Is global health aid distributed fairly?

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{***Noah***}

Coming up on Harvard Chan: This Week in Health…Is global health aid distributed fairly?

{***Jesse Bump Soundbite***}
(The need for health services, the need for health interventions, the need in the health area is unlimited. It’s a massive rationing challenge because the need for health-related services is unlimited and resources are always finite. So, the question of allocation is, how do you decide?)

International agencies give out billions of dollars in health aid each year.

But the process by which that money is allocated is often opaque and difficult to understand.

In this week’s podcast, we’ll explore how to bring more transparency to the aid allocation process—and to ensure that the countries receiving aid have more power in that process.

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{***Noah***}

Hello and welcome to Harvard Chan: This Week in Health…It’s Thursday, April 12, 2018. I’m Noah Leavitt.

{***Amie***}

And I’m Amie Montemurro.

{***Noah***}

Amie—each year tens of billions of dollars of health aid are distributed around the world.

According to the Institute for Health Metrics and Evaluation at the University of Washington, more than 36 billion dollars were allocated in 2015.

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And much of that money comes from multi-lateral agencies—organizations like the World Health Organization, UNICEF, or The World Bank.

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But exactly how that money is distributed is often opaque and may even be based on unreliable metrics.
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In this week’s episode, we’ll explore the state of the global health aid landscape—and examine ways to improve transparency and make aid distribution more equitable.

{***Noah***}

I recently spoke about this with Jesse Bump, executive director of the Takemi Program in International Health and lecturer on global health policy at the Harvard Chan School.

{***Amie***}

Bump and several co-authors recently wrote about global health aid in a special supplement in the journal Health Policy and Planning.

{***Noah***}

As part of this work, Bump examined aid distribution at a series of multi-lateral agencies.

I spoke with him about the aid distribution process, how it can be improved—and importantly—how the countries that receive this aid can have a louder voice in the process.

I began our conversation by asking Bump to explain the global aid landscape—and why the billions of dollars that are distributed annually are so important.

JESSE BUMP: You have this pot of money. And you need to decide how to spend it. And there are a variety of questions that come from this, but it all begins with a rationing question. And that is that the need for health services, the need for health interventions, the need in the health area is unlimited. No one ever has as much as they want. And certainly no population does.

And you see the consequences of that in national health systems, like the one here in the United States, where there’s always constant budgetary pressures. It’s enormous pressures. It’s a massive rationing challenge because the need for health-related services is unlimited and resources are always finite. So the question of allocation is, how do you decide?

How do you decide, based on what criteria, based on what values, according to what metrics? How do you decide where the money should go? And that question, you spread it out between geographies, for instance, so which countries, if you’re thinking about countries. You often are. Which countries are eligible?

You’re also asking, for what? So it’s not just money. It’s money for something. So you could be talking about– and the most generous, and this is the allowance that any kid would want, is cash. But it comes with constraints. So, OK, is it conditional on some actions? You can have the money if you do these things, or is it money for a specific purpose?

And then there are other types of non-financial resources. So there may be technical assistance, meaning advice. There could be policy development. There could be lots of forms of support. And it could be– let’s see, we’ve said financial. It could be in kind. It can be in commodities. That is, here’s a shipment of medicines of a certain type.

Those are all allocation questions. So you’re starting with that really big question of, how do you assign resources over infinite need? So you have to figure out some defensible mechanism of deciding. And then what exactly it is you’re delivering is the other question.

NOAH LEAVITT: And so in terms of the what you’re delivering– and you touched on there that the needs are almost infinite when it comes to health. So where are we seeing most global aid being delivered? Well, I guess, what are the most common needs that are receiving aid funding?

JESSE BUMP: You could say that the field of global health, in large part, has been constructed around the HIV/AIDS epidemic. Now, there’s a much longer heritage in things that have gone by other names. There are direct antecedents, like international health. And before that, there was colonial medicine. There are many antecedents.

This is a very long heritage of people traveling around the world or going to other places and thinking about how to advance humanity, or at least how to intervene in health areas. There’s a long missionary tradition. There’s a long commercial tradition. There’s a long military tradition. Nonetheless, here in global health, one of the main things that made it an area under that name was the influx of resources for HIV/AIDS starting in the 1990s.

In the year 2000, the Global Fund to Fight AIDS, TB and Malaria– that was launched in 2000 as a response by leading multilaterals, a response to the massive influx of resources. That’s a question of, well, people are giving money, a lot of money, billions of dollars. Countries are. Foundations are. How do you spend it?

So the Global Fund was the answer. The Global Fund to Fight AIDS, TB and Malaria has those three diseases right in the name. And the vast majority of resources that are targeted for specific diseases have gone into those areas, particularly in HIV. Polio is one of the other areas where there’s been massive investments over the last couple of decades.

