Senegal, Tajikistan, Tanzania, Uzbekistan, Vietnam; UMICs: Albania, Armenia, Bosnia and Herzegovina, Bulgaria, China, Dominican Republic, El Salvador, Gabon, Georgia, Grenada, Guatemala, Indonesia, Moldova, Montenegro, North Macedonia, Russian Federation, Serbia, Thailand, Turkey; HICs: Bahamas, The, Barbados, Belgium, Croatia, Cyprus, Czechia, Denmark, Estonia, Guyana, Hungary, Ireland, Israel, Italy, Japan, Korea, Rep., Latvia, Lithuania, Luxembourg, Malta, Netherlands, Panama, Poland, Portugal, Romania, Seychelles, Slovak Republic, Slovenia, St. Kitts and Nevis, United Arab Emirates, United Kingdom, United States, Uruguay. 7 In this group, projected growth 2019-2029 exceeds the average annual growth rate of the relevant income group during the decade before COVID-19. 15 Contraction countries Countries in the contraction category are projected to experience absolute declines in real GGE per capita between 2019 and 2029. All income groups in the category saw substantial declines during the period from 2019 to 2023. From 2023 to 2029, most income groups are projected to experience average annual growth rates just below zero, with the exception of LICs, which are expected to recover slightly starting in 2023, with an average annual growth rate of 1.2%. Figure 2: Per capita general government expenditure (GGE), by income group, 29 countries, 2010- 2029. (Constant 2021 US$) Source: Data from IMF, World Economic Outlook, April 2024 Stagnation countries In the stagnation category, countries are projected to experience sluggish growth in real GGE per capita over the decade from 2019 to 2029. In LICs, average GGE per capita growth remains relatively steady after a 2020 surge followed by a short downturn (Figure 3). LMICs are expected to see growth pick up after 2023, following slower increases earlier in the period. In contrast, UMICs and HICs are projected to experience slower growth after 2023, following faster gains in previous years. Figure 3: Per capita general government expenditure (GGE), by income group, 67 countries, 2000- 2029. (Constant 2021 US$) Source: Data from IMF, World Economic Outlook, April 2024 16 Expansion countries Countries in the expansion category are projected to experience substantial growth in real GGE per capita between 2019 and 2029. All income groups saw rapid increases during the 2019–2023 period. However, after 2023, growth rates are expected to decelerate across all groups—moderately in LMICs and UMICs, but more sharply in LICs and HICs (Figure 4). Figure 4: Per capita general government expenditure (GGE), by income group, 74 countries, 2000- 2029. (Constant 2021 US$) Source: Data from IMF, World Economic Outlook, April 2024 Most countries in the expansion group are expected to maintain rapid growth in GGE per capita throughout the decade. Nevertheless, some countries may face challenges in the later years. After 2023, 17 countries are projected to experience sluggish growth, while four countries are likely to face negative growth rates. Despite these challenges, the average growth over the decade remains substantial, driven by strong performance in the early years. Distribution of countries across GGE growth categories Significant differences exist in the distribution of countries across the contraction, stagnation, and expansion categories. Most notably, low-income countries are overrepresented in the stagnation category, while LMICs are prominent in both the contraction and stagnation categories. However, some LICs and LMICs can also be found in the expansion category. In contrast, HICs are more concentrated in the expansion category, although they also appear in the contraction and stagnation groups. This pattern also extends to fragile and conflict-affected countries (FCVS) and Small Island Developing States (SIDS), which tend to cluster in the contraction and stagnation categories, with a limited representation in the expansion category. Disparities in the distribution of countries are also evident across World Bank regions (Table 2). Countries in East Asia & Pacific, Latin America & the Caribbean, Middle East & North Africa, and Sub- Saharan Africa are overrepresented in the contraction and stagnation categories, where, on average, prospects for GGE per capita growth remain subdued. In the East Asia & Pacific region, this pattern largely results from the high concentration of SIDS, all of which fall into the contraction and stagnation groups. 17 In contrast, Europe & Central Asia and South Asia have a stronger presence in the expansion category, reflecting more favorable GGE per capita growth trajectories in these regions. Notably, the world's two most populous countries, China and India, both fall into the expansion category. Table 2. Distribution of countries across contraction, stagnation, and expansion categories, by income group and regional group, 170 countries. Income Group N Contraction Stagnation Expansion Regional Group N Contraction Stagnation Expansion All countries 170 17% 39% 44% All countries 170 17% 39% 44% LICs 18 11% 56% 33% EAP 25 24% 44% 32% LMICs 50 22% 44% 34% ECA 48 2% 29% 69% UMICs 47 15% 45% 40% LAC 30 20% 47% 33% HICs 55 16% 26% 58% MENA 16 38% 38% 25% FCV 24 29% 54% 17% SAR 6 0% 50% 50% SIDS 30 30% 47% 23% SSA 43 23% 42% 35% Abbreviations: LICs – Low-Income Countries; LMICs – Lower Middle-Income Countries; UMICs – Upper-Middle-Income Countries; HICs – High-Income Countries; FCV – Fragility, Conflict, and Violence; SIDS – Small Island Developing States; EAP – East Asia and Pacific; ECA – Europe and Central Asia; LAC – Latin America and the Caribbean; MENA – Middle East and North Africa; SAR – South Asia Region; SSA – Sub-Saharan Africa. Note: The 170 study countries include 2 countries of the North America Region. 18 GOVERNMENT HEALTH EXPENDITURE This section explores three potential pathways for future government health expenditure per capita (GHE per capita). As a reminder, GHE consists of two main components: the first is derived from general government revenues, borrowing, and on-budget external funding from development partners, while the second comes from compulsory social health insurance (SHI) contributions. The first two scenarios build on the earlier analysis of general government expenditure (GGE) per capita. They explore how trends in GGE per capita will shape future GHE per capita, using two different fixed shares of GHE within GGE: the pre-pandemic share and the elevated pandemic-era share. In contrast, the third scenario assumes that GHE per capita continues to grow according to the historical trends observed in the two decades leading up to the pandemic, independent of GGE per capita projections. Possible pathways for government health spending This section provides a detailed look at the three scenarios under consideration. As discussed, scenarios 1 and 2 are linked to GGE per capita projections, while Scenario 3 is not. Scenario 1: Maintaining pre-pandemic priorities. This scenario assumes that countries maintain the pre-pandemic share of GGE allocated to health. Projections apply this fixed share, with 2019 as the base year, to subsequent levels of GGE per capita. This scenario serves as the baseline. Scenario 2. Sustaining pandemic response priorities. This scenario retains the higher share of GGE allocated to health during the pandemic. Projections start in 2021, a period when the health share of GGE had risen on average across all income groups. Recent data show that these shares have been declining in many countries, but this scenario is used to explore whether the levels of spending would be sufficient to