Knowledge Brief Health, Nutrition and Population Global Practice HEALTH EARMARKS AND HEALTH TAXES: WHAT DO WE KNOW? Ceren Ozer, Danielle Bloom, Adolfo Martinez Valle, Eduardo Banzon, Kate Mandeville, Jeremias Paul, Evan Blecher, Susan Sparkes, and Sheena Chhabra* December 2020 KEY MESSAGES: • Earmarking means taking all or a portion of total revenue from a tax or group of taxes and setting it aside or “protecting” it for a designated expenditure purpose. Earmarking practices vary from “hard” to “soft,” and are associated with different levels of fiscal risk. • At least 80, and likely more, countries earmark for health. However, earmarking is unlikely to bring a sustained net increase in revenue due to offsetting, and can create rigidities and inefficiencies. • If allocations fail to match priorities or if a tax can make the priority more politically acceptable, soft earmarks that are closer to standard budget processes may be useful in the short term. • The primary intent of “health taxes” is to curb unhealthy behaviors that affect population health and can strain health systems. Health taxes can generate revenue without compromising equity, and their revenues can be earmarked, but they do not by design net more money for health. • In the context of fiscal constraints (e.g., with COVID-19), heath taxes may provide an overall source of revenue for governments, and help manage disease burden and fiscal pressure on the health system by reducing risk factors for COVID-19. Soft earmarks on health taxes may also help inject short-term funding into the health sector, if the appropriate public financial management safeguards are in place. INTRODUCTION Keeping tax revenues above 15 percent of GDP is a key It is estimated that 85 percent of countries around the ingredient for economic growth, for funding health and world will experience a GDP contraction as a result of the social sectors, and ultimately, poverty reduction and economic impact of COVID-19, amplifying fiscal human capital development. However, about half of constraints in general and for the health sector in developing countries were below this mark even before particular (Tandon 2020). Recent studies conducted by the pandemic hit. COVID-19 will lower tax to GDP ratios World Bank experts find that in the last two decades, over globally as a result of reduced revenue from taxes relative half of the increase in per capita public spending on to other public revenue sources—so much so that health has been the result of economic growth, attention may shift from achievement of well-established underscoring the need to manage reforms within goals like the Sustainable Development Goals (SDGs) to countries’ macrofiscal context (Tandon et al. 2018, 2020). simply staying afloat (Global Economic Prospects 2020). Countries now need to explore smart health financing policies that will help them to rebuild better following Page 1 HNP GP Knowledge Brief • COVID-19. This brief will review the concepts of diverted to other purposes, or other funds can be earmarking and health taxes, global evidence using these allocated to the earmarked priority—while subject to shifts polices, and their potential role in building more resilient in politics, it is generally a much less risky process and health systems under COVID-19. recommended over hard earmarks (Cashin, Sparkes, and Bloom 2017; Cashin 2020; Prady 2020). WHAT IS EARMARKING FOR HEALTH? TO EARMARK OR NOT TO EARMARK Earmarking means taking all or a portion of total revenue from a tax or group of taxes and setting it aside or Debates about earmarking can be polarizing. On the “protecting” it for a designated expenditure purpose. In negative side, earmarks are said to introduce budget practice, earmarking gives visibility to a revenue and rigidity, economic distortion, limit the ability of expenditure package—creating a transparent link governments to put in place countercyclical policies, between a funding source and exactly what it is spent increase fragmentation, decrease solidarity and increase on—and is driven by an implicit understanding that, all regressivity, and be susceptible to special interest groups else being equal, the package requested will be sufficient (Cashin, Sparkes, and Bloom 2017). to meet articulated expenditure needs. All earmarking policies have various revenue and expenditure On the positive side, there are many reasons that characteristics that dictate how they are set: (i) They can countries may choose to explore an earmark. Some dictate what proportion of a revenue source should be objectives are financial—linked to directing revenue allocated to the health sector or a target program, toward a particular expenditure purpose, such as the population, or service within the sector; (ii) They can health sector overall or a specific health program. Others mandate the proportion of funds that should be spent on a may be technical, such as increases in efficiency, specific target; or (iii) They can spell