Where did all the aid go? An in-depth analysis of increased health aid flows over the past 10 years

930 Bull World Health Organ 2009;87:930–939 | doi:10.2471/BLT.08.058677 Where did all the aid go? An in-depth analysis of increased health aid flows over the past 10 years Paolo Piva a & Rebecca Doddb Objective To examine how health aid is spent and channelled, including the distribution of resources across countries and between subsectors. Our aim was to complement the many qualitative critiques of health aid with a quantitative review and to provide insights on the level of development assistance available to recipient countries to address their health and health development needs. Methods We carried out a quantitative analysis of data from the Aggregate Aid Statistics and Creditor Reporting System databases of the Organisation for Economic Co-operation and Development, which are the most reliable sources of data on official development assistance (ODA) for health from all traditional bilateral and multilateral sources and from partnerships such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. Findings The analysis shows that while health ODA is rising and capturing a larger share of total ODA, there are significant imbalances in the allocation of health aid which run counter to internationally recognized principles of “effective aid”. Countries with comparable levels of poverty and health need receive remarkably different levels of aid. Funding for Millennium Development Goal 6 (combat HIV/ AIDS, malaria and other diseases) accounts for much of the recent increase in health ODA, while many other health priorities remain insufficiently funded. Aid is highly fragmented at country level, which entails high transaction costs, divergence from national policies and lack of coherence between development partners. Conclusion Although political momentum towards aid effectiveness is increasing at global level, some very real aid management challenges remain at country level. Continued monitoring is therefore necessary, and we recommend that a review of the type presented here be repeated every 3 years. Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. .ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا a Health System Governance and Service Delivery, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland. b World Health Organization, Hanoi, Viet Nam. Correspondence to Paolo Piva (e-mail: pivap@who.int). (Submitted: 5 September 2008 – Revised version received: 22 April 2009 – Accepted: 13 May 2009 – Published online: 25 August 2009 ) Introduction Most assessments of the changes in international health aid over the past 10 years have focused on the fragmented nature of the new global health financing landscape and the health governance challenges created by growing numbers of aid channels and instruments.1–4 In the last decade, global health concerns and develop- ment priorities, including the health-related Millennium Development Goals (MDGs), have resulted in the mush- rooming of new health initiatives targeting single diseases or programmes, many of them with substantial financing capa- bilities. As a result, concerns have been voiced that spending priorities are increasingly determined at global and regional levels rather than at the recipient country level. Concurrently, concerns about the efficiency of aid delivery have prompted the development community to promote the use of more efficient aid instruments, including general budget support and sector-wide approaches. While global levels of health aid are clearly rising, it is less clear whether the amount of money available to countries to allocate flexibly, in accordance with their health priorities and health system development needs, is also increasing. With notable exceptions,5,6 few studies have looked in detail at any of the issues mentioned above or at what official development assistance (ODA) resources for health are being spent on, at which countries are benefiting or at the potential for new resources to contribute to health development and health systems strengthening. This study attempts to answer some of these complex questions using statistical data from the Development Assistance Committee of the Organisation for Economic Co-operation and Development (OECD/DAC). It should be noted that much of the data reviewed here pre-dates the Paris Declaration on Aid Effectiveness,7 under which donors committed to provide their aid more coher- ently and in alignment with country priorities, systems and procedures. Methods This analysis focuses on ODA, i.e. grants or loans by govern- ments to developing countries with promotion of economic development and welfare as the main objective. The data come from donor reports to the OECD/DAC. The OECD’s Aggregate Aid Statistics and Creditor Reporting System (CRS) are the most reliable sources of aid data. The CRS is the main source used in this analysis, although data series referring to years before 2000 are from the Aggregate Aid Statistics. Part of the analysis focuses on the least developed countries (LDCs), since they are at the centre of global health development efforts. One limitation of OECD statistics, especially in recent years, is that they do not include funds provided by non- OECD governments such as China and India and by wealthy Middle-Eastern countries. Also excluded are funds provided 931Bull World Health Organ 2009;87:930–939 | doi:10.2471/BLT.08.058677 Research Health aid flows over the past 10 yearsPaolo Piva & Rebecca Dodd by private entities such as the Bill & Melinda Gates Foundation. The real magnitude of health aid flows is there- fore much higher: The World Bank re- ported, for example, that in 2006 total development assistance to health, in- cluding aid from private organizations, reached US$ 16.7 billion,8 whereas the CRS recorded only US$ 13.3 billion. In addition, although CRS statistics dat- ing back to 1973 are available, reliable in-depth analysis can only be carried out from 2000 onwards because of the lim- ited coverage of earlier data and changes in reporting guidelines. The secretariat of the OECD/DAC continuously monitors the quality of aid activity data reported by donors, focusing on the completeness