Rethinking how development assistance for health can catalyse progress on primary health care.

Global campaigns to control HIV, tuberculosis, malaria, and vaccine-preventable illnesses showed that large-scale impact can be achieved by using additional international financing to support selected, evidence-based, high-impact investment areas and to catalyse domestic resource mobilisation. Building on this paradigm, we make the case for targeting additional international funding for selected high-impact investments in primary health care. We have identified and costed a set of concrete, evidence-based investments that donors could support, which would be expected to have major impacts at an affordable cost. These investments are in: (1) individuals and communities empowered to engage in health decision making, (2) a new model of people-centred primary care, and (3) next generation community health workers. These three areas would be supported by strengthening two cross-cutting elements of national systems. The first is the digital tools and data that support facility, district, and national managers to improve processes, quality of care, and accountability across primary health care. The second is the educational, training, and supervisory systems needed to improve the quality of care. We estimate that with an additional international investment of between US$1·87 billion in a low-investment scenario and $3·85 billion in a high-investment scenario annually over the next 3 years, the international community could support the scale-up of this evidence-based package of investments in the 59 low-income and middle-income countries that are eligible for external financing from the World Bank Group's International Development Association.

Strategic donor behaviour and country vulnerability in health aid transitions.

BACKGROUND: When countries reach the middle-income threshold, many multilateral donors, including Gavi, the Vaccine Alliance (Gavi), begin to withdraw their official development assistance (ODA), known as graduation. We hypothesised that bilateral donors might follow Gavi's lead, except in countries where they have strategic interests. We aim to understand how bilateral donors behave after a recipient country graduates from Gavi support and how bilateral donors might treat Gavi support countries differently, based on 'strategic interest'. We also aim to identify countries that were more vulnerable to 'simultaneous' transitions and financial cliffs after Gavi transition. METHODS: This is an observational dyadic analysis using longitudinal data. We collected country-level data on 77 Gavi-eligible countries between 2009 and 2018 and paired donor and recipient country in a specific year to conduct dyadic analysis. We included Gavi graduation status and Gavi disbursement as explanatory variables. We controlled for (1) donor-recipient relationship variables that represent potential strategic relationships (eg, distance between donor and recipient country) and (2) recipient-level characteristics (eg, population, income). We used Odinary Least Squares regression, Tobit and two-part model in Stata SE 15.0. FINDINGS: We found a country would receive $3.1 million less all sector ODA from a bilateral donor, and $0.6 million less health ODA, after they graduate from Gavi. For every additional 1% ODA a country would receive from Gavi, it would receive 0.14% more ODA and 0.16% more health ODA from individual bilateral donors. Gavi's graduation status or disbursement brought more change in percentage term to health ODA than to total ODA. Additionally, Gavi's graduation was observed to have a larger negative impact on bilateral ODA in the longer term. Countries that sent more migrants, had been colonised, and received more US military assistance tended to receive more ODA. There are similarities and differences across different donors and bilateral donors tend to provide more ODA to nearby countries and countries receiving fewer exports from the donor. We found that former colonies did not see a decline in aid after Gavi graduation. CONCLUSION: Bilateral donors behave in a similar manner to Gavi when it comes to funding health systems in low and middle-income countries. Therefore, some countries may be at risk of losing donor resources for health from a multitude of sources around the same time. However, countries that have a strategic interest in bilateral donors may be spared from such funding cliffs. This research has important implications for global health donors' funding policies and approaches in addition to recipient countries' transition planning.

Chinese health funding in Africa: The untold story.

The motivations behind China's allocation of health aid to Africa remain complex due to limited information on the details of health aid project activities. Insufficient knowledge about the purpose of China's health aid hinders our understanding of China's comprehensive role in supporting Africa's healthcare system. To address this gap, our study aimed to gain better insights into China's health aid priorities and the factors driving these priorities across Africa. To achieve this, we utilized AidData's Chinese Official Finance Dataset and adhered to the Organisation for Economic Co-operation and Development (OECD) guidelines. We reclassified all 1,026 health projects in Africa, originally categorized under broad 3-digit OECD-DAC sector codes, into more specific 5-digit CRS codes. By analyzing the project count and financial value, we assessed the shifting priorities over time. Our analysis revealed that China's priorities in health aid have evolved between 2000 and 2017. In the early 2000s, China primarily allocated aid to basic health personnel and lacked diversity in sub-sectors. However, after 2004, China shifted its focus more toward basic infrastructure and reduced emphasis on clinical-level staff. Furthermore, China's interest in addressing malaria expanded both in scale and depth between 2006 and 2009. This trend continued in 2012 and 2014 when China responded to the Ebola outbreak by shifting its focus from basic infrastructure to infectious diseases. In summary, our findings demonstrate the changes in China's health aid strategy, starting with addressing diseases already eliminated in China and gradually transitioning towards global health security, health system strengthening, and shaping the governance mechanisms.

