An Empirical Investigation of Funding Trends and Organizational Composition in Global Health

Over the past two decades, development assistance for health and government health expenditure have both increased substantially. Despite the rise in public attention and funding levels internationally, there has been little empirical exploration of budgetary trends in global health funding. Through the use of public budgeting and finance theories, these three studies in aim to increase understanding of the flow of health funds between and within donor and recipient countries through time. Application of Punctuated Equilibrium Theory (PET) to multiple datasets of national health financing data illustrates a leptokurtic distribution for both own domestic health (government health expenditure) and other health (development assistance for health) spending. The distribution of change in government health expenditure by 15 OECD donor countries was found to be less punctuated that their development assistance for health to developing countries from 1990-2012, suggesting smoother, more constant pressures for “own health” spending versus spending for global health. Comparison of country-level annual changes in government spending on domestic health for 145 countries between 1995 and 2012 illustrated that overall, and when grouped by income, the distributions of countries’ pooled annual changes in government health spending were leptokurtic. There was a greater departure from the normal distribution as country income decreased across the highest and two lowest income groups, and the proportion of annual changes that were positive decreased. However, the high-income non-OECD and upper-middle income groups diverged from this trend in interesting ways. Empirical exploration of the changing organizational composition of the field through the lens of population ecology provides greater context for the funding trends in global health with a particular focus on the emergence of public private partnerships. Application of the Herfindahl-Hirschman Index (HHI) found a decrease in concentration in the organizational field of global health between 1990 and 2000, followed by stability in the field despite the introduction of a new organizational form. Over this period, there were increases in ‘market’ shares for non-profit organizations and PPPs within the global health organizational population. The grant making-behavior directed through PPPs by a significant US bilateral agency was explored to identify patterns in decision-making related to PPP lifespan, disease focus, program type, regional focus, implementing partner categories and financial commitment, as well as recession impact. The limited empirical research concerning actors in global health funding emphasizes the need for further exploration of this phenomenon