The global health sector has evolved dramatically over the past two decades, with the emergence of new organizations like the Bill and Melinda Gates Foundation and the GAVI Alliance accompanied by much higher volumes of funding. Development assistance for health (DAH) increased five-fold between 1990 and 2010 to reach US$28 billion.
Raising funding for health challenges and coordinating activities of diverse global health actors to ensure cost-effectiveness and good governance remain pressing global issues. Now is a critical time to reflect on the increasingly complex DAH landscape and evaluate its merits and disadvantages in a systematic manner.
The World Bank’s 1993 World Development Report (WDR), “Investing in Health” firmly established health as a priority on the global development agenda, arguing that investments in health are drivers of economic growth and individual welfare. Health is positively associated with a range of social indicators, including better education outcomes and economic productivity.
To commemorate the 20th anniversary of that landmark WDR, The Lancet Commission on Investing in Health will release a report in December 2013 that revisits the case for investing in health. The report will take stock of changes in health investment over the last 20 years, policy opportunities for achieving large health gains in developing countries, and the need for global collective action for health.
In collaboration with leading global health experts Professor Dean Jamison (University of Washington), Felicia Knaul (Harvard University), and Rifat Atun (The Global Fund), R4D staff has developed a background paper for The Lancet Commission’s report. Entitled “Global collective action in health: The WDR+20 landscape of core and supportive functions,” the paper reflects on the growth and shift in development assistance for health since 1990, the evolved system’s positive and negative implications for global health, the division of labor between large global health organizations, and the future role of large middle income countries (e.g. China and Brazil) in global health.
The working paper analyzes shifts in the DAH landscape since 1990 and reflects on those changes through the lens of a framework of “essential functions” for global health organizations. Essential functions include core functions, which benefit the world by producing global health public goods (e.g. vaccine development, health policy research); and supportive functions, which strengthen individual countries’ health systems (e.g. essential medicines delivery, infrastructure financing). To assess the balance between core and supportive functions in global health today, the R4D team analyzed budgets of the WHO, World Bank, the Global Fund, UNITAID, GAVI, USAID, and the Gates Foundation, and conducted interviews with leaders from those organizations. On balance, the recent growth in health investments through these organizations appears to have favored supportive functions over core functions. Even the WHO—recognized as the world’s leader in producing “core” international standards and norms—seems to have experienced a shift toward supportive functions due to rising dependence on extra-budgetary contributions for country-specific health programming.
The working paper highlights the importance of including global public goods in global health investment strategies moving forward. Establishing a post-2015 agenda and investment strategy for core functions could help ensure continued progress in the development of these global public goods such as new vaccines and medicines, biomedical and health policy research, global surveillance and disease control, and knowledge generation and dissemination.