of report- ing and its conformity with definitions. The quality of CRS data on commit- ments for the period 2002–2006, on which this analysis focuses, ranges from good to excellent. The CRS’s classification system, however, does not always perfectly fit some of the development benchmarks – such as the MDGs – against which health ODA resources are measured. We therefore aggregated the CRS cat- egories (Table 1) where required to match health development goals or we used proxies. For example, data in the CRS category “Sexually-transmitted disease (STD) control including HIV/ AIDS” are used as a proxy for HIV/ AIDS funding. This is justified because the overwhelming majority of activities Table 1. CRS categories under which health ODA is reported and definitions Definition 1. General health Health policy and administrative management Health sector policy, planning and programmes; aid to health ministries, public health administration; institution capacity-building and advice; medical insurance programmes; unspecified health activities Medical education/training Medical education and training for tertiary-level services Medical research General medical research (excluding basic health research) Medical services Laboratories, specialized clinics and hospitals (including equipment and supplies); ambulances; dental services; mental health care; medical rehabilitation; control of non-infectious diseases; drug and substance abuse control (excluding narcotics traffic control) Basic health Basic health care Basic and primary health-care programmes; paramedical and nursing care programmes; supply of drugs, medicines and vaccines related to basic health care Basic health infrastructure District-level hospitals, clinics and dispensaries and related medical equipment; excluding specialized hospitals and clinics Basic nutrition Direct feeding programmes (maternal feeding, breastfeeding and weaning foods, child feeding, school feeding); determination of micro-nutrient deficiencies; provision of vitamin A, iodine, iron etc.; monitoring of nutritional status; nutrition and food hygiene education; household food security Infectious disease control Immunization; prevention and control of malaria, tuberculosis, diarrhoeal diseases, vector-borne diseases (e.g. river blindness and guinea worm), etc. Health education Information, education and training of the population for improving health knowledge and practices; public health and awareness campaigns Health personnel development Training of health staff for basic health-care services 2. Population policies/programmes and reproductive health Population policy and administrative management Population/development policies; census work, vital registration; migration data; demographic research/analysis; reproductive health research; unspecified population activities Reproductive health care Promotion of reproductive health; prenatal and postnatal care including delivery; prevention and treatment of infertility; prevention and management of consequences of abortion; safe motherhood activities Family planning Family planning services including counselling; information, education and communication activities; delivery of contraceptives; capacity-building and training STD control including HIV/AIDS All activities related to sexually transmitted diseases and HIV/AIDS control e.g. information, education and communication; testing; prevention; treatment, care Personnel development for population and reproductive health Education and training of health staff for population and reproductive health-care services CRS, Creditor Reporting System; ODA, official development assistance; STDs, sexually-transmitted disease. Source: Organisation for Economic Co-operation and Development.9 funded in this category, both in value and in number, relate to HIV/AIDS control. Activities aimed at improving the health of the population in ODA recipient countries are reported to the CRS under two broad categories – “Health, general” and “Population policies/programmes and reproduc- tive health” – which are subdivided as shown in Table 1. The OECD/DAC’s CRS categories “Health” and “Popula- tion” are combined in this paper in a single category: “Health”. Aid activities are categorized in the CRS according to type (Box 1). In recent years the OECD/DAC has requested that donors also report on the channel through which activities 932 Bull World Health Organ 2009;87:930–939 | doi:10.2471/BLT.08.058677 Research Health aid flows over the past 10 years Paolo Piva & Rebecca Dodd are implemented, i.e. whether aid is channelled through the public sector, nongovernment organizations (NGOs) and civil society organizations, pub- lic–private partnerships or multilateral organizations. This information is re- ported for only 20% of health activities, however, which limits the usefulness of such data. Results Trends in overall levels Analysis of the Development Assistance Committee’s aggregate development aid data from 1980 to 2006 reveals that total bilateral ODA commitments from OECD/DAC members have increased by more than 50% in real terms since 1980–1984, from an annual aver- age of US$ 70.5 billion in the period 1980–1984 to US$ 108.7 billion in the period 2002–2006. (Five-year averages are used as many commitments entail expenditures for several years, so this produces a smoother trend.) Health is capturing an increasing share of all ODA. OECD/DAC members’ total bilateral aid commitments for health in 1980–1984 averaged US$ 2.8 billion per year (constant 2006 dollars), or 5.3% of all ODA. This figure remained virtually unchanged up to the end of the 1990s, increasing thereafter to an annual average of US$ 6.4 billion in 2002–2006, equivalent to 7.8% of total ODA. In 2006 alone, the CRS recorded Box 1. Types of aid reported in the CRS aid activity database Free-standing technical cooperation is defined as financing of activities whose primary purpose is to augment the level of knowledge, skills, technical know-how or productive aptitudes of the population of aid recipient countries, i.e. increasing their stock of human intellectual capital or their capacity for more effective use of their existing factor endowment. It includes the cost of personnel, training and