The recently released fourth annual edition of the financing series of the Institute of Health and Metric Evaluation (IHME), ‘Financing Global Health 2012: The End of the Golden Age?’ tracks Development Assistance for Health (DAH) from government aid agencies, multilateral donors, and private foundations. It also analyses health spending from governments in developing countries between 1990 and 2010. By combining health funding estimates with the results of the newly published Global Burden of Disease (GBD) Study 2010, the report provides metrics that can help inform donor priority setting. Comparisons between the amount of DAH that a country receives and its disease burden provide useful tools for assessing need versus funding.
“For some diseases, there is a clear disconnect between funding and burden measured by both mortality and disability,” explained IHME Assistant Professor Michael Hanlon. “These comparisons serve as a guide for policymakers to discuss, reassess, and improve upon their health spending.”
Here are some major findings of the report:
• According to IHME’s preliminary estimates, a total of $28.1 billion was disbursed in 2012 as DAH-- a $53 million drop from 2010. However, the long-term trajectory of DAH demonstrates the firm commitment of development assistance partners to realizing positive health outcomes globally.
• From 2011 to 2012, overall health spending channelled through government aid agencies dropped by 4.4%. Among the six largest bilateral donors, only donations from the UK and Australia increased from 2011 to 2012 at rates of 2.3% and 8.1%, respectively, while those from the US, the largest donor, dropped by 3.3%. GAVI (formerly the Global Alliance for Vaccines and Immunization) continued to have very strong rates of growth with its expenditure reaching an estimated $1.76 billion in 2012, a 41.9% increase over 2011.
• However, many developing countries with the highest disease burdens did not receive the most health funding. Certain countries received much less funding in comparison to their high disease burden. For example, the low-income countries of Burundi, Guinea, Mali, and Niger were among the top 20 countries in terms of malaria burden, but were not among the top 20 recipients of malaria funding. Of the top 20 countries with the highest all-cause disability adjusted life years (DALYs), only 12 were among the top 20 recipients of DAH. Only India Nigeria and Vietnam had comparable DAH and DALY levels, relative to other countries on the list. Many upper-middle-income countries – Russia, Brazil, Mexico, and Thailand– received particularly low DAH relative to their disease burden.
• With respect to specific health focus areas, DAH for HIV/AIDS, tuberculosis, and maternal new-born child health (MNCH) continued to grow through 2010, while that for health sector support, non- communicable diseases, and malaria fell slightly from 2009 to 2010. Growth in DAH for MNCH and TB was impressive at 8.8% and 13.8%, respectively, from 2009 to 2010. NCDs constituted by far the smallest health focus area tracked, as total expenditure amounted to just $185 million or 0.8% of the total allocable DAH in 2010.
Excluding India, the top recipients of total DAH from 2008 to 2010, were sub-Saharan African countries which received the largest share of health-funding in 2010—$8.1 billion or 28.7% of total health funding. India and South Africa, two middle-income countries, were among the top 10 recipients, highlighting the contradictions informing discussions about continued aid to middle-income countries. With the exceptions of India and the Democratic Republic of the Congo, US bilateral assistance, played a prominent role in funding the top 10 recipients of DAH. In South Africa, US bilateral assistance comprised nearly 80% of DAH expenditure. In India, the UK contributed the biggest proportion of funds, making it the single largest recipient of UK aid. However, the UK Department for International Development (DFID) announced in November 2012 that it will be phasing out its aid to India and that existing programs should be completed by 2015.
DAH for HIV/AIDS
HIV/AIDS constituted the most substantial portion of DAH (30.5%) in 2010-- an increase of 2.8% over 2009. US bilateral agencies funded more than half (58.8%) of DAH for HIV/AIDS, with $4 billion in DAH spent in 2010. GFATM was the second largest contributor at $1.4 billion. Even so, according to a report by the global advocacy group ONE in 2012, the world is not on track to reach the MDG HIV/AIDS targets as 8.4 million people are still in need of treatment and 2.5 million people continue to be infected annually. UNAIDS estimates that additional $2 to $3 billion are required annually to meet treatment and prevention needs. Of the top 20 countries with the highest HIV/AIDS DALYs, 13 are located in sub-Saharan Africa. Notably, South Africa ranked first in both HIV/AIDS DAH and HIV/AIDS DALYs, followed by India. However, disconnects between burden and DAH existed for Cameroon, Myanmar, and Brazil, which had particularly low levels of HIV/AIDS DAH despite their high burden.
DAH for MNCH
By 2010 DAH expenditure on MNCH reached almost $5.2 billion, an 8.8% increase from 2009. The US was the single largest contributor to MNCH, spending approximately 17.1% of the total in 2010, followed closely by UNICEF (16.6%) and UNFPA (15.9%). GAVI also made up a major proportion of spending on MNCH in 2010 at 4.9% with spending in this health focus area increasingly concentrating on vaccinations.
