Financing global health 2011 global health council_Jan2012_IHME

January 19, 2012

Christopher Murray, Director, IHME

Michael Hanlon, Lecturer, IHME

Financing Global Health 2011: Continued growth as MDG deadline approaches

Outline

Why Track Development Assistance for Health?

Financing Global Health 2011 Methods

Key Findings on DAH

Recipient Government Responses

What Is Coming in 2012?

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IHME tries to inform three questions

Question IHME’s work

What are people’s health problems?

Track adult, child, maternal mortality; The Global Burden of Disease 2010 Study

How well does a society address these health problems?

Track inputs, outputs and outcomes from public health, medical care, and other key social determinants

What can be done in the future to maximize health improvement?

Estimate cost effectiveness of major interventions and health system intervention options

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Increased pressure for financing information

• In donors with contracting budgets, increased demand for up-to-date information on financial flows: where money goes and for what priorities

• In donors with rising budgets (DFID, AusAid), enhanced interest in tracking flows and their likely impacts

• Looming 2015 MDG deadline will be a focus of extensive policy advocacy for funding

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Tracking health financing

• Third edition of Financing Global Health

• Track development assistance for health (DAH) and government health expenditure as source

• Working on a systematic analysis of all available sources of data on out-of-pocket household expenditures on health, 1990-2010

• Future editions of Financing Global Health will eventually include all three components: DAH, government and private expenditures on health

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Outline

Why Track Development Assistance for Health?

Financing Global Health 2011 Methods

Key Findings on DAH

Recipient Government Responses

What Is Coming in 2012?

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Funding sources, channels of assistance, and implementing institutions

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Data sources

Avoiding double counting

• We track dollars at the point of the penultimate organization disbursing funds – funds that subsequently go to an organization that spends the dollars.

• Using a variety of sources including audited financial statements where available, we back track these funds to their primary source.

• Organizations can be a channel and a source: the totals will be different depending on the perspective taken.

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Preliminary estimates for donors and agencies

• Following the methods used in Financing Global Health 2010, we estimate for 2010 and 2011 by analyzing the historical relationship between budgets for donors and agencies and disbursements.

• Experience demonstrates actual disbursement in 2009 differed from predicted estimates for a number of donors. Overall, our preliminary estimate of DAH for 2009 in Financing Global Health 2010 was 0.6% lower than actual 2009 disbursements.

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DAH by topic area

• We estimated DAH by topic area through keyword searches of project descriptions, titles, and codes reported by channels.

• All DAH from UNAIDS was counted as DAH for HIV/AIDS; all DAH from GAVI and UNFPA were classified as DAH for maternal, newborn, and child health.

Project Type Search Terms

HIV HIV, HIV/AIDS, AIDS, retroviral, etc.

Tuberculosis TB, tuberculosis, directly observed treatment, etc.

Malaria Malaria, bet nets, insecticide, etc.

Health sector support Sector wide approach in health, sector program, etc.

Maternal, newborn, and child health Antenatal, prenatal, maternal health, child mortality, etc.

Noncommunicable diseases Cancer, chemotherapy, tobacco, psychological, cardiovascular, etc.

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Outline

Why Track Development Assistance for Health?

Financing Global Health 2011 Methods

Key Findings on DAH

Recipient Government Responses

What Is Coming in 2012?

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DAH by channel of assistance, 1990 to 2011

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Change in DAH, 2010 to 2011

Global Fund: 2010 versus 2011

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Global Fund: trends 2002 to 2011

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DAH by source

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DAH as share of GDP: USA #4

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Total overseas health expenditures channeled through US NGOs by funding source, 1990-2011

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Top 15 NGOs in overseas health expenditure, 2005 to 2008

Fund balances for UN health-related agencies at end of 2009

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Top 30 country recipients of DAH, 2004 to 2009, compared with top 30 countries by all-cause burden of disease, 2004

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Total DAH per all-cause DALY, 2004 to 2009

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DAH for HIV-AIDS; maternal, newborn, and child health;malaria;health sector support; TB; and non-communicable disease

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DAH for maternal and child health by channel of assistance, 1990 to 2009

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DAH for health sector support by channel of assistance, 1990 to 2009

Outline

Why Track Development Assistance for Health?

Financing Global Health 2011 Methods

Key Findings on DAH

Recipient Government Responses

What Is Coming in 2012?

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GHE-S by Global Burden of Disease developing region, 1995 to 2009

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Domestic spending: continued growth

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Year Total growth East Asia growth

2004 8.7% 13.0%2005 6.2% 10.2%2006 12.1% 14.3%2007 12.0% 23.0%2008 11.1% 18.3%2009 11.4% 19.2%

Domestic spending: continued growth

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Asia, SouthAsia, Southeast

Latin America, CentralNorth Africa / Middle East

Latin America, AndeanSub-saharan Africa, Southern

Sub-saharan Africa, WestOceania

Latin American, TropicalSub-saharan Africa, EastLatin America, Southern

Asia, EastCaribbean

Asia, CentralSub-saharan Africa, Central

0 .2 .4 .6 .8Percent change in GHE-S per capita

0 .2 .4 .6 .8Percent change in GHE-S

However, “subadditionality” persists

• Government spent $100 last year, expected to spend $110 this year.

• Government receives DAH-G of $10.

• Government spending increases to only $104.40, for a total health investment of $ 114.40

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Relationship between GHE-S and DAH-G in East sub-Saharan Africa, 2006 to 2007

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Relationship between GHE-S and DAH-G in East sub-Saharan Africa, 2008 to 2009

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Subadditionality summarized

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• Domestic financing is crucial to achieving MDGs.

• Aggregate results consistent year-over-year.

• DAH-G and DAH-NG affect behavior differently. Does not imply DAH-NG is better at influencing population health!

Outline

Why Track Development Assistance for Health?

Financing Global Health 2011 Methods

Key Findings on DAH

Recipient Government Responses

What Is Coming in 2012?

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How much does subadditionality matter?

• Evidence mixed on the effect of spending. Why?

• Rising evidence DAH has had an impact: declines in HIV mortality due to ARV expansion; declines in malaria mortality due to ACT roll-out and ITN scale-up.

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Subadditionality’s effect

• Additionality is likely asymmetric: when DAH-G contracts, Ministries of Finance do not replace budgets as fast as they cut.

• Continued progress on MDG 4, 5, and 6 depends on the trajectory of DAH growth and response of Ministries of Finance.

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Estimating OOP

• Most household surveys underestimate expense.

• Via calibration with World Health Surveys, we adjust to form reliable estimates from 1990 to 2010.

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Living with slow growth?

1) From 2001 to 2008, unprecedented massive growth in DAH. Since 2008, growth at rates similar to the 1990s.

2) Global Fund declines are a critical component of slowing trend. Sustaining growth depends on the balance of expansion in GAVI, DFID, AusAid, World Bank, versus the declines or constant funding from other donors.

3) Rising needs to fund ARVs and the expanding agenda for MDG 4 and 5, malaria, tuberculosis, and NCDs will put intense pressure on limited funds.

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Lessons from DFID and AusAid

1) Expanding ODA and DAH disbursement at DFID and AusAid demonstrates ODA budget allocations are not a simple function of public finances in developed countries.

2) Critical to continue providing solid evidence on DAH’s contribution to accelerate health progress. Premium on transparency, accountability, and impact evaluation.

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