research, as well as associated equipment and administrative costs. Sector programme aid comprises contributions to carry out wide-ranging development plans in a defined sector such as agriculture, education, transportation, etc. Assistance is made available “in cash” or “in kind”, with or without restriction on the specific use of the funds, but on the condition that the recipient executes a development plan in favour of the sector concerned. Investment projects comprise: (i) schemes to increase and/or improve the recipient’s stock of physical capital, and (ii) financing the supply of goods and services in support of such schemes. Investment-related technical cooperation is defined as the financing of services by a donor country with the primary purpose of contributing to the design and/or implementation of a project or programme aiming to increase the physical capital stock of the recipient country. These services include consulting services, technical support, the provision of know-how linked to the execution of an investment project, and the contribution of the donor’s own personnel to the actual implementation of the project (managers, technicians, skilled labour etc.). CRS, Creditor Reporting System. Source: Organisation for Economic Co-operation and Development.9 Fig. 1. HIV/AIDS control as a proportion of total health ODA commitments, in millions of US$ (constant 2005 dollars), 1998–2006 0 M ill io ns o f U S$ 1998 Year Health, excluding STD control 10 000 9 000 8 000 7 000 6 000 5 000 4 000 3 000 2 000 1 000 Control of STDs, including HIV/AIDS 1999 2000 2001 2002 2003 2004 2005 2006 ODA, official development assistance; STD, sexually-transmitted disease; US$, United States dollars. Statistics from the Development Assistance Committee of the Organisation for Economic Co-operation and Development. bilateral and multilateral commitments for health from all members totalling US$ 13.3 billion – the highest level ever. The analysis also reveals that increased funding for HIV/AIDS activities ac- counts for a large share of the increases in health ODA in recent years. Funding for HIV/AIDS accounted for almost one third (32%) of total health ODA for the period 2002–2006 (Fig. 1). Commitments vs disbursements Ministries of health in recipient coun- tries often complain about delays in disbursing funds for projects or ac- tivities already under way or for which a formal commitment already exists.10 Recent changes in CRS reporting practices mean that reliable data on disbursements, suitable for assessing the magnitude of this phenomenon at the aggregate level, are available only from 2002 onwards (Box 2). It is difficult to evaluate disburse- ment rates for every health commit- ment reported to the CRS, as the time frame of disbursements for each commitment varies. We have therefore compared disbursements for each year during the period 2004–2006 with av- erage commitments made 3 and 5 years earlier (3 to 5 years being the average period over which committed funds are disbursed). The results, though only indicative, reveal that disbursements of health ODA amount to more than 80% of average annual commitments over the previous 3 to 5 years. Dis- bursements in 2006 were equivalent to 98% of average annual commitments over the previous 5 years and 87% of commitments over the previous 3 years. These data suggest that the difference between commitments and disbursements is not great; however, the figures may hide within-year delays in programme implementation. Unpacking health ODA While delivering all committed aid is important, on its own it is not enough to secure progress in health. Equally important factors are how money is channelled and spent, who benefits, what purpose it serves and how much 933Bull World Health Organ 2009;87:930–939 | doi:10.2471/BLT.08.058677 Research Health aid flows over the past 10 yearsPaolo Piva & Rebecca Dodd gets through to develop and strengthen the health system so that it is responsive to national health development needs and global health concerns. Multi-country initiatives In 2002–2006, global and regional multi-country initiatives accounted for 25% of all health ODA, including funds channelled through multilateral institutions (UN agencies, international NGOs and private entities) for ac- tivities that benefited several recipient countries. Examples include global immunization campaigns, HIV/AIDS prevention and control activities and support for basic health care. This category contrasts with funds sent di- rectly to countries through agreements between donors and recipient govern- ments. Although all sectors record multi-country regional activities, the volume in the health sector is unusually high. CRS data show that only 6.3% of education ODA and only 16.8% of total ODA is channelled through global and regional multi-country activities. The high levels in the health sector ap- pear to be related to the way HIV/AIDS funding is channelled. In 2002–2006, HIV/AIDS accounted for 40.7% of support for global and regional multi- country health initiatives (44.2% in 2004–2006). Global and regional multi-country initiatives are important mechanisms for targeting funding at global health challenges such as polio eradication and for sharing experiences across coun- tries with similar needs. Such areas are priorities in most poor countries and need support. However, as the over- arching operational and programming priorities of such initiatives are set at the regional or global level, they are often not fully aligned with national priorities. This can result in an uneven pattern of investment across the sector. In Uganda, for example, aid flows to HIV/AIDS have on average been higher than those going to all other health areas, which is perhaps justified given the high prevalence of HIV infection; however, other diseases, such as malaria, that are responsible for a significant share of the country’s burden of disease have not received as much attention from donors. Areas other than disease control, including human resources for health, rural health services, and family planning and reproductive health, also face relatively large funding gaps.11 Box 2. Commitments versus disbursements A commitment is a firm written obligation