out a benefit accountability, cost awareness, or flexibility. Still other rationale— connecting individuals with direct gains from objectives may be political; for instance, a country may their contributions. Additionally, the adoption and wish to gain public support, increase the acceptability of a implementation process, including how earmarked funds tax increase or reform to show political commitment to a flow and accountability mechanisms are established, can popular program or initiative, or to improve transparency also impact how effective an earmark is and the results it in how funds are allocated. Earmarking may also be used might generate. to further social objectives such as improved equity by targeting expansion of coverage to poor populations, or Figure 1: Continuum of Hard to Soft Earmarking by curbing consumption of unhealthy products (Cashin, Sparkes, and Bloom 2017). In general, if a budget process works well and health is well prioritized, then earmarking should not be needed. However, if the budget process fails to generate allocations that match priorities or if a tax can make the priority more politically acceptable, soft earmarking— when complemented by supporting analysis, such as the Source: Prady, 2020 Extended Cost Benefit Analysis (ECBA)2—may be useful in the short term. The way that earmarks are set can also place them on a continuum from “hard” to “soft,” terms that are associated COUNTRY EXPERIENCES EARMARKING FOR with varying levels of fiscal risk (Figure 1). In hard HEALTH earmarking, all revenue is allocated based on rules that may bypass the budget process and are specific to that As of 2017, at least 80 countries earmarked different earmark; for instance, a legislated amount of revenue revenue or expenditure sources for health. Figure 2 below may be connected to a narrow expenditure purpose, is organized by the predominant types of revenue sources which may be associated with an autonomous fund. This that have been used in health earmarking. Of these, the creates fiscal risk by limiting oversight and the ability of most common source of earmarked revenues for the governments to shift resources to align to spending needs health sector are payroll taxes to finance health care, and realities, including in response to fiscal crisis. In soft despite findings that these may increase inequality, earmarking, practices are aligned to the budgeting unnecessarily fragment the health system, and may not process and political discourse.1 Soft earmarking gives generate sufficient revenues (Cashin, Sparkes, and visibility to a political priority, is aligned to a standard Bloom 2017; Yazbeck et al. 2020). budget process, and links revenue less tightly: it can be Page 2 HNPGP Knowledge Brief • Figure 2: Countries Using Earmarking for Health • Earmarks work best when the objectives of health and finance stakeholders are aligned and can help garner political support and unlock stalemates. In Ghana, the Ministry of Finance (MoF) faced issues increasing the VAT rate until it was tied to funding the National Health Insurance Scheme (Cashin, Sparkes, and Bloom 2017). • Sunset clauses or periodic review can help ensure that earmarks are still meeting their intended purpose, as earmarks often only provide for short-term increases in fiscal space for health. For instance, South African parliamentary expenditure earmarks are subject to review each year, while treasury earmarks can be revised at any time (Cashin, Sparkes, and Bloom 2017). • Earmarks can limit flexibility to adapt to changing conditions, including demographics and labor markets, presenting challenges. For example, after years of effort, Estonia was finally Source: Cashin, Sparkes and Bloom 2017 able to decrease funding from payroll taxes in lieu of increased general revenue financing for its Cashin, Sparkes, and Bloom (2017) also presented National Health Insurance Fund, responding to experiences from across a set of six case study countries changes driven by population aging (Cashin, (Estonia, Ghana, Indonesia, the Philippines, South Africa Sparkes, and Bloom 2017; Thomson et al. 2011). and Viet Nam) that earmark across a set of sources • While the first best option is an open and including general revenue, payroll, value-added tax transparent budget that prioritizes health, soft (VAT), social security contributions, and health tax earmarks that are closer to standard budget revenues. Looking at this source and other evidence, a processes may be considered, allowing for a number of lessons emerge: balance between flexibility in the budget and reliability of some sort of commitment. In the • Short-term revenue gains from earmarked Philippines, earmarked revenue goes to the funds are often lost due to longer-term General Fund and throughout the regular reductions of other revenue sources. This loss budgetary process—while the Department of is due to the ability to offset or shift funds to other Health (DoH) is assured funds, its expenditure