NOAH LEAVITT: Are we seeing a shift at all in where aid is being distributed or is it largely still in those areas, HIV, TB, malaria? Are there any shifts going on in where, maybe, more funding’s being allocated?

JESSE BUMP: The question you’re asking– it has a bunch of dimensions. The first of these is, what do we– as an expert community, what do we think are big problems and problems that are coming, problems that are here, problems in the past? And many people will tell you that rapid aging, the demographic change that underlies that in rapidly aging societies– it changes everything about health care.

You have to spend more. There are more people who need more services in the changing ratio of young people, working-age people, to elderly people. As societies age, it means there are fewer working-age adults to support more older people. And since people use more health services and consume more health care as they get older, that is one of the leading crises that we’re not prepared for. It’s here, in many countries. We’re just not prepared.

You can add NCDs to that list. Ischemic heart disease is the top killer worldwide. And mental health would be a third area. In all three of these areas, global health people are thinking, these are disasters, and we’re not prepared. But they’re already here. They’re already here. And the question of what funding will be dedicated to those things, where will it come from, where will it go, into what interventions or into what measures of any kind– we don’t have a range of solutions for those things yet. We’re still in the formative stage.

So the way I would characterize it is we’re aware, as experts, that the problem is here. We have not yet developed interventions that can be deployed at scale or societal changes that we could make that would deal with these things. So the funding flows that you’re seeing in global health– they don’t yet reflect this change in disease burden.

NOAH LEAVITT: Is that a product of the fact that money naturally has to flow where solutions are already in place? So, for example, if we have a vaccine for this particular disease, we will fund this vaccine. Is that typically the way things flow?

JESSE BUMP: That’s a good micro answer. And the micro answer would be, if I could restate it, is it’s a value proposition, the basic cost-benefit analysis. We have this range of solutions, say, vaccines for these items. Vaccines are always among the simplest things to talk about. You have vaccines for these diseases.

The cost of production is X. The number of people who need it is Y. The benefit per person– that’s another variable. You just calculate it out, and you have an investment case. That’s the very definition of a vaccine investment case, along with a few other parameters that doesn’t change that basic calculus. But the bigger answer is, sometimes, need and indignity, sometimes a call to action, sometimes advocates. They’re able to produce solutions where there aren’t any.

And HIV is a perfect example, where that’s– the advocacy around HIV/AIDS started in the gay men’s community in New York and San Francisco. And they pursued a rights angle, successfully, and managed to produce global change. It’s one of the most impressive stories in activism over the last– certainly, over the last quarter century. But it’s one of the biggest in global health. This is how things got done.

And there was no intervention when they started. There were very few. There were no cost-effective interventions. There was nothing that could be delivered at public-health scale. But all those things were overcome by strident advocacy. And that’s one way of saying that humanity’s problems often do have a solution as long as there are enough people who are committed enough to produce that change.

NOAH LEAVITT: One of the main points I know you make as you write about the process for aid allocation– it’s not transparent and it’s not well understood. So I guess a two-part question, I mean, why is this process not transparent, and why is that such an issue moving forward?

JESSE BUMP: There are a variety of answers. Let’s just start on the transparency part. There’s roughly 7 billion people in the planet. Of those, 6 billion are living in low- and middle-income countries. And it’s those people whose lives are the most directly affected by development assistance for health. Those people have a direct stake.

Entire humanity has a stake in this. It’s a shared responsibility. But the consequences of these policies fall directly on people in low- and middle-income countries and particularly people who have one of the conditions or may be at risk for some of these conditions that are the subject or that are the focus of interventions in global health. It’s a careful way of saying it, because much of global health is based on interventions as opposed to the social determinants of health or to broader social change.

But just think of this as the global health industry or the global health practice area mainly is distributing interventions. So for people who directly need them, it’s an important question to say, why is it that some of them get these things and other people don’t? And one of the most fundamental principles of rationing is that fairness of process is essential to fairness of outcome. That’s the transparency part.

So our claim in this special issue is that the people who are directly affected by aid deserve to have a voice in how it’s allocated and they deserve to have an answer in– well, they deserve to have outcomes. So they deserve to know. The outcomes should be publicized. And the recipients– that is, recipient countries and their citizens– should have some accounting. There should be some defense to that. That’s the transparency part.

NOAH LEAVITT: The process is also not really well understood by people. And, I guess, why is that so concerning?

JESSE BUMP: So if you want fairness, you both want assurances that the process operates according to defensible principles and you want transparency so that you can see the results and you can participate. All three of those things, the transparency, the participation, and the outcomes of the process– those are all extremely important. So the fact that these processes are poorly understood means there’s no public discussion of what goes into them. There isn’t any accountability because there is none of this publicity around it.