by a government or official agency, backed by the appropriation or availability of the necessary funds, to provide resources of a specified amount under specified financial terms and conditions and for specified purposes for the benefit of the recipient country. A disbursement is the placement of resources at the disposal of a recipient country or agency, or in the case of internal development-related expenditures, the outlay of funds by the official sector. Source: Organisation for Economic Co-operation and Development.9 Moreover, regional- and global-level funds often have their own budget cycles and reporting and monitoring procedures, which may impose an addi- tional administrative burden on already overstretched recipient governments. A substantial part of global and regional multi-country funding is likely to involve WHO, the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA) and to support vertical initiatives such as Roll Back Malaria. International organizations have an important role to play in coordinating responses to global health challenges, which partly explains the high level of global and regional funding for health and also accounts for the rising levels of extra-budgetary (non-core) con- tributions to these organizations. As noted above, however, it is difficult to fully align such funding with national priorities. Technical cooperation A substantial part of health ODA is spent on technical cooperation, which the OECD defines as grants to nation- als of aid recipient countries receiving education or training at home or abroad and payments to consultants, advisers and similar personnel as well as teachers and administrators serving in recipient countries (including the cost of as- sociated equipment). Support of this kind, provided specifically to facilitate implementation of a capital project, is included indistinguishably among bilateral project and programme expen- ditures and is not separately identified as technical cooperation in statistics of aggregate aid flows. • In the period 2002–2006 more than 40% (41.7%) of all health ODA and 43.5% of all health aid activi- ties (e.g. projects and programmes, training courses, research projects) were technical cooperation initia- tives aimed at building human capital in recipient countries, which included, for example, salaries for local staff and international experts, consultants’ fees and training. • Technical cooperation accounted for the lion’s share of resources (58.6%) channelled through global or re- gional multi-country initiatives. In 2002–2006 technical cooperation funding committed directly to indi- vidual countries was a more modest 36.2%. • Technical cooperation also ac- counted for much of new HIV/ AIDS funding (53% of HIV/AIDS commitments in the period 2002– 2006). Technical cooperation for HIV/AIDS activities represented al- most half of all technical coopera- tion for health in 2005–2006. Size matters The size of projects matters. Large ac- tivities (in dollar terms) at the country level are more likely to attract political attention, receive significant technical input and, crucially, be of a scale that will have an impact on health and the health delivery system in recipient countries. This does not mean that smaller projects have no role to play. On the contrary, they are important for piloting new approaches, testing innovations, delivering benefits to individual communities and covering emerging or unplanned health system needs. Analysed in the light of the Paris Declaration, however, many small ac- tivities are likely to have high transac- tion costs for government, diverge from national policies and suffer from lack of coordination among development partners.12–14 Over the period 2002–2006, the CRS recorded 20 485 health projects, only 946 of which were aid activities valued at more than US$ 10 million, such activities accounting for less than 5% (4.6%) of all aid activities reported to the OECD/DAC. They represented, 934 Bull World Health Organ 2009;87:930–939 | doi:10.2471/BLT.08.058677 Research Health aid flows over the past 10 years Paolo Piva & Rebecca Dodd however, more than two thirds (68.3%) of total health ODA commitments in the period. Of the activities exceeding US$ 10 million, (i) more than 50% (51.4%) targeted tuberculosis, malaria, HIV/ AIDS and other communicable dis- eases (a good proxy for MDG-6); and (ii) just 9.1% supported activities relat- ing to reproductive health and family planning (a proxy for MDG-5). The CRS recorded 5720 activities valued at between US$ 0.5 million and US$ 10 million. These represented 28.1% of total health ODA and 27.9% of all health aid activities. In addition, there were 13 819 commitments for activities valued at under US$ 0.5 mil- lion each, which made up 67.5% of all health aid activities in the period but accounted for only 3.6% of health ODA recorded by the CRS. Fig. 2 summarizes information on the scale of health activities. In general, a reported aid activity is a specific project or programme for which funds are allocated in a particu- lar sector in a given recipient country. However, donors sometimes compile CRS reports at a more detailed level, in which case a reported activity may actu- ally be a component of an activity. On the other hand, activities are sometimes aggregated, so a single reported activity may comprise several distinct activi- ties. For many of these small reported activities, the normal project cycle will, however, have been followed: appraisal, possibly involving a mission; discussion of a project proposal with government officials and its subsequent submission to donors for approval; and production of a technical and financial report. This represents a substantial workload for recipients (and also donors). In the 5 years under examination, each LDC received, on average, a commitment of around US$ 30 000 every 2 to 3 weeks (1.7 projects/month). Over the period 2002–2006, Ethiopia had commitments totalling US$ 1.1 billion, including 26 activities amounting to US$ 743 million (67% of total health ODA commitments) and 296 activities each valued at under US$ 0.5 million (US$ 123 000, on av- erage, apiece), which represented 3.3% of its total health ODA. Similarly, in the United