Conclusions
Despite the promising trends in DAH over the past five to seven years, the outlook for the next few years is uncertain. What happens will depend on overall trends and innovations in development assistance, which in turn are driven by such factors as political changes and the rate of economic growth in OECD countries, and the willingness of high-income countries to honor their pledges to increase the share of GDP they devote to development.
Under most scenarios, the share of overall assistance going to health will likely continue its recent rise, given the current political focus on the global AIDS pandemic and the growing awareness of the challenges and opportunities associated with the MDGs for maternal and child health and communicable diseases.
Under a more conservative scenario, a number of factors could have a negative impact on DAH. Those factors could include an overall slowing in the rate of growth of development financing and the donor fatigue that could set in if the larger allocations for HIV/AIDS, TB, and malaria are not fully disbursed, are misused, or yield disappointing results on the ground.
Under a more optimistic scenario, DAH will continue to grow as developing countries and donors find new ways to disburse a higher volume of funds and use them effectively—for example, through subcontracts with NGOs and private health service delivery organizations. Sectorwide approaches and budget support through national poverty reduction programs may also result in expanded flows of DAH. New generations of technologies adapted to the developing world, such as more effective antimalarials, better TB diagnostics, and a vaccine to prevent HIV infection, would almost certainly attract increasing amounts of DAH.
Even under the more optimistic scenario, DAH will still face major challenges. The expected volume of financial assistance is unlikely to match the large needs of the developing world and the requirements to attain the MDGs. Countries and donors will therefore face difficult decisions in relation to priority setting and require better tools to make such allocation decisions. Cost-effectiveness analysis offers one such tool. Effective absorption of DAH will also continue to pose difficulties for countries with weak capacity. In such cases, increased use of NGOs and the private sector in general to complement public sector action may help make the information and services that poor households need to improve their health status more accessible.
Another issue is that the current architecture of development assistance does not contain a mechanism to ensure that adequate funds flow to the upstream stages of R&D on new health technologies, where the private sector lacks the market incentives to invest and where national research bodies have so far not been up to the task. The multilateral banks do not have the instruments to channel major funding to global, as opposed to national, health technology programs, and the bilateral agencies alone are not equal to this task. Even with the modest external funds allocated to the recently established public-private partnerships (such as the IAVI, the Medicines for Malaria Venture, the Global TB Drug Alliance, and the International Partnership for Microbicides), new technologies are emerging. However, they need to be reinforced with additional funding. One option would be to design a new funding facility within the multilateral banks that would allow them to allocate significant resources to global health research and product development. Another would be to use the nascent international finance facility to provide funds for global research.
To address those challenges, strong political will is the essential baseline ingredient, as recent experience with HIV/AIDS has clearly demonstrated. The United Nations and the multilateral agencies must remain firmly behind more robust DAH, as they are currently doing by means of the Millennium Project and the High-Level Forum on the Health-Related MDGs. Individual bilateral donors and foundations must continue to demonstrate their leadership. Finally, and perhaps most important, leaders and civil society organizations in poor countries need to continue to speak out for more and more effective DAH, indicating that health is their priority and that they are prepared to commit domestic resources to match the larger external flows provided through DAH.
