New approaches to ranking countries for the allocation of development assistance for health: choices, indicators and implications

Abstract

The distributions of income and health within and across countries are changing. This challenges the way donors allocate development assistance for health (DAH) and particularly the role of gross national income per capita (GNIpc) in classifying countries to determine whether countries are eligible to receive assistance and how much they receive. Informed by a literature review and stakeholder consultations and interviews, we developed a stepwise approach to the design and assessment of country classification frameworks for the allocation of DAH, with emphasis on critical value choices. We devised 25 frameworks, all which combined GNIpc and at least one other indicator into an index. Indicators were selected and assessed based on relevance, salience, validity, consistency, and availability and timeliness, where relevance concerned the extent to which the indicator represented country’s health needs, domestic capacity, the expected impact of DAH, or equity. We assessed how the use of the different frameworks changed the rankings of low- and middle-income countries relative to a country’s ranking based on GNIpc alone. We found that stakeholders generally considered needs to be the most important concern to be captured by classification frameworks, followed by inequality, expected impact and domestic capacity. We further found that integrating a health-needs indicator with GNIpc makes a significant difference for many countries and country categories—and especially middle-income countries with high burden of unmet health needs—while the choice of specific indicator makes less difference. This together with assessments of relevance, salience, validity, consistency, and availability and timeliness suggest that donors have reasons to include a health-needs indicator in the initial classification of countries. It specifically suggests that life expectancy and disability-adjusted life year rate are indicators worth considering. Indicators related to other concerns may be mainly relevant at different stages of the decision-making process, require better data, or both.

Equity in aid allocation and distribution: A qualitative study of key stakeholders in Northern Uganda

“…A recent study [23] found that donors considered a number of factors in the allocation and distribution of their aid to a country, including the health needs, domestic capacity, expected impact, and the cross-cutting concern for equity, in the case of development assistance for health. However, the relative importance of each of these factors varied across donors as well as the indicators used to operationalize each of the factors, a similar situation observed in our study.…”

Philanthropy for global mental health 2000–2015

“…A similar misalignment occurs with total DAMH (Gilbert et al ., 2015; Charlson et al ., 2017) and DAH (Dieleman et al ., 2014). While allocation of development assistance is determined by a variety of factors beyond needs, including policy environment and donor interests (Hoeffler and Outram, 2011), stakeholders recognise health needs as of primary concern (Ottersen et al ., 2018). Similarly, factors beyond needs drive philanthropic giving, including solicitation, cost-benefit, altruism, reputation, psychological benefits, values and efficacy (Bekkers and Wiepking, 2011).…”

Japan's development assistance for health: Historical trends and prospects for a new era

“…While donors, including Japan, have their own methodologies for deciding how to distribute DAH, the criteria for assessing equity in the distribution of their DAH can include national income (an indicator of economic needs) and disease burden (an indicator of health needs). 21 , 22 Figure 3 shows that the relationship between Japan's DAH per capita and GNI per capita in 2018 is weak. Although the general tendency is for higher GNI per capita to be associated with lower DAH per capita, there is wide variation in the amount of DAH received even among countries with similar levels of GNI.…”

“…Donors are likely to focus on the expected impact of DAH in terms of changes in health or determinants of health (including health service coverage), the ability (beyond financial factors) of countries to implement and expand services, and the fair distribution of resources and services. 21 In addition, DAH allocations from donor countries may be guided by a number of additional factors, such as historical diplomatic relations, geographic proximity, strategic political interests, and especially in the case of bilateral aid, trade-related considerations. 24,25 A fundamental challenge for donors, including Japan, is critically reviewing each country's own criteria and rationale for DAH allocation.…”