Challenges do exist in management, allocation and implementation of DAH

In 2014, the United Nations Conference on Trade and Development estimated an annual funding gap of US$2.5 trillion to achieving the Sustainable Development Goals (SDGs) in developing countries.3 As was estimated and forecasted by the International Monetary Fund, decline in public spending and consequently stagnated national health budgets have occurred widely in low-income and middle-income countries over the past decade, and will be aggravated by the impact of COVID-19 in the coming years.4 Against this backdrop, international institutions have been appealing for additional partners and resources to join the endeavour for development; thus, mobilising private finance and enhancing public–private partnerships (PPPs) have become an increasingly urgent requirement for development cooperation. Along with such trends and appeals, the financing paradigm of the DAH is also shifting towards this direction.

However, while the private sector is expected to provide additional financing, services and knowledge, DAH via PPPs is not yet a much matured mechanism. Concerns have been raised regarding process oversight and outcome assurance in relation to such partnerships, seeing the private sector is not always bound by effectiveness principles, including ownership, results orientation, transparency and accountability, and given its profit-seeking nature service affordability is not always guaranteed for low-income groups.5 6 Hence, stakeholders are faced with the challenge of establishing and implementing a holistic mechanism that enables cooperation, regulation and results monitoring of DAH via PPPs.

Meanwhile, concerns have been raised regarding disproportionate DAH allocations and suboptimal priorities. Prior to the COVID-19 pandemic, there had been an imbalance between DAH allocations and regional needs. In 2019, the largest DAH allocation (US$14.68 billion) flowed to sub-Saharan Africa, where the age-standardised rate of disability-adjusted life years (DALY) was 51 529.16 per 100 000 population, while South Asia, with an age-standardised DALY rate of 38 642.20 per 100 000 population, received the second largest allocation of US$2.10 billion, 14.31% of the amount allocated to sub-Saharan Africa.1 7 Furthermore, the priority health focus areas reflected by the DAH flows have not been well aligned with the level of disease burden. For instance, in 2019, non-communicable diseases (NCDs) were responsible for the highest age-standardised DALY rate (20 204.91 per 100 000 population), which was 7–125 times higher than that of other causes. This health focus area, however, only attracted limited global attention, receiving US$1.24 billion, which was only equal to approximately 12%–50% of the DAH allocated to other areas.1 7 Donors’ and recipients’ consideration over the cost-effectiveness of NCD prevention and control is understandable, but still all stakeholders need to recognise the grave burden of NCD and take measures to address it. In addition, in terms of regions and health focus areas, DAH allocated via bilateral agencies sometimes appeared to be less related to the level of disease burden than via multilateral organisations.1 7

The overall distribution of DAH allocations was then affected by the COVID-19 pandemic, when additional substantive resources of more than US$18 billion annually were allocated to COVID-19 response. In addition, DAH for sector-wide approaches and health system strengthening (SWAps and HSS) increased by 17.69%, while DAH for reproductive and maternal health and malaria prevention and control declined by 14.50% and 10.00%, respectively.1 ,7 As the impacts of the COVID-19 pandemic are being mitigated and the global attention is shifting away from pandemic response, and while the acknowledgement of public health emergency response must be maintained, the pattern of DAH allocation needs to be mutually reconsidered.

Another concern is how to best realise ‘assistance’ by means of DAH. Capacity building (including SWAps and HSS) and provision of public and private goods (including infrastructure construction, medical products distribution, etc) are the two main types of DAH, with the former always considered the fundamental approach to addressing health challenges in the most sustainable way. Indeed, seen from the financing flows, considerable attention has been attached to capacity building via comprehensive SWAps and HSS, with a proportion of about 15% of the total DAH annually over the last 20 years. However, despite an overall uptrend, the proportion of DAH for HSS in each health focus area varied and fluctuated over the years (figure 1; the methods are provided in the online supplemental material). For instance, of the total DAH for HIV prevention and control, the proportion allocated to the HSS approach increased from 17.58% in 1990 to 38.57% in 1993, reduced to 12.97% in 2003 and reboosted to 26.40% in 2013, yet reduced again to 14.76% in 2021. Such turbulence surely leaves the sustainability and effectiveness of this strategy much less predictive and thus impairs the possibility for recipient countries to formulate long-term plans towards building a resilient health system.

