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After the windfall

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Science  12 Sep 2014:
Vol. 345, Issue 6202, pp. 1258-1259
DOI: 10.1126/science.345.6202.1258

Plateauing budgets for global health sharpen the focus on what really works.

The good times are over in global health funding. After a decadelong surge, spending has plateaued—and the effects are being felt around the world.

The end of the surge

Aid for global health, by channel

Investments in health for poor and middle-income countries began growing in the 1990s, then exploded after the turn of the century, as the graph below shows. Rich countries stepped up their donations, with much of the funding channeled through new public-private partnerships like the Global Fund to Fight AIDS, Tuberculosis and Malaria and GAVI, the Vaccine Alliance. Billions earned in the software industry were transferred to developing nations after Bill and Melinda Gates started their charitable foundation in 2000. The bounty was spent buying and distributing drugs, vaccines, and bed nets; fighting malnutrition; and shoring up flagging health systems. Roughly one-tenth went to research and development, a bonanza for scientists.

The top 10 beneficiaries

Of 140 low- and middle-income countries receiving public health aid in the years 2009 to 2011, populous India received the most: more than $2.5 billion. Of the remaining top 10 countries, eight are in Africa, and for all but one, the United States was the single biggest donor. Mexico received roughly $1 billion in assistance from the World Bank, thanks to a special project to strengthen the country's health and health insurance systems.

But since 2008, the global financial crisis has led rich countries to tighten their belts. The global partnerships now have trouble raising money, and developing countries—some of which enjoy robust economic growth—are expected to shoulder more of the cost. And, increasingly, people are asking for hard data about the return on investment. Just showing that pills or bed nets were delivered is no longer enough: Donors want evidence of their impact.

Winners and losers

This map shows the biggest winners and losers in the global health bonanza, based on how many times the “expected” aid—based on disease burden and gross domestic product—they received in 2010. Botswana, Namibia, and South Africa, which all received major funding for HIV/AIDS, led the pack. Five countries—including Iran and Venezuela, which have strained relations with the United States—received less than one-fifth of the aid one would expect them to get. Many political, historical, and economic factors influence how much aid countries receive, says IHME researcher Joseph Dieleman; year-to-year variation also plays a role.

What are the results of the surge of the 2000s? Can we scientifically measure the impact of the billions invested? And now that the explosion has ended, what happens to poor countries that still have massive burdens of disease as well as rapidly growing populations? In this special news section, Science tracks the impact of the funding explosion in global health—and what happens now that it's over.

Skewed funding

The diseases that cause the highest burden—expressed in disability-adjusted life years, or DALYs—don't get most of the international largesse. In 2010, HIV/AIDS received the biggest chunk; little aid went to noncommunicable diseases like diabetes, whose burden is large and growing.

Meanwhile, here's another figure to keep things in perspective: The $31.3 billion spent on global health in 2013 is less than 1% of what rich countries spent on their own health last year. By any measure, the surge has ended too soon.

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