In a Viewpoint published simultaneously with the Murray Article on international health aid, Gorik Ooms, Institute of Tropical Medicine, Antwerp, Belgium, and colleagues discuss the possible reasons behind the 'crowding out' effect—where governments use health aid to partly replace, rather than supplement, their own domestic health budget.
The authors say: "We argue that explicit policy choices are behind crowding out effects, unfolding very differently dependent on the individual countries' situations."
They list the three reasons they deem as most plausible for crowding out: governments compensating for exceptional international generosity to the health sector by reallocating government funding to other sectors; governments anticipating long-term unreliability of international health aid by stalling possible increases of recurrent health expenditure; or governments smoothing aid by spreading spending across several years.
A number of options are tabled by the authors that could help in each of these scenarios. To compensate for reallocation to different sectors, donors could support all sectors equally, respecting the national priorities of the government concerned; alternatively, they could provide and increase funding only to those governments who keep their domestic health budget at least stable. For governments smoothing aid over several years, increased transparency is necessary, including more understanding of why governments take these steps, such as their anticipation of the unreliability of international aid long-term.
The authors highlight the Global Fund (to fight AIDS, Tuberculosis and Malaria) as a mechanism delivering stable and predictable financing, and suggest it shows the potential of pooling international health aid. They conclude: "If the Global Fund benefitted from a burden-sharing mechanism agreed between all countries providing international assistance for health, something similar to the burden-sharing from which the International Development Association of the World Bank benefits, and if the Fund's mandate were broadened to encompass all elements of comprehensive primary health care, then it could engage in broad and long-term partnerships, as promoted by the International Health Partnership plus related Initiatives. Donor countries acting individually, even coordinated by an external organisation, cannot make such commitments, because there would be too many partners to hold each other accountable. Envisaged as a world social health insurance, a global fund for health could make the necessary commitments for the partnerships that would be needed."
Gorik Ooms, Institute of Tropical Medicine, Antwerp, Belgium (at Yale University, USA, on Weds 7 April and Thursday 8 April-available for interviews between 2pm and 4pm UK time on both these days).T) +1 510 705 3889 E) gooms@itg.be
Alternative contact Pieter van Dooren, Press Office, Institute of Tropical Medicine, Antwerp, Belgium. T) +32 474 28 31 47 / +32 3 247 07 29 E) pvandooren@itg.be
For full Viewpoint, see: http://press.thelancet.com/crowdingout.pdf
Journal
The Lancet