Health taxes and universal health coverage in low- and middle-income countries: a scoping review of pathways, challenges and policy lessons.

BACKGROUND

Low- and middle-income countries (LMICs) face persistent challenges in achieving universal health coverage (UHC) due to limited financing and weak health systems, and the broader contribution of health taxes—despite their recognised public health and fiscal benefits—remains insufficiently synthesised.

OBJECTIVE

This scoping review examines the role of health taxes in advancing UHC in LMICs, including their effects across UHC dimensions, implementation challenges and policy implications.

ELIGIBILITY CRITERIA: Peer-reviewed and official grey literature published in English between 2000 and October 2025 examining health taxes in LMICs and reporting outcomes relevant to UHC.

SOURCES OF EVIDENCE: Nine bibliographic databases were searched alongside ProQuest, the National Bureau of Economic Research and international agency websites.

CHARTING

METHODS

Two reviewers independently screened studies using Covidence. Findings were synthesised narratively and revenue estimates were contextualised using gross domestic product and domestic government health expenditure. Reporting followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines.

RESULTS

Most studies addressed service coverage (86/87) and financial protection (63/87), while few examined population coverage (9/87). Health taxes were consistently associated with reduced non-communicable disease burden, lower out-of-pocket spending and increased fiscal space for health. Estimated revenues were modest relative to gross domestic product but potentially substantial relative to domestic government health expenditure. Evidence on population coverage was limited and largely confined to settings where revenues were explicitly linked to insurance expansion or entitlement reforms. Key enabling factors included strong tax design, regular rate adjustments and earmarking or strategic allocation of revenues, while political resistance, administrative complexity and concerns about regressivity and illicit trade constrained implementation.

CONCLUSIONS

Health taxes were associated with improvements in service coverage and financial protection in LMICs, but evidence on population coverage remains limited and context dependent. Their contribution to UHC depends on tax design, revenue allocation and institutional and political context. Health taxes should be considered as a strategic component of broader health financing and health system reform, rather than a standalone solution.