Will shrinking aid force changes to the global health landscape?

It’s not hard to find signs that funding is falling short of global health needs. The Global Fund to Fight AIDS, Tuberculosis and Malaria missed its $18 billion replenishment goal last year — the “minimum required” to get the world back on track to end HIV, malaria, and TB — by $2.3 billion. The Global Financing Facility, or GFF, is still struggling to meet its $800 million replenishment target this year to support the health of women, children, and adolescents. And even as its latest funding report announced a rise in external aid to low- and lower-middle-income countries in 2021, the World Health Organization cautioned in a press conference earlier this month that sustaining that level of giving will be difficult amid deteriorating global economic conditions. Looking ahead to 2024 and beyond, experts are now grappling with what this could mean at a moment when the crush of global health priorities is only increasing, with demands to prepare health systems for climate change and future pandemics coming alongside flagging efforts to meet global targets to reduce infectious and noncommunicable diseases and to achieve universal health coverage. “In the short term there is a worry, and it may be a little bit nasty for the next couple of years,” Peter Baker, a global health expert at the Center for Global Development, or CGDev, told Devex. “Most likely [funding] is going to be a bit stagnant and when you zoom out one more step, you’re looking at a chronic crisis. Most of us assume we’re not going to be able to achieve anywhere near what we thought we were going to.” It could also mean that 2024 marks the beginning of a recalibration in global health aid. It may seem a bit incongruous to be warning about a drop in money for global health from bilateral and multilateral funders when statistics show that 2021 actually delivered dramatic increases in donations. The amount of official development assistance for global health climbed to $34.9 billion, according to Donor Tracker, from $26.5 billion in 2020. But much of that increase is thanks to money to meet the demands of the COVID-19 pandemic, and experts agree the total is likely to fall off once data is reported for the subsequent two years. They are bracing for what will happen if that drop-off persists. Any funding shortfalls would be exacerbated by the systems that have been built up for distributing health aid. It is a tangle of bilateral and multilateral initiatives that are often targeted at specific diseases or interventions. That has led to enormous gains in individual fields, like HIV prevention and treatment, but also the creation of “fragmented health services,” Baker said. Those gains are threatened if funding for those streams drops and there aren’t sufficient domestic resources to fill the gap. Officials at UNAIDS have been warning for months that HIV is falling off the political agenda, for instance, which is threatening efforts to end AIDS as a global health threat by 2030 — despite it having claimed an outsized share of global resources for several decades. Officials working on diseases that receive less attention and less funding are even more concerned about what happens if global health aid begins to dry up. The Hepatitis Fund began operations in 2019 in response to the scattered efforts to address hepatitis globally. “There was a need for something more centralized to have this overall view of the funding need and then distribute it in the places where you find the highest need,” the fund’s executive director, Finn Jarle Rode, told Devex. And while the fund has been able to draw renewed attention and resources to the global goals to dramatically reduce new hepatitis infections, Rode said they are still struggling with an environment that often makes organizations responding to different diseases compete for available money. “You lose out in the marketing campaign,” he said. It also gives increasing importance to wealthy private donors, whose funds come with little accountability to governments or civil society groups. “With the increase of individual, high-net-worth individuals, giving becomes very personal,” Rode said. “They want to make a footprint that is their own legacy.” What’s driving the scramble for whatever money is available is the risk not just of falling short of global goals on lower-visibility problems, like hepatitis, but that they will flare into much bigger, much more expensive emergencies. “There are so many more players and so much confusion as to where to put the money,” Emma Ross, an expert in Chatham House’s global health program, told Devex. “One of the biggest problems is the lack of prioritization within the global health community.” It’s a bit murky, though, who would set those priorities and whether it would be possible to convince donor governments to adhere to them. Rode pointed to increasing efforts to identify overlaps within the work of major multilateral players like the Global Fund, Gavi, the Vaccine Alliance, and GFF. The Lusaka Declaration that emerged late this year from the Future of Global Health Initiatives explicitly called on the three organizations to develop a joint work plan. But they still have individual mandates and, combined, control only a fraction of the money directed to the global health response. The vast majority of the funds to meet the health needs across the global south, of course, come from the governments of those countries. And in an era of shrinking funding, there will be an expectation that they will take on even more of the cost. This “does shift power,” Ross said, and may give governments more control over their health priorities. A central demand for broader calls to decolonize the global health sector might help accelerate that movement. At the same time, though, some of the world’s poorest countries that are already struggling to fill key gaps may only see more unmet needs. The Hepatitis Fund is trying to use the money it has strategically to introduce catalytic investments that can help some of these governments take greater ownership of hepatitis programs that are closely aligned with other health interventions. Baker and his colleagues at CGDev have suggested a more radical approach that would see governments direct their funds toward the core priorities that they have identified. Donors would then step in to support the secondary priorities. This would help to ensure that key services are paid for no matter what happens in the global financing space. And as countries grow wealthier, they could take on more priorities. He acknowledged that it may be a tough sell to donor governments, who would have to justify paying for interventions that may not be as cost-effective as, say, providing ARVs or bednets. And it would require completely new mandates for organizations like Gavi and the Global Fund. But it speaks to the kind of reconceptualizing that shrinking global aid could introduce. “There’s been so much volatility recently with COVID, Trump,” he said. With this model, “the core, centered, solid government funds would generally be stable and then the stuff at the margins might be more volatile.”