The progressivity of health care revenue financing in 29 countries: A comparison

Background: This study assesses progressivity in public and private health care revenue collection among 29 high-income countries by combining the results of two previous articles comprising this special section of Health Policy. In those studies, we developed qualitatively based scores regarding revenue collection policies for three public revenue sources (income taxes, social insurance contributions, consumption taxes) and two private revenue sources (voluntary health insurance, out-of-pocket payments). Objective: The current study sums these scores, weighted by the shares of each revenue source in each country, to calculate an overall progressivity score for each country. Methods: We derived weights for each revenue source using publicly available OECD and Eurostat macrolevel data on the structure of health care financing and government revenues. Results: France was the country that had the most progressive system, and Latvia, Hungary, and Bulgaria, the least progressive. Conclusions: Countries relying more on out-of-pocket payments tend to be more regressive overall, suggesting that, from an equity perspective, their role should remain limited. Tax-based systems do not inherently ensure progressivity, especially when relying heavily on regressive consumption taxes. While wealthier countries and those with less income inequality tend to be more progressive, in contrast, Switzerland and Germany both scored among the more regressive countries. Our study shows that policy matters in promoting progressivity in health system revenue collection. Both public and private sources can be regressive if nothing is done. Yet, there are policy instruments that can mitigate regressivity, and even private sources of funds can be made less regressive.