Since the 2011 United Nations High Level Meeting on NCDs (noncommunicable diseases), the global health community has been pushing for investments (both by countries and donors) that are commensurate with the current burden of these diseases. NCDs, which include conditions like heart disease, cancers, diabetes and chronic respiratory diseases, and unhealthy risk factors such as smoking and an unhealthy diet, claim some $36 million lives every year. To put this into context, this figure is six times more than more high-profile global health challenges, such as HIV/AIDS, malaria, and tuberculosis combined.
Because of its status as one of the leading donors in global health, the US Government continues to be the subject of speculation about how much it spends on global NCDs.
A Council on Foreign Relations Task Force, comprising some of the leading minds in global health, attempted to answer this question. The report it produced last week, which was picked up in major media outlets like the New York Times, found that $10 million of a more than $8 billion US global health budget is allocated to global NCDs. This number sounds pretty low – about 0.1% of the total. In fact, it sounds suspiciously low, because it is.
Below are a few reasons why this figure of $10 million annually spent on NCDs does not adequately capture the full breadth of US Government activities on NCDs, nor are the methods used to calculate it indicative of the type of global strategy to NCDs that has been advocated for by governments, civil society, and the private sector.
Before I jump into the reasons, let me first breakdown how exactly the researchers came up with this figure. Taken from the report’s methodology:
“U.S. aid for NCDs from 2000 to 2011 is an estimate of development assistance for health (DAH) allocated to NCDs, obtained from the Financing Global Health 2013: Transition in an Age of Austerity DAH database. DAH is defined as financial and in-kind contributions primarily intended for the health sector. The main data source for bilateral U.S. DAH is the OECD Creditor Reporting System. DAH for NCDs is identified using sector codes, purpose codes, and keyword searches on all descriptive fields of the project-level data. Total NCD DAH is the sum of DAH allocated for NCDs from 2000 to 2011 that was channeled through the United States to each recipient country (in constant 2011 U.S. dollars) and includes DAH from the U.S. government that was channeled directly to recipient countries and DAH from the U.S. government that was channeled to recipient countries via NGOs.”
A few things to emphasize from this:
- They only consider development assistance for health , (a similar approach that has been taken in previous resource tracking studies) and with the nature of NCDs – the fact that many are the result of individual and environmental conditions controlled outside the health sector – there are obvious limitations for such a narrow view.
- DAH is exclusively bilateral assistance. I’ll come back to this point.
- The time frame used in the study is from 2000 to 2011.
Now, coming back to the original question: why is $10 million likely to be a fairly considerable underestimation of what the US Government is actually investing?
- First, the timetable question. For valid reasons, the study only goes up to 2011, this is because of the lag time it takes for the OECD to receive all the appropriate financial data from its donor members. But, as I mentioned in the very beginning, 2011 was a global rallying point for global NCDs. It was a point when countries around the world unanimously adopted a Political Declaration at the UN to address the issue. Funding often follows political commitment. If the UN High Level Meeting in 2011 was a significant political commitment, including for donor countries like the UN, one might assume investments to look different (ideally higher) after 2011 compared to before 2011.
- Next, the bilateral vs. multilateral question. As I mentioned, the study only considered bilateral DAH using the OECD Creditor Reporting System. According to the OECD’s webpage describing the system’s methodology, “DAC Members’ contributions to the regular budgets of the multilateral institutions is excluded when counting bilateral aid.” But, multilateral institutions like the WHO, are plays a significant role. Following the UN High Level Meeting, much of the progress on NCDs has been around global policy, such as the adoption of new global targets, establishment of a global monitoring framework, establishment of a UN Interagency Task Force, and more countries adopting national NCD plans, arguably one of the first steps to implementing a coordinated response. So, while the US contributed almost $110 million to WHO in FY2014 to help support the roughly 5.3% of the WHO budget dedicated to NCDs and injuries, this doesn’t get captured when exclusively considering bilateral aid. A similar argument can also be made for the Pan American Health Organization, which the US also contributes financially to and is similarly leading a coordinated response to NCDs in the Americas region
- Third, as I mentioned, much of the initial work over the past few years has been in global policy and planning activities mostly led by WHO. And even though the US Government sits on the WHO Executive Board, and has been a pivotal player at the policy table providing technical expertise and thought leadership, this doesn’t get captured either through a traditional bilateral DAH model.
- Lastly, many government officials and civil society advocates alike agree that global NCDs can’t be addressed using the same approaches as “traditional” global health issues like HIV/AIDS, other infectious diseases, and maternal and child health. But this is for good reason. There’s unanimity in the need for a “multi-sector” or “whole-of-government” or “whole-of-society” approach. What does this mean? It means that investments made outside of the health sector are going to be critical to preventing NCDs, some of which have already been agreed to as “best buys.” Interventions outside of the health sector, such as capacity building to enable countries to enforce and collect excise taxes on tobacco, are agreed to be essential, but wouldn’t be captured with a narrow focus on DAH only intended for the health sector.
Resource tracking for global NCDs is no doubt complex. The nature of the issue is equally complex in and of itself, with multiple diseases and risk factors, and a multitude of non-health interventions that are known to influence NCD risk. The nature of the US Government’s involvement in global NCDs is similarly complex, with more than just traditional “development” agencies playing roles different than just channeling financial assistance. How to identify and account for all these activities across the US Government, whether research, policy or programmatically focused, is something that coalitions like the NCD Roundtable have been calling for. Getting the methods right will be a huge undertaking, but one that’s well worth it if we’re going to better understand (and support) the existing and new ways the US Government is contributing to addressing NCDs and improving global health.