How Much Money Do Private Donors Give To Healthcare

Abstract

Global health funding has increased in recent years. This has been accompanied by a proliferation in the number of global health actors and initiatives. This newspaper describes the state of global heath finance, taking into account government and private sources of finance, and raises and discusses a number of policy bug related to global health governance. A schematic describing the different actors and three global wellness finance functions is used to organize the data presented, virtually of which are secondary data from the published literature and almanac reports of relevant actors. In two cases, we also refer to currently unpublished primary information that accept been nerveless past authors of this newspaper. Among the findings are that the volume of official development aid for health is frequently inflated; and that information on private sources of global health finance are inadequate but signal a large and important role of private actors. The fragmented, complicated, messy and inadequately tracked state of global health finance requires immediate attention. In particular information technology is necessary to track and monitor global health finance that is channelled by and through private sources, and to critically examine who benefits from the ascension in global health spending.

• Information technology is ofttimes stated that global health funding has increased dramatically over the past decade. However, there are inadequate information to describe the precise volume of global health expenditure; the source of this funding; its management; and how it is spent.

• A detailed description of global health funding is needed to amend the efficiency, accountability, performance and equity-impact of the many actors that populate the global health mural.

• In particular, information technology is necessary to track and monitor the activities of non-OECD donors as well equally the funding that is sourced by and channelled through private actors.

Introduction

Past most accounts, global funding for health has increased dramatically. According to the Globe Bank, evolution assistance for health grew from US$2.v billion in 1990 to most United states of america$xiv billion in 2005 (World Bank 2007). A contempo commodity in The Lancet claimed that official development assistance (ODA) grew from U.s.$8.5 billion in 2000 to US$13.5 billion in 2004 (Kates et al. 2006). In addition to the increment in ODA, there has been an increase in individual funding for global health, which is said to now account for nearly a quarter of all development help for health (Bloom 2007).

The increase in global funding for health has been accompanied by a rapid and large increment in the number of global health actors, transforming the global health landscape and making information technology more than difficult to study. In 2004, a Global Health Resources Tracking Working Group was established to calculate the amount of funding devoted to global health. It concluded, more than than two years afterwards, that the job was too difficult because of: the large and diverse number of public and private sources of funding; the many types of activities and programmes that fall nether the term 'global health'; the use of 'in-kind' donations of drugs and other inputs; inadequate financial direction information systems; and poorly designed donor accounting structures (CGD 2007). One of its key recommendations was for meliorate tracking and monitoring of global health financing.

This paper uses existing data on global health financing (mainly in 2006) to paint a picture of global health financing and to enhance a number of policy issues and questions near 'global wellness'. Information technology defines 'global health financing' every bit any external finance channelled towards the wellness sector of low and middle income countries (LMICs) in order to meet the needs of predominantly poor population groups. This definition excludes external finance aimed at reducing poverty, food insecurity, and the lack of admission to water, sanitation and education, which are important for health, as well every bit emergency/humanitarian assist (east.g. in response to conflict or natural disasters), even though this includes medical care. In addition, commercial bank loans and individual strange investment directed at the health sector of LMICs are also excluded.

We mainly employ publicly-available secondary data from the published literature and the annual reports of relevant actors. In addition, we quote a few unpublished information on the global wellness grants of some private foundations from a paper that is currently in printing elsewhere. Presenting data on income and expenditure is complicated past dissimilar almanac fiscal reporting cycles, different accounting practices and different currencies. Withal, we have not adjusted the data in lodge to standardize for a given period or time. Nigh of the secondary fiscal data were available every bit Usa dollars. Where this was not the case, nosotros have converted currencies to US dollars based on boilerplate nominal currency exchange rates for the relevant twelvemonth.

A schematic for the global health financing landscape

The schematic (Effigy 1) we developed consists of three functions related to global health finance combined with a set of categories for the various actors involved in global health. The kickoff office is labelled 'providing' and is concerned with the need to enhance or generate global health funds. Information technology consists of iv main categories of actors: donor country governments; private foundations; the general public; and businesses/private corporations.

Effigy 1

Schematic of the global health financing landscape

Figure ane

Schematic of the global health financing landscape

The second function is 'managing' and is concerned with the direction or pooling of global wellness funds as well as with mechanisms for channelling funds to recipients. It has six categories of actors: the official bilateral aid agencies of donor countries such as USAID (US) and DFID (UK); inter-governmental organizations (IGOs) that provide grants or concessionary loans for health improvement, in particular the World Banking concern and European Committee; global wellness partnerships (GHPs) with a primary funding function such equally the Global Fund to fight HIV/AIDS, TB and Malaria (Global Fund) and Global Alliance for Vaccines and Immunization (GAVI); not-governmental organizations (NGOs); individual foundations; and the business/corporate sector.

The third function is 'spending' and is concerned with the expenditure and consumption of global health finance. It consists of six principal categories of actors: multilateral agencies with a health focus such as the World Wellness Organization (WHO), UNICEF and UNAIDS; GHPs; private sector, for-profit organizations; LMIC governments; and LMIC ceremonious society organizations (CSOs).

While this schematic reflects the appearance of an ordered global health landscape, the reality is much more chaotic. For instance, several actors perform all three functions simultaneously, thus obscuring the different operational components of global health finance. In addition, the system for categorizing the different actors does not reveal the overlapping and fuzzy boundaries between them, nor the existence of hybrid organizations. Nonetheless, we believe that the schematic provides a useful framework for describing and studying global wellness finance. This article will now unpack and discuss each of the three functions of global health finance and their corresponding categories of actors, earlier discussing the overall picture of global health finance and various policy implications.

