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Misfinancing Global Health: The Case for Transparency in Disbursements and Decision-Making
September 2007
Devi Sridhar and Rajaie Batniji
Global Economic Governance Programme
Global health is high on the international agenda of policy-makers, civil servants and philanthropists. At the turn of the century, the Millennium Summit increased interest in global health with the creation of the Millennium Development Goals, which serve as the benchmark of international attention and finance. Recently health has moved higher on the policy agenda as it has integrated into security and foreign policy agendas and priorities (1-3). The increased attention given to global health since 2000 is reflected in the mobilisation of international political actors on global health issues. An unprecedented amount of money is being pledged and mobilized to fund research and services in global health. Although estimates are hard to come by, a recent estimate for 2004 approximated that international funding for global health reached $14 billion, and this figure is rapidly rising, due largely to the emergence and growth of the Bill and Melinda Gates Foundation, and the U.S.
government’s AIDS initiative (4). In parallel to increased financial commitment, there seems to be a growing consensus on technical strategies for global health(5), and an emerging, though controversial, epidemiological evidence-base that may inform the disbursement of global health funds(6).
We examine the relative (mis-)match between what needs to be done, according to public health evidence, and financial commitments by considering all disbursements made in 2005 among the major financiers relative to mortality. Decisions about disbursements and priority areas in global health are shaped by institutional mandate and direct political influence. This is consistent with a much-cited study on foreign aid, which showed that political and strategic relationships, including colonial past and political alliances, explain foreign aid allocations better than economic need(7). By relating disbursements to mortality, we create a baseline from which we can assess deviations in priority that may be due to political influence in each of the major global health financiers.
The increased political and financial commitments supporting global health are complemented by a growing consensus on strategies to prevent and treat the illnesses afflicting the poor (8). An enormous bank of information on ‘what works’ in reducing morbidity and mortality has been accumulated; this body of knowledge is best embodied by the publication of the Disease Control Priorities in Developing Countries which was supported by the World Health Organisation, the World Bank, and the Bill and Melinda Gates Foundation(5). The Lancet has published series on issue areas in global health, building consensus on both technical and social strategies for disease prevention and treatment. In international development, some scholars argue that we have the solutions to end ill health and poverty; we only need (international) financial commitment to deliver them (9). Such clarity on strategies, though perhaps flawed, can facilitate cooperation and political commitment. The articulation of shared objectives, scientific consensus on the means to these objectives(10), and the financial commitment which can begin to facilitate their realization makes this a more promising time than any for effective cooperation and coordination among the major institutions in global health.
Potentially restraining cooperation is a lack of knowledge on the current investments of the major financiers of global health. Previous efforts have been focused on tracking funding by disease (e.g. HIV/AIDS), by country (e.g. OECD DAC), and in-country (e.g. National Health Accounts) (11-17). For example, Shiffman’s 2006 article is an excellent examination of the donor funding priorities for communicable disease control from 1996 to 2003 (11). However, as has been noted in recent Center for Global Development and RAND reports, no information source exists to provide the “big picture” of health resource flows, leading to a lack of credible estimates of donor commitments and actual funds (18, 19). Due to the difficulties of tracking health-relating funding(19), no systematic effort to track all disbursements of the major global health financiers has been conducted. Such work is needed to inform and facilitate coordination. This paper, as discussed in the methods, uses the limited available sources to analyse global health disbursements. A primary objective of this paper is to prompt further disclosure of resource flows from major global health institutions which
may challenge these findings.
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