return to the pre-pandemic growth paths if they were maintained to 2029 (Kurowski et al. 2024). Scenario 3: Continuing pre-COVID trends. Unlike the first two scenarios, Scenario 3 is not based on GGE per capita projections. Instead, it extrapolates GHE per capita based on the average growth rates for each income group observed from 2000 to 2019. This scenario assumes that these trends continue uninterrupted, projecting, in general, a more optimistic trajectory for GHE per capita growth compared to Scenarios 1 and 2. The following sections examine the implications of these scenarios for countries classified as contraction, stagnation, and expansion cases, analyzing both average trends across income groups and country-specific patterns within each group. Country-level explorations focus on Scenario 1. This approach is chosen for several reasons. First, Scenario 1 provides projections based on detailed GGE per capita data for individual countries, making it well-suited for country-specific analysis. In contrast, Scenario 3 relies on income group averages, which limits its applicability for detailed assessments at the country level. Second, the differences between Scenario 1 and Scenario 2 are minimal, with the key distinction being that Scenario 1 uses 2019 as the base year, while Scenario 2 starts from 2021. 19 Contraction countries In Scenario 1, all income groups are projected to experience declines in GHE per capita from 2019 to 2029, driven by the negative trend in GGE per capita among contraction countries. The declines are modest in LICs but become more pronounced in LMICs, UMICs, and HICs. In Scenario 2, most income groups still face negative growth despite the higher share used for the analysis, though the declines are generally less severe than in Scenario 1. On average, LICs, UMICs, and HICs experience modest declines, with LICs seeing rates just below zero. By contrast, LMICs are projected to achieve small positive gains on average. Scenario 3, which is independent of GGE trends, presents a much more optimistic outlook. GHE per capita grows significantly across all income groups, with LICs seeing the largest increases, followed by strong gains in LMICs and UMICs, and more moderate annual growth rates in HICs. The stark contrast between the robust growth projected in Scenario 3 and the declines in Scenarios 1 and 2 highlights the wide range of possible government health spending levels in 2029, dependent on assumptions about spending growth. Figure 5: Per capita government health expenditure (GHE), by income group, 29 countries, 2015- 2029. (Constant 2021 US$) Source: Authors’ calculations using data from IMF, World Economic Outlook, April 2024 and WHO, Global Health Expenditure Database, 2024 Note: Scenario 3 reflects average GHE per capita growth from 2000 to 2019. This long-term trend may differ from the shorter- term pre-COVID trend depicted here. Achieving the outcomes of scenario 3 Achieving the spending levels of Scenario 3 by 2029 requires contraction countries to dramatically boost the share of government spending dedicated to health, even as overall government expenditure declines (Table 3). In LICs, the health share must grow by an average of 1.3 percentage points annually, meaning it more than doubles between 2019 and 2029. A similar pace of growth is required in UMICs, while LMICs and HICs need to increase their health allocations at about half that rate. 20 For comparison, these elevated growth rates mean sustaining the rapid increase in health budget shares observed during the pandemic years (2019 to 2021), but this time extended over an entire decade. Achieving this requires an extraordinary commitment to prioritize health spending. Table 3: Health shares in government spending Country-specific trends required to move from Scenario 1 to Scenario 3 While previous sections focused on averages, in 2029 and comparison with health share these masked important variations within the growth during the pandemic response, by contraction group across three key periods: the income group, 29 countries, 2019-2029. full decade from 2019 to 2029, the onset of Annual Annual COVID-19 to its aftermath, and the projected Income growth growth Group N 2019 2021 2029 rate 2019 - rate 2019 - outlook for 2023 to 2029. This analysis draws on 2021 2029 Scenario 1 to explore these variations, driven by LICs 2 9.4 11.3 22.4 0.95 1.30 individual country prospects for general LMICs 11 8.6 10.6 16.3 1.00 0.77 government expenditure (GGE) growth. UMICs 7 12.4 16.2 25.5 1.90 1.31 HICs 9 11.0 12.3 17.6 0.65 Over the entire period, government health 0.66 All 29 10.3 12.5 19.4 1.10 0.91 expenditure (GHE) per capita showed significant countries variation across countries, with declines ranging from slight negative growth to average annual Source: Authors’ calculations using data from IMF, World drops exceeding 5 percent (Figure 6). Breaking it Economic Outlook, April 2024 and WHO, Global Health Expenditure Database, 2024 down further, ten countries are expected to experience contractions in GHE per capita during both sub-periods, with declines moderating to an annual average of -1.3 percent between 2023 and 2029. Meanwhile, seven countries that saw modest growth from 2019 to 2023 are now projected to face contractions averaging -1.4 percent during the same period. On a more positive note, twelve countries that experienced significant declines from 2019 to 2023 are expected to see modest gains, with GHE per capita increasing by an average of 1.7 percent from 2023 to 2029. However, despite this recovery, the decade-long trend remains negative also for these countries, reflecting the lingering impact of earlier declines. Figure 6: Annual average growth rates in real GHE per capita, by country and income group, 29 countries, 2019-2029. Source: Authors’ calculations using data from IMF, World Economic Outlook, April 2024 and WHO, Global Health Expenditure Database, 2023 21 Stagnation countries In Scenario 1, all income groups experience modest growth in GHE per capita between 2019 and 2029, driven by the slow growth of GGE per capita trends in stagnation countries. LICs grow at an average annual rate of 1.4 percent, while LMICs and UMICs experience slightly slower growth. HICs see the slowest growth, averaging about half the rate of LICs. In Scenario 2, growth improves across all income groups, with LICs leading at 3.3 percent annually. LMICs and UMICs achieve similar gains, though slightly lower than LICs. HICs experience more moderate growth, trailing behind the other income groups. In Scenario 3, all income groups have a more optimistic outlook, similar to contraction countries, with significant increases in GHE per capita. Though the differences between Scenario 1 and Scenario 3 are more moderate for stagnation countries, they still illustrate the varied possibilities for government health spending by 2029 based on different spending growth assumptions. Figure 7: Per capita government health expenditure (GHE), by income group, 67 countries, 2015- 2029. (Constant 2021 US$) Source: Authors’ calculations using data from IMF, World Economic Outlook, April 2024 and WHO, Global Health Expenditure Database, 2023 Note: Scenario 3 reflects average GHE per capita growth from 2000 to 2019. This long-term trend may differ from the shorter- term pre-COVID trend depicted here. Achieving the outcomes of scenario 3 Achieving the outcomes of Scenario 3 by 2029 requires stagnation countries to significantly increase the share of government spending allocated to health, while GGE per capita grows slowly (Table 4). In LICs, the