The failure of global health advocacy spelled out in numbers

No fashionable university is without its own department doing studies and advocacy on global health these days and NGOs and consultancies proliferate. Richard Horton and his team at The Lancet seem to produce ever more elaborate reports and commissions demanding an extra $30 billion here or $50 billion there. None of them tell you that funding for global health has flatlined despite the expensive Western advocates.

Things are going to get worse: Australia and Canada have implemented major cuts in overseas development since the most recent data were compiled; Finland has just shredded its aid budget; Denmark may follow.

This great article from Humanosphere shows what has happened to donor funding. A couple of caveats: the international donors don’t, of course, have money of their own so the money labelled “Global Fund” or “Gavi” all comes from donor governments (and, to a lesser extent, Foundations) too. US spending is understated: its uniquely favourable treatment of charitable foundations means that donors such as the Gates Foundation (“BMGF” on this chart) get some help from US taxpayers. I’m not clear what the box labelled “NGOs” refers to and it looks suspiciously high to me — I suspect that much of it is, in fact, pass-through donor government spending.

Health as a percentage of ODA seems to be falling too, at least in Europe. In December 2014, Euractive reported that about a seventh of German ODA is earmarked for health aid yet “in 2012, Germany paid out 0.029% of its GNI in health aid, about a third of its 2015 target.”

Things are even worse than they seem because in most big developing countries, domestic health spending has stalled at a very low level (as in Nigeria where public spending on health is about 1 percent of GDP) or is actually falling (as in India which had an even more abysmal base level than Nigeria). Most worrying of all, several donor darling countries have started to cut health spending. Michael Gerson in the Washington Post recently suggested that this may be a displacement effect as countries rely on more and more donor funding. The enduring scandal of Angola, a country with a per capita GDP of about $7,000, is that many of its health indicators have barely improved since the end of the country’s civil war. Per capita spending there has increased substantially since 2010 in real terms (to 2.5% of GDP) but very little of it seems to be getting to the poor

Defence spending meanwhile is booming. In the year that India cut health spending by 20 percent, it increased defence spending by 11 percent. Defence gets $40 billion from the central government budget while health gets about $5 billion (health does, of course, get a lot from state budgets while security gets less). The Indian Defence Review says this still “falls critically short”. Almost all defence imports are heavily subsidised by taxpayers in Western Europe, Russia or North America (or, for countries other than India, by taxpayers in China)

Other sectors are doing well too. Air India gets about $2 billion in most years to let it run empty planes around the world. Uganda has cut health spending by about 25 percent over recent years but plans to spend about a billion dollars relaunching an international airline and building airports to match. Neither Airbus nor Boeing would survive a year without vast taxpayer handouts from their host governments, as their competing complaints to the World Trade Organisation make clear.

Why are defence and aerospace raking in donor and developing country money while health is starved? Look at the attitude of the health advocacy groups. Late last year, Action for Global Health coordinator Tim Roosen said “We are deeply concerned about the trend of an increased use of loans [in overseas development assistance]. Non-productive sectors such as health are unlikely to benefit from loans as the majority of funding needed for health is dependent on grants. If the increase of loans continues, grants will decrease.” A leading advocacy group positions health as “non-productive”; in fact, good health spending boosts productivity and increases family resources while military spending does neither.

Defence and aerospace have another big benefit too.: they have large private sector constituencies in developed countries. No-one argues that Boeing should give away its jets to Uganda or that Raytheon should offer to transfer its military technology for free to India. The health constituency is potentially bigger — pharmaceutical companies employ more people than aircraft manufacturers do — but has no incentive to push to boost health spending because better access to health in developing countries usually means calls to confiscate the assets or the know-how of pharma research and development companies.

The short lesson is that, despite the beaming group photos, global public health advocacy has failed. It’s time to re-think.