Financing for public health is dwindling in many countries, sapped by COVID-related economic difficulties, debt repayment and “poly crises” such as climate and conflict. 

“In the current economic conditions, the only way [some countries can spend more on health] when their overall government spending is going down, is to give more priority to health in government budgets,” said David Evans, visiting professor in interdisciplinary programmes at the Geneva Graduate Institute (GGI) told a recent event on health financing organised by the institute.

But, Evans warned: “Historically, when your government expenditure is falling, giving more priority to health is often very politically difficult. It doesn’t happen very often.”

“Some of you are involved in the push to have more money for pandemic preparedness and response. It’s very worthy, but if the budget is going down, where is that money going to come from?” asked Evans, who described competition between different urgent needs as a “zero-sum game”.

However, he said there was much diversity within low-income countries and middle-income countries, with some facing economic contraction or stagnation while others were progressing.

“It might be time to think about changing the criteria under which countries get development assistance.”

Evans also identified some opportunities including debt restructuring, special drawing rights at the International Monetary Fund (IMF) and the reform of international financial institutions to direct more money to countries most affected by economic crisis.

Seeking complementarity

Erika Placella, head of health at the Swiss Agency for Development and Cooperation (SDC), agreed that the “competition for replenishment” with a “proliferation of funds and the fragmentation of initiatives” was “a zero-sum game”.

“In this zero-sum game, there is a race to find the smallest comparative advantage and the sexiest narrative,” said Placella.

Every international negotiation forum and resolution calls for a dedicated fund and new global health instruments are also being introduced, she added.

“So it is a very fragmented landscape, [and] it’s very difficult to navigate it.”

SDC was pushing for “complementarity” at a global level, said Placella.

“I’m going to take off with the pandemic preparedness and response from the Swiss government. First of all, instead of supporting new ventures and new narratives and new funds, we tried to adapt the mandate of existing organizations to the current context and needs and to promote complementarity. 

“A lot of our partners already had pandemic prevention, preparedness and response (PPR) functions, but in our narrative, it was not understood as such,” she said.

Organisations such as UNAIDS, the Global Fund and FIND include PPR, she noted.

“So we are trying to leverage and to build on what partners were already contributing to in the PPR space, instead of further fragmenting the financing landscape.”

The Swiss government’s health funding uses “many instruments to support health”, including global and thematic work supported through large health organisations including the World Health Organization (WHO) as well as bilateral cooperation.

These different avenues are important to address bottlenecks, she added.

“We also take a systematic approach to avoid further fragmentation. For example with mpox, we are supporting strengthening the primary health care services to include sexual reproductive health services.”

Ethiopia’s dependence

Ethiopian health diplomat Alegnta Gebreyesus said that almost half of her country’s health expenditure depends on overseas development assistance (ODA) so the funding crunch could impact on all aspects of health.

To mitigate this, Ethiopia is discussing setting up a health fund – “a sort of basket fund” which will cover a range of key health issues, with government matching donor investment in some of these.

The fund “would cater for resilience, health system strengthening, equity and, of course, preparedness for pandemics,” she added.

But high prices for medicines, vaccines and other medical commodities can only be addressed by building “a conducive environment for sustainable local manufacturing” at country and regional level – covering research and development, supply chain and logistics, the regulatory system, technology transfer and know-how.

Kenyan Joyce Ng’ang’a, senior policy advisor at WACI Health, a Nairobi-based health advocacy organisation, said the current global health landscape is already in a poly crisis involving pandemics (COVD-19 and now mpox), food shortages and climate change. 

“We need to make health a priority. We need to make health a political agenda. I believe that there is enough money in the world to fund health and to replenish the global health institutions,” said Ng’ang’a.

“As civil societies and communities, we refuse to accept that there’s not enough money to fund systemic issues for health,” she said, calling for a health approach that started by tackling the social determinants of health.

“By the time cases are coming to the health facility or hospital, the community health system has failed because there should have been preventive and promotive care at community level.

“Most LMICs now have a deliberate strategy on community health and how health is structured, and at the basic unit is the primary level, which is a prevention and health promotion.”