Development Assistance for Health and the Challenge of NCDs Through the Lens of Type 2 Diabetes

Global health 2035: a world converging within a generation

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

HIV and NCDs: the need to build stronger health systems

Understanding health spending for SDG 3

In January this year, The Lancet Planetary Health called for research pertaining to all of the Sustainable Development Goals (SDGs). Now, with publication in The Lancet of a comprehensive guide to the state of global health financing, a clearer picture emerges of the perilous state of the health of the poorest members of our civilisation. Whether their countries' health systems can be funded and improved—in an environmentally sustainable way—is the looming challenge to the global community's ability to reach the SDGs that aim to end poverty, reduce inequality, and promote health for all. Between 1995 and 2016, per capita health spending grew by 2·7% per year worldwide to US$8·0 trillion overall, but in low-income countries (home to 732 million people) the yearly spend per person increased only 1·5%, from $30 in 1995 to $40 in 2016. In 22 countries, health spending rose by less than a dollar per person in the 20 years to 2016. Substantial improvements to health cannot occur with such a dearth of funding. The greatest contribution to increases in health financing in low-income countries came from development assistance for health (DAH), chiefly money from the US and other states' governments and private philanthropy. DAH is one of the great political and philanthropic endeavours of our time. However, appetite for DAH is politically volatile, the extent to which it displaces governmental spending on health (fungibility) is unclear, and issues surround accountability and priority setting. Moreover, if global development aid is diverted to combat climate change, health funding will suffer despite existing synergies. Growth in DAH in absolute terms has plateaued and is predicted to rise only slowly to 2050. Ultimately, any resilient health system will need to be able to operate in the absence of external donor funding. Poverty is not restricted to low-income nations, with most (73%) of the world's poor living in middle-income countries. DAH only comprises a small segment of total health spend in middle-income countries (0·2–3·2% in 2016). Nevertheless, these countries still received 57% of global DAH in 2016, suggesting substantial inequality, and that a hidden poor will be missing from high-level assessment of the SDGs if a country-level approach is taken. Measurement of the SDG targets ought to take account of unsustainable or unstable funding sources. In the health financing transition model, countries start with a low level of health spending, principally out of pocket, then transition to increased spending through government financing. In the short term, low-income countries will continue to rely on out-of-pocket payments and donor funding. In the longer term, strategies are needed that increase government investment and levels of prepaid resources to avoid individuals experiencing catastrophic health expenditure. How though, can low-income countries' governments prioritise health spending (the key driver of increased government spending, alongside overall economic development)? The decision to prioritise health is not in of itself an endpoint. Parkinson's law—the adage that work expands so as to fill any and all available time—is equally true of health-care costs. As income rises, countries can spend more on health but value may diminish. Research into sustainable approaches to end poverty and break the impasse in health funding in low-income countries is essential to the notion of planetary health. In particular, what advances could be made via leapfrogging (eg, skipping expensive development phases) or use of tried and tested approaches to resource allocation (eg, favouring strong primary care and disease prevention)? Is redistribution of DAH from middle-income countries to low-income countries viable or desirable? To what extent is fungibility a threat to government health spending? And at the individual level, how can the challenge of increasing out-of-pocket and other private spending (eg, health insurance or direct service payment by companies) be addressed? Low-income countries have been unable to realise the gains in health spending seen in middle-income countries over the past 20 years. While development assistance for health increased per person from $3 in 1995 to $10 in 2016, overall spending rose by just $10. If seven out of every ten extra dollars spent on health in low-income countries is DAH, it is clear that future developments need to take a different track. Governments also need development assistance to raise more and spend more money on health; a civilisation cannot be considered truly healthy while nearly a billion people are adrift.