United Kingdom aid cuts: implications for financing health systems.

Background: The United Kingdom (UK) used to be the second largest bilateral provider of official development assistance (ODA) for health. However, in 2021 the UK government cut its annual aid budget by 30%. We aim to understand how these cuts might affect financing for health systems in UK aid recipient countries. Methods: We conducted a retrospective analysis of domestic and external funding for 134 countries that received UK aid for the 2019-2020 budget year. We grouped countries into two cohorts: those that continued to receive aid in 2020-2021 ("budget") and those that did not ("no budget"). Data was collected from publicly available datasets and we compared UK's ODA, UK's health ODA with total ODA, general government expenditures and domestic general government health expenditure to assess the donor dependency and donor concentration of budget and no budget countries. Findings: Budget countries are more reliant on external aid to finance their governments and health systems than no budget countries, with a handful of exceptions. While the UK does not appear to be a major ODA contributor among most no budget countries, it is in many budget countries. Two no budget countries in particular may be faced with health systems financing challenges given their high ratios of UK health aid to domestic government health expenditures: the Gambia (1.24:1) and Eritrea (0.33:1). Although "safe" for this budget cycle, a number of low-income countries in Sub-Saharan Africa have very high ratios of UK health aid to domestic government health expenditures, including South Sudan (3.15:1), Sierra Leone (0.48:1), and the Democratic Republic of Congo (0.34:1). Interpretation: The 2021-2022 UK aid cuts could have negative impacts in a few countries highly dependent on UK health aid. Its departure could leave these countries with rather large funding gaps to fill and create a more concentrated donor climate.

Investing in a global pooled-funding mechanism for late-stage clinical trials of poverty-related and neglected diseases: an economic evaluation.

INTRODUCTION: Poverty-related and neglected diseases (PRNDs) cause over three million deaths annually. Despite this burden, there is a large gap between actual funding for PRND research and development (R&D) and the funding needed to launch PRND products from the R&D pipeline. This study provides an economic evaluation of a theoretical global pooled-funding mechanism to finance late-stage clinical trials of PRND products. METHODS: We modelled three pooled-funding design options, each based on a different level of coverage of candidate products for WHO's list of PRNDs: (1) vaccines covering 4 PRNDs, (2) vaccines and therapeutics covering 9 PRNDs and (3) vaccines, therapeutics and diagnostics covering 30 PRNDs. For each option, we constructed a discrete event simulation of the 2019 PRND R&D pipeline to estimate required funding for phase III trials and expected product launches through 2035. For each launch, we estimated global PRND treatment costs averted, deaths averted and disability-adjusted life-years (DALYs) averted. For each design option, we calculated the cost per death averted, cost per DALY averted, the benefit-cost ratio (BCR) and the incremental cost-effectiveness ratio (ICER). RESULTS: Option 1 averts 18.4 million deaths and 516 million DALYs, has a cost per DALY averted of US$84 and yields a BCR of 5.53. Option 2 averts 22.9 million deaths and 674 million DALYs, has a cost per DALY averted of US$75, an ICER over option 1 of US$49 and yields a BCR of 3.88. Option 3 averts 26.9 million deaths and 1 billion DALYs, has a cost per DALY averted of US$114, an ICER over option 2 of US$186 and yields a BCR of 2.52. CONCLUSIONS: All 3 options for a pooled-funding mechanism-vaccines for 4 PRNDs, vaccines and therapeutics for 9 PRNDs, and vaccines, therapeutics and diagnostics for 30 PRNDs-would generate a large return on investment, avert a substantial proportion of the global burden of morbidity and mortality for diseases of poverty and be cost-effective.

Estimating Chinese bilateral aid for health: an analysis of AidData's Global Chinese Official Finance Dataset Version 2.0.

