In May, the Institute for Health Metrics and Evaluation (IHME, who also published the influential Global Burden of Disease Study) published estimates of funding for global health for 1990-2013. The article contains noteworthy findings, including:
- In 2013, health aid surpassed $31 billion, the highest level of funding to date and 5.5 times larger than the level in 1990;
- In the past three years, ongoing increases in health aid have been fuelled largely by the Global Fund, GAVI Alliance and UK bilateral agencies, with reductions in funding elsewhere;
- Funding remains highly focused, with a small number of donors accounting for a high percentage of the total; and
- There are major disparities between burden of disease and funding allocated, with non-communicable diseases (NCDs) receiving a tiny percentage of funding, compared with their burden.
NCDs are now the leading global cause of death and disability, including in developing countries, as I explored in a recent report by ACFID. This new IHME study shows these diseases receive only a tiny amount of funding when compared with their burden. In 2011, $7.7 billion was allocated to HIV/AIDS projects, while malaria, TB, and maternal, newborn and child health received $1.8 billion, $1.3 billion, and $6.1 billion respectively. NCDs received only 1.5% of all health aid.
Why the disparity?
Why does this disparity exist? IHME suggests that data on cost-effectiveness of NCD interventions are less clear than those for HIV/AIDS and other diseases. Additionally, the most cost-effective interventions may include prevention through taxation and regulation that do not require ongoing financial investment. Further, management of diabetes requires long-term monitoring and medication – whereas a vaccine, for instance, can be administered in one or a few doses, and return on investment can be more easily calculated.
While there is merit to these suggestions, I think there are also other forces at work.
Even if we start with the assumption that the lack of data has hindered investment, the logical counterargument is that this situation provides the perfect rationale for investing in more research to help determine what works and what doesn’t, and to help define the overall agenda.
Yet NCDs research (defined broadly, including medical research, epidemiology, and health systems) has also remained largely under-funded. Australian Aid’s Medical Research Strategy, for instance, explicitly states that it won’t fund NCD-related research. There are signs of improvement, however, including through the Global Alliance for Chronic Disease initiative.
Digging deeper – questions of methodology
What other factors might be behind the manifestly inadequate funding levels for NCDs?
One possibility is there may be a methodological limitation in determining what gets defined as an NCDs investment. What constitutes ‘health aid’ is not clear in the IHME article, though it appears to be defined along lines of strengthening health systems and basic health care.
If we look at interventions taking place in the NCDs space, many are outside of what might be strictly referred to as ‘health aid’. A good example is the Australian Aid-funded Development through Sports program, which has the goal of reducing the impacts of NCDs by increasing physical activity. This highlights the need for a nuanced understanding of the variety of sectors and programs that contribute to preventing NCDs.
Another methodological point is that funding for tobacco control is categorised separately, for unknown reasons. As a leading risk factor for NCDs, tobacco prevention and control is an integral part of the NCDs agenda. While it also plays an important role in the progression of other diseases (for instance, smokers are more than 2 times as likely to die from TB than non-smokers), separating tobacco from NCDs seems artificial in this context and is not conducive to getting the most accurate picture.
That said, the funding amount for tobacco is so minimal that its inclusion in the NCDs category would not have made a big difference – funding for HIV/AIDS, was 113 times as large as funding for tobacco control. Perhaps the whole point of this division between NCDs and tobacco was to highlight the minimal amounts of funding for tobacco?
Digging deeper – bridging evidence and policy
The exclusion of NCDs from the Millennium Development Goals has been a major barrier to getting NCDs on the agenda. While they will likely be included in the next iteration of the MDGs, which will help to increase funding, this raises another question: why weren’t NCDs included in the MDGs (and why are they likely to be included in the next iteration)?
One answer is that research and policy have not been effectively bridged. The existence of good evidence does not itself lead to change. What’s needed is advocacy and good policy work to bridge this gap – not only synthesising the available evidence, but understanding how policy works, what the entry points are, and what drives decision makers.
In some contexts, the people doing the research can also act as advocates, and networks between researchers and policy makers are important in enhancing the use of evidence in policy-making processes. However, the skills involved in policy and advocacy can be quite different from those in research, and the advocacy and policy work is often a distant second in terms of priorities, if it’s considered at all.
Funding for NCDs in Australia’s aid program is illustrative. It still seems to be the case that NCDs are swept aside by more vocal interest groups, or placed in the ‘too hard’ basket. The Australian Government has a series of NCD investments in the Pacific, but there is little to indicate an interest in NCDs beyond our immediate region.
There is no unified ‘voice’ to push the agenda and to work with Government in finding solutions, which has also historically limited funding from other bilateral donors, multilateral bodies and philanthropic foundations.
At the global level, such a voice has now emerged, with the NCD Alliance playing an important role in elevating NCDs on the agenda and providing a model for how similar alliances can be established at country-level. NCDFREE also plays an important voice in generating social awareness about these challenges.
Yet in Australia, a cohesive coalition focused on the integration of NCDs in aid programming has yet to emerge, and consequently there has been little impetus for the Australian Government to establish a comprehensive, global approach to addressing NCDs.
With the growth of evidence, momentum, and global actors and frameworks, the NCDs funding situation will change dramatically over the next five years. Hopefully, this will mean future studies of global health funding will demonstrate a clear and proportionate commitment to addressing NCDs (and perhaps even the establishment of a Global Fund-type organisation committed to addressing them). Once this occurs, we might also start to see a reversal of the rise in the global burden of NCDs.