Do aid cuts offer a horizon(tal) opportunity in global health?

The aid cuts by the US and UK have their huge negative consequences, but might they also offer an opportunity to change global health? MSc Health and International Development student Esperanza Hughes-Salinas discusses how a break from aid dependency and ringfencing might offer hope for changing the way global health operates: from a vertical to a horizontal approach.

Terror has swept through the international development community recently following US President Trump’s decision to withdraw funding from USAID and major UN agencies, and pull out of the World Health Organization. I need not explain that it is a terrible blow to millions of us around the world, exacerbated by the actions of copy-cat countries like the UK. But could the fall of USAID also be an opportunity?

An opportunity on the horizon

The global health field has long struggled to move away from verticalised, top-down programmes that prioritise particular diseases over others, and more importantly, over strengthening health systems within and across countries. Despite the agreement in 1978 to focus on primary health care (PHC), big donors haven’t exactly fallen over themselves to stump up the money for it in the last ~50 years. And USAID definitely wasn’t at the forefront of those championing the Alma Ata goal.

The ‘horizontal’ PHC approach offers better value for money, is more equitable and inclusive, and enables national governments to work with donors to ensure resilience in their health systems (while also maintaining their sovereignty). If another surprise shock like COVID-19 comes along, investing only in HIV/AIDS isn’t going to help as much as investing in a system that can deal with both. Bill Gates has said that he “still has more to give”, but should we really be congratulating him on pumping more money into the same old disease programmes of which his Foundation is so fond?

Moving from aid dependency to the horizontal approach

Perhaps a blessing is that dependency on US aid (and now UK aid) is now moving out of the picture. Before the first Trump administration, there were thoughts that his presidency could serve as “a catalyst for change, rather than […] preserving the uncomfortable status quo in global health”. While I don’t believe Trump himself is going to be the change, the reaction to him will be. Alternative methods of financing development will arise (see Duncan Green’s recent blog post) – but they must be implemented in a way that prioritises the horizontal approach. Solutions like religious giving will be useful, but may easily fall into the vertical trap. We in the development community have a duty to ensure this does not happen.

Katie Dain, CEO of the NCD Alliance, has said that the dent in health budgets produced by the slashing of USAID will make governments less likely to spend money on non-communicable diseases, like diabetes or stroke, which are on the rise. The global health community is more conscious than ever of the social determinants of health, and many INGOS have done much in the last few years to promote health system strengthening, but it hasn’t been enough. Now is the time, while we are promoting alternative financing mechanisms, to change the entire global health field and move away from vertical programmes for good.

What needs to happen?

We’ve already started moving away (albeit involuntarily) from depending on higher-income nations for development funding. The second step is to convince those donors still in the game, and any new donors, to give up the ringfencing of funds and to allow cross-sector working and learning so we can focus on the social determinants of health. You might say, “If it didn’t happen before, why would it work now?” And I’d reply, “We might as well try.”

All this to say, all is not lost. Yes, funding has gone down, and yes, competition for a job at the end of this degree has certainly increased, but the funding has gone down to 2017 levels (check out IHME’s visualisations here). As one of the LSE faculty put it a few weeks ago, “we’ve done it before, so we know we can do it again.” I only hope we can do it better this time. There’s a horizontal opportunity on the horizon.

The views expressed in this post are those of the author and in no way reflect those of the International Development LSE blog or the London School of Economics and Political Science.

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