BACKGROUND: Although it is difficult to quantify, previous estimates suggested that China's global health aid has increased sharply since the early 2000s. Unlike many donors, China has no official aid reporting obligations, nor does it voluntarily disclose detailed aid information. Our study aimed to create a standardised estimate using commonly accepted definitions of aid and frameworks for categorising health projects. METHODS: We categorised AidData's Chinese Official Finance Dataset health-related projects according to health aid frameworks from the Organisation for Economic Co-operation and Development (OECD) and the Institute for Health Metrics and Evaluation (IHME). Only projects that complied with the definition of official development assistance were included. We analysed the project count and financial value to assess China's priority health aid areas. FINDINGS: Between 2000 and 2017, China funded 1339 health-related aid projects, or 13% of its total aid project portfolio. Most of these projects were located in sub-Saharan Africa. According to the OECD framework, the priority focus areas of these projects were: medical services, such as specialty equipment and tertiary services (n=489, 37%); basic health care, such as basic medical services and drugs (n=251, 19%); malaria control (n=234, 18%) and basic health infrastructure (n=178, 13%). Under the IHME framework, health systems strengthening accounted for 74% (n=991) of total projects, primarily due to China's contributions to human resources for health, infrastructure and equipment. The only other major allocation under the IHME framework was malaria (n=234, 18%). When we estimated missing financial values under the OECD framework, China was the fifth largest health aid donor to African countries from 2002 to 2017, after the USA, the UK, Canada and Germany. CONCLUSION: Our findings enable a better understanding of Chinese health aid in the absence of transparent aid reporting, which could contribute to better coordination, collaboration and resource allocation for both donor and recipient countries.

Tracking financing for global common goods for health: A machine learning approach using natural language processing techniques.

Objective: Tracking global health funding is a crucial but time consuming and labor-intensive process. This study aimed to develop a framework to automate the tracking of global health spending using natural language processing (NLP) and machine learning (ML) algorithms. We used the global common goods for health (CGH) categories developed by Schäferhoff et al. to design and evaluate ML models. Methods: We used data curated by Schäferhoff et al., which tracked the official development assistance (ODA) disbursements to global CGH for 2013, 2015, and 2017, for training and validating the ML models. To process raw text, we implemented different NLP techniques, such as removing stop words, lemmatization, and creation of synthetic text, to balance the dataset. We used four supervised learning ML algorithms-random forest (RF), XGBOOST, support vector machine (SVM), and multinomial naïve Bayes (MNB) (see Glossary)-to train and test the pre-coded dataset, and applied the best model on dataset that hasn't been manually coded to predict the financing for CGH in 2019. Results: After we trained the machine on the training dataset (n = 10,534), the weighted average F1-scores (a measure of a ML model's performance) on the testing dataset (n = 2,634) ranked 0.79-0.83 among four models, and the RF model had the best performance (F1-score = 0.83). The predicted total donor support for CGH projects by the RF model was $2.24 billion across 3 years, which was very close to the finding of $2.25 billion derived from coding and classification by humans. By applying the trained RF model on the 2019 dataset, we predicted that the total funding for global CGH was about $2.7 billion for 730 CGH projects. Conclusion: We have demonstrated that NLP and ML can be a feasible and efficient way to classify health projects into different global CGH categories, and thus track health funding for CGH routinely using data from publicly available databases.

Identifying the impact of COVID-19 on health systems and lessons for future emergency preparedness: A stakeholder analysis in Kenya.

The coronavirus pandemic (COVID-19) has triggered a public health and economic crisis in high and low resource settings since the beginning of 2020. With the first case being discovered on 12th March 2020, Kenya has responded by using health and non-health strategies to mitigate the direct and indirect impact of the disease on its population. However, this has had positive and negative implications for the country's overall health system. This paper aimed to understand the pandemic's impact and develop lessons for future response by identifying the key challenges and opportunities Kenya faced during the pandemic. We conducted a qualitative study with 15 key informants, purposefully sampled for in-depth interviews from September 2020 to February 2021. We conducted direct content analysis of the transcripts to understand the stakeholder's views and perceptions of how COVID-19 has affected the Kenyan healthcare system. Most of the respondents noted that Kenya's initial response was relatively good, especially in controlling the pandemic with the resources it had at the time. This included relaying information to citizens, creating technical working groups and fostering multisectoral collaboration. However, concerns were raised regarding service disruption and impact on reproductive health, HIV, TB, and non-communicable diseases services; poor coordination between the national and county governments; shortage of personal protective equipment and testing kits; and strain of human resources for health. Effective pandemic preparedness for future response calls for improved investments across the health system building blocks, including; human resources for health, financing, infrastructure, information, leadership, service delivery and medical products and technologies. These strategies will help build resilient health systems and improve self-reliance, especially for countries transitioning from donor aid such as Kenya in the event of a pandemic.

Transitioning from donor aid for health: perspectives of national stakeholders in Ghana.

