Rethinking external assistance for health

• Coronavirus disease (COVID-19) and the subsequent economic crisis have raised questions about the long-term sustainability of external assistance for health and the interventions that it supports.

• New thinking is needed on how external assistance for health may best contribute to the sustainable coverage of essential health interventions embedded within countries’ efforts to make progress towards Universal Health Coverage (UHC).

• We propose a research agenda to expand the evidence base and inform this rethink of external assistance to support sustainable coverage.

The COVID-19 pandemic, and the economic crisis that it has triggered, has challenged national health systems and the broader international aid architecture. For low- and lower-middle income countries especially, external assistance for health has played an influential and important role in health spending, with the share of health spending from external sources in low-income countries having increased from an average of 16% to 29% between 2000 and 2019 (World Health Organization, 2021). However, while there has been some increase in external assistance for health as part of the immediate response to COVID-19 (Ahmad and Carey, 2021), global economic pressures mean that the sustainability of this level of external assistance for health is now threatened.

As countries and donors alike revisit their approach to investing in health and well-being in the wake of COVID-19, there is an urgent need to rethink how we conceptualize, design and implement external assistance for health. How can external assistance for health best contribute to sustainable coverage of essential health interventions needed to support countries in their efforts to move closer to UHC?

The substantial increase in external assistance for health over the past 20 years was largely directed towards individual diseases, most notably HIV/AIDS, TB and malaria, through programmes supported by newly established global health initiatives (WHO Maximizing Positive Synergies Collaborative Group, 2009). But even before COVID-19, strong economic performance of many low-and-middle-income countries, together with a relative slowing of the pace of growth of external assistance (Dieleman et al., 2016), led to an increasing focus among donors on sustainability. The concept of ‘transition’ (i.e. no longer being eligible to receive grants or highly concessional loans from major global health funders on account of having achieved pre-defined income and health thresholds), became a central part of the lexicon of donors and external assistance more broadly. Pre-COVID, transition was often assumed to be a unidirectional process with economic growth enabling increased domestic, public financing for health and commensurate reductions in external assistance, toward the ultimate objective of countries ‘graduating’ from the need for external assistance for health. The economic shock of the COVID-19 pandemic has challenged the unidirectional assumption of the transition process, with a slowing down or even reversal of transition-related milestones and a large increase in external assistance for health related to the pandemic, underlining the need to manage transition processes better (Global Fund, 2021; MacGregor and Cornejo, 2021; UHC2030, 2018).

Beyond funding levels, the pandemic has also exposed fundamental issues in current models of external assistance, several of which are steeped in power asymmetries between donors and recipients (WHO, 2021). These include a continued focus on externally determined priorities; a framing of sustainability in terms of funding for donor funded ‘programmes’ rather than ensuring that achievements in service coverage are maintained; prioritizing countries that meet externally established co-financing targets; and emphasizing short-term attribution of outcomes to particular funding streams, that can work against sustainable, system-building efforts. While donors often recognize the critical necessity of stronger health systems, system-oriented investments are often subordinate to, and framed in terms of, their utility in the achievement of disease-specific objectives.

Where should a rethinking of external assistance begin? First, it is vital that external assistance aligns with and responds to the needs of domestic health systems and the people that they serve. In this way, external assistance for health should ‘enable’ rather than ‘undermine’ the sustainable coverage of services that is essential to move towards UHC (Adeyi, 2022; Brown, 2021; Okonjo-Iweala et al., 2021; Noor, 2022).

But better evidence is needed to guide such a re-consideration of external assistance, particularly when thinking about these more complex transition processes, where domestic stakeholders and systems are seeking to determine whether, and how, previously donor-supported services and related outcomes can be sustained in the absence of external assistance. This requires moving beyond quantitative analysis of official development assistance for health resource flows (Dieleman et al., 2014, 2016; Michaud and Murray, 1994; Suhrcke et al., 2005; Ravishankar et al., 2009; Stierman et al., 2013; Van de Maele et al., 2013), as well as analyses that focus on particular donors or disease interventions (Bennett et al., 2011; Bennett et al., 2015; Gotsadze et al., 2019; Ozawa et al., 2016; Rodríguez et al., 2021). New evidence needs to consider how these interventions and resource flows interact with each other and overall health systems (as in Zakumumpa et al., 2017). The donor transition process provides a clear entry point for this domestic, system-oriented research agenda on external assistance for health, as a way to unpack how health systems have adapted, as well as how and whether coverage has been sustained.

Three areas of research could help understand the dynamics around external assistance to improve sustainable coverage. First, the large influx of associated external assistance for health to address COVID-19 provides a concrete and opportune moment to assess how these resources have been used in relation to domestic health spending. Second, retrospective analyses of previous donor transition processes can help to inform and understand those factors that have influenced domestic ownership and the sustainability of intervention coverage post-transition. In particular, more knowledge is needed on how domestic health systems have adapted to maintain coverage of interventions in the face of transition, including through realizing efficiency gains. Third, current models of external assistance could be analysed as a way to improve and adapt future approaches that can effectively respond to new and emerging challenges (including those stemming from climate change, non-communicable diseases, and new pathogens). Within this sphere, new models should build on and be informed by critical analysis of existing power asymmetries between donors and recipients.

To encourage research on the thematic areas identified above, the Alliance for Health Policy and Systems Research in collaboration with the WHO Health Financing Policy Unit and UHC 2030 is issuing a call for papers that will be published in a supplement issue of Health Policy and Planning. This supplement issue will bring together original research, commentaries, and innovation and practice pieces focused on rethinking external assistance toward enhancing its alignment with domestic health systems and ensuring that assistance ‘enables’ rather than ‘undermines’ sustainable coverage. These papers will serve as a definitive collection of high-quality research, bringing together a diverse range of perspectives, including those of national policymakers, donors and civil society representatives. It will also spur debate on how such a rethink of external assistance can be realized at the level of policy and practice, something that is essential to move closer towards UHC and the Sustainable Development Goals (SDGs).

Author contribution

All authors contributed equally to the writing of the commentary.

Ethical approval.

Ethical approval for this type of study is not required by our organization as this is a commentary.

Conflict of interest statement.

We have read and understood the policy on declaration of interests and have no relevant interests to declare. Z.C.S., S.S., and M.S. are staff members of WHO. They themselves are alone responsible for the views expressed in this article which may not reflect the views of WHO.