priorities (fungibility) and reprioritization of general program must be approved. (Cashin, Sparkes, government revenue for health. In some cases, and Bloom 2017; Paul 2020). this leads to a net decrease in revenue going to health, for instance, in Gabon, Ghana, and From these country experiences, it is possible to conclude Estonia (Cashin, Sparkes, and Bloom 2017). that in general, if earmarks must be used they work best if • The expenditure purpose should be narrow implemented as a part of a comprehensive package of enough to be enforceable and link funding to policies aligned to health and finance objectives, and are priorities, but not create rigidities. The link established as flexible, soft earmarks that align to between revenue and expenditure should also be standard budget processes. flexible enough so that the amount of money available alone doesn’t drive spending, or that THE ROLE OF “HEALTH TAXES” expenditure is allowed to proceed unchecked. For instance, national health insurance or HIV/AIDS “Health taxes,” sometimes known as “sin taxes,” are taxes are specific purposes where funding flows can be imposed on products that have a negative public health tracked, but priorities within programs can be impact, such as taxes on tobacco, alcohol, or sugar- adjusted. In Indonesia, having subnational sweetened beverages (SSB). They can even extend to transfers earmarked broadly for health provided environmental taxes on pollutants that damage health challenges in enforcement and accountability and (fossil fuels) or social security contributions that are levied increased rigidity, limiting central governments’ in relation to health. The primary objective of introducing discretion over resource allocation (World Bank a health tax is to improve population health through 2020a; Cashin, Sparkes, and Bloom 2017). reduced consumption of unhealthy products. The Page 5 HNP GP Knowledge Brief • secondary objective is to raise overall government Opponents of health taxes have argued that they cost revenues. Importantly, while 54 countries earmark some jobs, harm business, and slow the economy; that they can form of health tax, a health tax does not necessitate that encourage illicit trade and harm a country’s Doing related revenue is earmarked for the health sector Business rating; and even that they are discriminatory, (Cashin, Sparkes and Bloom, 2017). unconstitutional, or illegal. However, evidence against many of these claims render them unfounded (Hattersley The calculation of health tax potential needs to take into et al. 2020a, b). Indeed, evidence on regressivity shows account the local administrative capacities and conditions, that when medical expenses and gains in working life are and overall prioritization of health within government taken into account, health taxes are generally progressive budgets (Petit 2018). However, in countries that have in the long term (Fuchs, Gonzalez Icaza, and Paz 2019). instituted or increased health taxes—particularly tobacco excise taxes—revenue gains are nontrivial (Figure 3). Further, in South Africa, it has been reported that industry overstates estimates of illicit trade, Figure 3: Tobacco Taxes and GDP Min, Max and compared to independent studies, creating a narrative Median (2013)* that it is growing at an alarming rate or as the result of a recent tax increase (Blecher 2010; Eriksen et al. 2015). South Africa is an example of a country that has implemented excise taxes on tobacco, alcohol, and sugar- sweetened beverages, It has raised rates on tobacco and alcohol dramatically since the early 1990s. For tobacco and alcohol, this has served to reduce sales volumes while still leading to large increases in tax revenue (R 14.5 billion and 31.5 billion, respectively). For sugar- sweetened beverages, the innovative structure of the reform creates an incentive for producers to reformulate their products to reduce sugar volumes but does not make as substantial a contribution to the fiscus (R 2.9 billion). South Africa does not earmark any of the tax Source: Petit, 2018 revenue in line with broader fiscal policy processes in the Notes: *IMF and WHO data. Excise only, and excluding revenue budget (Blecher 2020). from state enerprises ** including Nepal (3.19%). The second highest is Solomon EARMARKING OF HEALTH TAXES Islands (1.12%) *** Excluding notably Canada, USA and Brazil. Many Caribbean Islands rely on import duties If health taxes are earmarked, they require the same considerations as other earmarked sources—with soft The Task Force on Fiscal Policy for Health –select fiscal earmarks aligned to the standard budget processes as policy, development and health leaders from around the preferable—and face the same challenge as other globe with Mike Bloomberg and Larry Summers as co- earmarked revenue sources: they sometimes generate chairs—also estimated the impact of one-time health tax additional revenue for health, as can be seen through increases that would result in a 20 