Providing global health finance

Governments

The official development assistance (ODA) budgets and programmes of donor country governments are a major source of global wellness finance. The Development Aid Committee (DAC) of the Arrangement for Economic Cooperation and Evolution (OECD) monitors the evolution assist of 22 major donor countries ¹ plus the European Committee. In 2006, the total amount of ODA disbursed by the DAC donors was U.s.a.$104.4 billion, including Us$7.5 billion of debt relief (OECD 2008b).

Table 1 shows DAC donor commitments and actual disbursements of ODA for 'Health' and 'Population' (which includes reproductive health care, family planning, control of sexually transmitted infections, and HIV/AIDS) in 2004, 2005 and 2006. Information technology also provides figures for 'H2o and Sanitation' and 'Emergency Response' (which covers material relief aid and services, emergency food aid, relief co-ordination and protection services, but excludes longer term reconstruction and rehabilitation, and disaster prevention and preparedness).

Table 1

Development assistance from Development Assistance Committee (DAC) donors for selected sectors, 2004–06 (U.s.a.$ millions)

	2004			2005			2006
	H & P	Westward & Southward	ER	H & P	West & S	ER	H & P	W & S	ER
Commitments	8495	4828	6042	10 340	6031	8210	thirteen 645	6382	6712
Disbursements	5962	2309	5283	8112	3351	8216	9577	3476	6797

	2004			2005			2006
	H & P	W & S	ER	H & P	W & South	ER	H & P	W & S	ER
Commitments	8495	4828	6042	x 340	6031	8210	13 645	6382	6712
Disbursements	5962	2309	5283	8112	3351	8216	9577	3476	6797

Source: OECD (2008a).

Notes: H = Health; P = Population; Westward = H2o; South = Sanitation; ER = Emergency Response.

Table 1

Evolution assistance from Development Assistance Committee (DAC) donors for selected sectors, 2004–06 (US$ millions)

	2004			2005			2006
	H & P	Due west & S	ER	H & P	W & S	ER	H & P	W & South	ER
Commitments	8495	4828	6042	10 340	6031	8210	13 645	6382	6712
Disbursements	5962	2309	5283	8112	3351	8216	9577	3476	6797

	2004			2005			2006
	H & P	Westward & S	ER	H & P	W & S	ER	H & P	Westward & S	ER
Commitments	8495	4828	6042	x 340	6031	8210	thirteen 645	6382	6712
Disbursements	5962	2309	5283	8112	3351	8216	9577	3476	6797

Source: OECD (2008a).

Notes: H = Wellness; P = Population; West = Water; Due south = Sanitation; ER = Emergency Response.

The information evidence a clear ascension in ODA for wellness and population, with disbursements increasing from US$5.96 billion in 2004 to United states$ix.58 billion in 2006 (about ten% of total ODA in that year). They also testify a meaning departure between commitments and actual disbursements of ODA to health. In 2006 for example, disbursements were more US$4 billion less than commitments. If 'water and sanitation' are combined with 'wellness and population', the shortfall between what is pledged and what is actually disbursed increases to nearly US$7 billion.

The data besides betoken that the figures quoted earlier about the increment in development assist for health (the Lancet article estimated a figure of U.s.a.$13.v billion in 2004 and the Earth Depository financial institution estimated that development help for health had increased to almost US$xiv billion in 2005) appear to be exaggerations. Bodily disbursements of ODA for wellness and population by DAC donors only amounted to US$ix.58 billion in 2005.

While these data represent important landmarks on the global health financing landscape, in that location are a number of points to note. First, increases in the volume of ODA for health may exist offset by reductions in domestic spending and budget allocations. Ultimately, what matters are trends in overall health spending at the country level. Secondly, although the data from DAC covers the major donor governments involved in global health, several non-DAC countries are significant providers of ODA.

It is by and large accustomed that there are poor data on non-DAC ODA (Harmer and Cotterrell 2005; Brownish and Morton 2008). Nonetheless, the World Bank (2008) has estimated that not-DAC ODA in 2006, excluding ODA from Red china, amounted to US$5.17 billion. The size of Mainland china'south ODA is not known with any caste of accuracy, but a general view is that China is becoming a meaning thespian. For example, it has been reported that assist from China to Africa will reach The states$1bn in 2009, over and above support for debt counterfoil and training of African professionals (Manji 2008). India is also showing increased presence as a donor. India's resource allotment of foreign assistance for 2007–08 amounted to merely nether US$226 million, nigh of which was allocated to the countries in the region, particularly Bhutan and Afghanistan (Sridhar 2008).

Although in that location are no information on the size of the contribution of non-DAC donors to global health, a couple of general points about not-DAC ODA might be used to estimate the size of their contribution to global health. First, many non-DAC countries provide the bulk of their ODA for emergency and humanitarian crises (Harmer and Cotterell 2005). Co-ordinate to one analysis, non-DAC humanitarian assistance in 2006 amounted to US$435 one thousand thousand (Evolution Initiatives 2008, p. 10). If spending on the health sector is assumed to exist half that of spending on humanitarian help, the non-DAC contribution to global health finance would be estimated to be about US$220 meg. Secondly, it seems unlikely that not-DAC countries would allocate a higher proportion of their overall ODA to 'health' compared with DAC countries. Therefore, if a relatively generous supposition is fabricated that x% of not-DAC ODA is allocated to health and if total non-DAC ODA amounted to about US$7 billion in 2006, our estimate of the not-DAC contribution to global health finance would be well-nigh US$700 million.

Individual foundations

Data on the contribution made by private foundations towards international development are relatively limited. The World Bank stated that in 2005 private donors gave roughly US$4–four.5 billion to international development, but noted that philanthropic giving 'is significantly under-researched due to the lack of a world-broad data collection process' (Sulla 2006).

