Financing of global health: tracking development assistance for health from 1990 to 2007

Summary

Background

The need for timely and reliable information about global health resource flows to low-income and middle-income countries is widely recognised. We aimed to provide a comprehensive assessment of development assistance for health (DAH) from 1990 to 2007.

Methods

We defined DAH as all flows for health from public and private institutions whose primary purpose is to provide development assistance to low-income and middle-income countries. We used several data sources to measure the yearly volume of DAH in 2007 US$, and created an integrated project database to examine the composition of this assistance by recipient country.

Findings

DAH grew from $5·6 billion in 1990 to $21·8 billion in 2007. The proportion of DAH channelled via UN agencies and development banks decreased from 1990 to 2007, whereas the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Global Alliance for Vaccines and Immunization (GAVI), and non-governmental organisations became the conduit for an increasing share of DAH. DAH has risen sharply since 2002 because of increases in public funding, especially from the USA, and on the private side, from increased philanthropic donations and in-kind contributions from corporate donors. Of the $14·5 billion DAH in 2007 for which project-level information was available, $5·1 billion was for HIV/AIDS, compared with $0·7 billion for tuberculosis, $0·8 billion for malaria, and $0·9 billion for health-sector support. Total DAH received by low-income and middle-income countries was positively correlated with burden of disease, whereas per head DAH was negatively correlated with per head gross domestic product.

Interpretation

This study documents the substantial rise of resources for global health in recent years. Although the rise in DAH has resulted in increased funds for HIV/AIDS, other areas of global health have also expanded. The influx of funds has been accompanied by major changes in the institutional landscape of global health, with global health initiatives such as the Global Fund and GAVI having a central role in mobilising and channelling global health funds.

Funding

Bill & Melinda Gates Foundation.

Introduction

In the years leading up to the present global economic downturn, international support for improving health in low-income and middle-income countries grew substantially, which gave rise to a lively debate among global health experts on how development assistance for health (DAH) could be used effectively.1, 2, 3, 4 With the onset of a global recession, many expect decreases in future funding.5, 6, 7 Surprisingly, discussions about global health financing continue to take place in the absence of a comprehensive system for tracking DAH.

The existing research on health resource flows has yielded some important estimates, but has large gaps.8, 9, 10, 11, 12 The Development Assistance Committee of the Organisation for Economic Co-operation and Development (OECD) provides estimates of official development assistance by sector.¹³ However, these estimates track only public sources and exclude private philanthropy, which is an important source of development assistance.¹⁴ The OECD data also omit other important health flows, such as contributions from the Global Alliance for Vaccines and Immunization (GAVI) and core-funded activities of WHO.13, 15 Studies investigating resources for specific diseases or types of interventions16, 17, 18, 19 have similar disadvantages. Studies of aggregate flows provide only data from single years,12, 20 and those capturing time-series data are outdated.21, 22

In view of the interest in DAH, why have these flows been so difficult to track comprehensively and systematically? Defining what constitutes DAH is conceptually challenging. Clarity on the scope of health resource tracking is needed, including a delineation of the types of institutions that should be tracked, what counts as health dollars and what might be health-related such as support for allied sectors, and whether assistance for all countries or just those of low and middle income should be included. Additionally, whether the quantity of interest is commitments, disbursements, or expenditure (panel) needs to be clearly defined.

Several measurement challenges make careful analysis complex, time-consuming, and at times uncertain. First, crucial variables in OECD's databases such as yearly disbursements and project descriptions are often incomplete. Second, there are no integrated databases for health-related assistance flows from private foundations and non-governmental organisations (NGOs) worldwide. Third, development assistance flows from primary funding sources through various financial intermediaries to many implementing institutions, increasing the danger of the same money being counted multiple times. Fourth, the poor quality of data from previous years makes quantification of time trends difficult. Fifth, different published sources of information for the same organisation are often inconsistent. And last, organisations use different fiscal years and accounting methods, which complicate the task of developing coherent information over time.

We aimed to tackle these challenges and develop a consistent time series of DAH from 1990 to 2007 on the basis of clear definitions and data drawn from several sources.