Diversion of another sort – can we sustain malaria funding

Readers have expressed concern about our recent look at embezzlement of Global Fund Grants.  The Lancet has now published a study that addresses what one might call ‘legal’ diversion of government funds away from health programs.

Lu and colleagues have examined development assistance for health (DAH) across countries and learned how it affects domestic government health spending. Their analysis showed two key findings

  • DAH to government had a negative and significant effect on domestic government spending on health such that for every US$1 of DAH to government, government health expenditures from domestic resources were reduced by $0·43 (p=0) to $1·14 (p=0)
  • DAH to the non-governmental sector had a positive and signifi cant eff ect on domestic government health spending

In response Sridhar and Woods express “worry that others will draw two rather crude conclusions,” that health funding should not be routed through governments, but rather it should go to NGOs. In defense of this position they offer some realistic limitations – accurate calculation of government expenditures and donor tendency to skew assistance through disease-specific programs.

Ooms and colleagues offer another reason to take the findings of Lu et al. with caution. They see examples of both increases (Rwanda) and decreases (Ethiopia) in government response to increased DAH and encourage us to try to understand what governments may be facing and plausible reasons for their thinking such as …

  • Governments compensate for exceptional international generosity to the health sector by reallocating government funding to other sectors
  • Governments anticipate long-term unreliability of international health aid by stalling possible increases of recurrent health expenditure, or
  • Governments smooth aid by spreading aid across several years

Robert Davis, who provides an invaluable listserve drawing our attention to publications of child survival and health shared these Lancet pieces as well as another interesting article from 2007 on the role of DAH in immunization program achievements. Arevshatian and co-researchers documented that, “Rates of immunization coverage are improving dramatically in the WHO African Region. The huge increases in spending on immunization and the related improvements in programme performance are linked predominantly to increases in donor funding.”

Assuming that the global community shares goals of eliminating diseases like polio, onchocerciasis, and malaria, DAH is needed to address the scale of these endeavors. Governments of endemic countries, if left their own devices, may not have given the same elevated priorities to these diseases as do donors and experts elsewhere, but fortunately neither are they adverse to using assistance to help their people.

dscn7719-sm.JPGConsidering the current economic climate where the Global Fund worries constantly about replenishment, countries are right to question whether DAH commitment is really there to back these grand schemes into the future. As we have asked recently, are malaria donors prepared for a second round of universal net coverage in the next three years given the likely durability problems of LLINs?

Here is the reality. In Nigerian states that had not benefited from the earlier rounds of Global Fund support one could rarely find ACTs in government clinics.  Local government budgets for essential drugs were meager, and decisions had to be made whether using a sizable chunk for these expensive drugs was advisable or even feasible. Now with greater expansion of coverage in Round 8 as well as pilot efforts for the Affordable Medicines Facility malaria (AMFm), it is finally looking like affordable ACTs may be accessible at the community level.

Right now our challenges or concerns are not to bemoan the shifting of local government funds away from malaria drugs (which they were not purchasing anyway). We need to build the capacity of all levels of the health system to manage the new resources in a way that lives are saved and the Millennium Development Goals of 2015 are achieved.

… unfortunately the nagging thought remains, will these financial commitments to DAH be sustained?

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