Global Health Financing in an Age of Fiscal Austerity

With an election year up on us here in the United States, there have been repeat attacks on how we invest US dollars overseas, particularly through foreign aid programs and from some very vocal critics of foreign aid funding amongst the GOP primary candidates. (I’m looking at you, Ron Paul.). Both those outside and within the development bubble have begun to acknowledge the importance of becoming more results-driven and evidence focused in global health programming, as evident in the year-old USAID Evaluation policy, the focus on results-based financing projects, and the renewed interest in investing in operations research amongst some donors.

Tracking outcomes through rigorous monitoring and evaluation systems is one piece of that puzzle. The other is knowing where funding is being spent, in order to determine where we’re seeing the greatest impact for our dollar. Not a small order, given the complexity of how health programs around the world are financed through bilateral, multilateral and other agreements, with funds often shifting from on implementing agency to another through sub-contracting agreements.

The Institute for Health Metrics and Evaluation has recently published their third annual report on global health financing, one of the most comprehensive looks at where DAH is coming from, where funds are going, how funds are being used, and what kind of changes have we seen in the donor landscape over time. Authors Chris Murray and Michael Hanlon spoke on January 19th at the Global Health Council about their findings in the most recent iteration of the report, and some of the key trends that emerged.

From 1990 to 2011, DAH has increased from $6 billion to nearly $28 billion respectively, with the greatest increases in the past decade. This figure from the report shows how DAH has increased over the past two decades, breaking down each year by donor.


“Continued growth from 2010 to 2011 was a welcome surprise,” said Dr. Murray. While funding from some institutions like the Global Fund, United Nations, and US-based foundations, increases from other sources (NGOs, GAVI, bilaterals, and World Bank loans) increased and made up for the gap. Dr. Hanlon highlighted three key findings he took away from the analysis and writing the report: funding for HIV has flattened in recent years, malaria funding is increasing, and TB funding is increasing. Together, changes in funding for these three disease areas are driving the overall changes in trends.

Two key themes emerged through the presentation and comments from attendees at the event:

–          how does donor funding impact country government spending on health (substitutability or subadditionality, depending on who was talking about it), and

–          how does the emphasis on showing short, quick gains impact spending on health systems or health sector strengthening activities necessary to create sustainable programs?

I’ll explore the discussions around both in two subsequent posts in this series.

The report provides a wealth of information, including data on funding by technical area, country, and donor.  The data set is also publicly available if you’re a researcher looking to run your own analyses. Numerous static and interactive graphics are also available on the IHME website; I found the treemap of development assistance by technical area over time quite fun.

This post is the first of four on findings from the IHME Global Health Financing 2011 Report & how they fit in the broader context of the global health landscape.

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