Submission ID 118473
| Issue/Objective | The relationship between development assistance for health (DAH) and domestic health investment in low- and middle-income countries (LMICs) is complex and context-dependent. While DAH aims to supplement national budgets, concerns persist that it may displace domestic resources-a potentially rational response by governments to maximize welfare and improve cross-sectoral efficiency. This scoping review explores the relationship between DAH and domestic investment in health by examining: 1. What factors at the country level determine the government's allocation of overall development assistance to different sectors, in particular health? 2. How do different forms of development assistance impact government health spending? |
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| Methodology/Approach | A scoping review was conducted using iterative searches across PubMed, ScienceDirect, Google Scholar, and Google. Search terms covered aid types, domestic expenditure, modalities, and outcomes. Eighty-six studies (2003-2023) were included through database searches and snowballing. A political economy lens guided analysis, focusing on how recipient countries respond to DAH, considering aid characteristics (e.g., earmarking, budget alignment) and contextual factors (e.g., governance, economic base, and actors). |
| Results | This study maps the aid characteristics and recipient country context factors which mediate the effects of aid on public and domestic health expenditures, showing how features like earmarking, budget alignment, and volatility, alongside governance capacity and fiscal pressures, influence whether aid is additive, fungible, or crowds in additional resources. Most studies report partial fungibility-aid increases domestic health spending, but not fully. Some evidence points to crowding in or reverse fungibility, where domestic funds rise for health rise in targeted areas, or rise as aid declines. Aid reallocations away from the donor's targeted sector or region often reflected efforts to promote equity or efficiency. Methodological inconsistencies-including varied data sources and definitions-limit cross-study comparability. |
| Discussion/Conclusion | This study underscores that the relationship between aid and domestic health spending is context-specific and shaped by both aid design and domestic political dynamics. While mechanisms like earmarking and on-budget delivery can enhance additionality, this is not guaranteed. Future work should focus on unpacking the roles of domestic actors, institutional incentives, and decision-making processes to inform aid strategies that reinforce sustainable public investment in health. |
| Presenters and affiliations | Krista Kruja Evidence Link Sophie Witter Queen Margaret University David Evans World Bank Martin Schmidt World Bank Christoph Kurowski World Bank |