SummaryBackgroundThe rapid spread of COVID-19 renewed the focus on how health systems across the globe are financed, especially during public health emergencies. Development assistance is an important source of health financing in many low-income countries, yet little is known about how much of this funding was disbursed for COVID-19. We aimed to put development assistance for health for COVID-19 in the context of broader trends in global health financing, and to estimate total health spending from 1995 to 2050 and development assistance for COVID-19 in 2020.MethodsWe estimated domestic health spending and development assistance for health to generate total health-sector spending estimates for 204 countries and territories. We leveraged data from the WHO Global Health Expenditure Database to produce estimates of domestic health spending. To generate estimates for development assistance for health, we relied on project-level disbursement data from the major international development agencies' online databases and annual financial statements and reports for information on income sources. To adjust our estimates for 2020 to include disbursements related to COVID-19, we extracted project data on commitments and disbursements from a broader set of databases (because not all of the data sources used to estimate the historical series extend to 2020), including the UN Office of Humanitarian Assistance Financial Tracking Service and the International Aid Transparency Initiative. We reported all the historic and future spending estimates in inflation-adjusted 2020 US$, 2020 US$ per capita, purchasing-power parity-adjusted US$ per capita, and as a proportion of gross domestic product. We used various models to generate future health spending to 2050.FindingsIn 2019, health spending globally reached $8·8 trillion (95% uncertainty interval [UI] 8·7–8·8) or $1132 (1119–1143) per person. Spending on health varied within and across income groups and geographical regions. Of this total, $40·4 billion (0·5%, 95% UI 0·5–0·5) was development assistance for health provided to low-income and middle-income countries, which made up 24·6% (UI 24·0–25·1) of total spending in low-income countries. We estimate that $54·8 billion in development assistance for health was disbursed in 2020. Of this, $13·7 billion was targeted toward the COVID-19 health response. $12·3 billion was newly committed and $1·4 billion was repurposed from existing health projects. $3·1 billion (22·4%) of the funds focused on country-level coordination and $2·4 billion (17·9%) was for supply chain and logistics. Only $714·4 million (7·7%) of COVID-19 development assistance for health went to Latin America, despite this region reporting 34·3% of total recorded COVID-19 deaths in low-income or middle-income countries in 2020. Spending on health is expected to rise to $1519 (1448–1591) per person in 2050, although spending across countries is expected to remain varied.InterpretationGlobal health spending is expected to continue to grow, but remain unequally distributed between countries. We estimate that development organisations substantially increased the amount of development assistance for health provided in 2020. Continued efforts are needed to raise sufficient resources to mitigate the pandemic for the most vulnerable, and to help curtail the pandemic for all.FundingBill & Melinda Gates Foundation.

The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness. In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health, COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future health spending patterns, relative to need. In 2019, at the onset of the COVID-19 pandemic, US$9·2 trillion (95% uncertainty interval [UI] 9·1-9·3) was spent on health worldwide. We found great disparities in the amount of resources devoted to health, with high-income countries spending $7·3 trillion (95% UI 7·2-7·4) in 2019; 293·7 times the $24·8 billion (95% UI 24·3-25·3) spent by low-income countries in 2019. That same year, $43·1 billion in development assistance was provided to maintain or improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in 2020 and 2021, $1·8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, and $37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the health-related COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest that between 2022 and 2026, governments in 17 (95% UI 11-21) of the 137 LMICs will observe an increase in national government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP. There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is maintained. Bill & Melinda Gates Foundation.

BackgroundDonor countries in the Middle East and North Africa (MENA) including Saudi Arabia, Kuwait and United Arab Emirates (UAE) have been among the largest donors in the world. However, little is known about their contributions for health. In this study, we addressed this gap by estimating the amount of development assistance for health (DAH) contributed by MENA country donors from 2000 to 2017.MethodsWe tracked DAH provided and received by the MENA region leveraging publicly available development assistance data in the Development Assistance Committee (DAC) database of the Organisation for Economic Co-operation and Development (OECD), government agency reports and financial statements from key international development agencies. We generated estimates of DAH provided by the three largest donor countries in the MENA region (UAE, Kuwait, Saudi Arabia) and compared contributions to their relative gross domestic product (GDP) and government spending; We captured DAH contributions by other MENA country governments (Egypt, Iran, Qatar, Turkey, etc.) disbursed through multilateral agencies. Additionally, we compared DAH contributed from and provided to the MENA region.ResultsIn 2017, DAH contributed by the MENA region reached $514.8 million. While UAE ($220.1 million, 43.2%), Saudi Arabia ($177.3 million, 34.8%) and Kuwait ($59.8 million, 11.6%) as sources contributed the majority of DAH in 2017, 58.5% of total DAH from MENA was disbursed through their bilateral agencies, 12.0% through the World Health Organization (WHO) and 3.3% through other United Nations agencies. 44.8% of DAH contributions from MENA was directed to health system strengthening/sector-wide approaches. Relative to their GDP and government spending, DAH level fluctuated across 2000 to 2017 but UAE and Saudi Arabia indicated increasing trends. While considering all MENA countries as recipients, only 10.5% of DAH received by MENA countries were from MENA donors in 2017.ConclusionMENA country donors especially UAE, Saudi Arabia and Kuwait have been providing substantial amount of DAH, channeled through their bilateral agencies, WHO and other multilateral agencies, with a prioritized focus on health system strengthening. DAH from the MENA region has been increasing for the past decade and could lend itself to important contributions for the region and the globe.

