Allocating development assistance for health

Abstract Background In the past decade, development assistance for health (DAH) distributed to developing countries grew at an annual rate of 11·6%, to a total of US$31·3 billion in 2013. Although this substantial rise in DAH is well documented, little has been done to quantify the determinants of its allocation. Methods We derived estimates of total DAH received by recipient country during 5 year intervals from 1990–2010 from data published in the Institute for Health Metrics and Evaluation's Financing Global Health 2012 report. Disease burden information during the same period was available from the Global Burden of Disease Study 2010. Other country-level characteristics that might affect the allocation of aid, such as gross domestic product and quality of governance, were also included. We use linear regression to identify patterns that typify how DAH is allocated across countries and time. Findings Income is associated with the allocation of DAH across countries but not across time, meaning that donors provide more health aid for low-income countries than for high-income countries, but an increase in a country's wealth with time does not mean it will receive less aid. Countries that are democratic and have civil or political rights receive more aid. Regarding disease burden, countries with a larger disease burden receive more DAH. A 10% increase in disease burden is associated with a 6% increase in DAH. Unlike gross domestic product, changes in disease burden within a country, over time, do affect DAH allocation; this is especially true for transparent and democratic countries. In these countries, a 10% increase in burden (which might be caused by disease epidemic or rising population) would result in up to a 30% increase in DAH. Lastly, DAH allocation is especially responsive to a recipient country's burden of HIV/AIDS. Interpretation This analysis provides evidence that donors give less to high-income countries and more to democracies with increased disease burdens. However, when disease burden is examined in greater detail, the emergence of HIV/AIDS as a primary driver of aid allocation is interesting in view of the diverse set of priorities within the global health agenda. With the growth of DAH slowing due to the economic crisis and an increasing number of non-state organisations operating in global health, knowledge of which factors affect resource allocation at the aggregate level can inform discussions about whether resources are being distribu