Tracking Development Assistance for Health

1990 - 2007

Nirmala Ravishankar

October 7, 2009

2

Context for this research It is widely believed that the last decade saw a rapid rise in development

assistance for improving health in low- and middle-income countries.

It is now feared that the funds are shrinking as a result of the global economic downturn.

While there are established methods for accounting for domestic health expenditure, there was no comprehensive system for estimates of the total envelope of global health resources.o OECD’s estimates capture bilateral and multilateral assistance but not

private sourceso Other studies have focused on specific diseases or provided estimates

for select years (Powell-Jackson et al. 2006, Narasimhan & Attaran 2003; Sridhar and Batniji 2008, Michaud 2003)

There is a demand for this information from donors, policy-makers and the academic community

Information on resource inputs is crucial for assessing cost-effectiveness of interventions.

Defining Development Assistance for Health (DAH)

DAH refers to financial and in-kind contributions for improving health and health systems in low- and middle-income countries originating from both public and private sources that flow via institutions whose primary purpose is development assistance.

3

4

The DAH Landscape

Funding Sources

National treasuries

Private individuals

Corporate donations

Channels of Assistance

Bilateral Aid Agencies

UN Agencies

Development Banks

Global Health Initiatives

Private Foundations

International NGOs

Implementing Institutions

Governmental programs

National ministries of health

National Disease control programs

Non-governmental programs National NGOs

Private sector contractors

Universities and research institutions

Defining DAH We focused on the primary channels of

development assistance for health

We focused on direct health (specifically disease-specific support, health system support, and health research funded by the channels) and excluded aid for allied sectors

DAH is comprised of: Disbursements on grants Gross flows for concessionary loans Health-related program expenditures

Only DAH to low and middle income countries is counted

5

Data sources

6

Bilateral agencies in OECD DAC member countries & the European Commission

OECD DAC Aggregate database & the Creditor Reporting System (CRS)

UN Agencies: WHO, UNICEF, UNFPA, and UNAIDS

Financial reports and audited financial statements

The World Bank, ADB, AfDB and IDB

Online project databases and audited financial documents

GAVIGAVI annual reports, country fact sheets, and correspondences

The Global Fund Online grant database

NGOs registered in the USUSAID VolAg reports, tax filings, financial statements & correspondence

The Bill & Melinda Gates Foundation

Online grant database and tax filings

Other private US. FoundationsFoundation Center’s grants database

Key Measurement Challenges The problem of double-counting

Missing disbursement data

Hard to know health fraction of multi-sector grants and loans

International health expenditures by NGOs is not always reported

NGOs and UN agencies do not report country-wise program expenditures

Disease-focus of all grants, loans, and program expenditures is not reported

The role of Global Health Initiatives is growing

All figures show 2007 US dollars

8

US government is the single biggest contributor of global health dollars

9

Where are global health dollars from public sources going?

AUS = Australia, AUT = Austria, BEL = Belgium, CAN = Canada, CHE = Switzerland, DEU = Germany, DNK = Denmark, ESP = Spain, FIN = Finland, FRA = France, GBR = United Kingdom, GRC = Greece, IRL = Ireland, ITA = Italy, JPN = Japan, LUX = Luxembourg, NLD = the Netherlands, NOR =Norway, NZL = New Zealand, PRT = Portugal, SWE =Sweden, USA = United States.

10

For more than 30% of USG funds, information about recipient is not available

Other countries give more as a percent of GDP

AUS = Australia, AUT = Austria, BEL = Belgium, CAN = Canada, CHE = Switzerland, DEU = Germany, DNK = Denmark, ESP = Spain, FIN = Finland, FRA = France, GBR = United Kingdom, GRC = Greece, IRL = Ireland, ITA = Italy, JPN = Japan, LUX = Luxembourg, NLD = the Netherlands, NOR =Norway, NZL = New Zealand, PRT = Portugal, SWE =Sweden, USA = United States.