to 50 percent increase country examples - but do not by design necessitate a net in prices over a 50-year period and provide increase in revenue due to fungibility and revenue commensurate estimates of value for money (Figure 4- becoming a ceiling for expenditure. Bloomberg et al. 2020). In the Philippines, earmarking for health came about as Figure 4: The Task Force on Fiscal Policy for Health a result of a political promise during the Aquino administration to move toward universal health coverage (UHC) without introducing new taxes. As a result, the 2012 Sin Tax Reform introduced soft earmarks for UHC funded from incremental revenues generated by reforming the tax structures and increasing rates on alcohol and tobacco taxes (about 85 percent of incremental revenues). Approximately 80 percent of the 85 percent earmarked for health goes to National Health Insurance subsidies, with the balance going to health facility upgrades. The reforms continued under the Note: SSB= Sugar-sweetened beverages Duterte administration when in 2018, the Tax Reform for Page 4 HNPGP Knowledge Brief • Acceleration and Inclusion Law (TRAIN) imposed taxes to the earmark, there is pressure to cap the amounts on sugar-sweetened beverages and earmarked 30 (Galbally et al. 2012; Paul 2020; Pongutta et al. 2019). percent of incremental revenue from SSB to fund social mitigating measures including investment in health and BUILDING RESILIENCE DURING COVID-19 targeted nutrition programs. Under the UHC Law passed in 2019, the national government share from the income COVID-19 has kicked off a deep global economic of the Philippine Gaming Corporation (50 percent) and the contraction and highlighted the interplay between the Philippine Charity Sweepstakes Office (40 percent) were health of citizens and the economy. Latest estimates earmarked for UHC. Furthermore, the base of earmarks indicate that per capita economic growth rates will decline was changed in 2019 from incremental revenues to total on average by almost 7 percent globally, and between 4 revenues, such that by 2020 the corresponding shares to-8 percent across low- and lower-middle income earmarked for health are as follows: alcohol (100 countries. Exacerbated by the fact that many countries did percent), tobacco (50 percent), sugar-sweetened not enter this recession in a favorable economic condition, beverages (50 percent), heated tobacco (100 percent), and carried other risk factors like poor external and vaping products (100 percent). The earmarks have integration, the impact will be severe (Tandon 2020). provided not only a sustained but significant source of revenue, tripling resources for health in a period of 5 Countries may choose to explore health taxes as a way to years (2013–18). The earmarks have also helped to help rebuild better: to curb unhealthy behaviors that decrease smoking prevalence and improve equity by contribute to conditions like diabetes or obesity and act as expanding coverage and paying for health insurance for risk factors for COVID-19, to reduce burden on the health the poor (See Figure 5- Banzon 2020; Paul 2020). system, and to generate revenue for a country. However, without reprioritization, public financing for health will Figure 5: Expansion to Fund Premiums for Poor stagnate or decline in many countries, meaning that a clear case will need to be made to increase allocations for health during annual budget submissions, especially as countries are able to take a step back to examine the fiscal impacts of their response (Tandon 2020). For instance, while COVID-19 gives clear momentum to help strengthen and channel resources toward health systems, some countries have reduced, deferred, or temporarily covered health insurance contributions (Thomson, Habicht, and Evetovits 2020), and the reprocussions these decisions is yet to be seen. Indeed, as fiscal space shrinks, there is a risk that human capital investments across the board will decline, and in the coming months, Source: Paul 2020 countries will have difficult expenditure choices to make. Finally, Thailand presents an example of a hard earmark The question then arises as to whether earmarking can on revenue from health taxes. Since 2001, there has been be used in tandem with a health tax to help channel and a 2 percent surcharge on the base of excise taxes prioritize resources toward health during COVID-19. imposed on sales from alcohol and tobacco products for Already, some countries have begun to explore this the ThaiHealth Promotion Foundation. The revenue was practice. In India, the National Calamity Contingent Duty remitted directly to an extrabudgetary fund that is on Tobacco, Fuel, and Motor Vehicles represents a hard managed by ThaiHealth. ThaiHealth is an independent earmark for the National Disaster Response Fund organization with a governing board that includes the (NDRF). In March 2020, the Indian central government Prime Minister, Ministry for Public Health, and an made 35 percent of