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April 25, 2019

Global Health Spending and Development Assistance for Health

Author Affiliations
  • 1Institute for Health Metrics and Evaluation, Seattle, Washington
JAMA. 2019;321(21):2073-2074. doi:10.1001/jama.2019.3687

In 2015, member states of the United Nations adopted the ambitious Sustainable Development Goals (SDGs), which included 17 global goals that targeted economic and social development.1 Goal 3, “to ensure healthy lives and promote well-being for all at all ages,” targets specifically marked progress in universal health coverage; improved access to safe, effective, and affordable medicines; and the end of the HIV, malaria, and tuberculosis epidemics by 2030. Although these goals can spur innovation, social and political commitment, and a drive to achieve greater health gains for less money, financial support is necessary to achieve them. Financial resources enable building of new clinics, training of medical personnel, and development and procurement of new drugs. Money is needed to staff clinics and hospitals, as well as for organizing and administering public health programs and the broader health system. Without sufficient resources for health, the health system is forced to become selective about which patients receive care or which diseases get treated.

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    1 Comment for this article
    Reimagining DAH by Going Back to the Monterrey Consensus (2002)
    Eliudi Eliakimu, MD, MPH | Health Quality Assurance Unit; Ministry of Health, Community Development, Gender, Elderly and Children; in Dodoma, United Republic of Tanzania
    The authors have highlighted what needs to be done by key donors to assist low-income countries (LICs) to achieve the Sustainable Development Goals (SDGs). I support the facts provided. The authors have reminded us of important issues regarding Development Assistance for Health (DAH): contribution to health spending in LICs; economic situation for LICs to increase domestic spending on health; the principles of Paris Declaration (1); and the role of DAH in global public goods. The importance of DAH to LICs cannot be over emphasized Xu, et al noted that "from 2000 to 2015, government domestic funding as a share of current health expenditure increased from 66% to 70% in high-income countries; from 48% to 51% in middle-income countries, but fell from 30% to 22% in LICs" (2). Given this situation, it is hard for LICs to leverage funding necessary for achieving universal health coverage (UHC). Strengthening primary health care (PHC) is critical for UHC, however, PHC has been underfunded globally and also it requires reinvention to be able to address current challenges 40 years post Alma Ata (3). A reflection of domestic funding for PHC in PHC Vital Signs Profiles of Trailblazer Countries by PHC Performance Initiative (PHCPI) has shown a similar situation (4) . Government health spending on PHC ranged as low as 6% in Sri Lanka to as high as 72% in Ghana; and government as a source of PHC spending ranged as low as 6% in Cote d'Ivoire to as high as 60% in South Africa.

    DAH is also essential for global public goods. Binagwaho & Ghebreyesus (3) noted the need for global collaboration in developing standardized, evidence-based tools and resources for PHC. The recent G7 Health Ministers commitment to support establishment of "PHC Universal Knowledge Initiative" is another excellent move (5). It is also encouraging that "WHO; Global Fund; OECD; World Bank; and Gavi, have committed to work together to support establishment of the knowledge platform (5,6).  Both donors and recipient countries benefit from DAH. The DAH has been shown to be beneficial not only in improving health outcomes and saving lives but also has potential for reducing fragility (7,8).  Jakubowski, et al found that the United States (US) DAH has improved the image of US in the 45 countries surveyed (9). Since PHC is the foundation for UHC, it is imperative that donors reconsider DAH in a way that will strengthen PHC to address modern challenges including shift in disease patterns towards Non-communicable Diseases and also to address pandemics (7). In order to ensure that LICs are supported with adequate funding, I urge donor countries to consider the Monterrey Consensus (2002), which "urged developed countries to make concrete efforts towards the target of 0.7 per cent of gross national product (GNP) as official development assistance to developing countries." (10)


    1. https://www.oecd.org/dac/effectiveness/34428351.pdf
    2. https://apps.who.int/iris/bitstream/handle/10665/259632/WHO-HIS-HGF-HFWorkingPaper-17.10-eng.pdf;jsessionid=8D00453F240BE5FB0381BE80B4997A1F?sequence=1
    3. https://doi.org/10.1136/bmj.l2391
    4. https://improvingphc.org/blog/2018/10/17/phc-vital-signs-profiles
    5. https://solidarites-sante.gouv.fr/IMG/pdf/declaration_de_l_engagement_des_etats_du_g7_.pdf
    6. http://oecdobserver.org/news/fullstory.php/aid/6196/
    7. https://www.nejm.org/doi/full/10.1056/NEJMp1809808
    8. https://doi.org/10.1080/17441692.2018.1449232
    9. https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2019.305084
    10. https://www.un.org/en/events/pastevents/pdfs/MonterreyConsensus.pdf