Posted on Brookings Institution Future Development Blog on June 28, 2019
Many development donors use country income levels—typically gross national income per capita—to ensure that their support for health systems in the developing world goes to countries with the greatest need. As a result, donors often reduce support when countries graduate from low- to middle-income status. While this graduation reflects advancement in economic development and is cause for celebration, transitions away from donor assistance for health typically bring significant challenges for middle-income countries.
The evidence also appears to indicate that countries that are expected to graduate from multilateral health assistance over the next decade are more vulnerable to backsliding and disease resurgence than countries that graduated in the past. For example, a recent comparison of upcoming graduates and previous graduates found that upcoming graduates “seem to have, on average, lower per capita income, greater indebtedness, weaker capacity to efficiently use public resources, more limited and less effective health systems, weaker governance and public institutions, and greater inequality.”
This is particularly worrisome in countries where the main funding for treating and preventing deadly diseases such as HIV/AIDS in key populations—for instance, men who have sex with men or people who inject drugs—comes from donors. Vulnerable populations in these countries face possible service coverage disruptions if social contracting mechanisms—whereby governments provide funds directly to civil society to implement specific activities—are not in place prior to a donor exit. In short, a sudden reduction or withdrawal or, even worse, a simultaneous withdrawal of external assistance by several donors has the potential to cause major disruption to the health system. This disruption can be particularly devastating for a transitioning country when external health support is concentrated among a small number of donors.
Without proper preparation, the progress of transitioning countries may slow or even reverse as a result of the loss of donor aid and technical support. This undoubtedly is detrimental to global public health and impedes progress toward reaching the Sustainable Development Goals.