Discussions of international health priorities and responses often focus on external assistance to the health sector. Although such assistance accounts for only a small share (less than 3%) of health sector expenditures in developing countries (1), its impact could be critical in the areas of capital investment, research and strategic planning in these countries. Donor agencies, using minimal resources, have sometimes influenced government health sector policies by drawing attention to special problems or interventions. The success of UNICEF, WHO, and several bilateral donor agencies on the Expanded Programme of Immunization due to their influence on the developing countries' health agendas. Considering its potential importance in determining policy, external assistance to the health sector has been poorly quantified.
The objectives of the present study were specifically to: (1) quantify in detail the sources and recipients of external assistance to the health sector in 1990; (2) analyse time trends for external assistance to the health sector over the last two decades in as much detail as possible; and, (3) to the extent possible, describe the allocation of resources to specific activities in the health sector.
This study is not the first attempt to measure external assistance to the health sector. Two general databases on development assistance are maintained by the OECD (Organization for Economic Cooperation and Development) and are described more fully below. A number of ad hoc studies have used these databases, supplemented with other sources, to examine external assistance to the health sector or a component of the health sector (2-9).(a, b) Taken together, these studies have defined the rough order of magnitude of such external assistance but the likely government sources, the channels, recipients and activities funded remain poorly delineated.
Definitions, materials and methods
There are no clear boundaries defining the components that should be included in estimates of external assistance to the health sector. In previous studies, Howard included all water and sanitation investments while the OECD did not (3).(a) In the present analysis, the health sector was narrowly defined and included two major components -- health and population. Health activities include promotive, preventive, curative and rehabilitative interventions to improve the health status of individuals and population groups; programme food aid; vector control, training of health manpower and health research. Population activities pertain to family planning programmes, and the collection and analysis of demographic survey data. Water and sanitation, emergency food aid, and general education activities were excluded. We believe it is useful to analyse expenditures whose primary purpose is health improvement as distinct from all expenditures that contribute to health. Our definition is also consistent with the components included in the parallel study on national health expenditures (1) and facilitates comparison of the two results.
Total external assistance to the health sector has three main parts: official development assistance (ODA), multilateral loans, and nongovernmental flows. ODA is defined as those resources provided to developing countries and multilateral institutions by official agencies. Such resources must be administered with promotion of economic development as their main objective, and must be concessional in character, containing a grant element of at least 25%. Official contribution to private voluntary organizations are recorded as ODA, but private contributions are not. ODA excludes any kind of military assistance.
Governments and private households from the established market economies and some oil-exporting countries are the ultimate sources of external assistance for health. This assistance is then channelled to the developing countries through three main types of institutions -- bilateral and multilateral agencies and nongovernmental organizations. …