Matthew T Schneider

Public financing of health in developing countries: a cross-national systematic analysis

BACKGROUNDnGovernment spending on health from domestic sources is an important indicator of a governments commitment to the health of its people, and is essential for the sustainability of health programmes. We aimed to systematically analyse all data sources available for government spending on health in developing countries; describe trends in public financing of health; and test the extent to which they were related to changes in gross domestic product (GDP), government size, HIV prevalence, debt relief, and development assistance for health (DAH) to governmental and non-governmental sectors.nnnMETHODSnWe did a systematic analysis of all data sources available for government expenditures on health as agent (GHE-A) in developing countries, including government reports and databases from WHO and the International Monetary Fund (IMF). GHE-A consists of domestically and externally financed public health expenditures. We assessed the quality of these sources and used multiple imputation to generate a complete sequence of GHE-A. With these data and those for DAH to governments, we estimated government spending on health from domestic sources. We used panel-regression methods to estimate the association between government domestic spending on health and GDP, government size, HIV prevalence, debt relief, and DAH disbursed to governmental and non-governmental sectors. We tested the robustness of our conclusions using various models and subsets of countries.nnnFINDINGSnIn all developing countries, public financing of health in constant US

Development assistance for health: trends and prospects

from domestic sources increased by nearly 100% (IMF 120%; WHO 88%) from 1995 to 2006. Overall, this increase was the product of rising GDP, slight decreases in the share of GDP spent by government, and increases in the share of government spending on health. At the country level, while shares of government expenditures to health increased in many regions, they decreased in many sub-Saharan African countries. The statistical analysis showed that DAH to government had a negative and significant effect on domestic government spending on health such that for every US

Development assistance for health: past trends, associations, and the future of international financial flows for health

1 of DAH to government, government health expenditures from domestic resources were reduced by

Factors Associated With Increases in US Health Care Spending, 1996-2013

0.43 (p=0) to

Tracking development assistance for HIV/AIDS: the international response to a global epidemic

1.14 (p=0). However, DAH to the non-governmental sector had a positive and significant effect on domestic government health spending. Both results were robust to multiple specifications and subset analyses. Other factors, such as debt relief, had no detectable effect on domestic government health spending.nnnINTERPRETATIONnTo address the negative effect of DAH on domestic government health spending, we recommend strong standardised monitoring of government health expenditures and government spending in other health-related sectors; establishment of collaborative targets to maintain or increase the share of government expenditures going to health; investment in the capacity of developing countries to effectively receive and use DAH; careful assessment of the risks and benefits of expanded DAH to non-governmental sectors; and investigation of the use of global price subsidies or product transfers as mechanisms for DAH.nnnFUNDINGnBill & Melinda Gates Foundation.

The US Provided

The global economic crisis that began to unfold in 2008 has raised serious concerns about the ability of developing countries to meet targets for improvements in population health outcomes, and about the ability of developed countries to meet their commitments to fund health programmes in developing countries. This uncertainty underscores the importance of tracking spending on global health, to ensure resources are directed effi ciently to the world’s most pressing health issues. In 2009, Nirmala Ravishankar and colleagues from the Institute for Health Metrics and Evaluation, reported on the massive expansion of development assistance for health between 1990 and 2007. This study introduced standardised defi nitions for tracking such assistance, and integrated fi nancial statements, tax returns, and other data from the Organisation for Economic Co-operation and Development’s Creditor Reporting System, UN health agencies, the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the GAVI Alliance, foundations, and non-governmental organisations. The fi ndings gave quantitative detail about the expansion of global health, and the increase in the number of institutions and actors channelling these resources. New bodies, such as the Global Fund, GAVI Alliance, and the Bill & Melinda Gates Foundation, along with the UK’s Department for International Development and US development agencies, were responsible for a rising share of development assistance for health, whereas some organisations (such as WHO) accounted for a steadily decreasing fraction of resources. We have now updated that information, publishing new data, analysis, and preliminary estimates associated with development assistance for health. As part of this new study, we incorporated several key methodological improvements in response to reactions to our 2009 work. First, in addition to providing comparable fi gures for 2008, we generated preliminary estimates for 2009 and 2010. To do this, we examined the relation between past budgets and subsequent disbursements for bilateral development agencies, the European Commission, UN agencies, and the multilateral banks. These relations were used to project likely disbursements in 2009 and 2010, on the basis of annual budget data. For foundations and non-governmental organisations, we forecasted disbursements in 2010 on the basis of information from fi nancial data between 1990 and 2009, and key covariates, including gross domestic product per head and asset-value indices. Second, we used in-kind income as reported by US non-governmental organisations on their tax returns. Many non-governmental organisations use US wholesale prices for donated drugs and equipment. We studied the relation between US wholesale prices, international prices, and federal upper-limit prices for 386 unique products. We used Figure: Development assistance for health by channel of assistance, 1990–2010 IBRD=International Bank for Reconstruction and Development. IDA=International Development Association. *2009 and 2010 are preliminary estimates based on information from the channels, including budgets, appropriations, and correspondence. 28

13 Billion In Development Assistance For Health In 2016, Less Per Person Than Many Peer Nations

BACKGROUNDnDisbursements of development assistance for health (DAH) have risen substantially during the past several decades. More recently, the international communitys attention has turned to other international challenges, introducing uncertainty about the future of disbursements for DAH.nnnMETHODSnWe collected audited budget statements, annual reports, and project-level records from the main international agencies that disbursed DAH from 1990 to the end of 2015. We standardised and combined records to provide a comprehensive set of annual disbursements. We tracked each dollar of DAH back to the source and forward to the recipient. We removed transfers between agencies to avoid double-counting and adjusted for inflation. We classified assistance into nine primary health focus areas: HIV/AIDS, tuberculosis, malaria, maternal health, newborn and child health, other infectious diseases, non-communicable diseases, Ebola, and sector-wide approaches and health system strengthening. For our statistical analysis, we grouped these health focus areas into two categories: MDG-related focus areas (HIV/AIDS, tuberculosis, malaria, child and newborn health, and maternal health) and non-MDG-related focus areas (other infectious diseases, non-communicable diseases, sector-wide approaches, and other). We used linear regression to test for structural shifts in disbursement patterns at the onset of the Millennium Development Goals (MDGs; ie, from 2000) and the global financial crisis (impact estimated to occur in 2010). We built on past trends and associations with an ensemble model to estimate DAH through the end of 2040.nnnFINDINGSnIn 2015, US

Tracking development assistance for HIV/AIDS by type of investment, 1990–2015

36·4 billion of DAH was disbursed, marking the fifth consecutive year of little change in the amount of resources provided by global health development partners. Between 2000 and 2009, DAH increased at 11·3% per year, whereas between 2010 and 2015, annual growth was just 1·2%. In 2015, 29·7% of DAH was for HIV/AIDS, 17·9% was for child and newborn health, and 9·8% was for maternal health. Linear regression identifies three distinct periods of growth in DAH. Between 2000 and 2009, MDG-related DAH increased by

Sceptical optimism: a new take on global health data

290·4 million (95% uncertainty interval [UI] 174·3 million to 406·5 million) per year. These increases were significantly greater than were increases in non-MDG DAH during the same period (p=0·009), and were also significantly greater than increases in the previous period (p<0·0001). Between 2000 and 2009, growth in DAH was highest for HIV/AIDS, malaria, and tuberculosis. Since 2010, DAH for maternal health and newborn and child health has continued to climb, although DAH for HIV/AIDS and most other health focus areas has remained flat or decreased. Our estimates of future DAH based on past trends and associations present a wide range of potential futures, although our mean estimate of