Exploring the impact of health expenditure and its allocation on neonatal and child mortality at national level across 188 countries from 2000 to 2019: insights from the Global Burden of Disease Study

Background Exploring the impact of national health expenditure and its allocation on neonate and child mortality can help policy makers implement strategies aimed at achieving target 3.2 of Sustainable Development Goals (SDGs). The aim of the current study is to explore the impact of selected indicators of national health accounts on neonate and under-5 mortality across 188 countries from 2000 to 2019. Methods and findings This study has an ecological design. Data on health expenditure was obtained from the Global Health Expenditure Database (GHED) for 188 countries from 2000 to 2019. The Global Burden of Disease study (GBD) 2019 data on neonatal and under 5 mortality rates at national levels from 2000 to 2019 were obtained from the website of the Global Health Data Exchange (GHDx) supported by the Institute for Health Metrics and Evaluation. The income groups were stratified based on the World Bank classification. We employed a mixed-effects regression model to investigate the association of different health account indicators with changes in neonatal and under-5 mortality rates over time across countries. We used the Multiple Change Points model to determine the turning points in the association of health expenditure per capita with mortality across countries in 2019. And finally, we estimated the observed-to-expected ratio of mortality based on the segmented regression model for all 188 countries in 2019. Increase in the current health expenditure in International dollar Purchasing Power Parity (Int$ PPP) per capita was associated with lower mortality among both neonates and children in all strata of countries. Reductions were very minimal among high-income countries and were generally more prominent in low-income countries and decreased along with increase in income. Reductions were more noteworthy for under-5 mortality rates. The percentage of domestic general government health expenditure and the percentage of compulsory financing arrangements out of current health expenditure were inversely associated with mortality, while the association of percentage of domestic private health expenditure and out-of-pocket expenditure out of current health expenditure with mortality was positive. Results showed that the reduction in neonatal mortality associated with each ten-dollar increase in current health expenditure per capita is significantly more prominent for per capita expenditures less that the cut-point of 480 Int$ PPP per capita. The respective figure for under-5 mortality was 386 Int$ PPP per capita. Ultimately, a total of 110 countries had observed versus expected ratio less than one for neonatal mortality and 118 countries for child mortality. Conclusions Increase in health expenditure is significantly associated with decrease in neonate and under-5 mortality especially among low and low-middle income countries. However, the association fades among countries in which health expenditure per capita is higher than the threshold. In all countries, improvement in neonate and under-5 mortality requires modifying the health system infrastructure to move towards universal health coverage. However, the COVID-19 pandemic may have influenced the health spending at national levels. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The author(s) received no specific funding for this work. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: N/A I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All of the data are publicly available in the site of the World Health Organization, the World Bank, and the Institute for Health Metrics and Evaluation.