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Figure 1

Proportion of DAH for health system strengthening by health focus areas, 1990–2021 (in million US dollars). The size of each bubble reflects the amount of DAH for the corresponding health focus area of the year. Parts in darker colour are the DAH for health system strengthening of the corresponding health focus area, while parts in lighter colour are the DAH for other measures. DAH, development assistance for health; MAL, malaria; NCD, non-communicable disease; NCH, neonatal and child health; OID, other infectious diseases; RMH, reproductive and maternal health; TB, tuberculosis.

On the other hand, provision of public and private goods is the most direct approach to alleviating disease burden and enhancing global confidence in DAH. Since 1990, at least 60% of the total amount of DAH has been directed towards provision of public and private goods; however, continuous and ever-increasing investments are required if the world were to meet the needs of a growing global population. When the world is still faced with the problem that the funding mobilised cannot yet fill the estimated financing gap, measures need to be taken to improve the cost-effectiveness of this approach. In this sense, further innovation in both mechanism and technology is imperative and requires the intelligence of all stakeholders.

Steps towards addressing the challenges in a harmonised and innovative way

At the core of these challenges lies one fundamental defect of the current global DAH system, namely the lack of overall strategic planning and communication mechanisms, especially within the donors. This leads to unnecessary trial and errors in mechanism setting, redundancy, fragmentation and unpredictability of DAH allocation, and consequently significant wastage of resources. The most ideal approach to dealing with these challenges is for all stakeholders to work in a harmonised way, with United Nations (UN) agencies coordinating the activities. Meanwhile, to improve the effects of DAH, current cooperation mechanisms and technologies also need to be updated in response to the rapid changes in the world.

Regarding adaptation to the new financing paradigm, establishment and implementation of cooperation and regulation mechanisms in relation to DAH via PPPs require timely sharing of experiences among stakeholders with different backgrounds. Efforts have been made by traditional donors to explore feasible monitoring mechanisms for the long-term practice of development-related activities by means of PPPs,8 and various UN agencies and the World Bank have established country case studies to set up models for this paradigm.9 10 Also, seeing the emerging donor countries have been using PPPs for development cooperation for decades,11 12 the experience they have accumulated is invaluable and should be analysed with the view of guiding future applications. For countries where the private sector is less involved in the DAH system, governments and relevant multilateral organisations should consider providing incentives, not necessarily limited to monetary approach, to the private sector in order to encourage participation and devotion.

As to the disproportionate DAH allocations and suboptimal priorities, several factors may have contributed to such situations. For donor countries, decisions regarding DAH allocations can be affected by various factors, including the estimated cost-effectiveness, political and economic interests, and concerns over domestic national health security. For multilateral organisations, although their principles and strategies might result in better equality in resource allocation, it has been argued that flaws in their decision-making processes, including the non-transparent influence of donors and bureaucrats and the inadequate assessment of the needs of recipient countries, could diminish the fairness of their decisions.13 14 In both cases, transparency of methods and procedures with regard to the decision-making for DAH allocation requires improvement. In the mean time, more efforts should be focused on research and assessment to better map the needs of recipient countries, with primary emphasis on the effectiveness principle of country ownership. Harmonisation among various donors should also be enhanced to rationalise resource distribution and thereby take full advantage of the capacity of different donors, while ensuring that no one in need is overlooked. During such processes, innovative mechanisms and practices are of great necessity, and multilateral organisations should play a prominent role in building networks, coordinating activities, and providing knowledge and intelligence.

For the capacity building approach to DAH, in order to fully bring out the potential of SWAps and HSS, donors should stabilise their investments to enable a more ideal environment for implementation of national strategies,15 16 and all stakeholders need to put more emphasis on strengthening the relative building blocks of the health system, including government leadership, financing, health information systems and health workforce,17 so as to ensure a solid base for the next steps of development. International consensus and harmonisation among stakeholders on the importance of capacity building for health system resilience are the cornerstones of predictable inputs of resources. In the mean time, donor commitments should be strengthened and guaranteed by constraints with more power. For the goods provision approach, delivery of DAH in a cost-effective manner requires continuous innovation in terms of both mechanisms and technologies, that is, to reduce wastes and better the outputs through the whole process and across all aspects, including construction and operation of health infrastructures, and manufacture, transportation and preservation of medical products, together with enhancement of the effects of medicines and vaccines. Joint efforts across the globe are essential to the establishment and development of viable practices, as well as to ongoing research and development.