Private foundations accept been important actors in the health sector for decades, mainly considering of their power to use funding to shape international health policy and the broader discourse around global health (Birn and Solorzano 1999; Fox 2006). Still, the entry of the Neb & Melinda Gates Foundation into the global health landscape (bringing with it besides the donation of US$30 billion by Warren Buffett) has taken individual, philanthropic funding for international development, especially for wellness, to new and unprecedented heights. One estimate of the amount of private foundation spending on global health in 2005 was US$ane.vi billion, much of information technology coming from the Gates Foundation (MacArthur 2006).

In 2006, the Gates Foundation awarded 195 global health grants amounting to US$two.25bn in full (McCoy et al. 2009). In terms of money paid out to global health grants, US$916 million and Usa$i.22 billion were disbursed in 2006 and 2007, respectively. The Foundation is now a bigger international health donor than all governments bar the United States and the Great britain.

Other prominent foundations operating in the wellness sector include the Rockefeller Foundation, the Wellcome Trust, the Ford Foundation, UN Foundation and the Aga Khan Foundation. The total expenditures of these foundations in 2006, together with an estimation of the international wellness grants awarded by the Wellcome Trust, the Ford Foundation and the Rockefeller Foundation, are shown in Table two.

Table two

Full expenditure and value of international health grants awarded past selected private foundations in 2006

	Total expenditure 2006 (Us$ million) a	Value of international wellness grants awarded in 2006 (U.s.a.$ million)
Wellcome Trust	1000b	U.s.$42b
Rockefeller Foundation	193.24	US$xv.7
Ford Foundation	683.98	US$vii.v
Un Foundation	306	–
Aga Khan Foundation	184.nine	–

	Total expenditure 2006 (The states$ one thousand thousand) a	Value of international health grants awarded in 2006 (US$ meg)
Wellcome Trust	grandb	US$42b
Rockefeller Foundation	193.24	Us$15.7
Ford Foundation	683.98	US$seven.5
Un Foundation	306	–
Aga Khan Foundation	184.9	–

^a Sources: Wellcome Trust Almanac Study and Fiscal Statements 2006; The Rockefeller Foundation 2007 Annual Written report; Ford Foundation Annual Study 2006; Aga Khan Foundation Annual Written report 2006.

^bCrude approximation, converted from United kingdom sterling.

Table ii

Total expenditure and value of international wellness grants awarded by selected private foundations in 2006

	Total expenditure 2006 (United states$ million) a	Value of international health grants awarded in 2006 (US$ 1000000)
Wellcome Trust	1000b	US$42b
Rockefeller Foundation	193.24	Usa$xv.vii
Ford Foundation	683.98	US$7.five
UN Foundation	306	–
Aga Khan Foundation	184.9	–

	Total expenditure 2006 (US$ meg) a	Value of international health grants awarded in 2006 (US$ one thousand thousand)
Wellcome Trust	gb	Usa$42b
Rockefeller Foundation	193.24	Usa$15.vii
Ford Foundation	683.98	US$7.5
UN Foundation	306	–
Aga Khan Foundation	184.9	–

^a Sources: Wellcome Trust Annual Written report and Fiscal Statements 2006; The Rockefeller Foundation 2007 Annual Study; Ford Foundation Annual Study 2006; Aga Khan Foundation Annual Written report 2006.

^bRough approximation, converted from United kingdom sterling.

Finally, information technology should be noted that, particularly in the US, tax breaks afforded to private foundations amount to a public subsidy of their budgets and expenditure. In the Usa, it is estimated that 45% of the US$500 billion that foundations hold actually 'belongs to the American public' in the sense that it is money foregone by the land through tax exemptions (Dowie 2002).

The general public

The full general public contributes to evolution finance in LMICs mainly indirectly through their tax contributions to the public budget of donor governments. They also brand direct contributions, mainly through donations made to NGOs and remittances made by migrant workers. The latter source of funding, although considerable and an important source of income for many poor households in LMICs, is not usually allocated specifically to health nor considered part of the evolution help compages, and is therefore not considered further in this paper.

There are no reliable data on the amount of money raised by individual individuals to support NGO health programmes and projects in LMICs. However, we know that the corporeality generated for humanitarian disasters can be considerable. Voluntary contributions for humanitarian relief to the Red Cross/Red Crescent and 19 of the largest NGOs in 2006 was estimated to corporeality to US$2.31 billion (Development Initiatives 2008, p. 10), and nigh US$5 billion was raised by the general public in response to the Indian Ocean seismic sea wave in 2004 (Tsunami Evaluation Coalition 2006).

Another way of estimating private contributions to global health is to examine the income of international NGOs. For case, in 2006, the total income of the Medecins Sans Frontieres (MSF) international movement was approximately US$714 one thousand thousand (converted from Euro), of which 71.2% came from private individuals (MSF 2006). The Rotarian Foundation is another NGO with a health focus that relies on contributions from private individuals—presently, the Rotarian movement has a target to raise U.s.a.$100 meg dollars over iii years to support the international try to eradicate polio. Notwithstanding, most of the wealthiest international NGOs tend to work across a range of evolution sectors, making it difficult to guess the corporeality allocated to health specifically.

Business/Corporate sector

Private companies and corporations contribute to development objectives and global health through 'corporate social responsibleness' programmes, or what is referred to by some every bit 'corporate philanthropy'. As with individual foundations, the existence of taxation exemptions for some such activities means that a proportion of the expenditure consists of a public subsidy.

There are few data on 'corporate social responsibility' programmes (CGD 2007). Some papers argue that corporate donations to charities are less in aggregate than those made past individual individuals (Andreoni 2001; Charities Aid Foundation 2003). Every bit an illustration, iii.5% of MSF'due south income in 2006 came from private companies compared with 72.9% from individuals.

