Mobilize financial resources for health

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Attaining global health will require more than just improving the U.S. government machinery that oversees global health programming and activities. A greater financial commitment will also be needed, including advanced economies making good on their promises of aid.105 Low-income countries depend greatly on external assistance to fund health programming. In some 30 African countries, 30 percent of health spending comes from donors and nongovernmental organizations;106 in Rwanda, this figure is more than 50 percent.107

The task of achieving the MDGs has become even more challenging in light of the current economic crisis. Sub-Saharan Africa, one of the regions hit hardest by rising food prices, could be further affected if foreign direct investment and aid flows now decline.108 In the current volatile atmosphere, there is a risk that some hard-won advances in poverty reduction and health could unravel. It is therefore especially important that the global community uphold its commitments and remain focused on the MDGs.109 The United States will need to go beyond affirming its current financial commitments and pledge additional resources, while also taking a close look at the distribution of funding.

Increase U.S. commitments to achieve health-related MDGs

The global community uses two benchmarks to quantify the basic health “needs” of low-income countries: the costs of scaling up to meet the health-related MDGs, estimated at $20 billion to $70 billion annually;110 or the price estimate of $34 per capita per year for an essential health benefit package, as assessed by the WHO’s Commission on Macroeconomics and Health. To meet these needs, low-income countries have been asked to raise an additional 1 to 4 percent of GDP in public revenue.111 While the committee supports the call for increased health spending by low-income countries, it also recognizes that revenue performance during the past few years has been disappointing and even stagnant in some regions.112 Even if poor countries mobilized an additional 1 to 2 percent of GDP to finance health, it would amount to only $12 billion to $24 billion, which is insufficient to meet the MDG needs.113 Likewise, if the aim were to deliver the $34 per year benefit package, poor countries would need to increase their health spending by more than 40 percent—an unlikely prospect.114

If poor countries are to move closer to meeting the MDGs and delivering essential health services, foreign assistance for health from advanced economies will need to increase. In 2002, the UN Millennium Project estimated that total overseas development assistance (ODA) volumes would need to rise to 0.54 percent of rich country gross national income (GNI)—or $135 billion—by 2015 if the MDGs were to be met.115 Unfortunately, although global ODA directed to health has increased significantly, from 4.6 percent of ODA in 1990116 to 16 percent in 2006,117 the overall level of ODA commitment is still too low to meet the MDG funding gap.

Between 2001 and 2008, State Department and USAID global health programming grew by nearly 350 percent (see Figure 4). As a result, health now makes up a significantly larger portion of both the U.S. foreign affairs and the overall ODA budgets. In 2006, health aid comprised nearly one-quarter of U.S. allocable aid; this is more than the average proportion of spending on health aid by other advanced economies (see Figure 5).118

Figure 4. State Department Global HIV/AIDS Initiative (GHAI) and USAID spending on global health (2001–2008).

Figure 4

State Department Global HIV/AIDS Initiative (GHAI) and USAID spending on global health (2001–2008). Source: Committee’s calculations based on Salaam-Blyther, 2008.

Figure 5. Share of allocable aid to health by Organisation for Economic Co-operation and Development (OECD) countries (2006).

Figure 5

Share of allocable aid to health by Organisation for Economic Co-operation and Development (OECD) countries (2006). Source: Committee’s calculations based on OECD, 2008b.

Despite dramatic increases in spending for global health during the last decade, U.S. commitment to overall ODA has been below the efforts of other developed countries in relative terms. So even though the United States was the largest aid donor in absolute dollars ($21.8 billion) in 2007, it has one of the lowest levels of net ODA as a percentage of GNI: 0.16 percent (see Figure 6). This is well below the UN target of 0.54 percent and the Development Assistance Committee average of 0.45 percent. Even when private giving is included, the United States does not come close to the level of most other rich countries’ ODA. The U.S. government gives only 25 cents per day per person and an additional 10 cents per day being given by private donors. Sweden and Denmark, by comparison, give $1.00 and $1.07 per day per person, respectively, in public aid alone.119

Figure 6. Net official development assistance by Organisation for Economic Co-operation and Development (OECD) countries (2007).

Figure 6

Net official development assistance by Organisation for Economic Co-operation and Development (OECD) countries (2007). Source: OECD, 2008a.

The committee commends the recent increases in spending on global health but recognizes that an even greater commitment by the U.S. government is required to demonstrate leadership in global health. By 2012, the President should commit to spending a minimum of $13 billion annually on development assistance for health in support of the health-related MDGs. (This number is the product of the UN goal of 0.54 percent of GNI; the estimated GNI for the United States in 2012 [$15 trillion]; and the average proportion of ODA for health [16 percent] in countries belonging to the Organisation for Economic Co-operation and Development in 2006.) This level of spending, though still below the capacity of the United States and the overall resources needed for health, is justified on the basis of international norms and commitments.