Among the 10 countries with the highest MNCH DALYs, eight (all of which are low- or lower-middle-income countries) received the highest amounts of MNCH DAH. These included India on the top followed by Nigeria and Pakistan. China is the only upper-middle-income country ranked in the top 20 but it received vastly less MNCH DAH in relative terms, ranking 48th among recipients of cumulative MNCH. However, a number of upper-middle-income countries with lower DALYs (Argentina, Peru, and Colombia) received some of the highest levels of DAH for MNCH.
DAH for Malaria
In 2010 total DAH for malaria amounted to almost $1.9 billion, a decrease of 4.2% from 2009. The Roll Back Malaria Partnership identified a $3.6 billion gap in spending if global malaria targets are to be met by 2015. The countries afflicted with the highest malaria DALYs, are all low-income or lower-middle-income countries. China is the only upper-middle-income country to appear among the top 20 recipients of DAH for malaria. India is the only non- African country that ranks among the countries with the highest malaria burden.
DAH for tuberculosis
Worldwide, TB accounts for 2% of all DALYs, and ranks 13th in terms of causes of the disease. A total of $1.1 billion in DAH was spent on TB in 2010. GFATM contributed 39.4% of the funds and spent $432 million on TB in 2010. Bill and Melinda Gates Foundation also provided substantial support to TB programs, disbursing 24.2% of total TB DAH in 2010.
China, Russia, and South Africa and other upper-middle-income countries (Peru, Kazakhstan, and Brazil) were ranked among the top 20 recipients of cumulative TB DAH from 2008 to 2010. Kazakhstan and Peru in particular received large amounts of DAH for TB despite relatively small burdens.
Although contributions are expected to continue in coming years, the Global Tuberculosis Report 2012 estimates a funding gap of $1.4 billion for research and $3 billion for control and care annually between 2013 and 2015.
DAH for NCDs
Since 1990, the global burden of disease has shifted substantially away from communicable diseases to NCDs (which include cancer, diabetes, heart disease, and hypertension) and by 2010 NCDs had risen to 54% of global DALYs. However NCDs constituted the smallest health focus area tracked, as total expenditure fell 5.1% in 2010 and amounted to just $185 million or 0.8% of the total allocable DAH of $28.2 billion in 2010. As people live longer and communicable diseases are tackled better, NCDs will be an increasingly important issue for health systems in low- and middle-income countries.
The WHO has been one of the most consistent supporters of DAH for NCDs, providing $49 million or 26.5% of this funding in 2010. In recent years, the Bloomberg Family Foundation too has committed an increasing share of its resources to NCDs and now accounts for 42.7% of NCD DAH at $79 million.
DAH for health sector support
DAH for health sector support includes disbursements made directly to developing-country governments to spend on health system strengthening or other health priorities. The UK, which provides the most significant amount of DAH for health sector support, contributed $258 million in 2010, a 13.5% increase from 2009. DAH from the US for health sector support, meanwhile, decreased 14.5% from 2009 to 2010.
Although Financing Global Health 2012 focuses primarily on DAH, it does not undermine the role of government health expenditure (GHE) in covering the costs of health care in developing countries. Even at the peak of health funding from donors in 2010, the spending by governments on health in their own countries was $521 billion, which was more than 18 times higher than total donor funding in the same year. As development assistance partners make decisions about new funding commitments, the shifts in DAH, as shown in the report, should be kept in mind. If DAH for malaria, non-communicable diseases, and health system support, continues to wane, decision-makers need to be cognizant of the impact. If bilateral spending continues to drop, the increasing prominence of other players must be taken into consideration. Any retreat from DAH for middle-income countries will have to be observed closely, as 75% of the world’s poor now reside in middle-income countries. Accurate and timely information, as provided by this report, is thus increasingly necessary to ensure that stakeholders are able to respond to a quickly evolving global health landscape and make informed decisions about a multitude of global health challenges.
“This analysis highlights the mismatch between donor priorities and global health needs,” said Amanda Glassman, Director of Global Health Policy and a senior fellow at the Center for Global Development to Citizen News Service - CNS. “Before you can make a decision on where to allocate resources, you must first understand where that money is most needed.”
(The author is the Managing Editor of Citizen News Service - CNS. She is a J2J Fellow of National Press Foundation (NPF) USA. She received her editing training in Singapore, has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB, co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia", reports on Hepatitis C and HIV treatment access issues, and MDR-TB roll-out. Email: firstname.lastname@example.org, website: http://www.citizen-news.org)