Winners and losers in the global health aid money-go-round

Ok, so you’ll have been following all the news on the GAVI replenishment and will know that the UK has pledged (pledged, mind you, not given – and pledges aren’t always met) a very generous $1.3bn between now and 2015 to help this public-private partnership support vaccines for pneumococcol disease and rotavirus (amongst others). In total, GAVI has been assured $4.3bn. Great – no question.  The World Bank – or more specifically its International Development Association that funds ‘the poorest’ – has also done very well, receiving almost $50bn in pledges in December 2010. Roll Back Malaria also seems to be doing quite nicely thank you. The partnership has just published a Report which shows a quadrupling of R&D funding for malaria (from $121 million in 1993 to $612 million in 2009). So we have some pretty clear ‘winners’.

But before we start high-fiving, let’s get some perspective. For a start, one of the biggest recipients of government assistance in 2010 was the US military in Afghanistan and Iraq. Air conditioning its troops costs the US government a colossal $20bn annually! And let’s have a closer look at that Malaria good news. A perennial question is whether increases in funding for one health concern has a positive knock on effect – the metaphor of lifeboats is often employed (see here, for example). In a new study by Lordan et al the question was whether HIV/AIDS funding was diverting funds away from other health concerns – in their case malaria, TB, health sector, and ‘other’ (whatever was left over). The authors found that malaria was the ‘biggest loser’ (a 1% increase in funds devoted to HIV/AIDS in a particular country led to an 11% decrease in funds devoted to malaria the following year. Furthermore, the effect doubled for a subset of countries with malaria prevalence per population of =/>1%).

There have been other ‘losers’ too. The Global Fund hasn’t been so lucky (see my earlier post), getting just $11.7bn for its replenishment ($1.3bn shy of what many considered to be a worst-case-scenario of $13bn). And if Ireland, Sweden and Germany decide to halt some of their 2011 payments, that could further deplete the partnership’s funds. What about the billion poor who continue to suffer from neglected tropical diseases (NTDs)? We have a pretty good idea of how much is required – $228m annualy (see here and here) to eliminate 7 NTDs: ascariasis, trichuriasis, hookworm, lymphatic filariasis, onchocerciasis, schistomiasis, and trachoma. Half a billion African lives would be improved – immeasurably. Sadly, neglected diseases remain just that – neglected. Worst off, according to an updated estimate in the Lancet, are non-communicable diseases – receiving the least amount of funding compared with other health areas.

So what’s the prognosis, doctor? According to Murray et al (authors of the Lancet piece cited above) “Growth in global health spending will probably slow and might contract in 2011”. Two things will help secure future funds: show donors that what they fund delivers results, and make it clear that funding for health has positive development -wide effects. or, if you like, raises all development boats. There is still enthusiasm for funding health concerns – witness the spectacle that was the GAVI replenishment. But we need to make it clear that health is not a zero-sum game: we mustn’t have ‘winners’ at the expense of ‘losers’. Although, if the cost of curing half a billion Africans of horrible diseases meant switching off the AC for US troops in the Middle East, I probably wouldn’t lose any sleep.

Andrew Harmer


9 thoughts on “Winners and losers in the global health aid money-go-round

  1. I think the issue of whether to acknowledge resource scarcity or the “zero sum” nature of global health funding depends mostly on what your role is.
    If you are making spending decisions then you will do a great deal of harm if you ignore the reality of your budget envelope when making your spending decisions.
    For a health minister in a country, as he/she is planning how to use the mix of budget and donor resources available – he has a certain amt to call on (much of the budget will have constraints on use of course), and to ignore that fact is certain to undermine making good decisions.
    Also, aid agencies have a similar set of decisions on what to do with the amount of resources available, and again, to ignore the budget envelope is to make bad decisions.
    I also think country level program managers should take decisions in full awareness of the amount they have and make decisions explicitly taking into account the amount available.

    For other actors in global health, it is less clear. If you are raising money, then the question of whether to acknowledge or refer to trade-offs is a strategic one. The issue underlies claims about cost effectiveness for example. So if you wish to raise funds for something where there is an easy to market, cost effective intervention then you are well served to refer to the reality of resource scarcity in making your arguments for funding – as indeed the folks working to increase immunization/ vaccine dollars do.
    If you work on an issue where this isn’t a big selling point – (e.g. maternal health, HIV/ AIDS treatment) not so much.

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