The Coronavirus disease (COVID-19) pandemic has revealed the fragility of pre-crisis African health systems, in which too little was invested over the past decades. Yet, development assistance for health (DAH) more than doubled between 2000 and 2020, raising questions about the role and effectiveness of DAH in triggering and sustaining health systems investments. This paper analyses the inter-regional variations and trends of DAH in Africa in relation to some key indicators of health system financing and service delivery performance, examining (1) the trends of DAH in the five regional economic communities of Africa since 2000; (2) the relationship between DAH spending and health system performance indicators and (3) the quantitative and qualitative dimensions of aid substitution for domestic financing, policy-making and accountability. Africa is diverse and the health financing picture has evolved differently in its subregions. DAH represents 10% of total spending in Africa in 2020, but DAH benefitted Southern Africa significantly more than other regions over the past two decades. Results in terms of progress towards universal health coverage (UHC) are slightly associated with DAH. Overall, DAH may also have substituted for public domestic funding and undermined the formation of sustainable UHC financing models. As the COVID-19 crisis hit, DAH did not increase at the country level. We conclude that the current architecture of official development assistance (ODA) is no longer fit for purpose. It requires urgent transformation to place countries at the centre of its use. Domestic financing of public health institutions should be at the core of African social contracts. We call for a deliberate reassessment of ODA modalities, repurposing DAH on what it could sustainably finance. Finally, we call for a new transparent framework to monitor DAH that captures its contribution to building institutions and systems.

Who runs global health?

In recent decades, low– and middle–income countries (LMICs) have achieved decreased morbidity and mortality associated with infectious diseases and poor maternal– and child–health (MCH). However, despite these advances, LMICs now face an additional burden with the inexorable rise of non–communicable diseases (NCDs). Deaths due to NCDs in LMICs are expected to increase from 30.8 million in 2015 to 41.8 million by 2030 [1]. While improvements in life expectancy, lifestyle and urbanisation go some way to explaining why more people in LMICs are affected by NCDs, it is less clear why these populations are contracting NCDs at a younger age and with worse outcomes than in high–income countries (HICs) [2]. Despite having a lower cardiovascular disease risk factor burden, LMIC populations have a four–fold higher mortality rate from cardiovascular events than HIC populations [3] in part due to a lack of access to quality, integrated health services and the poor availability of early interventions and effective NCD prevention programmes. The HIV/AIDS epidemic was the last time the world confronted a global health challenge that so disproportionately caused premature adult deaths in LMICs. The conclusion is unavoidable: the time to act is now. Prevention of NCDs at a population and an individual level is key and requires policy and structural changes. We have a unique opportunity to learn from the successes of infectious disease control programmes in LMICs and leverage these to address the growing NCD burden. Translatable learnings include: 1) emphasizing primary prevention, particularly in those at highest risk; 2) targeting service delivery to high–risk populations; 3) enabling access to adequate, affordable care at community level; 4) engendering patient empowerment and involving people affected by chronic conditions; 5) enabling access to quality drugs and adherence programmes; 6) regularly measuring the effectiveness and impact of programmes to ensure their appropriateness and improvement; and 7) creating an environment of health financing for universal coverage. Innovations to counter the emerging NCD epidemic must encompass both prevention and the delivery of care. Infectious disease programmes have used task–shifting, where less skilled health workers and community members are involved in delivery of health services. In India, we have seen this used for NCDs in the Arogya Kiran model where the existing health workforce was overstretched. Volunteers and teachers successfully delivered diabetes and hypertension screening and management to over 600 000 people [4]. Patient empowerment, and community involvement in health care delivery and governance, will be critical in tackling NCDs, since most are chronic conditions, which initially present silently and require long–term management [5]. In Malawi, recognizing the close relationship of HIV infection and cardiovascular diseases has led to screening for hypertension being integrated into HIV care [6]. In Ghana, decentralised community–based hypertension care, using digital technology, is helping to empower patients to manage their own disease: a model that is again adapted from HIV management [7]. We are also starting to see examples in India of MCH care coupled with life–long NCD screening and awareness programmes [8]. While these examples of managing the dual burden of infectious diseases and NCDs are encouraging, more needs to be done. The largest gap is in NCD prevention. Tackling the obesity epidemic and wrestling with the issues around curbing tobacco sales and smoking are rightly high on the NCD prevention agenda. The greatest opportunity is preventing a tobacco–related epidemic in sub–Saharan Africa where smoking levels are still low. Health budgets and development assistance for health must allocate resources commensurate with the dual disease burden. Health spending of governments in LMICs has tripled over the past 20 years, but remains low [9]. In addition, more health care models should consider diversified revenue streams or hybrid financing (eg, tiered payment schemes) to ensure sustainability. If equity is to be improved, patients need access to quality health care, through sustainable health–financing systems for universal health coverage, while reducing out–of–pocket expenditure for the under–served population. Photo: © Nana Kofi Acquah/Novartis Foundation Implementing such models will require strong government leadership and interventions, and partnerships across the public and private sectors. Some public–private partnerships (PPPs) in infectious diseases have demonstrated their potential to catalyze the delivery of, and access to, prevention and care through providing complementary strengths [10]. The private sector draws on its business and scientific expertise, focusing on strong results–based operations, whereas the public sector brings a wealth of expertise in implementation with equity, management and documentation. The end–users of the services, including patients and health care providers, also need to be included from the outset to ensure that the models are people–centered, co–created, adapted to prevailing contextual nuances, and sustainable. If we build on what we have learnt from infectious disease management, we could have a transformational impact on the growing NCD burden.

