The global health system: actors, norms, and expectations in transition.

In the first in a series of four articles highlighting the changing nature of global health institutions, Nicole Szlezák and colleagues outline the origin and aim of the series.

Financing of global health: tracking development assistance for health from 1990 to 2007.

BACKGROUND: The need for timely and reliable information about global health resource flows to low-income and middle-income countries is widely recognised. We aimed to provide a comprehensive assessment of development assistance for health (DAH) from 1990 to 2007. METHODS: We defined DAH as all flows for health from public and private institutions whose primary purpose is to provide development assistance to low-income and middle-income countries. We used several data sources to measure the yearly volume of DAH in 2007 US$, and created an integrated project database to examine the composition of this assistance by recipient country. FINDINGS: DAH grew from $5.6 billion in 1990 to $21.8 billion in 2007. The proportion of DAH channelled via UN agencies and development banks decreased from 1990 to 2007, whereas the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Global Alliance for Vaccines and Immunization (GAVI), and non-governmental organisations became the conduit for an increasing share of DAH. DAH has risen sharply since 2002 because of increases in public funding, especially from the USA, and on the private side, from increased philanthropic donations and in-kind contributions from corporate donors. Of the $13.8 [corrected] billion DAH in 2007 for which project-level information was available, $4.9 [corrected] billion was for HIV/AIDS, compared with $0.6 [corrected] billion for tuberculosis, $0.7 [corrected] billion for malaria, and $0.9 billion for health-sector support. Total DAH received by low-income and middle-income countries was positively correlated with burden of disease, whereas per head DAH was negatively correlated with per head gross domestic product. INTERPRETATION: This study documents the substantial rise of resources for global health in recent years. Although the rise in DAH has resulted in increased funds for HIV/AIDS, other areas of global health have also expanded. The influx of funds has been accompanied by major changes in the institutional landscape of global health, with global health initiatives such as the Global Fund and GAVI having a central role in mobilising and channelling global health funds. FUNDING: Bill & Melinda Gates Foundation.

Absorptive capacity and disbursements by the Global Fund to Fight AIDS, Tuberculosis and Malaria: analysis of grant implementation.

BACKGROUND: The Global Fund to Fight AIDS, Tuberculosis and Malaria was launched in 2002 to attract and rapidly disburse money to fight these diseases. However, some commentators believe that poor countries cannot effectively use such resources to increase delivery of their health programmes-referred to as a lack of absorptive capacity. We aimed to investigate the major determinants of grant implementation in developing countries. METHODS: With information available publicly on the Global Fund's website, we did random-effects analysis to investigate the effect of grant characteristics, types of primary recipient and local fund agent, and country attributes on disbursements that were made between 2003 and 2005 (phase one of Global Fund payments). To check the robustness of findings, regression results from alternative estimation methods and model specifications were also tested. FINDINGS: Grant characteristics--such as size of commitment, lag time between signature and first disbursement, and funding round-had significant effects on grant implementation. Enhanced political stability was associated with high use of grants. Low-income countries, and those with less-developed health systems for a given level of income, were more likely to have a higher rate of grant implementation than nations with higher incomes or more-developed health systems. INTERPRETATION: The higher rate of grant implementation seen in countries with low income and low health-spending lends support to proponents of major increases in health assistance for the poorest countries and argues that focusing resources on low-income nations, particularly those with political stability, will not create difficulties of absorptive capacity. Our analysis was restricted to grant implementation, which is one part of the issue of absorptive capacity. In the future, assessment of the effect of Global Fund grants on intervention coverage will be vital.

Effect of the Global Alliance for Vaccines and Immunisation on diphtheria, tetanus, and pertussis vaccine coverage: an independent assessment.

BACKGROUND: The Global Alliance for Vaccines and Immunisation (GAVI) was created in 1999 to enable even the poorest countries to provide vaccines to all children. We aimed to assess the effect of GAVI on combined diphtheria, tetanus, and pertussis vaccine (DTP3) coverage. METHODS: We examined the relation between DTP3 coverage for GAVI recipient countries from 1995 to 2004 and immunisation services support (ISS) and non-ISS expenditure per surviving child, controlling for income per head and local political governance variables. We analysed DTP3 coverage reported by governments and estimated by WHO/UNICEF. We also investigated the effect of GAVI on country reporting behaviour. RESULTS: In countries with DTP3 coverage of 65% or less at baseline, ISS spending per surviving child had a significant positive effect on DTP3 coverage (p=0.0005). This effect was not present in countries with DTP3 coverage of 65-80% or 80% or more at baseline. If ISS expenditure only is assessed, the estimated cost per additional child immunised in countries with baseline coverage of 65% or less is US$14 and if ISS and non-ISS expenditures are included the cost per child is almost $20. INTERPRETATION: The success of ISS funding in countries with baseline DTP3 coverage of 65% or less provides evidence that a public-private partnership can work to reverse a negative trend in global health and that performance-related disbursement can work in some settings. Because ISS funding seems to have no effect in countries with baseline coverage greater than 65%, GAVI should consider redistributing its resources to countries with the lowest coverage.

The burden of disease and injury in the United States 1996.

BACKGROUND: Burden of disease studies have been implemented in many countries using the Disability-Adjusted Life Year (DALY) to assess major health problems. Important objectives of the study were to quantify intra-country differentials in health outcomes and to place the United States situation in the international context. METHODS: We applied methods developed for the Global Burden of Disease (GBD) to data specific to the United States to compute Disability-Adjusted Life Years. Estimates are provided by age and gender for the general population of the United States and for each of the four official race groups: White; Black; American Indian or Alaskan Native; and Asian or Pacific Islander. Several adjustments of GBD methods were made: the inclusion of race; a revised list of causes; and a revised algorithm to allocate cardiovascular disease garbage codes to ischaemic heart disease. We compared the results of this analysis to international estimates published by the World Health Organization for developed and developing regions of the world. RESULTS: In the mid-1990s the leading sources of premature death and disability in the United States, as measured by DALYs, were: cardiovascular conditions, breast and lung cancers, depression, osteoarthritis, diabetes mellitus, and alcohol use and abuse. In addition, motor vehicle-related injuries and the HIV epidemic exacted a substantial toll on the health status of the US population, particularly among racial minorities. The major sources of death and disability in these latter populations were more similar to patterns of burden in developing rather than developed countries. CONCLUSION: Estimating DALYs specifically for the United States provides a comprehensive assessment of health problems for this country compared to what is available using mortality data alone.

Assessing the burden of disease in the United States using disability-adjusted life years.

OBJECTIVES: Burden of disease studies have been implemented in many countries using the disability-adjusted life year (DALY) to assess major health problems. METHODS: We applied methods developed by the World Bank and World Health Organization (WHO) to data specific to the United States to compute DALYs. We compared the results of this analysis to international estimates published by WHO for developed and developing regions of the world. RESULTS: In the mid-1990s, the leading sources of premature death and disability in the United States, as measured by DALYs, were cardiovascular conditions, breast and lung cancers, depression, osteoarthritis, diabetes mellitus, and alcohol use and abuse. In addition, motor vehicle-related injuries and the HIV epidemic exacted a substantial toll on the health status of the U.S. population, particularly among racial/ethnic minorities. The major sources of death and disability in these latter populations were more similar to patterns of burden in developing rather than developed countries. CONCLUSIONS: This analysis provides the first detailed, comprehensive estimates using DALYs of the fatal and nonfatal conditions that exact large health burdens in the United States.