When Gavi pulls health funding, do donor countries follow?

For years, Wenhui Mao and a group of researchers at Duke University have been curious about how moments of donor transition — whether increasing or withdrawing aid — impact the health systems of the countries that receive the funds. Their earlier research has shown that “local governments may not have the capacity to immediately take over from the donor,” leading to short-term gaps, as well as the loss of monitoring and evaluation mechanisms. Now they have trained their sights on whether multilateral and bilateral donors follow similar patterns when withdrawing health-related official development assistance, or ODA. Taking Gavi, the Vaccine Alliance, as their example, they analyzed how 17 bilateral donors behaved when Gavi withdrew its assistance because a country had reached its threshold for transition. What they found, Mao said, “is they tend to have the same trend. When Gavi comes to the country, bilateral donors also come to the country. And when they leave, the bilateral donors also follow similar trends.” Devex spoke to Mao about her new research and the impact on the health systems of countries as they transition to middle-income status. This conversation has been edited for length and clarity. What led you to compare bilateral ODA trends with multilateral funding practices in the first place? We had been looking at the transition policies of different donors in global health and we had noticed some interesting phenomena. The first is that multilateral donors tend to have transparent transition policies. However, they still have a very strong focus on several indicators, like [gross national income] per capita or some disease-burden related indicators. But what happens if [many multilateral donors] follow similar indicators or thresholds? What happens if a country hits the threshold? They will lose eligibility for those multilateral donor funds. At the same time, we noticed many bilaterals, they don’t usually say we will graduate or lay out certain conditions. But we assumed, if they follow similar practices as other multilateral donors or if they are also referring to similar indicators, this will also lead them to transition from the country at the same time. That’s the rationale for conducting the study. Can you explain why you chose Gavi as the representative for multilateral donors? It’s the convenience, the data availability. Gavi has a very specific graduation or transition policy. They share the data of what countries they have supported or are currently supporting. Gavi is also a very typical global health donor, focusing on vaccines. You have said your most significant finding is the overlap between when Gavi and bilateral donors withdrew. That does not point to a collaboration, though? We cannot reach that conclusion. They may follow similar trends, practices, but we cannot say one affects another. Nevertheless, your analysis makes clear that the overlap does exist, both in when funding begins and when it is withdrawn. What are the implications for the health systems in the recipient countries? When countries are eligible, maybe [donors] should coordinate or consider different diverse criteria when they allocate ODA. Because when they graduate, they leave a country in a very short time. That is another thing they can improve, to help the country plan for the transition period, instead of just leaving and the country will have to start bearing all of the financial gaps. This builds on our previous research that lots of health programs, local governments may not have the capacity to immediately take over from the donor. Also, when donors come into the country, the programs usually have some monitoring and evaluation mechanism. When the donor [leaves], this kind of accountability mechanism will disappear and some people worry about corruption or that it will affect the efficiency of the health programs. There are some quite interesting implications from this study for the role of some new donors, like China, India and other instances of so-called south-south cooperation. From our previous research, we have found those emerging donors, they have quite a different rule when they allocate their ODA. This might actually fill in the gap. Were there exceptions to the findings of overlapping behavior? There are always some strategic interests for the [bilateral] donors when they allocate their ODA. One of the most significant is the former colony status. When Gavi left the country, bilateral donors also tend to reduce their ODA to the recipient country. But if the country used to be a colony of the bilateral donor, they tend not to be affected by this trend. We always talk about how ODA is kind of political. There are lot of nonhealth-need-related indicators that are affecting ODA allocation, but this is the empirical evidence to prove it exists, at least among the donors we included in this study.