Sector-wide or disease-specific? Implications of trends in development assistance for health for the SDG era

Abstract

The record of the Millennium Development Goals broadly reflects the trade-offs of disease-specific financing: substantial progress in particular areas, facilitated by time-bound targets that are easy to measure and communicate, which shifted attention and resources away from other areas, masked inequalities and exacerbated fragmentation. In many ways, the Sustainable Development Goals reflect a profound shift towards a more holistic, system-wide approach. To inform responses to this shift, this article builds upon existing work on aggregate trends in donor financing, bringing together what have largely been disparate analyses of sector-wide and disease-specific financing approaches. Looking across the last 26 years, the article examines how international donors have allocated development assistance for health (DAH) between these two approaches and how attempts to bridge them have fared in practice. Since 1990, DAH has overwhelmingly favoured disease-specific earmarks over health sector support, with the latter peaking in 1998. Attempts to integrate system strengthening elements into disease-specific funding mechanisms have varied by disease, and more integrated funding platforms have failed to gain traction. Health sector support largely remains an unfulfilled promise: proportionately low amounts (albeit absolute increases) which have been inconsistently allocated, and the overall approach inconsistently applied in practice. Thus, the expansive orientation of the Sustainable Development Goals runs counter to trends over the last several decades. Financing proposals and efforts to adapt global health institutions must acknowledge and account for the persistent challenges in the financing and implementation of integrated, cross-sector policies. National and subnational experimentation may offer alternatives within and beyond the health sector.

Figure 1.

Amount of development assistance for health allocated to specific diseases, health sector support and other areas: 1990–2015. Note: ‘Other’ refers to cases with project-level information that does not fall into any of the health focus areas tracked by IHME.

Figure 2.

Global agenda setting milestones and trends in health funding over time: amount and proportion of overall development assistance for health allocated to different health areas.

Figure 3.

Proportion of development assistance for health allocated to health sector support across countries with different Worldwide Governance Indicator rankings. (a) Countries ranking at the bottom, median and top of the Worldwide Governance Indicators. This includes two examples of bottom ranked countries: Somalia, which has featured prominently in world politics, and low profile Equatorial Guinea. (b) Countries with the biggest variation in Worldwide Governance Indicator rankings over time. Note: These graphs use 3-year moving averages to account for large tranche payments in a particular year.

Figure 4.

Proportion of disease-specific funding allocated to health-systems strengthening. Note: Solid lines represent the proportion of disease-specific funding (as a subset of overall development assistance for health) allocated to health-systems strengthening. The dotted line represents the proportion of overall development assistance for health allocated to health sector support.