The most important corporate actors in the health sector are the large pharmaceutical companies. Although contributions to global health by pharmaceutical companies tin exist seen equally forms of marketing and investment in business development, their dollar amounts are non insignificant. A review of the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) Health Partnerships Survey found that the industry'south combined contribution to the health-related MDGs in 2006 totalled United states of america$ane.9bn (Kanavos et al. 2008). This included the costs of donated commodities, commodities sold at price, cash, health intendance provision and training interventions.

As an example, the contributions to global health listed by Pfizer on its website include: providing 87 million treatments of azithromycin for the International Trachoma Initiative since 1998; donating US$735 million worth of fluconazole for AIDS treatment since 2000; funding 171 Pfizer Global Wellness Fellows (including Pfizer clinicians, epidemiologists, laboratory technicians, marketing managers and financial administrators) to work with NGOs in developing countries since 2003; and committing U.s.$33 one thousand thousand to improve cancer and tobacco-related health outcomes in 2007 over 3 years.

Managing global health money

Bilateral help agencies

About iii-quarters of disbursements of official development assistance for health by DAC countries in 2006 were channelled bilaterally (see Tabular array three). Every bit far as non-DAC countries are concerned, an even higher proportion of ODA is channelled bilaterally (Harmer and Cotterrell 2005). Much of this bilateral funding is directed past donor governments through dedicated 'assistance agencies', often located within Ministries of Foreign Affairs.

Table three

Disbursements of official development assistance by Development Assist Committee (DAC) donors, 2006 (U.s.$ millions)

	2006
	H & P	W & S	ER
Bilateral	7173	3074	5930
Multilateral	2404	402	867
Total	9577	3476	6797

	2006
	H & P	W & S	ER
Bilateral	7173	3074	5930
Multilateral	2404	402	867
Full	9577	3476	6797

Source: OECD (2008a).

Notes: H = Health; P = Population; W = Water; S = Sanitation; ER = Emergency Response.

Table 3

Disbursements of official evolution assistance by Development Aid Committee (DAC) donors, 2006 (US$ millions)

	2006
	H & P	W & S	ER
Bilateral	7173	3074	5930
Multilateral	2404	402	867
Total	9577	3476	6797

	2006
	H & P	Due west & South	ER
Bilateral	7173	3074	5930
Multilateral	2404	402	867
Total	9577	3476	6797

Source: OECD (2008a).

Notes: H = Wellness; P = Population; W = Water; Due south = Sanitation; ER = Emergency Response.

The biggest donor governments for global health are the Usa and the Great britain. UK assist for international health amounted to Usa$1.62 billion in 2006 and was mainly managed by the Section for International Development (DFID). Foreign assistance for health from the U.s. amounted to approximately US$iv.19 billion in 2006. However, unlike the UK, the US channels its strange assistance through multiple government agencies including USAID, PEPFAR, the President's Malaria Initiative and the Department of State (Global Health Watch 2008).

Inter-governmental organizations

Most of the ODA for health that is channelled multilaterally flows through two inter-governmental organizations: the World Banking concern and the European Committee (EC), the latter in the case of European donor countries.

The World Bank provides global wellness funding in the form of grants and concessionary loans to recipient countries through the International Development Association (IDA), which is mainly funded from the ODA budgets of donor countries. IDA spending on 'Health, Nutrition and Population' amounted to US$0.8 billion in financial year 2006 (World Bank 2007, p. 42). The Bank too makes loans for development to governments through the International Bank for Reconstruction and Evolution (IBRD) and for private sector development through the International Finance Corporation (IFC). Some of these monies may exist directed at the health sector just exercise not fall into the definition of global wellness finance used in this paper.

Equally far as the EC is concerned, their role in helping to manage global wellness finance is smaller than the Earth Bank, but appears to be growing. The EC is reported to have disbursed US$421 million to 'health and population' programmes in 2005 (Activeness for Global Health 2007), while in 2006, spending on 'wellness', 'population' and 'reproductive health' was said to have amounted to U.s.a.$580.17 million (Action for Global Wellness 2008, p. 10).

Global Health Partnerships

The emergence of GHPs has been an important development of the global health architecture in recent years. Some have been established specifically to human activity as global wellness funding agents, 2 of which stand out: the Global Fund and GAVI.

Income to the Global Fund was US$ii.56 billion in 2006 and US$3.15 billion in 2007; while expenditure was US$1.90 billion and Us$2.71 billion in 2006 and 2007, respectively (Global Fund 2007a). GAVI's expenditure in 2006 was considerably less, at US$563.05 meg (GAVI 2007). Although these ii agencies are often described as sources of global health finance, most of their income comes from donor governments.

The Global Fund is funded by governments through bilateral channels as well every bit through the EC (which has pledged approximately Usa$1.18 billion between 2002 and 2010). Individual funding to the Global Fund has been relatively small, although information technology increased in 2006 following a pledge of United states of america$500 million past the Gates Foundation over 3.5 years. There has been some other private financing to the Global Fund through the (Carmine)™ Initiative which gets participating companies to contribute a percent of their sales to the Fund. As of March 2008, the Initiative had contributed US$61 million. And so far the Global Fund has discouraged private sector assistance in the class of in-kind contributions (Global Fund 2008b).

Donors can support GAVI in iii different ways. Get-go, through straight donations; second, by making long-term pledges to The International Finance Facility for Immunization, which effectively allows GAVI to draw down on time to come regime donor pledges towards evolution assistance; and 3rd, past making pledges to the Advance Market Commitment mechanism which supports the evolution and availability of a pneumococcal vaccine for developing countries.

