1. Tracking Development Assistance for Health 1990 - 2007 Nirmala Ravishankar October 7, 2009

2. 2 Context for this research It is widely believed that the last decade saw a rapid rise in development assistance for improving health in low- and middle-income countries. It is now feared that the funds are shrinking as a result of the global economic downturn. While there are established methods for accounting for domestic health expenditure, there was no comprehensive system for estimates of the total envelope of global health resources. o OECDs estimates capture bilateral and multilateral assistance but not private sources o Other studies have focused on specific diseases or provided estimates for select years (Powell-Jackson et al. 2006, Narasimhan & Attaran 2003; Sridhar and Batniji 2008, Michaud 2003) There is a demand for this information from donors, policy-makers and the academic community Information on resource inputs is crucial for assessing cost-effectiveness of interventions.

3. Defining Development Assistance for Health (DAH) DAH refers to financial and in-kind contributions for improving health and health systems in low- and middle- income countries originating from both public and private sources that flow via institutions whose primary purpose is development assistance. 3

4. 4 The DAH Landscape Funding Sources National treasuries Private individuals Corporate donations Channels of Assistance Bilateral Aid Agencies UN Agencies Development Banks Global Health Initiatives Private Foundations International NGOs Implementing Institutions Governmental programs National ministries of health National Disease control programs Non-governmental programs National NGOs Private sector contractors Universities and research institutions

5. Defining DAH We focused on the primary channels of development assistance for health We focused on direct health (specifically disease-specific support, health system support, and health research funded by the channels) and excluded aid for allied sectors DAH is comprised of: Disbursements on grants Gross flows for concessionary loans Health-related program expenditures Only DAH to low and middle income countries is counted 5 Bilateral aid agenciesUN AgenciesDevelopment BanksGlobal Health InitiativesPrivate FoundationsInternational NGOs

6. Data sources 6 Bilateral agencies in OECD DAC member countries & the European Commission OECD DAC Aggregate database & the Creditor Reporting System (CRS) UN Agencies: WHO, UNICEF, UNFPA, and UNAIDS Financial reports and audited financial statements The World Bank, ADB, AfDB and IDB Online project databases and audited financial documents GAVI GAVI annual reports, country fact sheets, and correspondences The Global FundOnline grant database NGOs registered in the US USAID VolAg reports, tax filings, financial statements & correspondence The Bill & Melinda Gates Foundation Online grant database and tax filings Other private US. Foundations Foundation Centers grants database

7. Key Measurement Challenges The problem of double-counting Missing disbursement data Hard to know health fraction of multi-sector grants and loans International health expenditures by NGOs is not always reported NGOs and UN agencies do not report country-wise program expenditures Disease-focus of all grants, loans, and program expenditures is not reported

8. The role of Global Health Initiatives is growing All figures show 2007 US dollars 8

9. US government is the single biggest contributor of global health dollars 9

10. Where are global health dollars from public sources going? AUS = Australia, AUT = Austria, BEL = Belgium, CAN = Canada, CHE = Switzerland, DEU = Germany, DNK = Denmark, ESP = Spain, FIN = Finland, FRA = France, GBR = United Kingdom, GRC = Greece, IRL = Ireland, ITA = Italy, JPN = Japan, LUX = Luxembourg, NLD = the Netherlands, NOR =Norway, NZL = New Zealand, PRT = Portugal, SWE =Sweden, USA = United States. 10 For more than 30% of USG funds, information about recipient is not available

11. Other countries give more as a percent of GDP AUS = Australia, AUT = Austria, BEL = Belgium, CAN = Canada, CHE = Switzerland, DEU = Germany, DNK = Denmark, ESP = Spain, FIN = Finland, FRA = France, GBR = United Kingdom, GRC = Greece, IRL = Ireland, ITA = Italy, JPN = Japan, LUX = Luxembourg, NLD = the Netherlands, NOR =Norway, NZL = New Zealand, PRT = Portugal, SWE =Sweden, USA = United States.

12. HIV/AIDs draws considerable funds, but TB and Malaria have grown in recent years…. 12

13. USG and the Global Fund are the biggest contributors of HIV/AIDs funds 13

14. 14 The Global Fund and the Gates Foundation are the biggest contributors of Malaria funds

15. Sub-Saharan Africa attracts more health aid than other regions of the world 15

16. Aid is positively correlated with overall disease burden 16

17. But other factors are also driving who attracts health assistance Top 30 country recipients of DAH for health (2002-2007) vs. Top 30 countries ranked by all-cause DALYs in 2002

18. Key Findings Development assistance expanded greatly from 1990-2007, particularly post- 2002 Private sources are playing an increasingly important role in funding DAH The increase in DAH was fueled by a huge expansion of dollars for HIV/AIDS, but other areas of global health have also expanded dramatically New actors in the field of global health such as GAVI, GFATM and NGOs are competing for resources with other channels of assistance like the World Bank and UN agencies Countries with higher disease burden and poorer countries tend to receive more aid, but burden is not the sole determinant of aid Better quality data and standardized reporting guidelines are needed 18

19. Acknowledgements and References Team: Researchers at the Institute for Health Metrics and Evaluation at the University of Washington, led by Christopher JL Murray Funding: Core grant from the Bill and Melinda Gates Foundation Publication: Ravishankar N, Gubbins P, Cooley R, Leach-Kemon K, Michaud M, Jamison D, and Murray CJL, Financing Global Health: Tracking Development Assistance for Health, The Lancet, Vol. 373, No. 9861, June 20, 2009.