Republic of Tanzania, 2.6% of the US$ 1.35 billion in ODA committed to health was channelled Fig. 2. Number and scale of health aid activities in US$ and as a proportion of total health ODA commitments, 2002–2006 US$ 0.5 million or less 4% health ODA 13 819 activities US$ 0.5–10 million 28% health ODA 5 720 activities Over US$ 10 million 68% health ODA 946 activities ODA, official development assistance; US$, United States dollars. Statistics from the Development Assistance Committee of the Organisation for Economic Co-operation and Development. via 279 projects, each with an average value of US$ 127 000. Just 30 reported activities accounted for 70% of all health ODA in the 5 years under ex- amination. These figures relate only to activities targeting recipient countries directly; they do not include activities channelled through global and regional multi-country projects. We are not suggesting that smaller amounts are not important for health development or that they will not im- prove specific health outcomes among specific populations for discrete periods of time. There does, however, appear to be an excessively large number of small donor projects in the health sector, which would appear to indicate a high level of fragmentation in health aid. How much aid remains? The dramatic but welcome and over- due increase in funding for HIV/AIDS control activities and the prominence of technical cooperation in health ODA beg the question: How much aid remains for other health activities? Data from the CRS are troubling. Out of all health ODA provided di- rectly to LDCs in 2002–2006, com- mitments towards the achievement of MDG-6 (combat HIV/AIDS, malaria and other diseases) accounted for 46.8%. That left the equivalent of US$ 2.25 per capita per year for the strengthening of health systems and service delivery needed to achieve MDGs 4 and 5 (reduce child mortal- ity and improve maternal health, re- spectively). However, in 2006, WHO reported that training the numbers of health workers necessary to strengthen health systems would require an in- crease in health expenditure of US$ 2.80 per capita, while the additional cost of paying salaries of new doctors, nurses and midwives would mean a minimum increase of US$ 7.50 per person per year on average.15 Subtracting that part of health ODA aimed at building human capac- ity (i.e. technical cooperation) leaves just US$ 0.53 per capita a year for health activities not related to the achieve- ment of MDG-6. This is clearly insuf- ficient to provide meaningful support for the scaling up of health services in poor countries with low capacity and resource shortages. It is important to remember that resources other than those mentioned above are made available to countries through multi-country activities, and the CRS’s broad classification system may hide a more complex reality. For example, both the GAVI Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria now provide support for health systems develop- ment and capacity-building in recipi- ent countries. However, the extent to which countries should rely for health systems financing on funding mecha- nisms that were established primarily to 935Bull World Health Organ 2009;87:930–939 | doi:10.2471/BLT.08.058677 Research Health aid flows over the past 10 yearsPaolo Piva & Rebecca Dodd address specific diseases – as compared to other sources, such as low-interest loans from The World Bank – is a sub- ject of ongoing debate.6,16,17 General budget and sector support General budget support, wherein do- nors channel their aid directly into the budget of a recipient country, is arguably one of the most efficient aid modalities: it avoids many of the costs and inefficiencies associated with projects; it is easier to align with the recipient’s priorities; and it opens the way to a broader, strategic dialogue on economy-wide issues.18 If accountabil- ity and governance are poor, however, as they often are in developing countries, these resources may well be misspent. Overall, general budget support com- mitments account for a small part of all ODA: for example, in 2002–2006 they were equivalent to 6.4% of total ODA (excluding debt relief ). Since do- mestic allocations to health tend to be low, particularly in poor countries, the level of resources reaching the health sector via this modality is likely to be relatively small. Nevertheless, whatever its pros and cons, budget support has increasingly come to be seen as “effective aid”, cham- pioned by those donors who are also champions of the Paris Declaration.19 It is therefore surprising that ODA com- mitment to general budget support has Fig. 3. General budget support and health: official bilateral commitments, in millions of US$ (constant 2006 dollars), 1987–2006 0 M ill io ns o f U S$ 1987 Year General budget support 9 000 8 000 7 000 6 000 5 000 4 000 3 000 2 000 1 000 Health 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 US$, United States dollars. Statistics from the Development Assistance Committee of the Organisation for Economic Co-operation and Development. Fig. 4. Distribution of health ODA by country income group, 2002–2006 LDC 32% Other low-income country 22%Lower-middle-income country 17% Multi-country, regional 5% Multi-country, unspecified 20% Upper-middle- income country 4% ODA, official development assistance; LDC, least developed country. Statistics from the Development Assistance Committee of the Organisation for Economic Co-operation and Development. only in the last few years returned to the same levels as in the late 1980s (Fig. 3). Similar arguments can be advanced in favour of sector programmes: they reduce transaction costs for govern- ment, allow alignment with national priorities and help to develop a strategic, sector-wide vision. The CRS reveals, however, that the proportion of health aid spent on sector programmes is rela- tively minor: 7.7% of all health ODA in 2002–2006, and even that is likely to be an overestimate. Our review of data reported to the OECD/DAC in this category suggests that, notwithstanding substantial data quality improvements in recent years, the “sector programme” category still includes funding for ac- tivities which do not appear to meet the OECD/DAC’s own