According to GAVI Brotherhood Progress Reports, cumulative back up to countries from 2000 to 2006 and from 2000 to 2007 amounted to about Us$962 meg and US$1.411 billion, respectively (GAVI Alliance 2006; GAVI Brotherhood 2007). From this we can infer that cumulative support to countries in 2007 was approximately US$449 million. In terms of total expenses even so, the figures were Usa$1.216 billion and US$793 1000000 for 2007 and 2006, respectively (GAVI 2008a).

Most of GAVI's funding comes from government donors (GAVI 2007). The US, i of GAVI's original six donors, has contributed a total of United states$421.81 million over seven years. Another of GAVI's original half dozen donors, the UK, contributed United states$121.56 million between 1999 and 2008. Canada had contributed US$148.73 million by the end of 2007, and Norway's contributions by 2007 amounted to US$291.89 million. Both the Earth Depository financial institution and the EC fund GAVI as well, although in relatively minor amounts. But funding from the Neb & Melinda Gates Foundation is much more significant. An initial v-year grant of US$750 1000000 in 1999 helped plant the GAVI Fund. The Foundation pledged a further The states$750 million in 2005, committing a full of Us$1.51 billion to the end of 2014 (GAVI 2008b). Other foundations and individual donors contributed The states$8.03 million betwixt 1999 and 2007.

Ii other actors worth mentioning are the Affordable Medicines Facility for Malaria (AMFm) and UNITAID considering they exemplify the creation of global agencies charged specifically to manage the purchase of medical bolt. The AMFm was established to assist purchase artemisinin-combined treatments for malaria, and is estimated to require a budget of U.s.a.$1.5–1.nine billion over five years (AMFm 2008). UNITAID was established to provide long-term and anticipated funding to buy and help reduce the prices of drugs and diagnostics for HIV/AIDS, malaria and tuberculosis. Co-ordinate to its 2007 almanac report, UNITAID'south total expenditure from November 2006 to December 2007 was US$148 million (WHO 2008). All the same, it is thought that expenditure could ascension to US$500m in 2009 (UNITAID 2008).

Nearly of the funding for the AMFm is expected to come from ODA. However, UNITAID is notable in that well-nigh 82% of its funding comes from an airline ticket levy (UNITAID 2008), pointing to the need to consider consumption taxes as a new source of global health funding.

Non-government organizations (NGOs)

As mentioned before, NGOs are major recipients of donations made by private individuals, effectively pooling and managing their contributions. Many NGOs also receive funding from governments and philanthropic foundations.

Over recent years, the non-government sector has grown to become a significant thespian in international development. An OECD-DAC Informational Grouping (2008) estimated that CSOs raised US$20–25 billion in 2006, of which US$14.seven billion was raised from the ODA of DAC donor countries. It is not known what percentage of this funding is spent on wellness, simply it is probable that the pct is higher than the 10% of DAC ODA that is allocated to health. An estimate of twenty% would hateful that between United states$4–5 billon was spent on global health by CSOs in 2006.

About of the funding for international NGOs in Europe comes from individual sources. For example, 87% of MSF's income comes from private donations, about ii-thirds of which comes from individuals. However, the delivery of government foreign assistance through private voluntary organizations (PVOs) is a prominent characteristic of the United states of america. In FY2007, USAID channelled United states of america$2.4 billion of ODA through PVOs (USAID 2007). The percentage of US ODA channelled through PVOs increased from 0.eighteen% in 1980 to vi% in 2002 (OECD 2005). Every bit a upshot, many US-based NGOs are heavily funded by the US regime. For example, Care International United states receives about 60% of its income from the US government, while about a quarter of World Vision US's income comes from the US government.

NGOs as well receive funding from philanthropic foundations. Some NGOs, for case, are major recipients of Gates Foundation grants. One such NGO is the Seattle-based organization PATH, which received a number of grants from the Gates Foundation between 1999 and 2007, the sum of which amounted to US$824.09 million (McCoy et al. 2009). Universities are also recipients of grants from the Gates Foundation and other foundations such as the Wellcome Trust. Johns Hopkins University, for example, has received US$192.32 1000000 worth of grants from the Gates Foundation (McCoy et al. 2009).

Individual foundations and the business/corporate sector

Private foundations and private companies tin besides be 'managers' of global health finance as well as 'providers' of global health finance by virtue of implementing their own programmes and projects. The budgets they manage are derived from their own income, although, every bit mentioned earlier, a meaning amount of this income arises from public subsidies made in the form of revenue enhancement exemptions.

Spending global health funding

Multilateral agencies/IGOs

UN agencies with a health mandate are ane important category of recipients of global wellness finance. Iii key agencies are the WHO, UNICEF and UNAIDS. The WHO has a budget of well-nigh US$four.2 billion for the current 2008/2009 biennium (WHO 2007a), an increase from the previous biennium upkeep of well-nigh US$three.3 billion. Although total income to UNICEF is greater, having risen from US$2.78 billion in 2006 to $3.01 billion in 2007 (UNICEF 2007), only a proportion of this is spent specifically on health. UNAIDS' expenditure, by comparison, is small-scale. In 2006/07, it spent United states of america$292 one thousand thousand, although United states of america$120.7 million was transferred back to its 'cosponsors' (including WHO, UNICEF and the Earth Bank) to implement activities under its unified budget and workplan.

Inter-governmental organizations such every bit WHO and UNICEF tend to be mainly regime-funded. However, private foundations are not a negligible source of funding for the WHO. In 2006, the Gates Foundation was the third equal largest funder of the WHO (Global Health Watch 2008). UNICEF also receives non-governmental funding. In 2007, while the public sector (governments and other IGOs) contributed to 65.4% of UNICEF income, private sector contributions totalled US$868 million (28.8%), most of which was raised by local UNICEF 'national committees' that run public fundraising activities. Foundations and GHPs also contribute to UNICEF, particularly for health. For example, in 2007, the UN Foundation contributed The states$71.8 1000000, GAVI provided US$47.8 meg, the Global Fund granted US$12.3 meg, the Canadian Micronutrient Initiative gave Usa$10.three million, and Rotary International awarded US$7.5 million.

