It seems simple enough – a proliferation of donors in global health means more money to solve some of the world’s most pressing health issues. Right? Not exactly. A lot of new evidence is coming out that suggests that the lack of coordination of different funding sources can be a burden and perhaps a detriment to global health. And the way that traditional funders think about the locus of health spending in countries to which they donate may not even be entirely accurate. As a recent report from the Center for Global Development In fact, as the report finds, most funding for health is actually sub-national. While international donors and funders continue to give money to concentrated sources such as ministries of health, most of the actual spending for health in large middle-income countries, such as Indonesia and South Africa, comes from smaller, dispersed entities on a sub-national level. In some ways this is good news, since it implies greater “democratization” and a greater focus on local needs, which can be key in determining the right kinds of interventions for global health. But in other ways, this finding is a bit troubling. In fact, as the report points out, evidence on the effectiveness of subnational spending on global health is very mixed.
These findings tap into a more fundamental question that consistently plagues global health donors: What is the best way of coordinating significant donor spending and efforts on major global health issues? This question has long troubled the HIV/AIDS community, with consistent findings that national and sub-national HIV/AIDS strategies are often uncoordinated, resulting in inefficiencies, duplication of efforts, and inadvertent but devastating inequities.
Yet even beyond the question of national versus sub-national funding is the question of how to coordinate the ever-proliferating numbers of global health donors more generally. A recent Kaiser Family Foundation mapping of the donor landscape included several alarming findings. According to the report, there are:
- 37 donors responding to HIV in 143 countries;
- 22 donors responding to tuberculosis in 109 countries;
- 27 donors responding to malaria in 86 countries;
- 36 donors responding to family planning and reproductive health needs in 147 countries.
If it is true, and it may very well be, that the lack of coordination in global health funding produces inefficiencies, inequities, and even adverse health outcomes, where do we go from here? For one thing, greater transparency is needed from everyone involved. Every actor in the global health space, including country ministries of health and sub-national entities as well as large private donors such as Gates, needs to meticulously and publicly relate its activities and results. Online tools can even be developed that aggregate this information and allow for better decision-making on the part of donors and funders. In addition, funders and donors must be encouraged to collect information not only on activities and outputs but also on outcomes. This information must also be made public and should be similarly aggregated. When information on outcomes is collected and published, the chances of duplicating particularly unsuccessful efforts are greatly diminished. In addition to collecting and publishing outcomes, donors and funders should meticulously collect and publish more subjective information about the feasibility, difficulty, time intensity, and acceptability of their global health efforts. Again, this information, when made publicly available, allows other potential donors and funders to better understand not only what may have the greatest outcome but also what’s most realistic given political, environmental, and cultural barriers, among other considerations.
If we want to coordinate a better response to the world’s most pressing global health problems and truly deliver on our commitments to improve global health, then it is essential that we start thinking of ways to help donors and funders coordinate funding efforts. That may simply mean greater encouragement of more transparency or it may mean more active efforts such as building online data aggregation tools. Either way, much better coordination is absolutely essential to ensure that the best possible combination of efforts are being utilized for the greatest possible health impact.
Sara Gorman, PhD, MPH is a Manager at Janssen Global Public Health (the pharmaceutical companies of Johnson & Johnson). She works on alternative financing and new technologies for global health. Sara received her MPH from Columbia University Mailman School of Public Health in 2015 and her PhD in English Literature from Harvard University in 2013. Her book on how people make health decisions in forthcoming from Oxford University Press.