definition of “sector support”. Distribution across countries Fig. 4 shows the distribution of health ODA by country income group. LDCs receive the most health aid – close to the share received by other low-income countries and lower-middle income countries together. They also receive a substantially larger amount per capita: over US$ 4.50, compared to just over US$ 1.00 for other low-income coun- tries and only US$ 0.50 for lower- middle-income countries. Least developed countries The LDCs are the focus of major devel- opment efforts and the direct recipients of one third of all health ODA. This group includes many countries im- mersed in or emerging from conflict. These countries also have the worst health outcomes and are the least likely to meet the health-related MDGs.20 It is therefore important to understand how aid is distributed in support of health development efforts and service deliv- ery in these countries. Table 2 summarizes the main fea- tures and focus of health ODA in LDCs 936 Bull World Health Organ 2009;87:930–939 | doi:10.2471/BLT.08.058677 Research Health aid flows over the past 10 years Paolo Piva & Rebecca Dodd Table 2. Health ODA in selected least developed countries, 2002–2006 LDC recipient Average population (thousands) 2002–2006 Under-5 mortality rate 2004 Life expectancy at birth 2004 Health ODA per capita 2002–2006 MDG-6 % health ODA HIV/AIDS prevalence (15–49) – Est. 2005 MDG-5 % health ODA Technical cooperation % health ODA Zambia 11 277 182 40 19.97 58.5 17 0.6 36.2 Timor-Leste 1 009 NA NA 14.94 18.9 NA 0.8 20.4 Malawi 12 905 175 41 13.44 49.9 14.1 1.5 22.4 Lesotho 1 965 82 41 12.7 72.1 23.2 0.7 19.3 Rwanda 9 085 203 46 10.75 73.9 3.1 2.1 53.8 Haiti 9 151 117 55 10.07 63.1 3.8 15.2 57.3 Mozambique 20 065 152 45 9.92 47 16.1 4.5 34.9 Cambodia 13 724 141 54 7.68 54.9 1.6 5.4 44 Uganda 28 059 138 49 7.63 69 6.7 1.3 47.1 Senegal 11 477 137 55 7.44 28.9 0.9 1.5 45.7 United Republic of Tanzania 37 522 126 48 7.23 57.1 6.5 5.5 32.2 Benin 8 228 152 53 6.61 46.4 1.8 2.9 27.1 Afghanistan 24 112 257 42 6.39 7.3 0.1 1.9 46.1 Sierra Leone 5 361 283 39 5.61 40.9 1.6 1.3 8.1 Mali 11 276 219 46 5.46 39.8 1.7 6.4 33.9 Guinea-Bissau 1 550 203 47 5.1 34.4 3.8 5.2 24.6 Gambia 1 570 122 57 5.04 79.2 2.4 1.9 3.1 Eritrea 4 349 82 60 4.93 45.1 2.4 26.3 18.6 Lao People’s Democratic Republic 5 577 83 59 4.83 29 0.1 3.2 25.7 Burkina Faso 13 509 192 48 4.73 46.3 2 7 19.5 Mauritania 2 882 125 58 4.53 60 0.7 8.1 9.2 Burundi 7 588 190 45 4.4 67.6 3.3 9 18.9 Liberia 3 382 235 42 4.14 55.8 3.5 3.8 33.5 Central African Republic 4 127 193 41 3.9 65.4 10.7 2 9.6 Angola 15 641 260 40 3.8 54.1 3.7 2.5 29.6 Guinea 8 840 155 53 3.52 52 1.5 9.5 35.1 Niger 12 823 259 41 3.41 44.1 1.1 3.4 23.1 Democratic Republic of the Congo 57 003 205 44 3.19 39.1 3.2 0.5 31.1 Nepal 26 560 76 61 2.99 25 0.5 19.8 41.3 Ethiopia 77 036 166 50 2.9 68.3 2.2 5.8 35.8 Madagascar 18 143 123 57 2.77 41.9 0.5 3.6 30.2 Togo 6 074 140 54 2.35 65 3.2 2.2 10.8 Somalia 7 962 NA NA 2.14 64.4 NA 2.5 20.8 Yemen 20 496 111 59 1.88 17.8 0.1 35.2 22.8 Bangladesh 150 497 77 62 1.71 9.9 0.1 18.4 34.2 Sudan 36 188 91 58 1.71 60.1 1.6 1.2 43.2 Chad 9 802 200 46 1.59 39.7 3.5 4.6 36.9 Myanmar 47 570 NA NA 0.64 53.6 NA 3.6 24.6 LDC, least developed country; MDG, Millennium Development Goal; NA, not available; ODA, official development assistance. Statistics from the Development Assistance Committee of the Organisation for Economic Co-operation and Development. with a population of over 1 million. Countries are ranked in descending order according to per capita health ODA. The table shows that there are huge geographical variations in health ODA per capita in the LDC group: from almost US$ 20 per capita a year for Zambia to US$ 1.59 for Chad. The first 10 countries in Table 2 capture almost half (49.1%) of total health ODA for LDCs, although they account for only one fifth of the popu- lation (21%). In 20 (out of the 50) LDCs, more than 50% of health ODA is targeted to MDG-6. Health ODA for MDG-5 amounts to 10% or more of all health ODA in just 7 countries. Twenty countries receive more than 33% of their health ODA as technical cooperation. A major predictor of aid per capita in LDCs is HIV/AIDS prevalence. In countries such as Rwanda there is evidence that these resources have a positive effect on the health system as a whole.11 Countries with low HIV/ AIDS prevalence (but high levels of morbidity and mortality from other causes) receive much less aid and thus remain at a disadvantage. 937Bull World Health Organ 2009;87:930–939 | doi:10.2471/BLT.08.058677 Research Health aid flows over the past 10 yearsPaolo Piva & Rebecca Dodd Résumé Où est allée toute l’aide sanitaire ? Analyse approfondie des flux croissants d’aide sanitaire sur les dix dernières années Objectif Étudier comment l’aide sanitaire est dépensée et distribuée, et notamment comment les ressources sont réparties entre les pays et les sous-secteurs. Nous avions pour objectif de compléter les nombreuses critiques qualitatives de l’aide sanitaire par un bilan quantitatif et de donner un aperçu du niveau d’assistance au développement dont bénéficient les pays destinataires pour répondre à leurs besoins en termes de santé et de développement sanitaire. Méthodes Nous avons analysé quantitativement des données provenant des bases de données des Statistiques agrégées de l’aide et du Système de notification des pays créanciers de l’OCDE (Organisation de coopération et de développement économiques), qui constituent les sources les plus fiables de renseignements sur l’aide au développement officielle (ADO) en faveur de la santé, apportée par l’ensembles des sources bilatérales et multilatérales traditionnelles et par des partenariats tels que le Fonds mondial de lutte contre le Sida, la tuberculose et le paludisme. Résultats Il ressort de cette analyse que, si l’ADO en faveur de la santé est en augmentation et représente une part grandissante de l’ADO totale, il existe néanmoins des déséquilibres importants dans l’affectation de l’aide sanitaire, qui sont contraires au principe internationalement reconnu «d’efficacité de l’aide ». Des pays comparables par le niveau de pauvreté et les besoins sanitaires reçoivent des volumes d’assistance