Total levels of development assistance have increased substantially in recent years, from $92.2 billion in 2001 to a high of $148.4 billion in 2010. Health aid has increased even more substantially, reaching $28.2 billion in 2010, up from a mere $5.74 billion in 1990 and $10.7 billion in 2000 (IHME, 2012). Global interest in aid effectiveness has increased along with levels of aid, as reflected in a series of High Level Fora on Aid Effectiveness that have been organized since 2003 (OECD, 2008, 2012). Within the social sciences, there is an active debate about aid effectiveness (Collier, 2007; Easterly, 2006; Sachs, 2005), and empirical studies find that aid has a small but positive effect on growth (Clemens, Radelet, Bhavnani, & Bazzi, 2011), education (Dreher, Nunnenkamp, & Thiele, 2008) and health (Mishra & Newhouse, 2009). However, studies also highlight unintended, negative effects on governance (Bršutigam & Knack, 2004; Lu et al., 2010), and qualitative assessments of specific aid instruments highlight the complexities involved in increasing aid effectiveness and avoiding negative unintended consequences (Biesma et al., 2009; Vallaincourt, 2009).
In this project, we address two questions:
1. How does health aid affect health systems in aid-receiving countries?
2. What enables some aid-dependent health systems to use aid more effectively and sustainably than others?
We conduct a two-phase mixed method investigation of the effect of health aid on health systems in aid-receiving countries, simultaneously testing broad effects of health aid on various dimensions of health systems and investigating the complex processes through which aid effects health systems with three case studies.
This project employs nested case analysis (Lieberman, 2005), which is especially well-suited to the study of local manifestations of global phenomena (Jafflin, 2011b). In the first phase, we construct a cross-country time-series dataset to examine the effect of health aid on health systems. We test the effect aid, health aid, government versus non-government directed health aid and health aid volatility have on multiple dimensions of health system, including health outcomes, access to health services and government commitment to health, using fixed and random effects models and OLS with HC3 robust/cluster corrections. In the second phase, we use residual analysis to identify 3 countries for case studies. For the case studies, we conduct a desk review of the published and gray literature, carry out interviews with key actors in the health system, including government officials, representatives of donor groups and representatives of local health NGOs or private health services, and analyze government documents.
Our study will make an important contribution to the debate about aid effectiveness by investigating health aid’s impact on multiple dimensions of health systems and including complex models of aid effects. In addition, the carefully selected case studies will provide key insights into the complex processes by which aid affects health systems and what factors improve or impede aid effectiveness. Findings will add to the debate on the relationship between aid and development, and further our understanding of how recent innovations in health aid, like global health initiatives and SWAps, have influenced health systems in developing countries.