Abstract
International institutions provide well over US$10 billion in development assistance for health (DAH) annually and between 1990 and 2014, DAH disbursements totaled $458 billion but how do they decide who gets what, and for what purpose? In this article, we explore how allocation decisions were made by the nine convening agencies of the Equitable Access Initiative. We provide clear, plain language descriptions of the complete process from resource mobilization to allocation for the nine multilateral agencies with prominent agendas in global health. Then, through a comparative analysis we illuminate the choices and strategies employed in the nine international institutions. We find that resource allocation in all reviewed institutions follow a similar pattern, which we categorized in a framework of five steps: strategy definition, resource mobilization, eligibility of countries, support type and funds allocation. All the reviewed institutions generate resource allocation decisions through well-structured and fairly complex processes. Variations in those processes seem to reflect differences in institutional principles and goals. However, these processes have serious shortcomings. Technical problems include inadequate flexibility to account for or meet country needs. Although aid effectiveness and value for money are commonly referenced, we find that neither performance nor impact is a major criterion for allocating resources. We found very little formal consideration of the incentives generated by allocation choices. Political issues include non-transparent influence on allocation processes by donors and bureaucrats, and the common practice of earmarking funds to bypass the normal allocation process entirely. Ethical deficiencies include low accountability and transparency at international institutions, and limited participation by affected citizens or their representatives. We find that recipient countries have low influence on allocation processes themselves, although within these processes they have some influence in relatively narrow areas.
Highlights
International institutions provide well over US$10 billion in development assistance for health (DAH) annually and between 1990 and 2014, DAH disbursements totaled $458 billion but how do they decide who gets what, and for what purpose? In this article, we explore how allocation decisions were made by the nine convening agencies of the Equitable Access Initiative
We find that resource allocation in all reviewed institutions follow a similar pattern, which we categorized in a framework of five steps: strategy definition, resource mobilization, eligibility of countries, support type and funds allocation
International institutions provide well over US$10 billion in development assistance for health (DAH) annually, and between 1990 and 2014 DAH disbursements totalled $458 billion (IHME 2014)— but how do they decide who gets what, and for what purpose? The importance of these questions is difficult to overstate for the six billion people in Low- and Middle-Income Countries (LMIC) whose health can be directly affected by DAH
Summary
The importance of these questions is difficult to overstate for the six billion people in Low- and Middle-Income Countries (LMIC) whose health can be directly affected by DAH. Allocation decisions affect all three pillars of public health: the political, the technical, and the ethical (Roberts et al, 2003). Allocation processes determine which countries get what assistance, raising distributional issues at every level from the international down to individuals. The nine convening international agencies were concerned with understanding the consequences of using gross national income (GNI) per capita as a primary indicator of need, and interested in exploring alternatives. The EAI was convened to investigate how processes might better reflect disease burdens, national capacity to intervene, government health budgets and other factors (EAI 2015a, b) primarily the technical aspects such as classifying country needs and capacities in health
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