étonnamment différents. Le financement de l’Objectif du Millénaire pour le développement N° 6 (combattre le VIH/sida, le paludisme et d’autres maladies) représente une grande part de la récente augmentation de l’ADO sanitaire, alors que nombre d’autres priorités sanitaires restent sous-financées. L’aide est fortement fragmentée au niveau des pays, ce qui entraîne des coûts de transaction élevés, des écarts par rapport aux politiques nationales et un manque de cohérence entre les partenaires dans le développement. Conclusion Bien que l’impulsion politique en faveur d’une aide efficace s’amplifie à l’échelle mondiale, certaines difficultés de gestion bien réelles persistent au niveau des pays. Une surveillance continue s’impose donc et nous préconisons de refaire un bilan de ce type tous les 3 ans. Discussion The analysis presented in this paper relies primarily on figures reported to the OECD by official donors. The major limitation of these data is that the categories into which health ODA is classified are broad, making de- tailed analysis difficult. Nevertheless, we believe that our analysis highlights significant imbalances and distortions in the provision of health aid. We have deliberately avoided speculating on the causes of these imbalances. Rather, our aim has been to make the figures avail- able with a view to stimulating debate. Health ODA is increasing, and health is capturing a bigger share of all ODA. While this is encouraging, there are some marked imbalances in the allo- cation of health aid which run counter to the commitments of the Paris Dec- laration. Countries with comparable levels of poverty and health-related needs receive remarkably different levels of aid. Funding for MDG-6 accounts for much of the recent increase in health ODA. Many other health and health- related priorities remain insufficiently funded. In particular, “systems issues”, such as management, logistics, procure- ment, infrastructure and workforce development, are often neglected. These areas may not appeal to donors, but they will have to be tackled if current progress in disease control is to con- tinue and if the quality and coverage of health services are to improve. Given that HIV/AIDS control already ben- efits from comparatively high levels of support, but at the same time still faces a funding gap, raising the additional resources needed to strengthen health systems – and thereby address MDGs 4 and 5 – will be a challenge. In comparison to other sectors, a large proportion of aid in the health sector is channelled through multi- country projects or spent on technical cooperation. The latter plays an impor- tant role in transferring knowledge and skills to build capacity in developing countries. However, spending such large proportions of aid resources on technical cooperation seems difficult to justify, particularly in settings where national resources for health are meagre and large segments of the population have no access to drugs or basic health- care services. Further analysis – for example, to distinguish between fund- ing amounts for long- and short-term technical cooperation and between technical cooperation funds spent on international versus local personnel – would be useful. Finally, our findings suggest that control over spending decisions at the country level is limited, as global and regional priorities dominate aid al- location. Indeed, the amount of aid channelled through sector- and budget- support programmes remains low, de- spite recognition that this is one of the most efficient forms of aid. The imbalances identified by our analysis predate the Paris Declaration. The data currently available are insuf- ficient to assess whether that agreement has had an impact on health aid flows. Much of the debate on how to make health aid more effective has focused on institutional fragmentation in global health and on the need to reform the health aid architecture. However, our findings show that many other issues also need to be addressed. Continued close monitoring of financial flows is needed to fully understand the chal- lenges and to inform the debate on how health aid can be made more effective. We recommend that a review of the type presented here be repeated every 3 years. ■ Acknowledgements We are grateful to Shambhu Acharya, Andrew Cassels and Iqbal Shah at WHO Headquarters for their com- ments and input on this paper. Special thanks to the OECD Development As- sistance Committee staff for their valu- able assistance. Rebecca Dodd is also a PhD student at the School of Popula- tion Health, University of Queensland, Australia. Competing interests: None declared. 938 Bull World Health Organ 2009;87:930–939 | doi:10.2471/BLT.08.058677 Research Health aid flows over the past 10 years Paolo Piva & Rebecca Dodd Resumen ¿A dónde ha ido a parar toda la ayuda? Análisis detallado del aumento de la ayuda sanitaria en los últimos diez años Objetivo Determinar cómo se gasta y canaliza la ayuda sanitaria, en particular cómo se distribuyen los recursos entre los países y entre subsectores. Nos propusimos complementar las numerosas críticas cualitativas de la ayuda sanitaria con un examen cuantitativo, y esclarecer el nivel de asistencia para el desarrollo de que disponen los países beneficiarios para afrontar sus necesidades sanitarias y de desarrollo sanitario. Métodos Realizamos un análisis cuantitativo de datos extraídos de las bases de datos de las Estadísticas Agregadas sobre la Ayuda y del Sistema de Notificación por parte de los Países Acreedores (CRS) de la Organización de Cooperación y Desarrollo Económicos, que son las fuentes más fiables de datos sobre la asistencia oficial para el desarrollo (AOD) destinada a la salud proporcionada por todas las fuentes bilaterales y multilaterales tradicionales y por alianzas como el Fondo Mundial de Lucha contra el SIDA, la Tuberculosis y la Malaria. Resultados El análisis muestra que si bien la AOD destinada a la salud está aumentando y captando una mayor proporción de la AOD total, la asistencia para la salud presenta desequilibrios importantes que son contrarios a los principios reconocidos internacionalmente como característicos de una «ayuda eficaz». Países con niveles comparables de pobreza y salud