Balance traditional portfolio of U.S. investments in global health

Increased finances would provide an opportunity to balance the portfolio of U.S. government investments in global health to reflect the breadth of the health-related MDGs. Allocations during the last 8 years have been heavily skewed in favor of HIV/AIDS, which received more than 70 percent of funds in 2008 (see Figure 7). Between 2004 and 2008, projects to combat HIV/AIDS, TB, and malaria received $19.7 billion, far outpacing support for other health programs. During the same period, USAID programs for children and women’s health received only $4.6 billion, representing little or no increase in real terms.120

Figure 7. Top seven causes of death in low- and middle-income countries, below age 70 (2001).

Figure 7

Top seven causes of death in low- and middle-income countries, below age 70 (2001). SOURCE: Committee’s calculations based on Global burden of disease and risk factors, 2006. Allocation of PEPFAR and USAID global health funding by category (average (more...)

While pursuing the goal of $13 billion per year for the health-related MDGs, the committee strongly recommends that the Deputy for Global Health and the Interagency Committee work with Congress to create balance in the traditional portfolio of global health aid. The U.S. government should fulfill its implied commitments under PEPFAR reauthorization to global AIDS programs ($7.8 billion per year), malaria ($1 billion per year), and TB ($800 million per year). The remaining $3.4 billion per year would roughly double current spending levels for programs in support of health systems strengthening, child and women’s health, nutrition, family planning and reproductive health, and neglected diseases of poverty, all of which have been severely under-resourced during the past decade.

Concerns have been raised that PEPFAR commitments have already created a new global “entitlement” that could prevent an increase in funding for other initiatives. This entitlement exists in the form of an open-ended commitment to provide AIDS treatment in countries receiving PEPFAR money that would be very difficult to halt. (Treatment costs are themselves set to escalate, mainly due to three factors: antiretroviral drugs have successfully prolonged the lives of AIDS patients who now require lifelong treatment; new HIV infections continue to outpace the number of people receiving treatment, due to inadequate prevention; and a portion of those on first-line drugs, for which dramatic price reductions have been attained, will require more costly, second-line therapies as their disease progresses.)121

The importance of HIV prevention—as both a public health and fiscal imperative—cannot be overemphasized. The United States should maintain funding for antiretroviral treatment for individuals already supported by PEPFAR, but also act diligently to ensure that the program prevents as many HIV infections as possible, especially among young women in Africa (who are three times more likely to be infected than men of the same age in many high-burden countries).122 This committee supports the 2007 IOM committee findings on PEPFAR implementation, which state that in order to help countries make gains against the HIV/AIDS epidemic, PEPFAR will need to emphasize effective, evidence-based prevention with the same urgency and intensity it has focused on treatment.123 Without a stronger focus on prevention, PEPFAR costs could crowd out other equally important global health initiatives.124

Additional funding for noncommunicable diseases and injuries

While the recommended $13 billion per year for global health would support the health-related MDGs, additional resources will be required to meet the global burden of disease for the 21st century. Even though chronic diseases account for nearly half of the disease burden in low- and middle-income countries,125 virtually no USAID programs address chronic or noncommunicable diseases.126 Cost-effective strategies—such as higher tobacco taxes, reduction of salt in processed foods, and the administration of a multi-drug regimen to treat those with cardiovascular disease—hold the promise of averting 32 million premature deaths from noncommunicable diseases in low- and middle-income countries.127 Injuries, which account for an additional 12 percent of deaths below age 70 each year, also receive little U.S. attention.128 Preventive and low-cost treatment measures specially tailored to low-resource areas can help reduce the burden of chronic diseases and injuries,129 which threaten to overwhelm health systems in low- and middle-income countries.130

The Deputy for Global Health and the Interagency Committee should work with Congress and the federal Executive Branch agencies and departments—particularly CDC, NIH, and USAID—to identify specific ways to respond to the contemporary challenges of noncommunicable diseases and injuries. The committee believes an additional $2 billion to expand the U.S. portfolio to address noncommunicable diseases and injuries would be appropriate. The U.S. government should adopt clear health goals, such as lowering deaths from smoking or reducing injuries from domestic violence, to guide the allocation of funds. Expenditures should include the scale-up of proven interventions and policies to reduce avoidable deaths, as well as research efforts to translate existing knowledge (often individualized treatment) into population-based interventions that are cost-effective in low-resource settings with large at-risk populations.

Declare U.S. commitment to global health

The committee is calling on the President and Congress to double U.S. commitments to global health programming between 2008 ($7.5 billion) and 2012 ($15 billion). In recognition of the partnership needed to achieve the health-related MDGs and meet the global burden of disease for the 21st century, the President should call together world leaders at the UN General Assembly in the fall of 2009 to announce the U.S. commitment to the overall funding levels recommended in this report. In light of this commitment, the President should ask heads of state of other wealthy countries to re-commit to their financial promises on global health, and in the interest of sovereignty and sustainability, ask low-income countries to commit publicly to providing an additional 1 to 4 percent of their GNI by 2012 to finance their own health initiatives.