health share must rise by just over 1 percentage point annually, more than doubling between 2019 and 2029. LMICs, UMICs, and HICs will need to expand their health allocations at roughly half that rate. Although the necessary growth rates are lower than those in contraction countries, they still represent a substantial challenge, pushing health shares on average to levels that remain exceptional, particularly in LICs, UMICs, and HICs. Again for comparison, these growth rates generally exceed those 22 Table 4: Health shares in government spending observed during the pandemic response. required to move from Scenario 1 to Scenario 3 Sustaining this level of growth over an entire in 2029 and comparison with health share decade, especially in LICs, remains growth during the pandemic response, by unprecedented. income group, 67 countries, 2019-2029. Country-specific trends Annual Annual average average As with contraction countries, focusing on Income Group N 2019 2021 2029 growth growth averages for stagnation countries can miss rate 2019- rate 2019- 2021 2029 important differences across the decade from LICs 10 9.9 10.7 20.1 0.40 1.02 2019 to 2029, as well as between the sub- LMICs 22 9.6 10.2 13.8 0.30 0.42 periods from 2019 to 2023 and the projected UMICs 21 12.1 13 18.7 0.45 0.66 outlook from 2023 to 2029. This analysis draws HICs 14 16.8 15.6 21.9 -0.60 0.51 on Scenario 1 to delve into these variations in All countries 67 11.9 12.3 18.0 0.20 0.61 greater detail. Throughout the entire period, average annual Source: Authors’ calculations using data from IMF, World Economic Outlook, April 2024 and WHO, Global Health growth in government health expenditure (GHE) Expenditure Database, 2023 per capita in stagnation countries ranged from just above zero to nearly 3 percent (Figure 8). A closer examination reveals that 32 countries are expected to see positive GHE growth across both sub- periods, although this is projected to slow to an annual average growth of 1.2 percent between 2023 and 2029. Additionally, 19 countries that experienced sharp reductions in GHE per capita between 2019 and 2023 are expected to recover, with annual average growth of 3.0 percent during the outlook period. On the other hand, 16 countries that had shown strong growth from 2019 to 2023 are now anticipated to encounter contractions, with annual average declines of -1.0 percent between 2023 and 2029. Figure 8: Annual average growth rates in real GHE per capita, by country and income group, 67 countries, 2019-2029. Source: Authors’ calculations using data from IMF, World Economic Outlook, April 2024 and WHO, Global Health Expenditure Database, 2024 23 Expansion countries In Scenario 1, all income groups experience steady growth in GHE per capita from 2019 to 2029, mirroring the trends in GGE per capita for expansion countries. LICs see the fastest growth, with an average annual increase of 3.8 percent, while LMICs and UMICs follow closely behind. HICs grow more slowly, averaging 2.8 percent annually. In Scenario 2, all income groups see even higher growth, with LICs leading at 5.6 percent annually. LMICs and UMICs experience strong gains, though slightly below LIC levels. HICs continue to grow more moderately, remaining the slowest-growing group. In Scenario 3, all income groups benefit from the same optimistic outlook seen in contraction and stagnation countries, with significant increases in GHE per capita. The contrast between Scenario 1 and Scenario 3 is least pronounced for expansion countries, reflecting more consistent growth patterns. However, Scenario 3 illustrates the potential for higher government health spending by 2029 under more ambitious growth assumptions. Figure 9: Per capita government health expenditure (GHE), by income-group, 74 countries, 2015- 2029. (Constant US$ 2021) Source: Authors’ calculations using data from IMF, World Economic Outlook, April 2024 and WHO, Global Health Expenditure Database, 2024 Note: Scenario 3 reflects average GHE per capita growth from 2000 to 2019. This long-term trend may differ from the shorter- term pre-COVID trend depicted here. Achieving the outcomes of scenario 3 Achieving the outcomes of Scenario 3 by 2029 also requires expansion countries to increase the share of government spending allocated to health, even though overall GGE grows substantially (Table 5). In LICs, the health share must rise by an average of 0.6 percentage points annually, resulting in a 6 percentage point increase between 2019 and 2029. UMICs need to increase their health share by about half that rate, while LMICs and HICs will require smaller increases. 24 Although the required growth rates in health shares are lower than those in contraction and stagnation countries, they still represent a considerable effort, especially in LICs. Sustaining these gains over a full decade remains a significant challenge. Once again for comparison, average growth in the share allocated to health in response to the pandemic has been minimal or even negative across all income groups. Country-specific trends Table 5: Health shares in government spending required to move from Scenario 1 to Scenario 3 As with contraction and stagnation countries, in 2029 and comparison with health share the averages presented for expansion countries growth during the pandemic response, by can conceal important variations across the full income group, 74 countries, 2019-2029. period from 2019 to 2029, as well as the sub- periods from 2019 to 2023 and 2023 to 2029. Annual Annual average average This analysis once again draws on Scenario 1 to Income Group N 2019 2021 2029 growth rate 2019 - growth rate 2019 - explore these variations. 2021 2029 LICs 6 9.3 9.4 15.0 0.05 0.57 Throughout the entire period, average annual growth in government health expenditure per LMICs 17 8.2 8.1 8.9 -0.05 0.07 capita in expansion countries ranged from 1.2 UMICs 19 11.7 11.9 14.1 0.10 0.24 percent to nearly 20 percent (Figure 10). Most HICs 32 14.6 13.9 16.3 -0.35 0.17 countries in this group are projected to maintain All 74 11.9 11.7 13.9 -0.10 0.20 positive growth in both sub-periods. However, countries these 68 countries are expected to see a Source: Authors’ calculations using data from IMF, World slowdown in growth during the outlook period, Economic Outlook, April 2024 and WHO, Global Health averaging 3.0 percent annually between 2023 Expenditure Database, 2024 and 2029. Negative growth is expected in only a small number of countries during either period, with two facing mild reductions from 2019 to 2023 before rebounding strongly to an average of 4.1 percent annual growth. In contrast, four countries that experienced rapid growth from 2019 to 2023 are now projected to face contractions, with GHE per capita declining by an average of -1.3 percent annually between 2023 and 2029. 