UNIVERSITY OF WASHINGTON Financing Global Health 2010: Tracking development assistance for health in economic uncertainty Christopher Murray

Outline Why Track Development Assistance for Health? Financing Global Health 2010 Methods Key Findings on DAH Recipient Government Responses What is Coming in 2011?

IHME Tries to Inform Three Questions 1) What are people’s health problems? – e.g. tracking adult, child, or maternal mortality; the Global Burden of Disease ) How well is a society doing in addressing these health problems? – e.g. inputs, outputs and outcomes form public health, medical care and other key social determinants 3) What can be done in the future to maximize health improvement? – e.g. cost-effectiveness of major intervention and health system intervention options

Tracking Health Financing Financing Global Health 2009 tracked Development Assistance for Health – flows from key development focused organizations for the advancement of global health. Financing Global Health 2010 tracks Development Assistance for Health and government health expenditures. Working on a systematic analysis of all available sources of data on out-of-pocket household expenditures on health Future editions of FGH will eventually include all three components: DAH, government and private expenditures on health.

Outline Why Track Development Assistance for Health? Financing Global Health 2010 Methods Key Findings on DAH Recipient Government Responses What is Coming in 2011?

Channels of Development Assistance for Health 7

NGO Revision for In-Kind Revenue US NGOs claim drug and equipment donations at US wholesale prices while the donors claim at production costs. On average, international prices are only one-quarter to one-fifth of the US wholesale prices. We have estimated empirically this relationship and deflated all donations to all NGOs by the same average factor. NGO specific deflators have not been possible to develop.

Preliminary Estimates for Donors and Agencies In Financing Global Health 2009 and in The Lancet results on financing global health through 2007 reflecting the lag in audited financial statements. Using audited financial statements and tax returns we have data for We have developed preliminary estimates for 2009 and 2010 by analyzing the historical relationship between budgets for donors and agencies and disbursements. Preliminary estimates for non-US government NGO revenue are the most uncertain.

Outline Why Track Development Assistance for Health? Financing Global Health 2010 Methods Key Findings on DAH Recipient Government Responses What is Coming in 2011?

DAH by Channel of Assistance,

Total overseas health expenditures channeled through US NGOs by funding source,

Fund Balances for UN Health-Related Agencies at End of

DAH as a Percentage of National Income,

Public Sector DAH by Donor Country by Channels of Assistance,

Total DAH per All-Cause DALY,

Countries Ranked by DAH Versus Countries Ranked by the Burden of Disease 17

DAH by Topic 18 HIV/AIDS Scale-up most dramatic for HIV/AIDS, malaria and tuberculosis. Maternal, newborn and child slower but increasing. NCDs less than $120 million per year in 2008.

Outline Why Track Development Assistance for Health? Financing Global Health 2010 Methods Key Findings on DAH Recipient Government Responses What is Coming in 2011?

Domestic Financing of Health by Governments Has Been Increasing 20

What Happens to Domestic Finance In Countries that Receive Large Amounts of DAH? April 2010, published in The Lancet, our analysis of how Ministries of Finance respond when governments receive DAH. Responses vary substantially, but on average, MoFs decrease health expenditures from their own sources by 43 cents to $1.14 for every dollar of DAH received by governments. Debate is not on whether this occurs but whether it is welfare enhancing or not. Perspectives vary widely between macro-economists and health specialists and between donors, Ministries of Health and Ministries of Finance.

Outline Why Track Development Assistance for Health? Financing Global Health 2010 Methods Key Findings on DAH Recipient Government Responses What is Coming in 2011?

Understanding DAH Trends Public investment in DAH will be determined by three factors: – timing of fiscal contraction in order to reduce debt/GDP ratios, IMF estimates maximum contraction around 2013 – priority attached to development assistance during fiscal contraction – priority assigned to global health within development assistance Private investment in DAH likely to follow more closely economic cycle and asset prices.

Good News….. UK austerity budget includes expanded investments in development assistance. GFATM replenishment at $11.7 billion for was lower than projected needs but represents continued growth compared to replenishment. Is this a vote of confidence in GFATM or an early sign of global health continued priority more generally? Will “preliminary estimates” from the GFATM secretariat of $1.1 billion eventuate?

Not So Good News….. Comparing and , already evidence of declining or flat rates of growth for many donors. Excluding US and UK bilateral, GAVI and GFATM, global health DAH peaked in Continued expansion of global heath driven to a large extent by these four channels. GAVI has no leader at present. US budget debate just beginning. Broad ‘corridor discussion’ in donor country Ministries of Finance of whether health has been over-emphasized in recent years.

Outcome Not Predetermined I believe that the outcome of these key discussions is not predetermined by macro-economic circumstances. By emphasizing evidence of impact of past and current investments, the global health community can influence US and other decision-making on the priority for global health in times of general fiscal contraction. Commitment to rigorous monitoring and evaluation of DAH and of government financial response will be key in the short and medium-term to sustaining financing for global health.