While beingness major recipients of global health funding, WHO and UNICEF also fund other organizations, illustrating another example of the limitation of the schematic used in this paper. The WHO, for example, funds a considerable amount of technical work conducted past research institutes and universities. And similarly, UNICEF funds government and not-government agencies to conduct a multifariousness of health care activities.

Global Health Partnerships

Unlike the Global Fund and GAVI, many GHPs are non funding agencies but are primarily implementing agencies (although some also award grants to other actors). They include the Finish TB Partnership, the Medicines for Malaria Venture, the International Trachoma Initiative, and several that have been established to develop new vaccines and medicines. Funding sources for these partnerships vary but usually include a mix of government ODA, philanthropic funding, individual individual donations and in-kind contributions from the private sector. As many as lxx GHPs exist with aggregate almanac expenditure running into hundreds of millions of dollars, although individually well-nigh spend less than US$100 million per year.

The expenditure of the Stop TB Partnership in 2006 was U.s.a.$52.97 million, with 93% of this funding coming from governments, US$ii.1 million coming from foundations and Novartis contributing US$3.2 million worth of drug donations (WHO 2007b). Income into the Medicines for Malaria Venture (MMV) was United states$76.97 1000000 in 2007, upward from U.s.a.$xxx.62 million in 2006 (79% of funding in 2007 came from 'private foundations and individuals', mainly the Gates Foundation) (MMV 2007). The Global Brotherhood for TB Drug Development spent United states of america$twenty.09 million in 2006 (TB Brotherhood 2007), while the International AIDS Vaccine Initiative spent United states$76.99 million and US$87 one thousand thousand in 2006 and 2007, respectively (over 80% of funding coming from governments). The International Partnership for Microbicides spent about US$72 million in 2006 (IPM 2006) and the Drugs for Neglected Diseases Initiative spent US$8.27 1000000 in 2006 (DNDi 2006).

Non-government organizations

International NGOs are significant spenders of global health finance. In that location are now a huge number of NGOs operating in the field of international evolution and health. Their funding comes from multiple sources and it is not possible to establish an accurate figure for the corporeality of global wellness finance spent past NGOs. All the same, it is worth noting the budgets and expenditures of some of the larger NGOs in order to gain some perspective on the significance of their presence on the global wellness landscape.

Save the Children United states and United kingdom of great britain and northern ireland spent US$361.2 1000000 and approximately The states$280 1000000, respectively, in fiscal year 2007, a proportion of which would have been on child health. Care International U.s. and Oxfam Great Britain spent United states of america$608 million and approximately U.s.a.$426.v million, respectively, in 2007. Full expenditure of the MSF international movement in 2006 was approximately US$700 1000000. The combined income of World Vision United states of america and Uk in 2007 was simply over United states of america$i billion. The Clinton Foundation spent United states of america$92.79 one thousand thousand in 2006, of which 30% was allocated to its HIV/AIDS Initiative which focuses on paediatric AIDS treatment, and viii% to its Global Initiative which funds a number of health programmes (William J. Clinton Foundation 2007). The Carter Centre's health programme expenses for 2006 were United states of america$95.59 million.

Private sector

The private sector is also a large spender of global health finance, although a large corporeality of corporate contributions in the form of drug donations or discounts can effectively be viewed as coin spent by those companies on themselves. In add-on, a large amount of other global wellness spending is directed at the purchase of medicines and other commodities from private companies. For example, up to and including the Global Fund's 6 rounds of funding, an estimated 48% of expenditure was on commodities, products and medicines from the private sector (Global Fund 2007b). A large proportion of Gates funding is also channelled to the private sector, either to stimulate new research and development or to aid purchase existing products. Similarly, a big proportion of spending by the GAVI Alliance, the Clinton Foundation, the Affordable Medicines Facility for Malaria and UNITAID volition be on commodities from the individual sector.

Low and heart income land (LMIC) recipients

Developing country governments are clearly important recipients of global wellness funds, specially through the channels of bilateral and multilateral ODA, likewise as from the Global Fund and the GAVI Alliance. Civil society organizations in LMIC countries are likewise recipients of global health finance from various sources. For example, developing country CSOs may receive grants directly from donor governments, northern-based international NGOs or the general public. There are, however, limited data on the amount and distribution of global health finance channelled to CSOs in LMICs.

Discussion

This paper presents a conceptual map of the contours of global health funding using a schematic that (a) differentiates the source, management and spending of global health funds, and (b) draws attention to the unlike categories of actors in the global health mural. Effigy 2 shows the main actors in global health finance in dollar terms for 2006 and their inter-relationships, showing the many routes by which global health funding is channelled. Given the many actors and the lack of information, the map we nowadays is imprecise and hazy. However, this only serves to emphasize the need for a framework with which to describe and analyse the roles and relationships of the many actors operating in the messy and complex reality of global health.