25 Figure 10: Annual average growth rates in real GHE per capita, by country and income group, 74 countries, 2019-2029. Source: Authors’ calculations using data from IMF, World Economic Outlook, April 2024 and WHO, Global Health Expenditure Database, 2024 Note: Guyana is not shown because of very high growth rates: 19.7 in 2019-2029, 35.3 percent in 2019-2023, and 5.9 percent in 2023-2029 Interest payments on public debt Interest payments on public debt are an important component of government budgets, directly affecting the resources available for health. Governments base their expenditures on a mix of revenues, grants, and borrowing, but as the share of interest payments rises, the funds for other priorities, like health, are increasingly constrained (Wendling, Pedastsaar, and Rahim 2022). Therefore, interest payment dynamics are especially important when considering future government health spending, particularly in countries with large shares allocated to debt servicing. The average share of interest payments in GGE is projected to intensify across all income groups from 2019 to 2029 (Table 6). In LICs and LMICs, this share will rise to a peak in 2025 before starting to decline, but it will remain higher in 2029 than in 2019, and also higher than in 2000, when major debt relief efforts, such as the HIPC initiative, were underway. Although these increases are modest on average, their impact varies widely across countries. For most, the projected shifts will have only a minor effect on GHE per capita. However, twenty out of 170 countries are expected to see an increase of more than five percentage points in their share of interest payments in GGE between 2019 and 2029 (Figure 11). In these countries, where government spending is either contracting or stagnant, maintaining or raising GHE per capita will be especially challenging. 26 Table 6: Projected share of interest payments on public debt in GGE, 2019-2029. Income group N 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 All countries 170 6.2 6.0 6.3 6.4 7.2 7.8 7.9 8.0 7.8 7.8 7.7 LICs 18 7.3 6.8 7.4 7.5 8.7 10.1 10.4 10.4 9.7 9.4 8.9 LMICs 50 8.1 7.9 8.0 8.0 9.3 10.2 10.3 10.1 9.7 9.6 9.5 UMICs 47 7.0 6.9 7.3 7.4 8.0 8.3 8.5 8.7 8.7 8.8 8.7 HICs 55 3.6 3.4 3.5 3.8 4.1 4.4 4.5 4.5 4.6 4.6 4.6 Source: Authors’ calculations, using data from IMF, World Economic Outlook, April 2024 Figure 11: Countries with more than a five-percentage point change in the share of interest payments in GGE (Panel A) and countries with shares greater than 15 percent in 2029 (Panel B). Panel A Panel B Source: Authors’ calculations, using data from IMF, World Economic Outlook, April 2024 While the share of interest payments is projected to rise in many countries, by the end of the projection period 20 countries are expected to have interest payments exceeding 15 percent of GGE (Figure 12). Among them, Angola, Egypt, Ghana, Pakistan, and Zambia will see their interest shares peak and decline after 2023. In contrast, other countries are expected to face steady increases or remain at near-peak levels, raising concerns about the sustainability of their health spending. Conversely, four countries—Jamaica, The Gambia, Grenada, and Mozambique—are projected to see declines of more than five percentage points in their share of interest payments. This reduction is expected to ease budgetary pressures, enabling these countries to prioritize health more effectively and potentially increase GHE per capita. 27 CONCLUSIONS This paper presents projections of government health expenditure (GHE) through 2029, covering 170 countries and representing over 95 percent of the world’s population. The analysis places special focus on low- and lower middle-income countries (LICs and LMICs), which face profound challenges in financing health as the world enters the decisive period for the Sustainable Development Goals (SDGs). The paper updates the earlier World Bank Health Spending Outlook, Old Scars, New Wounds (Kurowski et al. 2022). The IMF’s macro-fiscal forecasts from April 2024 indicate that, on average, overall government spending will increase across all income groups from 2023 to 2029. However, this growth is expected to be slower than during the rapid expansion seen in the pandemic years and the preceding two decades. This shift signals a more constrained fiscal environment, raising critical questions about how countries will prioritize health spending in the coming years. While average government spending is expected to grow slowly, countries' fiscal capacities vary widely, leading to significant differences in per capita expenditure both within and across income groups. Among the 170 countries, 74 are expected to experience substantial growth in real per capita general government expenditure (GGE) between 2019 and 2029. In contrast, 67 countries are projected to experience slow or sluggish growth, while 29 countries are expected to see a contraction in per capita spending over the same period. Contraction and stagnation trends are more common to low-income and lower middle-income countries, FCVS, SIDS, and regions such as Latin America, the Pacific, and Sub-Saharan Africa. Diverging fiscal pressures The varied outlook for government spending creates diverging fiscal pressures on the sustainability of health financing. If the health share in GGE reverts to pre-pandemic levels—or even if it remains at the higher shares seen during the pandemic—real GHE per capita in countries with contracting GGE is projected to decline between 2019 and 2029. For countries with stagnating GGE, per capita GHE is expected to grow only modestly by 2029. In both cases, spending is expected to remain well below the levels in scenario 3, where GHE per capita is projected to grow at the historical rates observed from 2000 to 2019. The situation is especially precarious for the LIC and LMICs within these two groups. The concurrently published Health Spending Review shows that many LICs and LMICs did not sustain the higher shares of GHE in GGE seen during the crisis and instead experienced negative growth in the share of GHE between 2019 and 2023 (Kurowski et al. 2024). Additionally, in many of these countries, rising or high interest payments on public debt further constrain their ability to allocate larger shares of government spending to health. Facing severe funding shortfalls Regardless of the macro-fiscal outlook, expected spending trajectories in LICs and LMICs are, with few exceptions, insufficient to reach the minimum annual per capita government health spending levels needed to meet global health goals by 2030. These levels have been estimated at about US$80 in LICs and US$100 in LMICs (in 2023-dollar values). It is also important to recall that these estimates are conservative, covering only the recurrent costs of delivering essential health services and assuming efficient use of resources. Without decisive policy action, especially in low-income countries with contracting or stagnating fiscal space, spending will remain well below necessary levels. 28 Navigating difficult choices To address these financing shortfalls, one critical option for governments—especially where health represents a relatively small share of government budgets—is to increase the priority given to health in spending decisions. However, this is especially difficult when overall budget envelopes are shrinking or stagnant, particularly now, as development priorities are multiplying and placing growing demands on governments across sectors (Kurowski et al. 2021a). Further exploration is necessary to better understand effective strategies and approaches that countries can adopt in this evolving context. Increasing the share of health in government spending is only one approach to raise health spending for faster progress toward broader coverage with essential health services and financial protection. A range of complementary domestic policies will also play an important role. Some policies fall under the remit of Ministries of Finance and monetary authorities rather than Ministries of Health. These include fiscal reforms to enhance government revenue, alongside fiscal and monetary measures to manage public debt, control inflation and stimulate growth. Other policies have an economy wide scope and require the active involvement of all government sectors, including health. These strategies