Assessing equity in the distribution of bilateral development assistance for health, 1990-2010

Approximately $30 billion in development assistance for health (DAH) is disbursed annually, but the amount of funding provided to each country varies dramatically, beyond what can be explained by differences in population. Of total DAH, bilateral aid accounts for 40% and its distribution is acknowledged to be widely influenced by economic and political relationships between countries, which likely contribute to inequitable aid distribution. This analysis is the first to examine the equity of donor countries’ DAH distribution over time, using recipient country disease burden as an objective and comparable metric of need.

This study utilizes publicly-available data on annual bilateral DAH from 23 donor countries to 135 recipient countries, between 1990 and 2010; and recipient country disease burden, measured by annual all-cause disability-adjusted life-years (DALYs), for five-year intervals from 1990 to 2010. Multiple log-linear regression models are used to assess the variation in DAH per DALY, by donor country and year.

Key findings indicate that variation between recipient countries in bilateral DAH per DALY has increased over time (DAH per DALY: SD=$1.76 in 1990, $2.61 in 2010.) Donor countries vary substantially in their distributional equity of bilateral DAH per DALY to different recipient countries (coefficient of variation among donors in 2010: min=1.40, max=5.40.)

This study highlights important global inequities in the allocation of bilateral DAH. Using disease burden as an objective measure of health need in each country, there is wide variation in the amount of bilateral DAH provided to countries to improve population health, given need. Explicit use of disease burden measurements is recommended to allocate health aid more equitably, and further investigation of country-specific factors dictating disbursement decisions is warranted.