Figure 2

Overview of the chief blocks of global funding for wellness in 2006 Notes: (1) This figure refers to the calculation past the Development Aid Committee (DAC) of bodily disbursements fabricated for wellness and population in 2006. Information technology is expressed in 2004 dollar terms having been controlled for inflation and fluctuating exchange rates. Source: OECD (2008a). (ii) This figure is an gauge based on a guesstimate that full non-DAC official development assistance (ODA) in 2006, including Mainland china, was about US$7 billion and that health sector spending would be no more than than x% of this figure. (3) This effigy represents expenditure for 2006. Information technology is worth noting that expenditure for 2007 was U.s.$1220 million. (4) This figure is a guesstimate based on a calculation of the grants awarded for health programmes past three of the bigger health-funding foundations: Wellcome Trust, Rockefeller Foundation and Ford Foundation (Rachlis et al. unpublished). (v) This effigy is a guesstimate based on an assumption that voluntary contributions to health may be like in size to voluntary contributions to humanitarian relief every bit estimated by Development Initiatives (2008). (half dozen) This effigy comes from the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) which estimated the size of the pharmaceutical industry'south contribution to the health-related MDGs in 2006. (7) This figure represents International Development Association (IDA) spending on Health, Nutrition and Population as reported by the Earth Banking concern. (8) This figure indicates European Commission (EC) spending on 'health' and 'population and reproductive health' and comes from a report past Activeness for Global Wellness. (9) This figure represents expenditure/disbursements for 2006. (10) This figure is the total expenses of GAVI. Source: GAVI (2007). (eleven) This figure comes from the UNITAID annual written report. It is expected that expenditure will increase to Us$ 500 meg in 2009. (12) (13) This effigy represents half of WHO'due south reported biennial budget for 2006-07. (14) This figure is a guesstimate based on the assumption that a 3rd of UNICEF's total income in 2006 would have been spent on health. According to UNICEF's Almanac Report, total expenditure through directly programme assistance on HIV/AIDS and kid survival and development was The states$1197 million (UNICEF 2006, p. 40). (15) This figure represents total UNAIDS expenditure for the FY 2006/07. (16) This figure is a guesstimate derived from the budgets of the global wellness partnerships described earlier in the text. (17) This figure is a guesstimate derived from the expenditure of Médecins Sans Frontières (MSF) and the budgets of several of the large international NGOs described earlier in the text. (eighteen) This figure is a guesstimate derived from the data on corporate contributions to global wellness together with estimations of GAVI, Global Fund, UNITAID, Clinton Foundation and Gates Foundation funding of bolt. (19) Co-ordinate to the OECD, 96.four% of DAC funding for health was allocated to low and lower-middle income countries. From this, a spending effigy of US$9230 million can exist estimated for 2006 (using the same exchange rates used in Figure three).

Figure 2

Overview of the main blocks of global funding for health in 2006 Notes: (1) This figure refers to the calculation by the Development Help Commission (DAC) of actual disbursements fabricated for health and population in 2006. It is expressed in 2004 dollar terms having been controlled for inflation and fluctuating commutation rates. Source: OECD (2008a). (two) This figure is an judge based on a guesstimate that total non-DAC official evolution assistance (ODA) in 2006, including China, was about US$7 billion and that wellness sector spending would be no more 10% of this figure. (3) This figure represents expenditure for 2006. Information technology is worth noting that expenditure for 2007 was United states$1220 1000000. (4) This figure is a guesstimate based on a calculation of the grants awarded for health programmes by three of the bigger health-funding foundations: Wellcome Trust, Rockefeller Foundation and Ford Foundation (Rachlis et al. unpublished). (5) This figure is a guesstimate based on an assumption that voluntary contributions to health may be similar in size to voluntary contributions to humanitarian relief every bit estimated by Development Initiatives (2008). (6) This effigy comes from the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) which estimated the size of the pharmaceutical industry's contribution to the health-related MDGs in 2006. (7) This figure represents International Development Clan (IDA) spending on Health, Diet and Population as reported by the World Bank. (viii) This figure indicates European Commission (EC) spending on 'health' and 'population and reproductive health' and comes from a report by Action for Global Wellness. (9) This figure represents expenditure/disbursements for 2006. (x) This figure is the total expenses of GAVI. Source: GAVI (2007). (xi) This figure comes from the UNITAID annual report. It is expected that expenditure will increase to US$ 500 million in 2009. (12) (13) This figure represents half of WHO's reported biennial budget for 2006-07. (fourteen) This figure is a guesstimate based on the assumption that a third of UNICEF's total income in 2006 would have been spent on wellness. According to UNICEF'south Annual Report, full expenditure through direct programme aid on HIV/AIDS and child survival and evolution was US$1197 meg (UNICEF 2006, p. 40). (fifteen) This figure represents total UNAIDS expenditure for the FY 2006/07. (16) This figure is a guesstimate derived from the budgets of the global health partnerships described earlier in the text. (17) This figure is a guesstimate derived from the expenditure of Médecins Sans Frontières (MSF) and the budgets of several of the large international NGOs described earlier in the text. (xviii) This effigy is a guesstimate derived from the data on corporate contributions to global health together with estimations of GAVI, Global Fund, UNITAID, Clinton Foundation and Gates Foundation funding of commodities. (xix) According to the OECD, 96.4% of DAC funding for health was allocated to depression and lower-eye income countries. From this, a spending figure of US$9230 million tin can exist estimated for 2006 (using the same exchange rates used in Effigy 3).

A number of points stand out from Effigy ii and the before discussion. Outset, global wellness financing is fragmented, complicated and inadequately monitored and tracked. While the increase in number of global health actors may positively reflect the greater corporeality of resources and attention for global health, it may lead to an uncoordinated and competitive environment that is problematic for governments and CSOs in LMICs. Many transaction costs come fastened to the proliferation of global health actors and initiatives and to the convoluted channels of financing. Ensuring acceptable financial and programmatic accountability to the public of government donors, international NGOs, Un agencies and philanthropic foundations has go difficult, if not incommunicable.