reciben niveles de ayuda considerablemente distintos. La financiación del sexto Objetivo de Desarrollo del Milenio (combatir el VIH/sida, la malaria y otras enfermedades) representa gran parte del aumento reciente de la AOD destinada a la salud, mientras que muchas otras prioridades sanitarias siguen sin contar con financiación suficiente. La ayuda está muy fragmentada a nivel de país, lo que entraña altos costos de transacción, divergencias respecto a las políticas nacionales y falta de coherencia entre los asociados para el desarrollo. Conclusión Aunque el impulso político para potenciar la eficacia de la ayuda está aumentando en el plano mundial, a nivel de país la gestión de la ayuda sigue tropezando con obstáculos muy reales. Se requiere en consecuencia una vigilancia permanente, por lo que recomendamos que cada tres años se vuelva a realizar un estudio como el aquí presentado. References 1. Caines K. Key evidence from major studies of selected global health partnerships:background paper prepared for the High-Level Forum on the Health MDGs. London: Department for International Development Health Resource Centre; 2005. 2. Cohen J. The New World of Global Health. Science 2006;311:162-7. PMID:16410496 doi:10.1126/science.311.5758.162 3. Fidler D. Architecture amidst anarchy: global health’s quest for governance. Global Health Governance 2007;1. Available from: http://ghgj.org/Fidler_1.1_ Architecture.htm [accessed on 27 July 2009]. 4. Kickbusch I. The development of international health policies – accountability intact? Soc Sci Med 2000;51:979-89. PMID:10972440 doi:10.1016/S0277- 9536(00)00076-9 5. Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other health issues? Health Policy Plan 2008;23:95-100. PMID:18156161 doi:10.1093/ heapol/czm045 6. Lane C, Glassman A. Bigger and better? Scaling up and innovation in health aid. Health Aff 2007;26:935-48. PMID: 17630435 doi:10.1377/ hlthaff.26.4.935 7. Paris Declaration on Aid Effectiveness. Adopted at the: Paris High-Level Forum, Paris, 28 February–2 March 2005. Available from: http://www.oecd. org/dataoecd/11/41/34428351.pdf [accessed on 27 July 2009]. 8. Global monitoring report 2008. Washington, DC: The World Bank; 2008. 9. Organisation for Economic Co-operation and Development. Reporting directives for the Creditor Reporting System. Paris: OECD; 2007 (DCD/ DAC(2007)39/FINAL). 10. Williams G. Fiscal space and sustainability from the perspective of the health sector. In: High-Level Forum on the Health Millennium Development Goal: selected papers, 2003–2005. Geneva: World Health Organization; 2006. صخلم ةيرخلأا تاونس شرعلا للاخ ةيحصلا تادعاسلما بّسرت ةدايزل قمعتم ليلحت ؟تادعاسلما لك تبهذ نيأ ابم ،قافنلإا اذه تاونقو ةيحصلا تادعاسلما قافنإ ةيفيك صحف وه :ضرغلا نوثحابلا فده دقل .ةيعرفلا تاعاطقلا ينبو نادلبلا برع دراولما عيزوت كلذ في عم ةيحصلا تادعاسملل ةيفيكلا ةيداقتنلاا لئاسولا نم ديدعلا جامدإ لىإ ةحاتلما ةيمنتلا تادعاسم ىوتسم لوح ةيعاو ةيؤر حرطل ةيّمكلا ةعجارلما ةيمنتلا تاجايتحابو ةحصلاب مماتهلاا ءلايلإ تادعاسملل ةلبقتسلما نادلبلل .اهيدل ةيحصلا تايئاصحإ لمجم نم ةدراولا تانايبلل ًاّيمك ًلايلحت نوثحابلا ىرجأ :ةقيرطلا يداصتقلاا نواعتلا ةمظنلم نياتملإا ليجستلا ماظن تانايب دعاوقو ،تادعاسلما ةيمسرلا ةيمنتلا تادعاسم لوح ةقث تامولعلما رداصم ثركأ يهو ،ةيمنتلاو فارطلأا ةيئانثلا ةيديلقتلا ليومتلا رداصم عيمج نم ةحصلاب ةصاخلا ةحفاكلم يلماعلا قودنصلا لثم ةكاشرلا تاهج نمو فارطلأا ةددعتلماو .ايرلالماو لسلاو زديلإا ةيمسرلا ةيمنتلا تادعاسم ديازت نم مغرلاب هنأ ليلحتلا رهظأ :تادوجولما تادعاسم ليماجإ نم بركلأا بيصنلا لىع اهذاوحتساو ةحصلاب ةصاخلا يرست يتلاو ةيحصلا تادعاسلما صيصخت في نزاوت مدع كانه نأ لاإ ،ةيمنتلا تاذ نادلبلاف .”ةلاّعفلا تادعاسملل“ اهب فترعلما ةيلودلا ئدابلما سكع تايوتسم ىقلتت ةحصلاو رقفلا تاجايتحا ثيح نم ةهباشتلما تايوتسلما يمارلما نم سداسلا ىمرلما ليوتم لغشيو .تادعاسلما نم نيابتلا ةديدش ضارملأاو ،ايرلالماو ،هسويرفب ىودعلاو زديلإا ةبراحم( ةيفللأل ةيئانملإا ةيمسرلا ةيمنتلا تادعاسم في تققحت يتلا ةدايزلا نم ًايربك ًازيح )ىرخلأا يرغ ىرخلأا ةيحصلا تايولولأا نم يرثك ليوتم لظي مانيب ،ةحصلاب ةصاخلا ،ؤزجتلا ديدش ًمايسقت ةدعاسلما ميسقت يرطقلا ىوتسلما لىع يرجيو .ٍفاك نع فارحنلاا لىإ يدؤيو ،ةيدقنلا تلايوحتلا في ةظهاب فيلاكت فزنتسي مام .ةيمنتلا في ءاكشرلا ينب طباترلا مادعناو ،ةينطولا تاسايسلا لىع تادعاسلما ةيلاعف بوص سيايسلا عفدلا ةوق ديازت نم مغرلاب :جاتنتسلاا تادعاسلما ةرادإ في ةيقيقحلا تايدحتلا ضعب كانه لازام ،يلماعلا ديعصلا نوثحابلا صيويو ،دصرلا رارمتسا يروضرلا نمف كلذلو ،يرطقلا ىوتسلما لىع .تاونس ثلاث لك هراركتو ثحبلا اذه في مدقلما طمنلا ةعجاربم 939Bull World Health Organ 2009;87:930–939 | doi:10.2471/BLT.08.058677 Research Health aid flows over the past 10 yearsPaolo Piva & Rebecca Dodd 11. Effective Aid – Better Health. Report prepared for the: Third High-Level Forum on Aid Effectiveness, Accra (Ghana), 2–4 September 2008. Geneva: World Health Organization; 2008. 12. Buse K, Walt G. An unruly melange? Coordinating external resources to the health sector: a review. Soc Sci Med 1997;45:449-63. PMID:9232739 doi:10.1016/S0277-9536(96)00365-6 13. Cassels A. Health sector reform: key issues in less developed countries. J Int Dev 1995;7:329-47. PMID:12290761 doi:10.1002/jid.3380070303 14. Walt G, Buse K. Partnership and fragmentation in international health: threat or opportunity? Trop Med Int Health 2000;5:467-71. PMID:10964268 doi:10.1046/j.1365-3156.2000.00596.x 15. World health report 2006: working together for health. Geneva: World Health Organization; 2006. 16. Global health initiatives and health systems strengthening: the challenge of providing technical support (technical approach paper). London: HLSP Institute; 2008.Available from: http://www.hlspinstitute.org/files/ project/216258/TS_for_HSS_June08.pdf [accessed on 27 July 2009]. 17. Shiffman J. Donor funding priorities for communicable disease control in the developing world. Health Policy Plan 2006;21:411-20. PMID:16984894 doi:10.1093/heapol/czl028 18. Killick T, Lawson A. Budget support to Ghana: a risk worth taking? (briefing paper 24). London: Overseas Development Institute; 2007. 19. Lister S, Carter R. Evaluation of general budget support: synthesis report: executive summary. London: Department for International Development; 2006. 20. Why we need to work more effectively in fragile states. London: Department for International Development; 2005.