Foreign aid is shrinking. Rich countries are cutting their budgets for helping the world’s poor, partly because they need to spend more on defence and partly because they suspect that aid does not work well. To make the best use of a smaller pot, aid agencies and recipients alike will have to prioritise. One of the best approaches would be to concentrate more on public health, and on funding mechanisms that have been proved to work.
Many people in poor countries lack basic health care, and the cheapest life-saving medicines are extremely cheap, so health aid can be wonderfully cost-effective. On average, each dollar spent on vaccination yields a hefty $54 in returns. Between 1974 and 2010, health aid extended life expectancy across the developing world and saved a vast number of children from dying before the age of five.
This is not only good in itself. It also contributes to future prosperity, since healthier populations tend to be more productive. Meanwhile, medical research keeps throwing up fresh opportunities to do good. Two new malaria vaccines are innovative, cheap and effective. Yet the money to roll them out has yet to be found.
Curbing infectious diseases creates benign spillovers. An Ebola outbreak that is spotted fast and scotched at source does far less harm than one that is allowed to spread. The donor-funded drugs that keep HIV patients alive also prevent them from passing on the virus. The benefits extend to the rich world, too, since bugs respect no borders and treatment is far more expensive in rich countries than in poor ones. In America just two cases of Ebola cost one hospital over $1m in 2014; each extra HIV infection costs hundreds of thousands of dollars to treat over a patient’s lifetime.
Sometimes health aid is done badly. It can crowd out domestic health spending and foster dependency. Donors with conflicting agendas can skew national health systems towards their priorities. Stop-start disbursements can make it impossible for local authorities to plan. Yet in recent decades some donors have learned from the mistakes of the past. The best give predictable, long-term support. They provide technical help for programmes that have proved to be cost-effective. And they often offer matching funds—a dollar of aid for every dollar the receiving government chips in—to spur more public spending on health.
Exemplars of this approach include Gavi, a global alliance to promote vaccines, and the Global Fund, which fights AIDS, tuberculosis and malaria. Gavi bulk-orders vaccines, thus making them cheaper, so that more can be bought and distributed. It buys from many suppliers, ensuring that the system has redundancy. Crucially, Gavi does not simply give vaccines away. Recipient countries must cover part of the cost, with Gavi offering larger subsidies to poorer ones. Nineteen countries have “graduated” from this arrangement, and are now deemed rich enough to pay the full (but still reasonable) price. Gavi is also an important part of the world’s defences against the next pandemic, maintaining stockpiles of vaccines for diseases such as Ebola, cholera and yellow fever. It has plans to do the same for mpox. When another big one strikes, the world will be grateful.
However, even Gavi struggles to raise enough money. It needs $9bn to help inoculate 500m children over the next five years, and to save hundreds of thousands of lives in Africa with the new malaria vaccines. Yet it had to postpone a recent refinancing meeting because donor countries were busy, and a leak to the New York Times suggests that America plans to cut it off. Gavi, the Global Fund and many other health-aid organisations face crippling uncertainty. They simply do not know what funds will be available in the coming years. The least donors can do, even as they cut back on aid, is to say clearly what they will and won’t pay for.
Governments in the global south will have to step up, too. Many have neglected health. In 35 poor and middle-income countries, home to 2.5bn people, public-health spending has fallen since 2019 both per person and as a share of the budget. As aid gets less generous, policymakers will have to decide what matters most. Jabbing babies is a good place to start. ■
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