COMMENTARY - Development assistance for health: trends and prospects

Abstract

The global economic crisis that began to unfold in 2008 raised serious concerns about the ability of developing countries to meet targets for improvements in population health outcomes and about the ability of developed countries to meet their commitments to fund health programs in developing countries. The commentary, Development assistance for health: trends and prospects, points out how the uncertainty underscores the importance of tracking spending on global health to ensure resources are directed efficiently to the world’s most pressing health issues. IHME released its first study on financing global health in 2009 (Ravishankar et al) and updated estimates, including further analysis, in November 2010 in the report Financing Global Health 2010: Development Assistance and Country Spending in Economic Uncertainty.

Research objective

• Track every available financial stream to update estimates of development assistance for health (DAH) from 1990 to 2008, with preliminary estimates for 2009 and 2010
• Estimate aggregate flows by source and channel
• Include tracking of additional channels of assistance and health focus areas
• Analyze how much money governments allocate to health, how health sector budgets have changed over time, and how changes in government spending on health in developing countries relate to incoming DAH
• Incorporate key methodological improvements in response to reactions to the 2009 study

Research findings

• Global health financing continued to expand between 2007 and 2010, from US$20.4 billion to $26.9 billion.
• DAH increased at an annual percentage rate of 17% between 2007 and 2008. But the growth rate slowed dramatically to just 6% between 2008 and 2009 and was 7% between 2009 and 2010.
• The shift in the balance of contributions between the different channels continued to be an underlying trend during this period, with UN agencies playing a smaller role and the Global Fund, GAVI, US and UK bilateral aid, and the Gates Foundation growing in importance as channels of assistance.
• The top ten recipients of DAH were India, Nigeria, Tanzania, Ethiopia, Uganda, Kenya, Zambia, Mozambique, South Africa, and Pakistan.
• Generally, countries with higher disease burdens received more aid, but not always. There are 11 countries that were in the top 30 recipients of DAH from 2003 to 2008 but not in the top 30 in terms of burden of disease: Zambia, Argentina, Colombia, Ghana, Malawi, Rwanda, Cambodia, Senegal, Haiti, Zimbabwe, and Peru.
• Funding for HIV/AIDS continued to rise, while programs targeting maternal, newborn, and child health received the second largest share. Noncommunicable diseases received the least amount of funding compared with other health areas.

Analytical approach

Researchers examined the relation between past budgets and subsequent disbursements for bilateral development agencies, the European Commission, UN agencies, and the multilateral banks. These relations were used to project likely disbursements in 2009 and 2010 on the basis of annual budget data. For foundations and non-governmental organizations, we forecasted disbursements in 2010 on the basis of information from financial data between 1990 and 2009 and key covariates, including gross domestic product per head and asset-value indices. Second, we used in-kind income as reported by US non-governmental organizations on their tax returns. Many non-governmental organizations use US wholesale prices for donated drugs and equipment. We studied the relation between US wholesale prices, international prices, and federal upper-limit prices for 386 unique products. We used regression coefficients for US federal upper-limit prices compared with US wholesale prices to correct in-kind income reported by non-governmental organizations. This analysis led to a downward adjustment of 82%, on average, for the figures based on tax returns from 1990 to 2010.

Policy implications

Growth in global health spending will probably slow and is likely to contract in 2011. Although the global health community is unlikely to influence the politics of fiscal contraction, it can take on two specific challenges: provide compelling evidence that past and continuing investments are making an impact, and show that resources devoted to health programs are an effective means to advance health and broader development goals. It will be crucial in this environment for the global health community to transparently evaluate and communicate about the successes and failures of global health funding. Only real evidence of success will sustain global health financing in coming years.