Swedish development assistance for health: critical questions to ask going forward
Authors: Jesper Sundewall, Pia Engstrand, Anders Nordström
Journal: The Lancet Global Health (2018)

The world has agreed on an ambitious pathway for global health in the 2030 Agenda for Sustainable Development By this deadline, countries should have achieved universal health coverage, providing people with protection from financial hardship as a result of ill health. This challenge is particularly daunting at a time when global development assistance for health (DAH) is plateauing. In view of the bleak outlook for future DAH growth, together with the need for domestic finance for health to increase, Sweden and other donors need to revisit their role going forward and consider what can be done to truly strengthen national health systems in low-income and lower-middle-income countries. In this Comment, we summarise the development of Swedish DAH and propose some key questions that should be answered going forward. In the Swedish Government's 2018 budget bill, development assistance substantially increased, both in the relative share and in absolute terms. The proposed 2018 aid frame meets the government's target of 1% of gross national income, which translates into 48·95 billion Swedish krona (SEK; roughly US$5·8 billion), an increase of 2·82 billion SEK from 2017.1Government of SwedenBudgetpropositionen för 2018, utgiftsområde 7: internationellt bistånd.http://www.regeringen.se/4a65d0/contentassets/79f6d27416794f0bb146c792e02b65fc/utgiftsomrade-7-internationellt-bistand.pdfGoogle Scholar The in-country refugee costs in Sweden negatively affected the development cooperation budgets in 2016 and 2017; however, this budget line has decreased substantially in 2018, which means that funds allocated to international development assistance have increased. Health is a thematic priority of Sweden's Framework for Development Cooperation.2Government Offices of SwedenPolicy framework for Swedish development cooperation and humanitarian assistance. Government communication 2016/17:60.http://www.government.se/49a184/contentassets/43972c7f81c34d51a82e6a7502860895/skr-60-engelsk-version_web.pdfGoogle Scholar Swedish DAH increased from 3165 million SEK in 2010 to 4581 million SEK in 2016, an increase of 44·7% in real terms, compared with the 7·4% growth of DAH globally during the same period3Global Burden of Disease NetworkEvolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries.Lancet. 2017; 389: 1981-2004Summary Full Text Full Text PDF PubMed Scopus (177) Google Scholar (figure 1). During this period, the share of Swedish DAH also increased from 11·5% to 14·2% of the total Swedish international development assistance.4Government of SwedenSvenskt hälsobistånd.https://www.sida.se/globalassets/global/sa-arbetar-vi/results/rapport-halsa-2012-ud.pdfDate: 2012Google Scholar, 5Government of SwedenSveriges hälsobistånd.https://www.sida.se/contentassets/5e42448f51174290bd963d3c4b255650/171002-sveriges-halsobistand-2016.pdfDate: 2016Google Scholar An analysis5Government of SwedenSveriges hälsobistånd.https://www.sida.se/contentassets/5e42448f51174290bd963d3c4b255650/171002-sveriges-halsobistand-2016.pdfDate: 2016Google Scholar of Swedish health aid showed that very little Swedish bilateral DAH (9%) is channelled through public institutions in recipient countries, despite Sweden's support of the ambition outlined in the aid and development effectiveness agenda6OECDThe Paris Declaration on Aid Effectiveness and the Accra Agenda for Action.http://www.oecd.org/dac/effectiveness/34428351.pdfDate: 2005/2008Google Scholar to work with countries to strengthen national health systems. In 2013–16, the share of Swedish bilateral DAH channelled through public institutions varied between 2·1% and 11·8% (figure 2). Instead, an increasing share of DAH channelled through the Swedish International Development Cooperation Agency (Sida) is distributed through multilateral agencies or non-governmental organisations.5Government of SwedenSveriges hälsobistånd.https://www.sida.se/contentassets/5e42448f51174290bd963d3c4b255650/171002-sveriges-halsobistand-2016.pdfDate: 2016Google Scholar Thus, although the aid effectiveness principles of harmonisation, alignment, and country ownership remain important principles for Swedish DAH, these principles do not translate into channelling of funds to or through public institutions. One important reason for this lack of channelling of funds to public institutions is that a large share of Sweden's development assistance targets fragile states or countries that are, or have recently been, in conflict and hence have weak public financial and control systems. Yet, improving health in people in low-income countries will require increased focus on health systems and the role of public institutions. A question Sweden and other donor countries should tackle is how providers of DAH can promote their agencies' thematic priorities and simultaneously support the evolution of sustainable health system capacities. Swedish development assistance for sexual and reproductive health and rights (SRHR) has increased. In 2016, SRHR absorbed 57% of all Swedish DAH, up from 53% in 2013. This focus on SRHR is a result of government priorities, but means that other important areas, such as health systems' strengthening, communicable and non-communicable diseases (NCDs), and prevention of chronic diseases, do not receive the same emphasis as SRHR. In many low-income and lower-middle-income countries, the burden of disease is becoming increasingly complex, with a rapid increase in NCDs. A question that needs answering is what role governments can have in prevention of NCDs, focusing on risk factors and more healthy societies. Sweden could potentially have a part in promoting a broader approach to public health, enabling people to make more healthy choices. The multisectoral response to HIV has provided experiences and learning opportunities in that regard. Although Swedish DAH is increasing, generally, DAH is still marginal in the context of global health financing. DAH accounts for 0·4% of total health spending worldwide, which, in 2014, amounted to US$9·21 trillion. However, development assistance remains an important source of health financing in low-income countries, where it forms about 35·7% of health spending.7Global Burden of Disease NetworkFuture and potential spending on health 2015–40: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries.Lancet. 2017; 389: 2005-2030Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar The payoff from investing in health care is potentially enormous, both in terms of reduction of human suffering and gains in economic growth.8Jamison DT Summers LH Alleyne G et al.Global health 2035: a world converging within a generation.Lancet. 2013; 382: 1898-1955Summary Full Text Full Text PDF PubMed Scopus (786) Google Scholar Therefore, Sweden's current trajectory of increasing DAH is promising and should be acknowledged in a time when global DAH remains stagnant and health-care costs in low-income and lower-middle-income countries are increasing rapidly. In countries with high aid dependency, the question of transitioning from financing health with aid to domestic resources becomes important. A question that needs reflecting on is how Sweden will be able to responsibly assist as countries transition from aid, and what can be learned from previous experiences (eg, Gavi, the Global Fund). The role and importance of international cooperation and DAH is rapidly changing. In low-income and lower-middle-income countries, the traditional burden of communicable diseases is compounded by increasing NCDs and the need to make health systems more efficient, fair, and affordable. The 2030 Agenda provides the global health community with new opportunities, but also requires that providers of DAH are prepared to adapt and find ways to work with governments to strengthen health systems, to achieve universal health coverage, and to responsibly transition to increased reliance on domestic funding for primary health care. This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on March 9, 2018 This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on March 9, 2018 We declare no competing interests. Correction to Lancet Glob Health 2018; 6: e242–43Sundewall J, Engstrand P, Nordström A. Swedish development assistance for health: critical questions to ask going forward. Lancet Glob Health 2018; 6: e242–43—The key in figure 1 in this Comment has been corrected. This correction has been made as of March 9, 2018. Full-Text PDF Open Access