BACKGROUND: Ghana's shift from low-income to middle-income status will make it ineligible to receive concessional aid in the future. While transition may be a reflection of positive changes in a country, such as economic development or health progress, a loss of support from donor agencies could have negative impacts on health system performance and population health. We aimed to identify key challenges and opportunities that Ghana will face in dealing with aid transition, specifically from the point of view of country-level stakeholders. METHODS: We conducted key informant interviews with 18 stakeholders from the government, civil society organisations and donor agencies in Ghana using a semistructured interview guide. We performed directed content analysis of the interview transcripts to identify key themes related to anticipated challenges and opportunities that might result from donor transitions. RESULTS: Overall, stakeholders identified challenges more frequently than opportunities. All stakeholders interviewed believe that Ghana will face substantial challenges due to donor transitions. Challenges include difficulty filling financial gaps left by donors, the shifting of national priorities away from the health sector, lack of human resources for health, interrupted care for beneficiaries of donor-funded health programmes, neglect of vulnerable populations and loss of the accountability mechanisms that are linked with donor financing. However, stakeholders also identified key opportunities that transitions might present, including efficiency gains, increased self-determination and self-sufficiency, enhanced capacity to leverage domestic resources and improved revenue mobilisation. CONCLUSION: Stakeholders in Ghana believe transitioning away from aid for health presents both challenges and opportunities. The challenges could be addressed by conducting a transition readiness assessment, identifying health sector priorities, developing a transition plan with a budget to continue critical health programmes and mobilising greater political commitment to health. The loss of aid could be turned into an opportunity to integrate vertical programmes into a more comprehensive health system.

Pulling the purse strings: Are there sectoral differences in political preferencing of Chinese aid to Africa?

OBJECTIVE: China is emerging as an increasingly important player in the global development space, but may be less bound to compacts that aim to curb political preferencing and therefore may produce less yield in terms of impact toward Sustainable Development Goals. This research tests the hypothesis that the disproportionate aid allocation to the birth regions of the current African political leaders that applies to some sectors more than others. DESIGN: We applied a two-part model to first estimate the probability that a region receives an aid project. Then when at least one aid project is present in a leader's birth region, we estimated the mean amount of aid the region received. SETTING: This analysis covers 699 subnational units (first administrative level) across 44 African countries over 2000-2014. These administrative units were compiled into a region year panel resulting in 10,485 observations. RESULTS: Birth regions of the current political leader are significantly more likely than the average of all of the regions to receive education (1.3 percentage points), social infrastructure and services (1.2 percentage points), and energy aid (1.7 percentage points). No significant association was found between aid flows to the birth region of the current political leader in the agriculture, communication, education, government, health or transportation sectors. Within the education sector, the coefficients for birth region are positive in both parts and statistically significant. Both the probability of aid allocation and the amount of aid conditional on any projects increase in the birth region of the current political leader. CONCLUSIONS: This sector-specific analysis provides a more nuanced picture of Chinese aid than previous analyses that determine the presence of political preference according to aggregate aid flows. The sectors where political preferencing exists are also those sectors that are typically associated with limited counterfactual-based program evaluation. We present evidence that demonstrates the importance of disaggregating aid flows in order to support a new policy framework designed to target the Sustainable Development Goals.

International Funding for Global Common Goods for Health: An Analysis Using the Creditor Reporting System and G-FINDER Databases.

West Africa's Ebola epidemic of 2014-2016 exposed, among other problems, the under-funding of transnational global health activities known as global common goods for health (CGH), global functions such as pandemic preparedness and research and development (R&D) for neglected diseases. To mobilize sustainable funding for global CGH, it is critical first to understand existing financing flowing to different types of global CGH. In this study, we estimate trends in international spending for global CGH in 2013, 2015, and 2017, encompassing the era before and after the Ebola epidemic. We use a measure of international funding that combines official development assistance (ODA) for health with additional international spending on R&D for diseases of poverty, a measure called ODA+. We classify ODA+ into funding for three global functions-provision of global public goods, management of cross-border externalities, and fostering of global health leadership and stewardship-and country-specific aid. International funding for global functions increased between 2013 and 2015 by $1.4 billion to a total of $7.3 billion in 2015. It then declined to $7.0 billion in 2017, accounting for 24% of all ODA+ in 2017. These findings provide empirical evidence of the reactive nature of international funders for global CGH. While international funders increased funding for global functions in response to the Ebola outbreak, they failed to sustain that funding. To meet future global health challenges proactively, international funders should allocate more funding for global functions.