Financing Global Health 2010:
Tracking development assistance for health in economic
uncertainty
January 31, 2011
Christopher Murray
Director, IHME
Outline
Why Track Development Assistance for Health?
Financing Global Health 2010 Methods
Key Findings on DAH
Recipient Government Responses
What is Coming in 2011?
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IHME Tries to Inform Three Questions
1) What are people’s health problems? – e.g. tracking
adult, child, or maternal mortality; the Global Burden of
Disease 2010
2) How well is a society doing in addressing these health
problems? – e.g. inputs, outputs and outcomes from
public health, medical care and other key social
determinants
3) What can be done in the future to maximize health
improvement? – e.g. cost-effectiveness of major
intervention and health system intervention options
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Tracking Health Financing
• Financing Global Health 2009 tracked Development
Assistance for Health – flows from key development
focused organizations for the advancement of global
health.
• Financing Global Health 2010 tracks Development
Assistance for Health and government health
expenditures.
• Working on a systematic analysis of all available sources
of data on out-of-pocket household expenditures on
health 1990-2010.
• Future editions of FGH will eventually include all three
components: DAH, government, and private expenditures
on health.
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Outline
Why Track Development Assistance for Health?
Financing Global Health 2010 Methods
Key Findings on DAH
Recipient Government Responses
What is Coming in 2011?
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Channels of Development Assistance for Health
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NGO Revision for In-Kind Revenue
• US NGOs claim drug and equipment donations at US
wholesale prices while the donors claim at production
costs.
• Analyzed US retail, US wholesale, Federal Upper Limit,
and drug indicator guide for 386 unique products.
• We have estimated empirically this relationship and
deflated all donations to all NGOs by the same average
factor, 82%.
• NGO-specific deflators have not been possible to
develop.
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Preliminary Estimates for Donors and Agencies
• In Financing Global Health 2009 and in The Lancet results
on financing global health through 2007 reflecting the lag in
audited financial statements.
• Using audited financial statements and tax returns we have
data for 2008.
• We developed preliminary estimates for 2009 and 2010 by
analyzing the historical relationship between budgets for
donors and agencies and disbursements. Relationships are
very strong and provide a reasonable basis for mapping
from budgets to estimated disbursements.
• Preliminary estimates for non-US government NGO
revenue are the most uncertain.
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Outline
Why Track Development Assistance for Health?
Financing Global Health 2010 Methods
Key Findings on DAH
Recipient Government Responses
What is Coming in 2011?
10
DAH by Channel of Assistance, 1990-2010
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DAH by country of origin, 1990-2010
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Public sector DAH by donor country received by
channels of assistance, 2008
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Total overseas health expenditures channeled
through US NGOs by funding source, 1990-2010
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Fund balances for UN health agencies at end of 2009
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Top 30 country
recipients of
DAH,
2003-2008,
compared with
top 30 countries
by all-cause
burden of
disease, 2004
Total DAH per all-cause DALY, 2003-2008
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DAH for HIV/AIDS by channel of assistance,
1990-2008
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DAH for maternal, newborn, and child health
by channel of assistance, 1990-2008
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Outline
Why Track Development Assistance for Health?
Financing Global Health 2010 Methods
Key Findings on DAH
Recipient Government Responses
What is Coming in 2011?
20
Domestic Financing of Health by Governments
Has Been Increasing
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What Happens to Domestic Finance in Countries
that Receive Large Amounts of DAH?
• April 2010, published in The Lancet, our analysis of how
Ministries of Finance respond when governments receive
DAH.
• Responses vary substantially, but on average, MoFs
decrease health expenditures from their own sources by
43 cents to $1.14 for every dollar of DAH received by
governments.
• Debate is not on whether this occurs but whether it is
welfare enhancing or not.
• Perspectives vary widely between macro-economists and
health specialists and between donors, Ministries of
Health and Ministries of Finance.
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Outline
Why Track Development Assistance for Health?
Financing Global Health 2010 Methods
Key Findings on DAH
Recipient Government Responses
What is Coming in 2011?
23
Understanding DAH Trends
• Private investment in DAH likely to follow more closely
economic cycle and asset prices. DAH from private
sources should increase again in 2011.
• Public investment in DAH will be determined by three
factors:
– timing of fiscal contraction in order to reduce
debt/GDP ratios, IMF estimates maximum contraction
around 2013
– priority attached to development assistance during
fiscal contraction
– priority assigned to global health within development
assistance
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Potential Good News for DAH…..
• UK austerity budget includes expanded investments in
development assistance.
• GFATM replenishment at $11.7 billion for 2011-2013
was lower than projected needs but represents
continued growth compared to 2008-2010
replenishment.
• IDA Round 16 replenishment at the World Bank of
$49.3 billion, a nearly 18% increase over the previous
round.
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Not So Good News for DAH…..
• Comparing 2006-2008 and 2008-2010, already evidence
of declining or flat rates of growth for many donors.
• USG 2011 global health disbursements very unlikely to
expand compared to 2010 and may well be lower.
• Rapid freezing of Global Fund contributions by Germany,
Sweden, and Ireland in response to recent media on
corruption in a small number of GFATM grantees.
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Implications of a Global Health Recession
• It appears likely that after nearly 20 years of year on year
growth, DAH will decline in 2011.
• Effect on recipient countries will still be in percentage terms
small but some programs in some countries may see
immediate impacts.
• Effect on the donors, multilateral institutions, NGOs, and
universities involved in global health will more far-reaching.
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Implications for Sustaining Broad Support for
the Global Health Endeavour
• Urgent need to provide immediate and satisfactory
responses to questions on financial transactions for all
global health organizations to restore public confidence.
• Strong demand for evidence that the expected benefits
from global health investments have actually been realized.
• Well conducted ex post evaluations of investments will add
to our scientific understanding of what works and what
does not.
• BUT, we need in 2011 more convincing evidence on what
has likely been achieved with the $181 billion spent on
global health in the last decade.
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Pressure for “More Health for the Money”
• Continued expanded needs for global health programs:
rising numbers needing ART, enhanced priorities for
maternal, newborn and child health, new political attention
for NCDs.
• Expect a renewed focus on how to deliver programs more
efficiently – e.g. understand why the cost per person
completing a year of ART likely varies 10 fold across sites.
• Shared learning about efficiency of service delivery,
however, requires transparency on cost and outcome.
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Implications for Global Health Actors
• Intensified competition between different health programs
especially MNCH and HIV/AIDS.
• Increased attention to improving health through multisectoral action: World Bank and UNICEF likely to be
important in this arena.
• Potential for a sea-change on campuses in perception of
global health as the social issue for this generation.
• This trend needs to be counter-balanced by reinforcing the
global health triad of: moral imperative, effective
technologies and demonstrated successes.
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