Hats off to the authors from the Institute for Health Metrics and Evaluation at the University of Washington and the Harvard Initiative for Global Health who published initial findings from their study on tracking development assistance for health in the Lancet recently. In Financing of global health: tracking development assistance for health from 1990 to 2007 they’ve charted the outlines of a comprehensive system for tracking where all that darn global health money goes – something that has been sorely needed much before now.
This exercise has not been easy because the parameters of development assistance for health (DAH) remain murky. Does one count, for example, funding for basic health research at institutions that contribute to the science of global health? What about efforts to improve sanitation or build safer roads? Reliable and timely data on disease burdens and DAH disbursements, the hobgoblin of figuring out whether we really have improved global health, remains a major problem.
Still, this article reveals some interesting features of the financial landscape of global health.
If you’ve ever wanted to know which countries are the Most Favored Nations (MFNs) for health, the authors point out several interesting facts about where DAH investments are highest (and lowest) both cumulatively across all health issues and by disease as well as where that investment stands in relation to DALYs in low- and middle-income countries. The good news; there is a positive correlation between disease burden and DAH, and there appears to be a trend toward investing more DAH in the lower-income countries. The bad news; even in countries where the disease burden is similar, there can be a great variation in donor assistance. For example, there is 33 times the DAH investment made in Nicaragua than in Turkmenistan.
So who are the MFNs of health? Looking at the article’s webappendix provides some provocative graphs highlighting both cumulative DAH levels by country as well as disease-specific assistance for the big three – HIV/AIDS, malaria and TB.
Among the low-income countries, those receiving the most DAH dollars include: Ethiopia at the top, followed by Uganda, Tanzania and Nigeria, then Kenya, Zambia, Mozambique and Pakistan. However, the investment levels do not precisely match up with the degree of disease burden (cumulative) measured by DALYs. For example, all-cause DALYs for Nigeria are higher than for Ethiopia, but Nigeria receives less DAH. The Congo DRC has a disease burden approximately equivalent to Ethiopia, but doesn’t make the top of the DAH list at all. And let’s not even talk about Afghanistan, Myanmar or North Korea – definitely among the LFNs (Least Favored Nations) for health when one compares DAH to all-cause DALYs.
Among the lower-middle income countries, here’s how DAH stacks up. India is in the lead both for DAH and all-cause DALYs (Interesting to note, however, that India is not leading – indeed is lagging – in the area of DAH investments per capita.) Colombia (really?), Indonesia, China and Iraq follow. Then the Philippines, Nicaragua, Peru and Egypt show the highest DAH. The losers in this category (meaning those countries where all-cause DALYs have not inspired as much DAH) include Angola, Sudan, Thailand, Ukraine, and Iran.
The big news in the upper-middle income countries are those rather prominent countries that are not raking in DAH. Both Brazil and Russia, the B and the R in BRIC countries, have the highest all-cause DALYs in this category, yet they do not receive the most DAH. Brazil makes a reasonable showing, falling behind only South Africa (big winner in DAH) and Argentina. But Russia, poor distant Russia, has DAH funding closer to the level invested in Turkey than the level invested in South Africa. Also, Poland and Malaysia (relatively high all-cause DALYs) fall way behind the DAH showered upon Uruguay, Jamaica and Costa Rica.
Rather than point to the winners in disease-specific DAH levels, let’s look at the ugly stepchildren of global health assistance.
For HIV/AIDS, the countries receiving the least DAH per DALY include (in no particular order) Chad, Congo DRC, Central African Republic, Sudan, India, Venezuela, Paraguay, Poland and Malaysia.
On the malaria front Botswana, South Africa, Chad, Iran, Turkey, and Malaysia receive very little DAH per malaria DALY and overall spending is low in much of Western Africa and parts of Southeast Asia.
And finally, countries receiving the least DAH per TB-DALY include Gabon, Republic of the Congo, Algeria, Uruguay, Iran, Hungary, and the Baltic states. Nigeria, Zimbabwe, Afghanistan, Kazakhstan, Pakistan and India aren’t doing too well either.
We all know that there are reasons why some countries repeatedly show up on the low end of DAH – war, corruption, political instability and political insanity, for instance. But what this article doesn’t show us is whether or not some perfectly lovely countries are not receiving DAH because donors have decided that they’re just not politically important enough to attract significant investments. The converse is true as well – are some DAH darlings able to justify the level of external investments by demonstrating significant health improvements or are they just places where donors are investing heavily for other reasons?
Of course, this article doesn’t reflect the level of domestic spending in each country or whether international assistance or domestic spending is being directed toward poor or marginalized communities either. Those are other pieces of the pie that I hope the authors will turn their attention toward in future.
Laura Barnitz, the former director of policy communications with the Global Health Council, is currently a freelance writer and health and development communications consultant. This guest blog reflects the author’s individual opinions only, and should not be construed to represent the opinions or positions of the Global Health Council.