HIV/AIDs draws considerable funds, but TB and Malaria have grown in recent years….

12

USG and the Global Fund are the biggest contributors of HIV/AIDs funds

13

14

The Global Fund and the Gates Foundation are the biggest contributors of Malaria funds

Sub-Saharan Africa attracts more health aid than other regions of the world

15

Aid is positively correlated with overall disease burden

16

Argentina

Botswana

Belize

Belarus

Brazil

Bulgaria

Chile

Costa Rica

Cuba

Dominica

FijiGabon

Grenada

Croatia

Jamaica Kazakhstan

Lebanon

Latvia

Lithuania

LibyaMauritius

Mexico

Malaysia

Suriname

Poland

Panama

Palau

Russia

St. Kitts & Nevis

Seychelles

South Africa

St. Lucia

Turkey

Uruguay

St. Vincent & the Grenadines

Venezuela

Algeria

Azerbaijan

AlbaniaArmenia

Angola

Bosnia & Herzegovina

Bolivia

Bhutan

Sri Lanka

Congo

China

Cameroon

Colombia

Cape Verde Djibouti

Dominican Republic

Ecuador

Egypt

El Salvador

Micronesia

Georgia

Guatemala

Guyana

Honduras

Indonesia

India

Iran

Iraq

Jordan

Kiribati

LesothoMoldova

MongoliaMacedonia

Morocco

Maldives

Vanuatu

Nicaragua

Paraguay

Peru

Marshall Is.

Philippines

Sudan

Syria

Thailand

Tonga

Tunisia

Timor Leste

Turkmenistan

Ukraine

Namibia

Samoa

Swaziland

Afghanistan

Bangladesh

Myanmar

Benin

Solomon Is.

Burundi

Cambodia

Chad

Congo, DRC

Comoros

Central African Republic

Eritrea

Ethiopia

The Gambia

Ghana

Guinea

Haiti

Cote d'Ivoire

Kenya

Kyrgyzstan

North Korea

Laos

Liberia

Madagascar

Malawi

Mali

Mauritania

Mozambique

Niger

Nigeria

Nepal

Pakistan

Papua New Guinea

Guinea-Bissau

RwandaSenegal

Sierra Leone

SomaliaTajikistan

Togo

Sao Tome & Principe

TanzaniaUganda

Burkina Faso

Uzbekistan

Vietnam

Yemen

Zambia

Zimbabwe

67

89

10

Cum

ula

tive D

AH

(Log 1

0)

4 5 6 7 8 92002 All-Cause DALYs (Log 10)

Upper Middle Income

Lower Middle Income

Low Income

CUMULATIVE DAH FROM 2002-2007 VERSUS ALL-CAUSE DALYs 2002

But other factors are also driving who attracts health assistance

Top 30 country recipients of DAH for health (2002-2007)

vs.

Top 30 countries ranked by

all-cause DALYs in 2002

Key FindingsDevelopment assistance expanded greatly from 1990-2007, particularly post-2002

Private sources are playing an increasingly important role in funding DAH

The increase in DAH was fueled by a huge expansion of dollars for HIV/AIDS, but other areas of global health have also expanded dramatically

New actors in the field of global health such as GAVI, GFATM and NGOs are competing for resources with other channels of assistance like the World Bank and UN agencies

Countries with higher disease burden and poorer countries tend to receive more aid, but burden is not the sole determinant of aid

Better quality data and standardized reporting guidelines are needed

18

Acknowledgements and References

Team: Researchers at the Institute for Health Metrics and Evaluation at the University of Washington, led by Christopher JL Murray

Funding: Core grant from the Bill and Melinda Gates Foundation

Publication: Ravishankar N, Gubbins P, Cooley R, Leach-Kemon K, Michaud M, Jamison D, and Murray CJL, Financing Global Health: Tracking Development Assistance for Health, The Lancet, Vol. 373, No. 9861, June 20, 2009.