build on spending reviews to identify measures that improve spending efficiency, such as eliminating ineffective subsidies and combating corruption (Kurowski et al. 2020). For guidance with these measures, countries can draw on an extensive body of publications detailing successful experiences (Barroy et al. 2018; Mathauer et al. 2019; World Bank 2019; Jowett et al. 2020; Mathauer et al. 2020; Kurowski et al. 2021a; Barroy, Blecher, and Lakin 2022). As the macro-fiscal landscape shifts, insights like those in this report are critical for policymakers, who often lack access to this level of information. They enable them to adapt domestic policies in response to anticipated declines in GGE—or to expand ambitions if macro-fiscal trends are more favorable. Regular updates of this type of analysis can also help external partners anticipate requests for additional Development Assistance for Health (DAH) and reconsider targeting criteria to better support countries facing the greatest challenges in increasing health spending through domestic resources. Time for a rethink The current spending outlook does not bode well for achieving global health goals. Without decisive policy action, spending levels in most LICs and LMICs in 2029 are expected to fall significantly short of the per capita government health spending required to meet the Sustainable Development Goals (SDGs) by 2030, particularly in countries where GHE per capita is projected to be contracting or sluggish. Even with the higher spending growth rates observed during the first two decades of the century, most LICs and LMICs have struggled to make adequate progress toward the necessary levels of health spending. (World Bank 2019; WHO 2022). If these funding shortfalls are not addressed, the consequences will be profound, impacting all stakeholders. Ministries of health and other sector agencies will be tasked to address large and rising unmet health needs with inadequate and stagnant budgets, severely impeding their ability to strengthen health systems, improve population health, and enhance financial protection. Insufficient health investments will undermine human capital development, and as stressed by the G20 Ministers of Finance, erode the foundation for long-term growth and revenue generation (World Bank 2019). Meanwhile, development partners will eventually see gains from past Development Assistance for Health (DAH) diminish and progress on global priorities, including pandemic prevention and preparedness, stall. The SDG era has been envisioned as a transformative period for global health, however, following pandemic setbacks, the government health spending outlook, if unaddressed, threatens to turn it into an era of limited gains and unfulfilled promises. The situation demands a critical reassessment of 29 financing strategies to achieve the health-related SDGs in light of the macro-fiscal headwinds and multiplying development demands. The stakes are high, not only for those in the health sector but also for Ministries of finance and development partners, who risk missing vital opportunities unless they collaborate to forge new paths forward. Encouragingly, the analyses also show that some countries are successfully navigating these obstacles and have embarked on strategies to sustainably expand health investments, demonstrating that progress is possible even amid significant macro-fiscal constraints. 30 BIBLIOGRAPHY Barroy, Helene, Susan Sparkes, Elina Dale, and Jacky Mathonnat. 2018. “Can Low- and Middle-Income Countries Increase Domestic Fiscal Space for Health: A Mixed-Methods Approach to Assess Possible Sources of Expansion.� Health Systems and Reform 4 (3): 214–26. https://doi.org/10.1080/23288604.2018.1441620. Barroy H, Blecher M, Lakin J, eds. 2022. How to make budgets work for health? A practical guide to designing, implementing and monitoring programme budgets in health. Geneva: World Health Organization. Commission on Macroeconomics and Health (CMH). Macroeconomics and Health: Investing in Health for Economic Development. Geneva: World Health Organization, 2001. https://iris.who.int/bitstream/handle/10665/42435/924154550X.pdf. IMF. 2024a. “World Economic Outlook, April 2024: Steady but Slow: Resilience amid Divergence.� https://www.imf.org/en/Publications/WEO/Issues/2024/04/16/world-economic-outlook-april- 2024. ———. 2024b. “World Economic Outlook, April 2024: Steady but Slow: Resilience amid Divergence.� https://www.imf.org/en/Publications/WEO/Issues/2024/04/16/world-economic-outlook-april- 2024. High-Level Taskforce on Innovative International Financing for Health Systems (HLTF). “Constraints to Scaling Up and Costs.� Working Group 1 Technical Report. Geneva: World Health Organization, 2009. https://www.uhc2030.org/fileadmin/uploads/ihp/Documents/Results___Evidence/HAE__result s___lessons/Working%20Group%201%20Technical%20Background%20Report%20(World%20H ealth%20Organization).pdf. Jamison, Dean T., et al. 2024. "Global Health 2050: The Path to Halving Premature Death by Mid- Century." The Lancet 404 (10462): 1561–1614. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01439-9/fulltext. Jowett M, Dale E, Griekspoor A, Kabaniha G, Mataria A, Bertone M et al. 2020. Health financing policy and implementation in fragile and conflict-affected settings: a synthesis of evidence and policy recommendations. Geneva: World Health Organization. Kurowski, Christoph, David B. Evans, Ajay Tandon, Patrick Hoang-Vu Eozenou, Martin Schmidt, and Alec Irwin. 2021a. “From Double Shock to Double Recovery: Implications and Options for Health Financing in the Time of COVID-19.� Double Shock, Double Recovery Series. Washington, DC. World Bank. Kurowski, Christoph, David B Evans, Ajay Tandon, Patrick Hoang-Vu Eozenou, Martin Schmidt, Alec Irwin, Jewelwayne Salcedo Cain, Eko Setyo Pambudi, and Iryna Postolovska. 2021b. “From Double Shock to Double Recovery: Implications and Options for Health Financing in the Time of COVID-19 - Technical Update: Widening Rifts.� Double Shock, Double Recovery Series. Washington, DC. World Bank. Kurowski, Christoph, David B Evans, Ajay Tandon, Patrick Hoang-Vu Eozenou, Martin Schmidt, Alec Irwin, Jewelwayne Salcedo Cain, Eko Setyo Pambudi, and Iryna Postolovska. 2022. “From Double Shock to Double Recovery: Implications and Options for Health Financing in the Time of COVID- 19 - Technical Update 2: Old Scars, New Wounds.� Double Shock, Double Recovery Series. Washington, DC. World Bank. 31 Kurowski, C., A. Kumar, J. Mieses, M. Schmidt, D. V. Silfverberg. 2023. “Health Financing in a Time of Global Shocks Strong Advance, Early Retreat�. Double Shock, Double Recovery Series. Washington, DC. World Bank. Kurowski, C., M. Schmidt, A. Kumar, J. Mieses, J. Gabani. 2024. “Government Health Spending Trends 2019 to 2023: Peaks, Declines, and Mounting Risks�. Double Shock, Double Recovery Series. Washington, DC. World Bank. Mathauer, Inke, Elina Dale, Matthew Jowett, and Joe Kutzin. 2019. “Purchasing Health Services for Universal Health Coverage: How to Make It More Strategic?� World Health Organization. https://www.who.int/publications/i/item/WHO-UCH-HGF-PolicyBrief-19.6. Mathauer, Inke, Lluis Vinyals Torres, Joseph Kutzin, Melitta Jakab, and Kara Hanson. 2020. “Pooling Financial Resources for Universal Health Coverage: Options for Reform.� Bulletin of the World Health Organization. Vol. 98. World Health Organization. https://doi.org/10.2471/BLT.19.234153. McIntyre, Di, Frederick Meheus, and John-Arne Røttingen. 2017. “What Level of Domestic Government Health Expenditure Should We Aspire to for Universal Health Coverage?