Historically, the US has been the largest contributor to development assistance for health (DAH), although its allocation has shifted in response to outside forces. This included, for example, the establishment of the Millennium Development Goals (MDGs) in 2000, which emphasised child mortality, maternal health, HIV/AIDS, and malaria. This led to funds being earmarked for disease-specific interventions rather than health system strengthening (HSS). In 2007, the World Health Organization (WHO) published six health system building blocks, representing essential components of strong health systems. In 2015, the MDGs were replaced by the Sustainable Development Goals (SDGs), which emphasised capacity-building as opposed to specific health problems. The Lancet Commission on Global Surgery, meanwhile, highlighted surgical capacity building as essential to achieving Universal Health Coverage (UHC). Given the renewed emphasis on a comprehensive approach rather than disease-specific interventions, one might anticipate the US aligning with this rhetoric in its allocation of DAH. However, we hypothesise that this is not the case. We queried the Organization for Economic Co-operation and Development (OECD) database for allocation of US DAH to low- and middle-income countries between 1995 and 2019, thereby excluding data after 2019 to avoid the influence of the coronavirus disease 2019 pandemic. OECD entries were assigned to health systems strengthening (HSS) or disease-specific interventions categories. The WHO building blocks were used as a framework for health systems strengthening. From 1995 to 1999, US DAH allocated to HSS decreased from 42% to 34%. The allocation decreased further from 34% in 2000 to 4% in 2007; correspondingly, DAH allocated to disease-specific interventions increased from 67% to 96%. Between 2008 and 2019, the distribution of US DAH remained relatively stable, with funds allocated to HSS versus disease-specific interventions ranging from 3-12% and 88-98% respectively. While total US DAH contributions in the 1990s and early 2000s were significantly lower compared to the decade that followed, the distribution of these funds was more evenly divided between HSS and disease-specific interventions. Despite attempts by the WHO and United Nations to redirect attention to HSS as the path to achieving UHC, the US continues to largely support disease-specific interventions and overlook the importance of HSS, including surgical capacity building.

Financing of global health: tracking development assistance for health from 1990 to 2007

Development assistance for health (DAH) is an important part of financing healthcare in low- and middle-income countries. We estimated the gross disbursement of DAH of the 29 Development Assistance Committee (DAC) member countries of the Organisation for Economic Co-operation and Development (OECD) for 2011–2019; and clarified its flows, including aid type, channel, target region, and target health focus area. Data from the OECD iLibrary were used. The DAH definition was based on the OECD sector classification. For core funding to non-health-specific multilateral agencies, we estimated DAH and its flows based on the OECD methodology for calculating imputed multilateral official development assistance (ODA). The total amount of DAH for all countries combined was 18.5 billion USD in 2019, at 17.4 USD per capita, with the 2011–2019 average of 19.7 billion USD. The average share of DAH in ODA for the 29 countries was about 7.9% in 2019. Between 2011 and 2019, most DAC countries allocated approximately 60% of their DAH to primary health care, with the remaining 40% allocated to health system strengthening. We expect that the estimates of this study will help DAC member countries strategize future DAH wisely, efficiently, and effectively while ensuring transparency.

After years of unprecedented growth in development assistance for health (DAH), the DAH system is challenged on several fronts: by the economic downturn and stagnation of DAH, by the epidemiological transition and increase in non-communicable diseases and by the economic transition and rise of the middle-income countries. Central to any potent response is a fair and effective allocation of DAH across countries. A myriad of criteria has been proposed or is currently used, but there have been no comprehensive assessment of their distributional implications. We simulated the implications of 11 quantitative allocation criteria across countries and country categories. We found that the distributions varied profoundly. The group of low-income countries received most DAH from needs-based criteria linked to domestic capacity, while the group of upper-middle-income countries was most favoured by an income-inequality criterion. Compared to a baseline distribution guided by gross national income per capita, low-income countries received less DAH by almost all criteria. The findings can inform funders when examining and revising the criteria they use, and provide input to the broader debate about what criteria should be used.