Center for Health System Sustainability

Background: The Global Fund to Fight AIDS, Tuberculosis, and Malaria is one of the world’s largest global health donor agencies, playing a key role by filling recipient countries’ domestic health financing gaps; however, little is known about how well it achieves value for money. Given the current uncertainty regarding global health development assistance, it is critical to understand how to prioritize external donor funding allocations in an effort to maximize health impact.

Methods: In this study, we evaluated 66 recipient countries’ efficiency relative to peers in achieving improvement in health outcomes for TB, malaria, and HIV given their 2017–2019 Global Fund expenditures for (1) health products, (2) program activities, and (3) program management. Using a combination of frontier analysis, linear regression, and cluster analysis, we examined how macroeconomic conditions, epidemiological context, health system factors, and Global Fund spending decisions explain variation in country program performance.

Results: For malaria and HIV, we found a negative relationship between Global Fund spending on program activity and health product costs respectively and countries’ efficiency at translating funds to health impact. For malaria and HIV, there was also significant variation in efficiency across countries according to their economic capacity, disease burden, and most prominent spending area.

Conclusions: Our results suggest possible structural inefficiencies in country program management, dampening the health impact of frontline programs. The lack of broad patterns to predict performance signals the importance of tailoring spending strategies to country-specific contexts.

Researchers and policy-makers have long compared health system performance. International comparisons raise awareness of health systems’ relative strengths and shortcomings, prompting policy debates and informing policy decisions. Yet determining how these international comparisons can be used to improve health system performance is challenging. Health systems can differ in many ways, including how they are governed, how they are funded, how they generate and deploy resources, and how they deliver services. While the international health community widely agrees that these functions influence health system performance, understanding of how much they matter, which ones matter most, and how they are affected by the context in which they operate remains limited. To gain relevant and meaningful insights from health systems comparisons that offer lessons for policy, we must agree on how to compare health systems. In this article, we argue that doing so requires collecting better, more granular data on a broad range of health system characteristics and using those data to choose the most appropriate health system comparators.

The choice of price index has major implications for comparative analysis. Despite their widespread use internationally, general price indices likely underestimate the contribution of price growth to overall health expenditure growth. We find that in addition to its reputation for having high health price levels compared to other high-income countries, the United States also faces health price growth for goods and services paid for by government and households in excess of general price growth. Furthermore, US households are exposed to greater health price growth than households in comparator countries.

Jonathan Cylus and colleagues argue that inflationary pressures mean the NHS may have reached the limit on its ability to contain costs for goods and staff without affecting care.

Book edited by Irene Papanicolas, Dheepa Rajan, Marina Karanikolos, Agnes Soucat, Josep Figueras. Health Policy Series 57.