Is the world prepared for the next pandemic?
Published February 27, 2023
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Spending on health comes from one of four places. Development assistance for health (also known as DAH) is one place.
- The other three categories are government spending, out-of-pocket spending, and prepaid private spending.
- In 2019, $43.1 billion went towards DAH, which includes financial and in-kind resources that are transferred through international development agencies to low- and middle-income countries with the primary purpose of maintaining or improving health.
- $5.49 trillion went toward government spending, which includes spending on public health system infrastructure and government-provided social health insurance.
- $1.67 trillion went toward out-of-pocket spending, which includes out-of-pocket payments made by individuals for health maintenance, restoration, or enhancement at or after the time of health care delivery, including health insurance copayments or payments devoted to deductibles. Health insurance premiums are not considered out-of-pocket.
- Lastly, $1.97 trillion was devoted to prepaid private spending, which includes sources from non-public programs that are funded prior to obtaining health care, such as private health insurance and services provided for free by non-governmental agencies.
- Total health spending does not include indirect health spending, such as lost wages due to illness or transportation costs; informal care (spending on care provided by a family member or by traditional healers); or illegal transactions.
Funding for DAH mainly comes from high-income countries such as the US, UK, and Germany and foundations such as the Bill and Melinda Gates Foundation. These groups support efforts to maintain or improve health in low- and middle-income countries. According to IHME’s recent analysis, donors spent just over 43 billion dollars in DAH in 2019.
- DAH represented 0.5% of total global health spending in 2019, government spending represented the largest portion with 59.8%, out-of-pocket spending represented 18.2%, and prepaid private spending represented 21.5%.
After two decades of growth, DAH began to slow down and stagnate in 2010.
- The trend for DAH changed over the years of 1990 to 2019. Money towards development assistance for health was trending steadily upwards from 1990 to 2010. In 1990, DAH was 8.6 billion US dollars. and DAH was $37.7 billion in 2010. From 2010 to 2019, DAH experienced slowdown and even fell between 2013 and 2016. By 2019, DAH was $43.1 billion.
But DAH rebounded during the pandemic. From 2019 to 2020, contributions grew 44% and increased another 9% by 2021.
- DAH jumped from $43.1 billion in 2019 to $62.1 billion in 2020. In 2021, DAH increased to $67.4 billion.
Table: Development assistance for health per year, from 1990 to 2021
Year (descending) Development assistance for health 2021 $67.4 billion 2020 $62.1 billion 2019 $43.1 billion 2018 $43.1 billion 2017 $43.5 billion 2016 $40.4 billion 2015 $39.8 billion 2014 $40.9 billion 2013 $42.6 billion 2012 $39.9 billion 2011 $39.7 billion 2010 $37.7 billion 2009 $33.7 billion 2008 $32.4 billion 2007 $27.5 billion 2006 $24.7 billion 2005 $23.1 billion 2004 $20.2 billion 2003 $18.3 billion 2002 $14.8 billion 2001 $14.2 billion 2000 $13.9 billion 1999 $12.5 billion 1998 $11.9 billion 1997 $11 billion 1996 $11 billion 1995 $11.4 billion 1994 $10.6 billion 1993 $9 billion 1992 $9.1 billion 1991 $7.7 billion 1990 $8.6 billion
A global COVID-19 health response increased DAH spending significantly. Activities like vaccine procurement and country-level coordination were key drivers.
- DAH was $43.1 billion in 2019. Note that prior to 2020, there was no DAH spending for the COVID-19 health response. In 2020, DAH for the COVID-19 health response was $16 billion and DAH for all areas other than COVID was $46 billion. In 2021, DAH for the COVID-19 health response increased to $21.8 billion, while DAH for all areas other than COVID dipped slightly to $45.6 billion.
At the onset of the pandemic in 2020, the COVID-19 health response accounted for about one in four DAH dollars, and by 2021, one in three.
- In 2020, DAH for the COVID-19 health response was $16 billion, or about 26% of the total DAH of $62.1 billion. By the next year in 2021, DAH for the COVID-19 health response increased to $21.8 billion, or about 32% of the total $67.4 billion for DAH that year.
Perhaps motivated by the pandemic, donors increased their pandemic preparedness contributions in 2020 but tightened spending again in 2021.