� Health Economics, Policy and Law 12: 125–37. https://www.cambridge.org/core/journals/health-economics-policy- and-law/article/what-level-of-domestic-government-health-expenditure-should-we-aspire-to- for-universal-health-coverage/B03E4FAA9DB51F4C9738CB584C9C8B31. Stenberg, Karin, Odd Hanssen, Tessa Tan-Torres Edejer, Melanie Bertram, Callum Brindley, Andreia Meshreky, and James E. Rosen, et al. 2017. “Financing Transformative Health Systems Towards Achievement of the Health Sustainable Development Goals: A Model for Projected Resource Needs in 67 Low-Income and Middle-Income Countries.� The Lancet Global Health 5 (9): e875– 87. https://doi.org/10.1016/S2214-109X(17)30263-2. Wendling, Claude P., Eliko Pedastsaar, and Fazeer Sheik Rahim. 2022. “How to Prepare Expenditure Baselines.� https://www.imf.org/en/Publications/Fiscal-Affairs-Department-How-To- Notes/Issues/2022/06/01/How-to-Prepare-Expenditure-Baselines-517869. World Bank. 2019. “High-Performance Health Financing for Universal Health Coverage: Driving Sustainable, Inclusive Growth in the 21st Century.� Washington, DC. https://www.worldbank.org/en/topic/universalhealthcoverage/publication/high-performance- health-financing-for-universal-health-coverage-driving-sustainable-inclusive-growth-in-the- 21st-century. World Bank. 2024. Classification of fragile and conflict-affected situations. Washington, DC. World Bank. Classification of Fragile and Conflict-Affected Situations (worldbank.org) World Health Organization. 2010. The World Health Report 2010. Health Systems Financing. The Path to Universal Coverage. Geneva. World Health Organization. World Health Organization. 2022. “Stronger collaboration for an equitable and resilient recovery towards the health-related Sustainable Development Goals, incentivizing collaboration: 2022 progress report on the Global Action Plan for Healthy Lives and Well-being for All�. Geneva: World Health Organization who progress report may 2022.pdf World Health Organization and World Bank. 2023. “Tracking Universal Health Coverage: 2023 Global Monitoring Report�. Geneva. World Health Organization. WHO. 2024. “Global Health Expenditure Database.� 2024. https://apps.who.int/nha/database. 32 ANNEX 1. MACRO-FISCAL FORECASTS This annex summarizes the IMF projections for real per capita gross Domestic Product (GDP) and General Government Revenues (GGR) that directly influence the projections of general government expenditure (GGE) described in the body of the text. It also briefly describes the projected trends in the share of interest payments on public debt in GGE which was used in the discussion of the scenarios for real per capita government health expenditure (GHE) to 2029. Countries included The IMF regularly provides macro-fiscal projections for 196 countries/territories. From this group, 26 are excluded from the analysis in this paper, either because the IMF currently did not project government spending up to 2029 (Afghanistan; Ecuador; Eritrea; Lebanon; Sri Lanka; Syria; Venezuela; West Bank and Gaza) or because WHO’s Global Health Expenditure Database does not contain health expenditure data for these jurisdictions (Aruba; Hong Kong SAR, China; Kosovo; Libya; Macao SAR, China; Puerto Rico; Somalia; Taiwan, China; Yemen). Furthermore, South Sudan, Sudan, and Zimbabwe are dropped from the analysis because recent periods of very high inflation render intertemporal comparisons unreliable. Finally, six countries where the data needed to project health spending, taking into account interest payments on public debt, were unavailable were also excluded (Andorra, Nauru, Palau, Samoa, Singapore, and Turkmenistan). The analysis reported here focuses on the remaining group of 170 countries/territories: 18 LICs, 50 LMICs, 47 UMICs, and 55 HICs. Gross Domestic Product Immediately after the onset of the pandemic, average real per capita GDP fell - globally and in all country income groups on average (Figure A1.1). By 2021, it had already returned to pre-COVID-19 levels in HICs, but it did not do so until 2022 in LICs and UMICs, and until 2023 in LMICs. In April 2024, the IMF revised global growth prospects upward. Between 2024 and 2029, the average annual growth rate in real per capita GDP is expected to be 2.3 percent across all countries, with growth rates at 2.6 percent for LICs, 2.4 percent for LMICs, 2.4 percent for UMICs, and 2.1 percent for HICs. This marked a significant improvement compared to the period from 2019 to 2024, where the average annual growth rates were 1.4 percent across all countries, with LICs and LMICs at 1.1 percent, UMICs at 1.6 percent, and HICs at 1.7 percent. However, macroeconomic scars persist in the low and middle-income groups in 2024. The GDP per capita growth for these groups has not met the original projections for the period 2019 to 2024. GDP per capita was originally forecast to grow, on average, by 13.5 percent but now is expected to grow only by 4.9 percent in LICs. In LMICs, the growth forecast for the period was 13.6 percent, but expected growth now is only 4.5 percent. In UMICs, the original forecast of 12.3 percent was revised down to 6.8 percent. In contrast, in HICs, GDP per capita growth fully converged with the original projections after the initial recession, with an original forecast of 11.3 percent compared to the current expectation of 12.0 percent. 33 Figure A1. 1. Real GDP per capita Source: Data from IMF, World Economic Outlook, April 2024 Note: The figure compares the IMF real GDP per capita projections to 2024 that had been made immediately before the pandemic (fall 2019) with the actual trends and the latest projections up to 2029. The light blue dotted line represents the projections from 2019 as a proxy for the path that per capita GDP would likely have taken in the absence of the pandemic and other global economic shocks. The dark blue filled line shows the actual GDP growth trend from 2019 to 2024, with the dotted extension representing the most recent IMF projections up to 2029. General government revenues General government revenue (GGR) comprises income from taxes, levies and charges, social contributions and any on-budget development assistance. Economic growth increases the capacity of countries to raise domestic revenues whereas revenues often fall during periods of economic contraction. All income groups saw falls in the average real general government revenue (GGR) per capita during the great lockdown in 2020 (Figure A1.2). GGR per capita started growing in 2021, and all groups are now projected to experience consistent growth to 2029, with values exceeding the pre- COVID-19 levels in all years during that period. Between 2024 and 2029, the average annual growth rate in real GGR per capita is expected to be 2.0 percent across all countries. Growth rates are projected to be 3.0 percent for LICs, 2.4 percent for LMICs, and 1.7 percent for both UMICs and HICs. This marks an improvement for LMICs compared to 2019 to 2024, where the average annual growth was 1.7 percent. Growth rates for LICs and UMICs are expected to slow from 3.6 and 2.6 percent. GGR per capita growth is very similar to the 1.9 percent of the previous period. By 2029, GGR per capita is projected to be, on average, 23.4 percent higher than in 2019. The average increase in LICs would be 24.0 percent in LICs, 24.0 percent in LMICs, 22.3 percent in UMICs, and 23.0 percent in HICs. 34 Figure A1. 