Mortality changes after grants from the Global Fund to Fight AIDS, tuberculosis and malaria: an econometric analysis from 1995 to 2010

Abstract

Background: Since its founding in 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) has become the dominant multilateral health financier in low- and middle-income countries. The health impact of the Global Fund remains unknown because existing evaluations measure intermediate outcomes or do not account for preexisting and counterfactual trends.

Methods: We conducted an econometric analysis of data from all countries eligible to receive Global Fund grants from 1995 to 2010, prior to and during the Global Fund's activities. We analyzed three outcomes: all-cause adult (15-59 years), all-cause under-five, and malaria-specific under-five mortality. Our main exposure was a continuous longitudinal measure of Global Fund disbursements per capita. We used panel fixed effect regressions, and analyzed mortality trends controlling for health spending, health worker density (a measure of health system capacity), gross domestic product, urbanization, and country fixed-effects.

Results and discussion: We find that following Global Fund disbursements, adult mortality rate declined by 1.4 % per year faster with every $10 per capita increase in disbursements (p = 0.005). Similarly, malaria-specific under-five mortality declined by 6.9 % per year faster (p = 0.033) with every $10 high per capita Global Fund disbursements. However, we find no association between Global Fund support and all-cause under-five mortality. These findings were consistent after subanalyses by baseline HIV prevalence, adjusting for effects of concurrent health aid from other donors, and varying time lags between funding and mortality changes.

Conclusions: Grants from the Global Fund are closely related to accelerated reductions in all-cause adult mortality and malaria-specific under-five mortality. However, up to 2010 the Global Fund has not measurably contributed to reducing all-cause under-five mortality.

Fig. 1

Geographical distribution of Global Fund support. Countries are shaded according to the tertile of per capita total Global Fund disbursements between 2002 and 2010, from lowest (lightest) to highest (darkest)

Fig. 2

Mortality trends relative to year of first Global Fund disbursements among eligible countries, divided into tertiles of per capita disbursements: a all-cause adult mortality, b all-cause under-five mortality, and c malaria-specific under-five mortality. The mortality rate of each country is presented as the difference between the country’s year-specific mortality and its mean mortality between 1995 and 2010 (de-meaned). Each funding group’s mortality rate is the average of the de-meaned values for all countries within the group, thus removing from the graphs the large mortality level differences between groups that persisted throughout the time period evaluated (see Table 1), and approximating the fixed-effects regression. For each country, Year 0 represents the first year of support from the Global Fund