In its latest Wellness, Diet and Population Strategy, the World Bank itself noted that having to work with so many organizations and initiatives at the global level was challenging, and that there was a need for it to be more selective over its engagement with other actors. It went on to warn that 'unless deficiencies in the global aid architecture are corrected and major reforms occur at the land level', the international community could squander the rising in attention and money directed at improving the health of the earth's poor (Globe Bank 2007). Similarly, the UK government has described the 40 bilateral donors, 90 global health initiatives, 26 UN agencies and 20 global and regional funds working in global health as being 'over-complex' (DFID 2007). At times GHPs are established to help coordinate efforts in a particular expanse or aspect of health, simply inevitably end up adding to the problem of an already over-complicated architecture and an over-crowded landscape.

The importance of coordination and accountability (including common accountability) is further heightened by the vertical and affliction-based focus of many global health initiatives, together with the growing adoption of output-based operation measures that farther encourages verticalization at the expense of the wider health system and country ownership. The chase for funding, success and public attention undermines efforts to ensure a more than organized system of mutual accountability, coordination and cooperation (Buse and Harmer 2007).

While the Paris Declaration on Assist Effectiveness and the International Wellness Partnerships are designed to improve coordination and harmonization amidst donors, success has been limited. For example, one of the findings of a recent report published by the OECD on the Paris Declaration was that many donors nonetheless insist on using their own parallel fiduciary systems even where country systems are of good quality (OECD 2008c). It also reported on xiv 000 separate donor missions having been conducted in 54 recipient countries in one year, with Vietnam fielding an average of three per day.

A 2nd point relates to the book of global wellness funding. It is generally accepted that global wellness funding has increased over contempo years every bit a result of a ascent in ODA from donor governments and the emergence of the Gates Foundation as a major donor. However, the extent and calibration of the increment in ODA for global wellness appears to have been inflated. Disbursements for 'health and population programmes' by DAC donor countries amounted to U.s.$8.11 billion and US$9.58 billion in 2005 and 2006—less than the figure of US$fourteen billion which is commonly used to describe levels of development assistance for wellness.

Alarmingly, the total volume of ODA from DAC donor countries fell by 8.4% in real terms in 2007 relative to 2006 (OECD 2008b). According to a recent survey conducted past the OECD, although 102 recipient countries can expect a real increment in their aid by 2010, only 33 of them will experience an increase of US$100m or more. More than worryingly, 51 recipient countries can expect a decrease in aid by 2010, while ODA to eight To the lowest degree Developed Countries and four frail states is expected to autumn by over U.s.a.$20bn (OECD Development Assistance Committee 2008). The current level of development aid for health therefore falls far brusque of the additional Usa$22 billion required by 2007 as estimated by the WHO Commission on Macroeconomics and Health (2001). The current globe fiscal crunch and the prospect of a worldwide recession, with donor governments cutting back further on assist budgets, nowadays additional and serious concerns that volition need to be faced.

A tertiary issue concerns the pattern of global health spending and consumption. Global wellness is a multi-billion dollar industry and there are clearly competing interests amongst dissimilar actors to make use of this funding. An important question is whether global health financing is organized to suit the interests of particular actors.

For example, pharmaceutical companies appear to benefit considerably from global health programmes that emphasize the commitment of medical bolt and handling (equally well equally from the positive image created by their participation in GHPs). NGOs, global wellness enquiry institutions and UN bureaucracies likewise have an interest in increasing or maintaining their levels of income. The expanded part of NGOs is especially noteworthy. Many NGOs are at present big multi-national enterprises. The MSF international move, for example, although consisting of fairly autonomous country 'capacity', commands an annual budget of about 3-quarters of a billion dollars. The income of the Seattle-based not-profit organization, PATH, in 2006 was over Usa$130 1000000 (PATH 2007).

Conscientious attention and debate also needs to be applied to the possibility of global wellness funding and policy evolution being 'captured' past vested interests and used to support inappropriate spending on the private commercial sector, or on a large and plush global health bureaucracy and technocracy based in the North. It is of import to look at not just the volume of money raised, but besides how it is spent and who it benefits so as to assistance ensure that the needs of recipient countries are kept at the forefront.

Nevertheless, the lack of data on many aspects of global wellness finance makes information technology impossible to conduct a comprehensive and detailed cess. The gap in information and assay on international health funding past non-DAC regime donors and individual foundations, and on funding that is channelled through and spent by NGOs, GHPs and the private sector, needs to exist filled. Improve information on the pattern and flow of global health financing would enable a more critical analysis of the functioning of funders and global health actors in delivering advisable and effective evolution assistance for health to LMICs.

While ameliorate data are required at the global level, what is maybe more important are financial management and information systems in recipient countries that are capable of providing a blended motion picture of health expenditure that integrates external and domestic financing for wellness. Initiatives to strengthen budgeting and expenditure reporting systems such every bit the promotion of National Health Accounts and the Creditor Reporting System (CRS) of the OECD are of import steps, simply need to be expanded and improved. Greater apply by donor governments of sector-wide or multilateral approaches to development assistance would likewise assist considerably.

Finally, all the recommendations made above must be accompanied by the development of civil society capacity within countries to play a 'watchdog' function on how governments and external agencies are performing. An empowered and informed civil guild in LMICs, including local universities and other research institutions likewise as the local media, must brainstorm to engage with the complex and fragmented supra-national infrastructure of finance, actors and initiatives, and assist to ensure that information technology impinges upon their delicate wellness systems in a more positive manner.

Endnotes

¹ Australia, Republic of austria, Belgium, Canada, Denmark, Republic of finland, France, Germany, Greece, Republic of ireland, Italia, Nihon, Grand duchy of luxembourg, Netherlands, New Zealand, Norway, Portugal, Espana, Sweden, Switzerland, U.k. and United States.

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Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2009; all rights reserved.

Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2009; all rights reserved.

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