Financing Global Health 2010: Tracking development assistance for health in economic uncertainty January 31, 2011 Christopher Murray Director, IHME

Outline Why Track Development Assistance for Health? Financing Global Health 2010 Methods Key Findings on DAH Recipient Government Responses What is Coming in 2011? 3

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 from 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 4

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. 5

Outline Why Track Development Assistance for Health? Financing Global Health 2010 Methods Key Findings on DAH Recipient Government Responses What is Coming in 2011? 6

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. Analyzed US retail, US wholesale, Federal Upper Limit, and drug indicator guide for 386 unique products. We have estimated empirically this relationship and deflated all donations to all NGOs by the same average factor, 82%. NGO-specific deflators have not been possible to develop. 8

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 developed preliminary estimates for 2009 and 2010 by analyzing the historical relationship between budgets for donors and agencies and disbursements. Relationships are very strong and provide a reasonable basis for mapping from budgets to estimated disbursements. Preliminary estimates for non-US government NGO revenue are the most uncertain. 9

Outline Why Track Development Assistance for Health? Financing Global Health 2010 Methods Key Findings on DAH Recipient Government Responses What is Coming in 2011? 10

DAH by Channel of Assistance,

DAH by country of origin,

Public sector DAH by donor country received by channels of assistance,

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

Fund balances for UN health agencies at end of

Top 30 country recipients of DAH, , compared with top 30 countries by all-cause burden of disease, 2004

Total DAH per all-cause DALY,

DAH for HIV/AIDS by channel of assistance,

DAH for maternal, newborn, and child health by channel of assistance,

Outline Why Track Development Assistance for Health? Financing Global Health 2010 Methods Key Findings on DAH Recipient Government Responses What is Coming in 2011? 20

Domestic Financing of Health by Governments Has Been Increasing 21

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. 22

Outline Why Track Development Assistance for Health? Financing Global Health 2010 Methods Key Findings on DAH Recipient Government Responses What is Coming in 2011? 23

Understanding DAH Trends Private investment in DAH likely to follow more closely economic cycle and asset prices. DAH from private sources should increase again in 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 24

Potential Good News for DAH….. 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. IDA Round 16 replenishment at the World Bank of $49.3 billion, a nearly 18% increase over the previous round. 25

Not So Good News for DAH….. Comparing and , already evidence of declining or flat rates of growth for many donors. USG 2011 global health disbursements very unlikely to expand compared to 2010 and may well be lower. Rapid freezing of Global Fund contributions by Germany, Sweden, and Ireland in response to recent media on corruption in a small number of GFATM grantees. 26

Implications of a Global Health Recession It appears likely that after nearly 20 years of year on year growth, DAH will decline in Effect on recipient countries will still be in percentage terms small but some programs in some countries may see immediate impacts. Effect on the donors, multilateral institutions, NGOs, and universities involved in global health will more far-reaching. 27

Implications for Sustaining Broad Support for the Global Health Endeavour Urgent need to provide immediate and satisfactory responses to questions on financial transactions for all global health organizations to restore public confidence. Strong demand for evidence that the expected benefits from global health investments have actually been realized. Well conducted ex post evaluations of investments will add to our scientific understanding of what works and what does not. BUT, we need in 2011 more convincing evidence on what has likely been achieved with the $181 billion spent on global health in the last decade. 28

Pressure for “More Health for the Money” Continued expanded needs for global health programs: rising numbers needing ART, enhanced priorities for maternal, newborn and child health, new political attention for NCDs. Expect a renewed focus on how to deliver programs more efficiently – e.g. understand why the cost per person completing a year of ART likely varies 10 fold across sites. Shared learning about efficiency of service delivery, however, requires transparency on cost and outcome. 29

Implications for Global Health Actors Intensified competition between different health programs especially MNCH and HIV/AIDS. Increased attention to improving health through multi- sectoral action: World Bank and UNICEF likely to be important in this arena. Potential for a sea-change on campuses in perception of global health as the social issue for this generation. This trend needs to be counter-balanced by reinforcing the global health triad of: moral imperative, effective technologies and demonstrated successes. 30