Let’s say there are decisions whose outcomes we don’t like. Let’s just posit that. Well, how do we change it, or to whom would we complain? If you’re not sure about who did it or how they did it, then there’s no recourse. The transparency issue goes to the relative secrecy of the processes themselves. And I would observe upfront that I don’t think there’s a concerted effort to make them secret.

But these are sensitive processes. They’re based both on technical factors, which can be hard to calculate, and on political factors, which are always extremely sensitive. So there’s really no benefit, from a technocratic perspective, from a bureaucrat’s perspective, to publicizing these, or there’s very limited benefit. There’s obviously a very large downside.

NOAH LEAVITT: You noted in the supplement that although Gross National Income per capita has long been used as a central consideration in allocation, it is an unreliable metric in many low- and middle-income countries. Can you explain why?

JESSE BUMP: There are always technical criteria. Whether those are accurately measured or whether those fully reflect reality– that’s a difficult question. Even probably the most reliable of these indicators, gross domestic product or gross national income per capita– those are notoriously weak indicators in low- and middle-income countries.

You would think that the most basic economic data would be fairly reliable by now, but that’s not true. It’s not true. And, in fact, that’s one of the things that launched a global discussion on allocation a few years ago. And it had to do with recalculating the GDP. So the way this works is there will be a survey, an intensive survey in a low- or middle-income country. And that will be used as the base year.

So for one year, the economic data will be scrutinized. There will be an extra effort to collect more. And that will be the base year. Then there is just an adjustment calculation to carry that forward, so some assumption about how the country’s doing.

And then, when you go back and measure again, you rebase the GNI. That is, you go study it again. And it can change dramatically because this doesn’t happen every year. It happens once every, sometimes, 10 years, sometimes 15 years, sometimes five years. It can be quite a while. And the economy can change very differently from forecast.

So one of the things that put this on the agenda was in 2010, Ghana rebased its gross domestic product. And it changed the estimated size of the economy by 69%. So just think, one day to the next, the economy is basically the same. But when you rebase it, it’s updating an estimate that’s years old and then correcting for an assumed growth pattern that may have been totally wrong or very wrong.

So in Ghana’s case, they updated, rebased it, and the GNI changed by 69%. The same thing happened in other countries. In Nigeria in 2013, the economy changed by 89%. It’s almost inconceivable to think about how dramatic that change is, and yet, day to day, nothing’s happened. This is a pure measurement question, measurement and forecasting.

So the allocation problem– it’s raised by this directly, because let’s say you have an eligibility criterion. That is, you would like to give aid to countries at a certain income level. Setting that income level is not straightforward, but it’s a defensible principle that you would like to give more aid to countries that have less money per capita.

Well, if you use GNI per capita as the indication of relative wealth, relative income, that is, if GNI per capita is the relative measure of income, and then you’ve just changed it by a factor of 2/3 or half or more, even, that means that countries that were eligible suddenly are not eligible if their economies have been growing. And if they’ve been contracting, perhaps economies that were not eligible have been eligible, but you weren’t delivering any aid because you didn’t realize the economy shrank.

NOAH LEAVITT: So I know you touched on– you examined these nine multilateral agencies, agencies like the WHO, for example. And you said that even in these agencies, people were not really sure about the aid-allocation processes. So in assessing these multilateral agencies, I mean, I guess, what were some similarities in their processes? I mean, I guess, what were some of the main takeaways from looking at these agencies?

JESSE BUMP: That’s a good question. When I said that even insiders were uncertain, I think, to be fair, everyone has a general sense of how it works. But what exactly goes into the calculation and how exactly the calculation gets adjusted– that was known to only very, very few people. Overall, we found across the multilaterals that we could categorize the allocation process.

Like a lot of things when you design a cycle, it doesn’t work exactly this way in process because a lot of the things are happening simultaneously. But just to break it down into a sequence, we found that useful for analytic purposes. But the first step would be the definition of a strategy. And typically, that happens by the organization’s board of directors.

It’s some large, standard-setting or objective-setting exercise that takes place maybe every few years, in some institutions every year. But periodically, the institution will set a strategy. It’s the objectives. What are the things that it wants to do? It will then mobilize resources. So you could imagine this as someone developing a plan, then taking that plan to potential funders and getting some resources on board.

The third step is the eligibility of countries. Typically, this is done on a per-capita income basis. But whatever the criteria or the criterion would be, you decide which countries are eligible for support. The next one would be to decide what types of support. So once you’ve decided this basket of countries that are eligible, you’d say what sorts of resources, what types of support would you provide to each of them.

And then the final step would be the allocation of funds. That’s when you decide who’s going to get what. And, ostensibly, the result of that would all be evaluated and then feed back into the definition of strategy.

NOAH LEAVITT: And so when we talk about improving this aid-allocation process, maybe to make it more transparent, are there particular steps in that process that you think could be targeted to improve the overall aid-allocation process?

