In many ways, the last twenty years have been somewhat of a “revolution” in global health, as marked by rising attention, growing funding, and the creation of new, large scale initiatives to address global health challenges in low and middle income countries.  Indeed, the 1990s brought a steady increase in global concern about health, largely centered on the HIV epidemic and due to civil society organizing to draw attention to the growing crisis, leading to the creation of the Millennium Development Goals, and soon thereafter, the GAVI Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and the U.S. President’s Emergency Plan for AIDS Relief, and other efforts.

A key driver of increased funding has been donors – governments and multilateral agencies, non-governmental organizations (NGOs), and foundations.  And tracking their funding has become one of the critical measures of the global health response.

A new analysis from Dieleman et al., published as a Health Affairs Web First on April 8, provides a needed contribution to the literature on donor funding for health, including an understanding not just of where donor funding is going but of the relationship between aid, burden, and income.

Development Assistance For Health

First, on development assistance for health (DAH), the authors find a significant rise in DAH over the prior decade, but much more tempered growth since then (still, DAH reached its highest level yet in 2013, according to their estimates), confirming trends seen elsewhere, such as analyses on donor government funding for HIV and for health more broadly, as well as for philanthropic support.

Taken together, these analyses illustrate the lasting effects on donor budgets of the global economic crisis that took hold in 2008, although it is not yet clear what it all means for further scaling up of programs and achieving success in global health.  It is also unclear whether these effects will continue beyond 2013.

One inkling could come from the United States, the largest government donor to global health, whose most recent budget request for 2015 proposed reductions, which would bring global health funding to its lowest level since FY 2009 (the President’s FY 15 budget request does include a new “Opportunity, Growth, and Security Initiative” that would provide additional funding across several areas, including global health, but it requires Congressional approval and remains uncertain).  If many key donors choose to reduce their funding, it could have serious implications for how much progress countries can make toward global health goals in the years to come.

Funding By Health Area

Second, the analysis looks at funding by health area and finds that while HIV received the greatest amount of support, as has been the case for some time, funding for maternal, newborn, and child health (MNCH) increased the fastest between 2006 and 2011. This could reflect more attention to MNCH in recent years, including through the G8 Muskoka Initiative, and increased funding by some donors, such as the U.S.

Going forward, further analyses could delve more deeply into MNCH funding – Dieleman et al. include funding for family planning and reproductive health in their larger MNCH envelope.  Yet family planning has only recently received renewed attention (see, for example, the FP 2020 Initiative, launched in 2012, too recently to be reflected in the data in this article) and may not itself be the driver of the increases seen in this analysis.  Efforts to track donor funding for family planning post-FP2020 are now underway.

Lastly, Dieleman et al. offer an insightful look at the relationship between aid for health, disease burden and income.  Among their findings, there was significant variation in allocation by health focus area relative to burden – for example, a low income country with a high HIV burden received significantly more for HIV than a low-income country with a high burden of non-communicable diseases (NCDs) received for NCDs.

Moreover, NCDs overall received very little funding relative to disease burden. The authors posit that this could be due to the relative lack of cost-effective data on interventions for NCDs, in contrast to proven cost-effective interventions for HIV, malaria, TB, immunizations, and other areas.

However, it is also important to note that there is significant unfinished business to be done in combatting HIV (as well TB, malaria, and MNCH, particularly in sub-Saharan Africa – MDGs 4, 5, and 6), and current allocations reflect a very deliberate scaling-up that only began about a decade ago.  Attention to NCDs is much more recent and there are challenging questions about the role of donors in funding an NCD response.

Global Funding Allocation

Dieleman et al. also find that while high-burden, low-income countries received the most development assistance for health across all health focus areas, and funding allocation was more responsive to disease burden than income, there were several outliers or “mismatches”.  As the authors note, the non-health literature has found that aid allocations are not determined by need alone.  Rather, other factors, such as perceived corruption and historical relationships between donors and recipients, could affect allocations.

Further research could explore this relationship for health aid specifically, and include other potential factors that might influence donor decisions, such as a recipient government’s infrastructure and capacity for delivering health; its willingness to provide health services; human rights concerns; whether it is a weak or fragile state; and, whether it offers other non-health assets to donors (e.g., military assets, resources such as oil).   In addition, research could also examine how health aid allocation varies by donor.  Do allocations made by the U.S. or the UK, for example, follow similar patterns or do other factors come into play?

These findings also of course raise important questions about the future for policy makers, particularly those in donor governments and international institutions who have in large part put a premium on addressing global health as part of development over the past decade.  While it appears that the global health funding revolution is likely over, policymakers will increasingly be confronted with the challenge of addressing the unfinished business of HIV, TB, malaria, MNCH and other areas – and ensuring that their health investments are lasting – in an era of fiscal constraint (for them and for recipient countries) even as newer challenges, such as NCDs, rise on the global agenda.