Does Health Aid Reach the Poor?

A new report by the World Health Organization argues that the poor should be prioritized under universal health coverage (UHC). To that end, the WHO makes three arguments:

(1)    wider pooling to share risks and reducing fragmentation of benefit packages within countries;

(2)    using health aid for domestic pooled resources rather than vertical programs (of global health funding agencies); and

(3)    encouraging civil society to see efficiency improvements as a means to save more lives rather than cut budgets. (sounds familiar!)

No disagreements on points (1) and (3), but (2) seems to raise more questions than answer them.  

First, does health aid, pooled or not, predominantly reach the poor? Consider health aid for AIDS, malaria, and TB, which makes up about 44% of all health aid globally. Malaria and TB generally affect people of lower socioeconomic status, so perhaps aid for these diseases does reach the poor. However, AIDS appears to exhibit a paradox, such that in wealthier regions/countries, poorer individuals are more likely to be infected with HIV, whereas in poorer regions/countries, wealthier individuals are more likely to be infected with HIV (see here). Our More Health for the Money report argues for better targeting of resources, both of interventions and key populations, but for disease control purposes. So even if AIDS is concentrated among the richest, in fact it would be necessary to target that population to control an epidemic.

But more broadly, the institutions that fund these three diseases have been slow at targeting overall. In our own work, we found it impossible to say to whom, for example, the Global Fund’s resources were targeted in country (see our paper on this). But even as the WHO (unusually) declares that vertical health aid does not reach the poor, consider the alternative: can the WHO can say whether its funding, more “pooled” and “horizontal” and aimed at “health systems,” really benefits the poor more than the Global Fund or other agencies? I would argue that we have no idea.

Second, telling vertical global health donors to pool their funds would be nice for all sorts of benefits, including perhaps better coordination of resources to target to the poor. But it’s not politically feasible, particularly since these donors have all sorts of mandates to achieve a variety of results, which could be much harder to do in a pooled fund. Further, these funders have institutions and interests to continue fundraising, for their diseases and for their institutions.

Perhaps resigned at the status quo, WHO therefore says that “donors working to support health financing should therefore be mindful of the impact their work has on the population as a whole, and particularly the poor and otherwise vulnerable, rather than being solely focused on their project’s immediate beneficiaries.” But will more mindfulness help the sprawling state of the global health family and lead to more cooperative actions among donors—and ultimately prioritize the poor or at highest risk of a disease? Our More Health for the Money report found cases where there was little knowledge by one funder of another funders’ programs—in the same country. There is very little knowledge to be mindful about.  

So I’d argue that policies to coordinate and pool information are crucial—as a minimum before pooling money. So I’m encouraged by a recent glimmer of intentions to try to create a “one-country platform” for information and accountability, thereby reducing a “burden of global reporting” (see here). That in turn might lead to better coordination (and a greater focus on the poor, maybe?).

Perhaps that group will also take a clue from GAVI which is working to improve their information systems, though in a rather lonely way (see my post here). Amanda Glassman and colleagues have also been at work on Data for Development initiative, to improve all the bad and fragmented data funded by donors. And maybe then, there will be more momentum to move towards pooled funding, something previously proposed under the Health Systems Funding Platform, which admittedly has never really taken off.

Finally, missing from all three points is perhaps the most central challenge of achieving universal health coverage, which can undoubtedly help target the poor better: expansion towards UHC necessarily requires selectivity. Countries have to choose who benefits and for what, first. In other words, countries have to set priorities, and those priorities can include the poor or those at highest risk. In fact Amanda Glassman along with Kalipso Chalkidou of NICE International, has a report on priority setting. Why didn’t the WHO even mention institutions for priority setting as part of the core for ensuring that UHC benefits the poor?

Victoria Fan is a research fellow and health economist at the Center for Global Development. The authors thank Jenny Ottenhoff for helpful comments. You can follow Victoria Fan at @FanVictoria  on Twitter.