JESSE BUMP: There’s an opportunity to do better at every step, starting with the definition of strategy. Some of the agencies consult widely with countries to develop that strategy, but not all of them do. And not all things are available for debate in those discussions.

So the first place to begin would be in strategy definition. Try to define the strategies more closely aligned with the needs of countries. Try to get more participation by the citizens of those countries, their representatives in civil society, the representatives in government. That’s a participatory process that could help define strategies that are better aligned with the needs.

Then, in resource mobilization, one of the shifts, one of the big shifts over the last 10 years has been to emphasize the mobilization of domestic resources. This is a way of saying, by traditional donors, whether they’re bilateral aid agencies or foundations or others, is a way of saying that the aid sector is relatively small and that most resources will be raised internally by countries themselves.

So in resource mobilization, the opportunity to get countries’ opinions and citizens’ perspectives on what sorts of resources are needed– that’s really important, and particularly, where they’ll come from. Sustainability is always important when you’re thinking about health because that’s a very long-term phenomena.

The question of these resources, well, where do they come from? Are they sustainable? Who’s paying? Those are all resource mobilization questions that, in the past, were answered by collection by rich countries and interest payment on loans made to poor countries. But it’s much more complicated now.

The eligibility question and the type of support– those are questions that also engage opportunities to solicit participation by citizens of developing countries or other people whose lives are directly affected. And then, in allocation of funds, that final step of the process– it’s the cumulative result of all the others.

So, again, if developing countries’ citizens have participated in the development of the strategy, the mobilization of resources, and the other steps, then by allocation you should be getting toward results that are already agreed upon. And there will be still some things to discuss, such as the exact amounts and the exact types of support. But in all five of those stages, there are many opportunities to do better.

NOAH LEAVITT: Is part of the transparency process also reporting back on the results of allocation? So money was spent in this country for this purpose, and these were the results of the spending. Is that somehow involved in all this, or should it be?

JESSE BUMP: Oh, yeah, I would definitely agree. There’s opportunities to do much better in evaluating the impact of aid and the outcomes of aid. Now, in a historical perspective, the evaluation of development assistance– that became a very widespread phenomenon in the late 1990s and grew in the 2000s. And impact evaluation has been one of the more consistent areas of focus for donors, but it tends to address pretty narrow questions.

The larger questions of, should you have invested in HIV, TB, and malaria as opposed to either some of those diseases and a mix of others or a basket of other diseases, or did these resources put toward those purposes do the best they could have– those questions are not easily answered in impact evaluation. So the narrower questions– those are already being evaluated. And there’s always an opportunity to do better. But the bigger questions at the level of institutional strategy– those are very poorly evaluated.

NOAH LEAVITT: You mentioned that one of your goals was increasing awareness among the public about aid allocation. And you just talked about this, that making it more of a participatory, collaborative process– is that maybe something to aim for going forward, that as people become more aware about aid allocation in their own countries, that they can participate more actively in the process? And do you think that’s realistic for that to, I guess, almost become a norm in the future?

JESSE BUMP: As a historian, I look back over the last 400 years, and I see a strong secular trend toward greater empowerment for developing countries and their citizens. Now, that’s a very long road. And the empowerment has been extremely slow for much of that period. But over the last quarter century, I think you’ve seen developing countries gain a lot of bargaining power.

In the Cold War era, for instance, there were really only two sources of aid, the US and its allies on one side and the Soviets and their allies on the other side. And that’s a two-choice game. So countries could go to one, or they could go to the other.

And typically, once they aligned with one of them, they were unable to get benefits from the other. Very few countries were able to get benefits from both sides, both major donors in the Cold War. India is one case. Egypt is another. Some countries switched sides and managed to get resources from both.

But look at how many aid agencies there are now. Every country and their dog has an aid agency. And those are all possible donors for countries. So if one isn’t doing what they want, then they can approach another one. And sometimes countries have so many choices that they limit their preferred partners. That’s not a story that you would have heard 40 years ago. It’s not a story that you would have heard even 30 years ago.

There’s been a secular trend toward greater empowerment. And it’s time for countries to demand a better deal. They can get one. They just have to ask for it. And they need to coordinate that. So this is a G77 project. A G77 project is for the countries of the global south to discuss amongst themselves what they would like in a new global social contract and ask for it.

So that would impact the kind of assistance they get, the conditions under which they get it, who’s responsible, what responsibilities are shared and by whom under what conditions. It would affect the governance structures of the multilateral agencies. It could change a lot.

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{***Noah***}

That was our conversation with Jesse Bump about the distribution of global health aid.

{***Amie***}

If you want to read any of that special supplement in the journal Health Policy and Planning, you can find a link on our website, hsph.me/thisweekinhealth.

{***Noah***}

That’s all for this week’s episode…a reminder that you can always find us on iTunes, Soundcloud, Stitcher, and Spotify.