2. Real general government revenue (GGR) per capita Source: Data from IMF, World Economic Outlook, April 2024 Interest payments on public debt Globally, average real per capita interest payments on public debt surged during the COVID-19 crisis and continued to rise through 2024, with further increases projected to 2029 (Table A1.1). By 2024, the average interest payments per capita are expected to be 32 percent higher than in 2019 and projected to increase another 14 percent by 2029. In LICs, these payments are projected to be 55 percent higher in 2024 than in 2019, and then stagnate through 2029. In LMICs, they are expected to rise to a peak in 2026, 40 percent higher than in 2019, but then fall slightly by 2029. In UMICs and HICs, on the other hand, real per capita interest payments on public debt are projected to continue to increase each year over the forecast period: by 2029 they are expected to be approximately 50 percent higher than in 2019 on average in both UMICs and HICs. Table A1. 1. Average interest payments per capita on public debt in government expenditure (GGE), 2019-2029 (Constant 2021 US$) Income group N 2019 2024 2025 2026 2027 2028 2029 All countries 170 194 255 263 271 277 285 291 LICs 18 11 18 18 18 18 17 17 LMICs 50 53 73 74 75 73 73 74 UMICs 47 157 208 215 224 226 232 235 HICs 55 414 540 556 572 592 611 624 Source: Authors’ calculations. Shares of interest payments in GGE The average share of interest payments in GGE also increased after the onset of the pandemic, but it is then projected to fall after 2026 for all countries taken together (Table A1.2). Similar to the patterns 35 of interest payments per capita, the share in GHE peaks – in 2026 for LICs and 2024 for LMICs - before falling slightly by 2029. On the other hand, the average share rises to 2028 in UMICs, then falls slightly, and rises until 2027 in the HICs before stabilizing. The result is that the average shares in 2029 will remain substantially above those in 2019: 1.6 percentage points higher in LICs, 1.4 points higher in LMICs, 1.7 points higher in UMICs, and 1.0 points higher in HICs. Table A1. 2. Average share of interest payments on public debt in government expenditure (GGE), 2019-2029 (Percent) Income group N 2019 2024 2025 2026 2027 2028 2029 All countries 170 6.2 7.8 7.9 8.0 7.8 7.8 7.7 LICs 18 7.3 10.1 10.4 10.4 9.7 9.4 8.9 LMICs 50 8.1 10.2 10.3 10.1 9.7 9.6 9.5 UMICs 47 7 8.3 8.5 8.7 8.7 8.8 8.7 HICs 55 3.6 4.4 4.5 4.5 4.6 4.6 4.6 Source: Authors’ calculations based on IMF (2024a). Trends in the average shares hide cross-country variation in each income group. By 2029, the shares of 47 countries are projected to surpass 10 percent, and in ten of them, rise above 20 percent. Most of these countries are LICs and LMICs. In addition, the growth in interest shares between 2019 and 2029 varies widely between countries, ranging from a decrease of more than 10 percent to an increase close to 15 percent. Average real interest payments per capita as well as the share of GGE taken by interest payments differs as well across the contraction, stagnation and expansion groups. This is illustrated using per capita interest payments below. Contraction countries In the 29 contraction countries, real interest payments per capita increased after 2019 and are projected to continue rising through 2029. These payments are expected to increase steadily each year in all income groups in this category, except UMICs, where they are projected to peak in 2026 before slightly falling until 2029. Stagnation countries As in the contraction countries, real per capita interest payments in the 67 stagnation countries rose on average in all income groups after 2019. They are projected to continue to rise steadily to 2029 in the stagnation HICs. In the other three income groups, average per capita interest payments are projected to rise to 2026, then fall, but they will still be substantially higher in 2029 than they had been before the outbreak of the pandemic. Expansion countries Average real per capita interest payments on public debt are projected to rise in the 74 expansion countries as a group. The increases occur continuously across all income groups except for LICs where interest payments peak in 2026 and then fall: though their interest payments will be, on average, 60 percent higher in 2029 than in 2019. Despite the increase in interest payments on public debt, both per capita GGE and the GGE remaining after interest payments are expected to rise relatively rapidly in the expansion countries. These data provide the basis of the discussion about the impact of interest payments on public debt on per capita GHE in the body of the text. 36 ANNEX 2. IMPLICATIONS OF THE GOVERNMENT HEALTH SPENDING SCENARIOS BY COUNTRY Table A2.1. GHE per capita and GHE-to-GGE ratios for 29 contraction countries GHE per capita (in constant 2021 US$) GHE-to-GGE ratio (in percent) Country 2019 2021 2029 2029 2029 2019 2021 2029 2029 2029 WHO GHED WHO GHED scenario 1 scenario 2 scenario 3 WHO GHED WHO GHED scenario 1 scenario 2 scenario 3 LICs Burundi 11 9 10 8 24 13.1 10.2 13.1 10.2 30.5 Liberia 13 16 12 17 30 5.8 7.9 5.8 7.9 14.3 LMICs Algeria 142 120 133 133 235 8.8 8.8 8.8 8.8 15.6 Angola 28 39 19 31 47 5.7 9.2 5.7 9.2 13.8 Bolivia 180 205 171 217 297 13.6 17.3 13.6 17.3 23.6 Comoros 25 30 22 29 41 8.6 11.0 8.6 11.0 15.8 Congo, Rep. 30 41 28 40 50 5.9 8.6 5.9 8.6 10.7 Haiti 13 19 12 20 21 6.9 11.5 6.9 11.5 12.2 Lesotho 104 88 96 85 172 15.8 13.9 15.8 13.9 28.4 Papua New Guinea 58 38 43 38 95 8.8 7.9 8.8 7.9 19.5 Solomon Islands 87 91 74 84 144 11.6 13.1 11.6 13.1 22.5 Timor-Leste 66 120 62 98 109 2.6 4.2 2.6 4.2 4.6 Vanuatu 87 91 70 75 143 6.5 6.9 6.5 6.9 13.3 UMICs Argentina 671 665 638 652 1174 16.2 16.5 16.2 16.5 29.8 Belize 195 204 188 216 342 12.2 14.0 12.2 14.0 22.2 Botswana 340 366 319 382 595 12.7 15.3 12.7 15.3 23.8 Equatorial Guinea 62 58 59 83 108 3.9 5.4 3.9 5.4 7.0 Namibia 221 236 205 227 386 11.1 12.3 11.1 12.3 21.0 South Africa 348 348 348 348 609 15.3 15.3 15.3 15.3 26.8 Suriname 386 166 212 146 675 15.1 10.4 15.1 10.4 48.2 HICs Australia 4699 5400 4631 4836 6641 19.2 20.1 19.2 20.1 27.6 Bahrain 624 735 495 620 883 7.1 8.8 7.1 8.8 12.6 Brunei Darussalam 646 653 585 643 913 6.4 7.0 6.4 7.0 10.0 Kuwait 1429 1489 1332 1445 2020 9.2 9.9 9.2 9.9 13.9 Norway 8196 7684 7846 7862 11582 17.8 17.9 17.8 17.9 26.3 Oman 639 749 373 457 903 8.6 10.5 8.6 10.5 20.8 Qatar 1783 1609 1518 1517 2520 8.4 8.4 8.4 8.4 13.9 Saudi Arabia 1158 1296 1092 1313 1636 12.0 14.4 12.0 14.4 17.9 Trinidad and Tobago 616 578 570 617 870 10.3 11.1 10.3 11.1 15.6 37 Table A2.2. GHE per capita and GHE-to-GGE ratios for 67 stagnation countries GHE per capita (in constant 2021 US$) GHE-to-GGE ratio (in percent) Country 2019 2021 2029 2029 2029 2019 2021 2029 2029 2029 WHO GHED WHO GHED scenario 1 scenario 2 scenario 3 WHO GHED WHO GHED scenario 1 scenario 2 scenario 3 LICs Central African Republic 7 13 7 12 16 7.8 12.5 7.8 12.5 17.4 Ethiopia 12 14 14 17 29 9.0 10.8 9.0 10.8 17.9 Gambia, The 11 13 11 15 25 5.4 7.5 5.4 7.5 12.0 Guinea-Bissau 17 26 22 25 38 9.8 11.1 9.8 11.1 17.0 Madagascar 6 9 7 12 14 7.1 12.2 7.1 12.2 14.2 Malawi 22 22 24 20 50 19.4 16.4 19.4 16.4 40.4 Mali 13 16 16 18 29 5.8 6.7 5.8 6.7 10.9 Mozambique 23 28 24 28 53 15.5 18.1 15.5 18.1 34.3 Niger 17 18 20 19 39 12.9 12.2 12.9 12.2 25.4 Sierra Leone 6 10 8 9 15 5.8 6.9 5.8 6.9 11.2 LMICs Cabo Verde 131 204 151 250 216 11.0 18.1 11.0 18.1 15.7 Cambodia 33 46 43 51 55 8.3 9.9 8.3 9.9 10.6 Cameroon 11 15 11 17 18 3.5 5.2 3.5 5.2 5.6 Djibouti 38 52 43 61 63 4.6 6.7 4.6 6.7 6.8 Egypt, Arab Rep. 54 73 60 83 89 5.0 6.9 5.0 6.9 7.4 Eswatini 192 198 205 229 316 14.1 15.7 14.1 15.7 21.7 Ghana 62 63 67 56 102 11.0 9.1 11.0 9.1 16.6 Honduras 86 110 104 121 142 11.7 13.7 11.7 13.7 16.0 Jordan 131 125 146 