- DAH for pandemic preparedness spiked in 2020 compared to all previous years going back to 1990. From 1990 to 1999, DAH for pandemic preparedness did not break $0.05 billion. From 2000 to 2009, pandemic preparedness increased slightly but did not break $0.13 billion. Pandemic preparedness saw some growth from $0.23 billion in 2010 to $0.36 billion in 2016 before dipping to $0.3 billion in 2017. In 2020, pandemic preparedness spiked to $1.05 billion and fell to $0.79 billion in 2021, which was still more money allocated to pandemic preparedness than in earlier years.
The unprecedented growth in DAH benefited some other global health priorities. Support for HIV/AIDS and tuberculosis grew.
- DAH for HIV/AIDS was greater than DAH for tuberculosis for every year from 1990 to 2021. DAH for HIV/AIDS saw dramatic growth from 2000 to 2012, reaching a peak of $12.23 billion. Spending oscillated in the years that followed, but was on an upward trajectory from $8.48 billion in 2019 to $9.7 billion in 2020 to $9.91 billion in 2021.
- As for DAH for tuberculosis, spending never broke $2.5 billion in any year from 1990 to 2021. However, spending was slowly trending upward from $1.95 billion in 2019 to $1.99 billion in 2020 to $2.03 billion in 2021.
But spending on reproductive and maternal health declined steadily for two consecutive years.
- DAH for reproductive and maternal health ebbed and flowed from 1990 to 2021. DAH for reproductive and maternal health was $1.94 billion in 1990. Spending was uneven from 1990 to 2004, and there was steadier growth from 2004 to 2013, going from $2.04 billion to $5.84 billion. By 2019, DAH for reproductive and maternal health was $6.17 billion. However, spending fell to $5.68 billion in 2020 and fell even further to $5.3 billion in 2021.
Historically, pandemic preparedness has been underfunded…
- The overall trend from 1990 to 2021 for DAH for seven health focus areas – HIV/AIDS, malaria, tuberculosis, neonatal and child health, reproductive and maternal health, non-communicable diseases, and pandemic preparedness – denotes an increase in spending, but some less steadily than others. Of these seven health focus areas, pandemic preparedness has historically received the least funding, with non-communicable diseases a close second. Neither health focus area topped $1.2 billion in any year from 1990 to 2021. Finally, DAH for COVID-19 topped spending for every other health focus area in 2020 and 2021 by a wide margin.
Table: DAH by health focus area from 1990 to 2021
Year (descending) DAH for HIV/AIDS DAH for malaria DAH for tuberculosis DAH for neonatal and child health DAH for reproductive and maternal health DAH for non-communicable diseases DAH for COVID-19 DAH for pandemic preparedness 2021 $9.91 billion $2.44 billion $2.03 billion $9.5 billion $5.3 billion $1.08 billion $21.79 billion $0.79 billion 2020 $9.7 billion $2.15 billion $1.99 billion $8.61 billion $5.68 billion $1.11 billion $16.04 billion $1.05 billion 2019 $8.48 billion $2.52 billion $1.95 billion $8.98 billion $6.17 billion $1.06 billion 0 $0.48 billion 2018 $9.85 billion $2.23 billion $2.07 billion $8.24 billion $5.7 billion $0.91 billion 0 $0.41 billion 2017 $11.06 billion $2.61 billion $1.98 billion $8.72 billion $5.41 billion $0.72 billion 0 $0.3 billion 2016 $9.86 billion $2.46 billion $1.69 billion $7.87 billion $5.03 billion $0.74 billion 0 $0.36 billion 2015 $8.97 billion $1.89 billion $1.37 billion $8.48 billion $5.23 billion $0.61 billion 0 $0.36 billion 2014 $10.83 billion $2.06 billion $1.31 billion $7.1 billion $5.42 billion $0.6 billion 0 $0.34 billion 2013 $12.05 billion $2.25 billion $1.77 billion $7.31 billion $5.84 billion $0.78 billion 0 $0.26 billion 2012 $12.23 billion $2.26 billion $1.37 billion $6.36 billion $5.53 billion $0.52 billion 0 $0.24 billion 2011 $12.1 billion $1.99 billion $1.47 billion $5.21 billion $5.11 billion $0.51 billion 0 $0.21 billion 2010 $11.77 billion $2.15 billion $1.64 billion $5.12 