Seattle researchers have quantified what has long been an open secret about international aid: Many poor nations cut back on their own health spending after they get funding from wealthy donor nations.
For every dollar in health aid received, governments in the developing world on average shifted between 43 cents and $1.14 from their own health budgets into other priorities, says an analysis published Friday in the medical journal The Lancet and funded by the Bill & Melinda Gates Foundation.
The other priorities could include education, road building — or even the military. But the University of Washington’s Institute for Health Metrics and Evaluation (IHME) wasn’t able to track where the money went, said Director Christopher Murray.
In a finding sure to fuel debate, the Seattle scientists also report that aid money given directly to governments led those governments to cut their own health spending, while money funneled through nongovernmental organizations did not.
The majority of U.S. health aid is awarded to NGOs, which, in turn, build clinics, train health workers and oversee other health projects. The Gates Foundation takes a similar approach. But many other nations give money directly to governments, which is meant to bolster national health systems.
Lancet Editor Dr. Richard Horton said the results raise “a red flag over aid effectiveness.”
But some economists argue that it makes sense for poor nations to reallocate their scarce resources to plug budget gaps, Murray pointed out.
The findings aren’t a surprise to global health insiders, said Sir Richard Feachem, former executive director of Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund, which pools money from wealthy nations and foundations, requires recipient nations to maintain their own level of spending. But everyone knew budget shifting was going on.
“This is the first really serious and thorough effort to quantify this phenomenon,” said Feachem, now director of the Global Health Group at the University of California, San Francisco.
Celebrities and corporations have embraced the cause of global health and Americans have poured unprecedented amounts into bed net drives and charities like the ONE Campaign. Many may be distressed to realize their money hasn’t boosted health spending as much as they thought, Feachem said.
“I suspect to some of them, this will be a bit of a shock.”
The institute’s analysis focused on money earmarked for health programs, not the much larger pot devoted to overall development. Fueled, in part, by an influx of cash from the Gates Foundation, international health aid has nearly tripled over the past 10 years to a total of $22 billion in 2007.
Most of that aid goes to African nations where scourges like malaria, diarrhea and tuberculosis claim millions of lives every year.
That’s also where the biggest budget shifts occurred, Murray and his colleagues found.
They also found a lot of variation across the continent. While Zambia slashed its own health budget in direct proportion to aid donations, its tiny neighbor, Malawi, boosted government health spending at the same time it was taking in large amounts of international aid. Malawi is now making the fastest progress of any African nation on reducing child mortality, Murray pointed out.
Poor and middle-income nations in Latin America and Asia have also boosted their own spending on health over the past decade, the analysis found. Worldwide, the combination of international aid and government spending has roughly doubled the amount devoted to health in developing nations.
“There’s more money being spent on health, and we’re seeing progress on health,” Murray said. “That’s good news.”
A commentary published along with the IHME analysis cautioned against jumping to the conclusion that governments in developing nations can’t be trusted to make the best use of aid money.
Funneling money away from national health ministries and into NGO-run programs, many of which focus only on specific diseases, could undermine government health systems that are crucial to things foreign aid rarely supports, like prenatal care, hiring health workers and buying drugs, wrote Devi Sridhar and Ngaire Woods, of the University of Oxford.
They also questioned the data in the report, which relies on incomplete and conflicting budget numbers.
Feachem said his major concern is that governments that cut their own health budgets and rely mainly on aid are vulnerable.
“International aid is fickle,” he said. “Developing countries have to build their own foundation for a future, sustainable health-care system.”
Founded with a $105 million grant from the Gates Foundation, IHME’s charge is to bring statistical rigor to the field of global health, where claims of success are sometimes overblown and politics can influence data.
But Murray and his team have antagonized many in the field.
For this study, they and the Lancet shared the results in advance and invited global health experts to participate in a round-table discussion in London on Friday.
“IHME’s basic remit is to get the numbers straight,” Feachem said. When those numbers are controversial, the institute should also reach out and give interested parties a chance to debate and discuss, he added.
“IHME should take no pleasure in surprising people.”
By Sandi Doughton, 206-464-2491 or [email protected] Seattle Times science reporter