its resources for fiscal year 2019–20 independent expert. The board sets ThaiHealth’s policies, available for medical supplies needed for COVID-19. As strategies, and budget, and funds are directly expended of today, US$700 million has been made available to the on projects that improve health in collaboration with State Disaster Response Funds. Additionally, at least 16 nongovernmental organizations. Over one-third of the states in India significantly increased taxes and excise funds are dedicated to prevention of three primary risk duty on alcohol to mobilize additional revenue post- factors: tobacco use, unsafe alcohol use, and unsafe COVID, including: a) increase of excise duty on alcohol driving. The budget is approximately US$120 million per ranging from 6 percent in Karnataka to about 75 percent year, representing only 0.9 percent of government Andhra Pradesh; b) 25 percent increase in cess on expenditure on health. While there is no major opposition Page 5 HNP GP Knowledge Brief • alcohol in Assam, Arunachal Pradesh, and Meghalaya; c) Resource Mobilization Collaborative, Joint Learning Network’s 14 cents to US $3 increase in the price of liquor per bottle Health Financing Technical Initiative Webinar, July 2, 2020. in Uttar Pradesh and Uttarakhand; and d) levying a new “COVID fee” on maximum retail price ranging from 11 Blecher, E. H. 2010. “A Mountain or a Molehill: Is the Illicit percent in Karnataka to 50 percent in Odisha (Chhabra Trade in Cigarettes Undermining Tobacco Control Policy in 2020; Paul 2020). South Africa?” Trends in Organized Crime 13 (4): 299–315. In Mexico, there are three health taxes in place: taxes on Blecher, E. 2020. Correspondence with author. alcoholic beverages; cigarettes, cigars, and other tobacco products; and sugar sweetened beverages—although Cashin, C., S. Sparkes, and D. Bloom. 2017. “Earmarking for Health: From Theory to Practice.” Geneva: World Health only the first two are currently earmarked for health. Organization. Licence: CC BY-NC-SA 3.0 IGO. However, there is political will to allocate more resources to health through earmarked taxes due to COVID-19. Cashin, C. 2020. Presentation for “Pro-Poor Earmarking of Congress is now discussing options, especially as other Health Taxes for Domestic Resource Mobilization.” Domestic sources of revenue seem unfeasible due to the current Resource Mobilization Collaborative, Joint Learning Network’s state of the economy (Martinez Valle 2020). Health Financing Technical Initiative Webinar, August 20, 2020. Still, there may be secondary impacts of other social policies during COVID and of the revenue potential of Chhabra, Sheena. 2020. Presentation on India for “Filling the health taxes. During the COVID-19 lockdown, South Coffers Post-COVID through Pro-Health Taxes.” Domestic Africa banned sales of tobacco and alcohol, thereby Resource Mobilization Collaborative, Joint Learning Network’s forgoing the tax revenue. In April 2020 alone it was Health Financing Technical Initiative Webinar, July 2, 2020. estimated that this loss amounted to R35 million daily. 2 Eriksen, M., J. Mackay, N. Schluger, and F. I. Gomeshtapeh. Conclusion 2015. The Tobacco Atlas, 6th ed. Atlanta, GA: American Cancer Society. In terms of health taxes, the time is now: health taxes that Fuchs, Alan, Fernanda Gonzalez Icaza, and Daniela Paz. 2019. improve health outcomes and raise revenue can also help “Distributional Effects of Tobacco Taxation: A Comparative rebuild better and ultimately decrease health system Analysis.” Policy Research Working Paper No. 8805, World impact in future waves of the pandemic or other health Bank, Washington DC. shocks. If a budget process works well and health is prioritized, then earmarking of health tax revenue or other Galbally R, Fidler A, Chowdhury M, Tang KC, Good S, sources may not be needed. However, if there is a failure Tantivess S. 2012. “Ten-Year Review of Thai Health Promotion to generate allocations that match priorities or if a tax can Foundation, Nov. 2001–Nov. 2011.” Bangkok: Thai Health help improve political support, soft earmarking may be Promotion Foundation. useful in the short term. Emphasis on soft earmarks with clear time horizons is important to avoid rigidity, Hattersley, L., Fuchs A., Alberto Gonima, A., Silver L., and fragmentation, and ensure alignment with the standard Kate Mandeville, K. 2020a. “Business, Employment, and budget process, while also maintaining transparency. It is Productivity Impacts of Sugar-Sweetened Beverages also important to analyze if a health tax and earmarking Taxes.” Health, Nutrition and Population Knowledge policy proposal is pro-poor. Further, where earmarks of Brief, World Bank, Washington, DC. health taxes are channeled to the health sector, the ability https://openknowledge.worldbank.org/handle/10986/34082. to sustainably fund, manage, and monitor the impacts of Hattersley, L., Fuchs A., Alberto Gonima, A., Silver L., and an earmark should all be clearly assessed