billion $4.5 billion $0.46 billion 0 $0.23 billion 2009 $9.34 billion $2.25 billion $1.28 billion $4.69 billion $4.42 billion $0.38 billion 0 $0.12 billion 2008 $9.26 billion $1.59 billion $1.2 billion $4.74 billion $3.68 billion $0.35 billion 0 $0.12 billion 2007 $8.65 billion $0.97 billion $1.05 billion $4.06 billion $2.77 billion $0.28 billion 0 $0.09 billion 2006 $7.14 billion $0.91 billion $0.72 billion $2.99 billion $2.67 billion $0.24 billion 0 $0.09 billion 2005 $5.68 billion $0.76 billion $0.54 billion $3.38 billion $2.5 billion $0.17 billion 0 $0.08 billion 2004 $4.73 billion $0.5 billion $0.53 billion $2.77 billion $2.04 billion $0.15 billion 0 $0.09 billion 2003 $3.55 billion $0.28 billion $0.32 billion $2.7 billion $2.41 billion $0.15 billion 0 $0.1 billion 2002 $2.77 billion $0.18 billion $0.28 billion $2.33 billion $2.06 billion $0.17 billion 0 $0.1 billion 2001 $1.77 billion $0.22 billion $0.21 billion $2.23 billion $2.66 billion $0.22 billion 0 $0.1 billion 2000 $1.53 billion $0.17 billion $0.14 billion $1.98 billion $2.8 billion $0.18 billion 0 $0.1 billion 1999 $1.03 billion $0.11 billion $0.11 billion $1.57 billion $2.49 billion $0.13 billion 0 $0.04 billion 1998 $0.88 billion $0.09 billion $0.08 billion $1.04 billion $2.29 billion $0.11 billion 0 $0.04 billion 1997 $0.8 billion $0.08 billion $0.07 billion $1.1 billion $2 billion $0.09 billion 0 $0.05 billion 1996 $0.93 billion $0.06 billion $0.1 billion $1.13 billion $1.89 billion $0.09 billion 0 $0.05 billion 1995 $0.94 billion $0.09 billion $0.07 billion $1.34 billion $2.65 billion $0.1 billion 0 $0.06 billion 1994 $1.03 billion $0.06 billion $0.07 billion $1.25 billion $2.47 billion $0.2 billion 0 $0.06 billion 1993 $0.68 billion $0.04 billion $0.04 billion $0.9 billion $1.69 billion $0.17 billion 0 $0.05 billion 1992 $0.72 billion $0.05 billion $0.03 billion $1 billion $1.93 billion $0.11 billion 0 $0.05 billion 1991 $0.62 billion $0.05 billion $0.03 billion $0.74 billion $1.84 billion $0.06 billion 0 $0.05 billion 1990 $0.46 billion $0.05 billion $0.02 billion $0.75 billion $1.94 billion $0.05 billion 0 $0.05 billion
Pandemic preparedness represented a mere 1% of total DAH.
- From 2010 to 2021, total DAH ranged from $37.71 billion to $67.41 billion. By contrast, DAH for pandemic preparedness ranged from $0.23 billion in 2010 to $0.79 billion in 2021.
Table: DAH for pandemic preparedness compared to total DAH, by year 1990-2021
Year (descending) DAH for pandemic preparedness Total DAH 2021 $0.79 billion $67.41 billion 2020 $1.05 billion $62.07 billion 2019 $0.48 billion $43.12 billion 2018 $0.41 billion $43.12 billion 2017 $0.3 billion $43.5 billion 2016 $0.36 billion $40.36 billion 2015 $0.36 billion $39.82 billion 2014 $0.34 billion $40.92 billion 2013 $0.26 billion $42.6 billion 2012 $0.24 billion $39.9 billion 2011 $0.21 billion $39.75 billion 2010 $0.23 billion $37.72 billion
It’s no match for future pandemics.
- DAH for pandemic preparedness was 1.7% of total DAH in 2020 and 1.2% of total DAH in 2021.
If recommendations set by the G20 High Level Independent Panel are the goal, donors will need to dedicate about 30% of DAH toward pandemic preparedness to respond effectively and save lives.
- To meet HLIP recommendations, the projected amount needed for DAH for pandemic preparedness is much greater than 1% of total DAH. In 2022, 26.4% of total DAH should be allocated to pandemic preparedness. For 2023 to 2026, the projected percentages needed are 32.6%, 31.8%, 30.9%, and 30.3% of total DAH, respectively.
But recent donor activity suggests that the additional 15 billion dollars needed annually is achievable. Forward-thinking donors, in partnership with world leaders, have a unique opportunity to end this cycle of panic and neglect.
- DAH for the COVID-19 health response was 25.8% of total DAH in 2020 and 32.3% of total DAH in 2021, demonstrating that dedicating 30% of DAH toward pandemic preparedness in the coming years is not impossible.