title: Development assistance for health: past trends, associations, and the future of international financial flows for health.
abstract: BACKGROUND
  Disbursements of development assistance for health (DAH) have risen substantially during the past several decades. More recently, the international community's attention has turned to other international challenges, introducing uncertainty about the future of disbursements for DAH.
  
  
  METHODS
  We collected audited budget statements, annual reports, and project-level records from the main international agencies that disbursed DAH from 1990 to the end of 2015. We standardised and combined records to provide a comprehensive set of annual disbursements. We tracked each dollar of DAH back to the source and forward to the recipient. We removed transfers between agencies to avoid double-counting and adjusted for inflation. We classified assistance into nine primary health focus areas: HIV/AIDS, tuberculosis, malaria, maternal health, newborn and child health, other infectious diseases, non-communicable diseases, Ebola, and sector-wide approaches and health system strengthening. For our statistical analysis, we grouped these health focus areas into two categories: MDG-related focus areas (HIV/AIDS, tuberculosis, malaria, child and newborn health, and maternal health) and non-MDG-related focus areas (other infectious diseases, non-communicable diseases, sector-wide approaches, and other). We used linear regression to test for structural shifts in disbursement patterns at the onset of the Millennium Development Goals (MDGs; ie, from 2000) and the global financial crisis (impact estimated to occur in 2010). We built on past trends and associations with an ensemble model to estimate DAH through the end of 2040.
  
  
  RESULTS
  In 2015, US$36·4 billion of DAH was disbursed, marking the fifth consecutive year of little change in the amount of resources provided by global health development partners. Between 2000 and 2009, DAH increased at 11·3% per year, whereas between 2010 and 2015, annual growth was just 1·2%. In 2015, 29·7% of DAH was for HIV/AIDS, 17·9% was for child and newborn health, and 9·8% was for maternal health. Linear regression identifies three distinct periods of growth in DAH. Between 2000 and 2009, MDG-related DAH increased by $290·4 million (95% uncertainty interval [UI] 174·3 million to 406·5 million) per year. These increases were significantly greater than were increases in non-MDG DAH during the same period (p=0·009), and were also significantly greater than increases in the previous period (p<0·0001). Between 2000 and 2009, growth in DAH was highest for HIV/AIDS, malaria, and tuberculosis. Since 2010, DAH for maternal health and newborn and child health has continued to climb, although DAH for HIV/AIDS and most other health focus areas has remained flat or decreased. Our estimates of future DAH based on past trends and associations present a wide range of potential futures, although our mean estimate of $64·1 billion (95% UI $30·4 billion to $161·8 billion) shows an increase between now and 2040, although with a large uncertainty interval.
  
  
  CONCLUSIONS
  Our results provide evidence of two substantial shifts in DAH growth during the past 26 years. DAH disbursements increased faster in the first decade of the 2000s than in the 1990s, but DAH associated with the MDGs increased the most out of all focus areas. Since 2010, limited growth has characterised DAH and we expect this pattern to persist. Despite the fact that DAH is still growing, albeit minimally, DAH is shifting among the major health focus areas, with relatively little growth for HIV/AIDS, malaria, and tuberculosis. These changes in the growth and focus of DAH will have critical effects on health services in some low-income countries. Coordination and collaboration between donors and domestic governments is more important than ever because they have a great opportunity and responsibility to ensure robust health systems and service provision for those most in need.
  
  
  BACKGROUND
  Bill & Melinda Gates Foundation.
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA. Electronic address: dieleman@uw.edu.
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Dieleman
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Schneider
authors.affiliation: Harvard TH Chan School of Public Health, Boston, MA, USA.
authors.forename: Annie
authors.initials: A
authors.lastname: Haakenstad
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Lavanya
authors.initials: L
authors.lastname: Singh
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Nafis
authors.initials: N
authors.lastname: Sadat
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Maxwell
authors.initials: M
authors.lastname: Birger
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Alex
authors.initials: A
authors.lastname: Reynolds
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Tara
authors.initials: T
authors.lastname: Templin
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Hannah
authors.initials: H
authors.lastname: Hamavid
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Abigail
authors.initials: A
authors.lastname: Chapin
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Christopher J L
authors.initials: CJ
authors.lastname: Murray
mesh_terms: D003906:Developing Countries / Q000191:economics*; D057217:Economic Development / Q000639:trends*; D014943:Global Health / Q000191:economics / Q000639:trends*; D061889:Healthcare Financing; D006801:Humans; D007390:International Agencies / Q000191:economics / Q000639:trends; D007391:International Cooperation