132 216 10.3 9.3 10.3 9.3 15.3 Kenya 46 60 58 75 76 8.8 11.2 8.8 11.2 11.4 Kiribati 220 250 256 362 362 8.9 12.6 8.9 12.6 12.6 Lao PDR 37 18 45 26 61 7.8 4.6 7.8 4.6 10.5 Micronesia, Fed. Sts. 447 435 571 463 737 19.7 16.0 19.7 16.0 25.5 Morocco 82 95 102 106 135 7.5 7.8 7.5 7.8 10.0 Myanmar 10 14 11 15 17 3.5 4.6 3.5 4.6 5.3 Nepal 14 26 16 30 24 4.2 7.8 4.2 7.8 6.2 Nicaragua 108 138 131 140 179 19.7 20.9 19.7 20.9 26.8 Pakistan 16 16 16 17 26 5.3 5.4 5.3 5.4 8.5 Sao Tome and Principe 89 153 90 139 146 16.4 25.2 16.4 25.2 26.5 Tunisia 148 165 160 169 244 12.1 12.7 12.1 12.7 18.4 Ukraine 155 199 181 236 256 7.8 10.1 7.8 10.1 11.0 Zambia 35 39 35 39 57 10.0 11.3 10.0 11.3 16.4 UMICs Azerbaijan 59 82 59 83 103 3.3 4.6 3.3 4.6 5.8 Belarus 294 357 338 403 514 11.0 13.1 11.0 13.1 16.8 38 GHE per capita (in constant 2021 US$) GHE-to-GGE ratio (in percent) Country 2019 2021 2029 2029 2029 2019 2021 2029 2029 2029 WHO GHED WHO GHED scenario 1 scenario 2 scenario 3 WHO GHED WHO GHED scenario 1 scenario 2 scenario 3 Brazil 324 369 367 453 567 8.4 10.4 8.4 10.4 13.0 Colombia 341 408 380 438 596 16.5 19.1 16.5 19.1 26.0 Costa Rica 649 661 652 685 1135 24.2 25.4 24.2 25.4 42.1 Dominica 288 353 311 276 504 7.6 6.7 7.6 6.7 12.3 Fiji 162 170 189 217 283 8.8 10.1 8.8 10.1 13.2 Iraq 126 130 146 170 220 6.0 7.0 6.0 7.0 9.1 Jamaica 231 277 264 318 403 13.5 16.3 13.5 16.3 20.7 Kazakhstan 175 266 220 309 307 8.3 11.6 8.3 11.6 11.5 Malaysia 237 282 258 305 414 8.5 10.1 8.5 10.1 13.7 Maldives 960 1181 1193 1396 1679 18.2 21.3 18.2 21.3 25.6 Marshall Islands 846 673 929 707 1480 21.5 16.4 21.5 16.4 34.2 Mauritius 292 292 366 374 511 10.2 10.4 10.2 10.4 14.3 Mexico 278 301 312 335 487 10.3 11.1 10.3 11.1 16.1 Paraguay 180 244 195 245 314 14.7 18.5 14.7 18.5 23.7 Peru 227 273 234 258 397 15.4 16.9 15.4 16.9 26.1 St. Lucia 256 333 260 349 447 8.4 11.3 8.4 11.3 14.5 St. Vincent and the Grenadines 234 295 288 289 409 9.9 9.9 9.9 9.9 14.0 Tonga 186 241 237 244 326 10.1 10.4 10.1 10.4 13.9 Tuvalu 1189 930 1470 1065 2080 19.0 13.8 19.0 13.8 26.9 HICs Antigua and Barbuda 476 584 488 665 673 11.3 15.4 11.3 15.4 15.6 Austria 4369 5094 4732 4953 6174 16.1 16.9 16.1 16.9 21.0 Canada 4091 4710 4212 4410 5782 18.9 19.7 18.9 19.7 25.9 Chile 754 836 839 723 1066 18.0 15.5 18.0 15.5 22.9 Finland 3938 4505 4313 4709 5565 13.8 15.1 13.8 15.1 17.8 France 3853 4205 4147 4339 5445 15.1 15.8 15.1 15.8 19.8 Germany 4693 5239 5225 5200 6633 20.1 20.0 20.1 20.0 25.5 Greece 815 1094 919 1042 1151 8.3 9.4 8.3 9.4 10.4 Iceland 5242 5640 5402 5401 7408 16.3 16.3 16.3 16.3 22.3 New Zealand 3474 3795 3688 3678 4910 18.6 18.6 18.6 18.6 24.8 San Marino 3709 3617 4040 2237 5242 32.2 17.9 32.2 17.9 41.8 Spain 2096 2321 2361 2349 2963 15.3 15.2 15.3 15.2 19.1 Sweden 5500 5888 6165 6432 7773 19.2 20.0 19.2 20.0 24.2 Switzerland 3436 3946 3722 3900 4855 11.6 12.2 11.6 12.2 15.2 39 Table A2.3. GHE per capita and GHE-to-GGE ratios for 74 expansion countries GHE per capita (in constant 2021 US$) GHE-to-GGE ratio (in percent) Country 2019 2021 2029 2029 2029 2019 2021 2029 2029 2029 WHO GHED WHO GHED scenario 1 scenario 2 scenario 3 WHO GHED WHO GHED scenario 1 scenario 2 scenario 3 LICs Burkina Faso 26 32 35 36 60 12.8 13.1 12.8 13.1 21.6 Chad 9 10 13 12 21 8.2 7.9 8.2 7.9 13.3 Congo, Dem. Rep. 8 9 11 12 18 9.7 10.1 9.7 10.1 15.6 Rwanda 32 40 43 47 74 13.7 14.8 13.7 14.8 23.3 Togo 13 14 23 18 31 8.5 6.6 8.5 6.6 11.2 Uganda 6 22 8 26 14 3.1 9.9 3.1 9.9 5.2 LMICs Bangladesh 10 12 19 22 17 3.3 3.7 3.3 3.7 2.9 Benin 9 11 16 14 14 4.6 3.9 4.6 3.9 4.1 Bhutan 98 92 156 105 162 10.7 7.2 10.7 7.2 11.1 Cote d'Ivoire 27 32 44 43 45 6.5 6.4 6.5 6.4 6.6 Guinea 14 14 21 19 24 8.9 8.2 8.9 8.2 10.3 India 23 26 37 39 38 3.9 4.1 3.9 4.1 4.0 Iran, Islamic Rep. 90 109 121 138 148 19.7 22.5 19.7 22.5 24.1 Kyrgyz Republic 34 38 46 54 56 7.4 8.6 7.4 8.6 9.0 Mauritania 35 58 53 80 57 8.6 13.0 8.6 13.0 9.2 Mongolia 102 204 148 272 168 6.9 12.7 6.9 12.7 7.8 Nigeria 11 12 16 17 19 4.2 4.5 4.2 4.5 4.9 Philippines 66 84 103 113 108 7.9 8.6 7.9 8.6 8.3 Senegal 30 24 43 32 50 7.9 5.8 7.9 5.8 9.1 Tajikistan 17 21 26 31 27 6.9 8.0 6.9 8.0 7.2 Tanzania 25 21 37 28 42 13.3 10.1 13.3 10.1 15.1 Uzbekistan 43 61 70 83 71 8.3 9.9 8.3 9.9 8.4 Vietnam 74 74 129 123 121 10.2 9.7 10.2 9.7 9.6 UMICs Albania 175 184 263 237 307 10.2 9.2 10.2 9.2 11.9 Armenia 69 104 128 172 121 5.8 7.8 5.8 7.8 5.4 Bosnia and 408 448 566 595 714 15.7 16.5 15.7 16.5 19.8 Herzegovina Bulgaria 491 667 758 910 859 11.7 14.1 11.7 14.1 13.3 China 340 366 524 532 595 8.8 8.9 8.8 8.9 10.0 Dominican Republic 229 299 309 378 401 14.7 18.0 14.7 18.0 19.1 El Salvador 212 293 294 341 370 17.3 20.1 17.3 20.1 21.8 Gabon 163 159 245 258 286 9.6 10.1 9.6 10.1 11.2 Georgia 133 226 232 350 233 14.3 9.5 14.3 9.5 Grenada 227 233 333 264 398 9.5 7.5 9.5 7.5 11.3 Guatemala 110 119 144 151 192 17.7 18.6 17.7 18.6 23.7 40 GHE per capita (in constant 2021 US$) GHE-to-GGE ratio (in percent) Country 2019 2021 2029 2029 2029 2019 2021 2029 2029 2029 WHO GHED WHO GHED scenario 1 scenario 2 scenario 3 WHO GHED WHO GHED scenario 1 scenario 2 scenario 3 Indonesia 62 99 93 136 108 8.6 12.6 8.6 12.6 10.0 Moldova 192 272 339 411 335 12.3 14.9 12.3 14.9 12.1 Montenegro 500 610 648 809 875 11.5 14.4 11.5 14.4 15.6 North Macedonia 288 311 424 407 504 13.6 13.0 13.6 13.0 16.1 Russian Federation 419 662 556 825 733 10.2 15.1 10.2 15.1 13.4 Serbia 440 576 708 772 770 12.4 13.5 12.4 13.5 13.4 Thailand 207 262 280 289 362 13.3 13.7 13.3 13.7 17.2 Turkey 294 347 382 458 514 9.7 11.7 9.7 11.7 13.1 HICs Bahamas, The 1019 1132 1205 1102 1440 15.0 13.8 15.0 13.8 18.0 Barbados 560 747 671 779 792 10.8 12.6 10.8 12.6 12.8 Belgium 4210 4410 4960 4901 5949 15.6 15.5 15.6 15.5 18.8 Croatia 919 1211 1326 1458 1299 12.7 14.0 12.7 14.0 12.5 Cyprus 1230 2562 1678 3067 1738 10.2 18.6 10.2 18.6 10.5 Czechia 1734 2191 1987 2228 2450 15.7 17.6 15.7 17.6 19.3 Denmark 5696 6290 6550 6959 8049 17.1 18.2 17.1 18.2 21.0 Estonia 1318 1595 1607 1716 1863 12.9 13.7 12.9 13.7 14.9 Guyana 168 328 1016 1252 237 10.5 13.0 10.5 13.0 2.5 Hungary 782 998 1000 1183 1105 9.3 11.0 9.3 11.0 10.3 Ireland 4216 5206 5564 5674 5958 20.5 20.9 20.5 20.9 22.0 Israel 2352 2811 2897 3210 3323 13.4 12.1 13.4 13.9 13.9 Italy 2334 2529 2650 2484 3299 12.3 13.2 12.3 16.4 16.4 Japan 3737 3657 4448 3865 5282 21.5 24.7 21.5 29.3 29.3 Korea, Rep. 1605 1991 2133 2239 2268 22.0 21.0 22.0 22.3 22.3 Latvia 793 1317 1020 1416 1121 14.6 10.5 14.6 11.6 11.6 Lithuania 1028 1254 1420 1489 1452 14.2 13.5 14.2 13.8 13.8 Luxembourg 6164 6638 7223 7619 8711 11.5 10.9 11.5 13.1 13.1 Malta 2016 2455 2669 2729 2849 16.3 15.9 16.3 17.0 17.0 Netherlands 3909 4563 4743 5014 5524 16.8 15.9 16.8 18.5 18.5 Panama 773 803 885 881 1093 21.8 21.9 21.8 27.1 27.1 Poland 790 837 1258 1203 1117 10.5 11.0 10.5 9.8 9.8 Portugal 1484 1738 1768 1911 2098 14.7 13.6 14.7 16.2 16.2 Romania 663 729 1048 1005 936 13.2 13.7 13.2 12.3 12.3 Seychelles 551 598 653 658 778 10.2 10.1 10.2 12.0 12.0 Slovak Republic 1172 1344 1578 1590 1657 13.6 13.5 13.6 14.1 14.1 Slovenia 1763 2039 2294 2276 2491 14.0 14.2 14.0 15.4 15.4 St. Kitts and Nevis 540 636 620 780 764 8.6 6.9 8.6 8.4 8.4 United Arab Emirates 992 1477 1213 1973 1402 12.9 7.9 12.9 9.2 9.2 United Kingdom 3855 4804 4551 4949 5448 22.4 20.6 22.4 24.7 24.7 United States 5954 6749 7193 6679 8414 22.2 23.9 22.2 28.0 28.0 41 GHE per capita (in constant 2021 US$) GHE-to-GGE ratio (in percent) Country 2019 2021 2029 2029 2029 2019 2021 2029 2029 2029 WHO GHED WHO GHED scenario 1 scenario 2 scenario 3 WHO GHED WHO GHED scenario 1 scenario 2 scenario 3 Uruguay 1087 1161 1242 1378 1536 22.4 20.2 22.4 25.0 25.0 42