Global health funding: Huge increases since 2000, but also huge disparities

This was originally published on Global Health TV on July 27, 2015.

As the end of the era of the Millennium Development Goals (MDGs) (2000-2015) draws near, we who work in global health can look back with some satisfaction at the $228 billion that was allocated to address the three health-related MDGs during that time.

Although spending grew rapidly in the first ten years, it was stagnant between 2010 and 2014, and actually decreased by 1.6% between 2013 and 2014. Global health funding in 2014 amounted to $36 billion in 2014 (of which $1 billion was for Ebola).

That information comes from Financing Global Health 2014: Shifts in Funding as the MDG Era Closes, the annual report of global health funding published last month by the Institute for Health Metrics and Evaluation (IHME).

And two weeks ago, the Kaiser Family Foundation and UNAIDS issued a report that showed that although there was only a slight increase in funding for HIV in low- and middle-income countries in 2014 (less than 2%), seven of 14 donor countries actually decreased funding despite the recent gains made against the epidemic.

The United States continued to be the largest source of funds, both for general development assistance for health (DAH) and for HIV/AIDS. It provided $12.4 billion in DAH and $5.6 billion in HIV funding in 2014, though the HIV funding remained “essentially flat,” according to Kaiser/UNAIDS. The U.K. was Number 2, with $3.8 billion in DAH and $1.1 billion in HIV funding in 2014.

The amount of money provided by the big Western donors to save lives and fight disability over the last 15 years has been undeniably tremendous but what is equally impressive — and less noticed — is that spending by low- and middle-income countries themselves reached an all-time high of $711 billion in 2012, growing almost 10% from 2011 to 2012. The report says that this contrast (between donor and local health spending) “hints at new trends in global health financing.”

“While a great deal of attention is focused on donors’ efforts to improve health in developing countries, the countries themselves invest much more money,” said Dr. Joseph Dieleman, assistant professor at IHME and the report’s main author. “For every one dollar donors spend in global health, developing countries spend nearly $20. However, in some low-income countries, it’s one donor dollar for every dollar spent by the country.”

What has always puzzled me are the huge disparities between global health spending and the global disease burden, which reveals where disease, death and disability are actually occurring.

For example, IHME reported the leading causes of deaths in the world in 2013 as ischemic heart disease, stroke, chronic obstructive pulmonary disease, pneumonia, alzheimer’s disease, lung cancer, road injuries, HIV/AIDS, diabetes and tuberculosis, in that order.

Lancet reported the leading causes of deaths of children 1-59 months in 2013 as lower respiratory infection (19%), non-communicable diseases (16%), malaria (16%), diarrheal disease (13%), road injuries (8.7%) and nutritional deficiencies (7%). HIV/AIDS was 1.7%.

But the biggest recipients of DAH in 2014, according to IHME’s new report, are HIV/AIDS (30.3%), newborn and child health (18.5%), maternal health (8.4%), health sector support (6.6%), tuberculosis (3.8%) and non-communicable disease (1.7%). The rest is “other” or “unallocable.”

In maternal and child health, donors spent $3.2 billion on child vaccines, $1.1 billion on child nutrition and $778 million on family planning in 2014, IHME reports. In recent years, DAH for vaccines and nutrition experienced major gains, but funding for family planning remained “relatively stagnant.” Family planning will never show up in the global disease burden (because it is not a disease) but it could reduce all of the causes of death listed above because it will allow women to avoid unwanted pregnancies.

In comparison, says IHME, DAH for addressing mental health and combatting tobacco use was much smaller, amounting to $164 and $31 million respectively, in 2014. (See my Global Health TV blog last month for more on the great disparity between the need and funding for mental health in Africa).

Clearly, the money is not always going where the disease, death and disability is occurring. I asked IHME which health areas have the greatest disparities. They told me:

“Among the different disease-specific funding areas we track, the disparities between disease burden and funding are most extreme in HIV/AIDS on the high end and in non-communicable diseases on the low end. Some countries receive more than $500 per DALY (disability-adjusted life year) for HIV/AIDS (Libya, Morocco, Namibia, and Tunisia), while the countries receiving the highest amount of funding for non-communicable diseases receive around $20 per DALY (Tonga and The Gambia).”

A review of cost-effectiveness studies of DAH going to low- and middle-income countries in the July issue of Health Affairs found the relationship between health aid and incremental cost-effectiveness ratios “is negative and significant” and that “changing the allocation of health aid earmarked funding could lead to greater health gains even without expanding overall disbursements.”

I’m certainly not arguing for reducing the amount of money going to fight HIV/AIDS — not when we have a realistic change of eliminating it by 2030 — or other health areas that have benefitted greatly from global health funding trends over the last 15 years. But I am arguing for better funding of areas that occupy a huge part of the global disease burden, like non-communicable disease, and are getting too few resources.

Here’s where you can find the full report Financing Global Health 2014: Shifts in Funding as the MDG Era Closes. And here’s a one-page summary. This graph by National Public Radio shows the amount contributed by the U.S. as a percentage of total funding for major global health areas in 2014.