at the outset Kate Mandeville, K. 2020b. “Countering Common Arguments (Cashin, Sparkes, and Bloom 2017). Further research against Taxes on Sugary Drinks.” Health, Nutrition and might explore the operational considerations behind how Population Knowledge Brief, World Bank, Washington, DC. earmarks are managed and operated. As with all https://openknowledge.worldbank.org/handle/10986/34361. practices, earmarks should be pursued with safeguards and an understanding of local conditions and impacts. Martinez Valle, A. 2020. Presentation on Mexico for “Filling the Coffers Post-COVID through Pro-Health Taxes.” Domestic Resource Mobilization Collaborative, Joint Learning Network’s References Health Financing Technical Initiative Webinar, July 2, 2020. Banzon, Eduardo. 2020. Presentation on Philippines for “Filling Ozer, C, Mandeville, K., Blecher E., Borowitz, M. 2020. the Coffers Post-COVID through Pro-Health Taxes.” Domestic Presentation for “Filling the Coffers Post-COVID through Pro- Page 6 HNPGP Knowledge Brief • Health Taxes.” Domestic Resource Mobilization Collaborative, Thomson, S., T. Habicht, L. Roovali, T. Evetovits, and J. Joint Learning Network’s Health Financing Technical Initiative Habicht. 2011. “Responding to the Challenge of Financial Webinar, July 2, 2020. Sustainability in Estonia's Health System: One Year on.” Copenhagen: World Health Organization Regional Office for Paul, J. 2020. 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Domestic World Bank 2020b. “Taxes on Sugar-Sweetened Beverages: Resource Mobilization Collaborative, Joint Learning Network’s Summary of International Evidence and Experiences.” World Revisiting Health Financing Technical Initiative Meeting, April Bank, Washington, DC. 16–17, 2018. WHO (World Health Organization). 2016. “A Global Analysis Pongutta, S., R. Suphanchaimat, W. Patcharanarumol, and V. of Earmarked Tobacco Taxes and Lessons Learned from Nine Tangcharoensathien. 2019. “Lessons from the Thai Health Countries.” Geneva: WHO. Promotion Foundation.” WHO Bulletin 97 (3): 213–20. Yazbeck, A., W. D. Savedoff, W. C. Hsiao, J. Kutzin, A. Prady, D. 2020. Presentation for “Pro-Poor Earmarking of Soucat, A. Tandon, A. Wagstaff, and W. Chi-Man Yop. 2020. Health Taxes for Domestic Resource Mobilization.” Domestic “The Case against Labor-Tax Financed Social Health Insurance Resource Mobilization Collaborative, Joint Learning Network’s for Low and Low-Middle-Income Countries.” Health Affairs 39 Health Financing Technical Initiative Webinar, August 20, (5). 2020. ENDNOTES Bloomberg, M., Summers, L., Ahmed, M., Aziz, Z., Basu, K., 1. An earmark is soft if tax revenues are designated for a specific purpose but do Cardenas, M., Chan, M.. 2020; “Health Taxes to Save Lives. not determine the amount spent- there is no hard expenditure ceiling and Eploying effective excise taxes on tobacco, alcohol and sugary transfers to and from general funds are possible. Defined in Cashin et al. 2017 2.A methodology that accounts for different behavioral responses to the health beverages” Bloomberg-Summers Task Force on Fiscal Policy tax shock and subsequent price increases. for Health, April 2019. 3. In South Africa there have been some estimates of lost revenue, but difficulty in doing so without a counterfactual. Treasury has reported totals for excise but Tandon, A, Cain, J., Kurowski, C. and Postolovska, I. 2018. that includes fuel (which was not banned, but sales are still depressed). Other estimates have focused on impact of tobacco tax revenues and may be used to “Intertemporal Dynamics of Public Financing for Universal gain an understanding of the magnitude of the impact: Health Coverage: Accounting for Fiscal Space Across https://africacheck.org/reports/up-in-smoke-roughly-r35-mil-in-tobacco-tax- Countries.” Health, Nutrition and Population Discussion Paper, revenues-lost-daily-during-south-africas-lockdown/. World Bank, Washington, DC. Tandon, A., J. Cain, J. Kurowski, A. Dozol, and I. Postolovska. * This HNP Knowledge Brief provides an overview of published learnings from earmarking for health, building upon a webinar series hosted by the 2020. “From Slippery Slopes to Steep Hills; Contrasting Domestic Resource Mobilization (DRM) Collaborative under the Joint Landscapes of Economic Growth and Public Spending for Learning Network for Universal Health Coverage. Contributions from the Health.” Social Science and Medicine 259. DRM Collaborative team led by Ajay Tandon, country members of the Tandon, A. 2020. Presentation on Economic Impact of COVID- DRM Collaborative, and from Michael Borowitz and other members of the Global Fund team as the co-organizers of the webinar series are 19 on Fiscal Space for “Filling the Coffers Post-COVID.” gratefully acknowledged. The authors represent a mix of presenters, Domestic Resource Mobilization Collaborative, Joint Learning facilitators and authors of referenced publications. Network, July 2020. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 5