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I have always wanted to use Cuba Gooding Junior’s line from “Jerry Maguire” in a piece about evidence-based medicine. Development assistance for health (DAH) has increased to fight major diseases and achieve the Millennium Development Goals. DAH
has risen steadily since 1995 from about US$8 billion to nearly $19 billion in 2006, so you would think that it is imperative to show us where that money is being spent. Think again. Although DAH has grown, most public health spending comes from domestic sources. Good data is lacking on domestic versus external funding, despite efforts by World Health Organisation (WHO) to set up National Health Accounts.

In the Lancet online this week, a systematic analysis of all data available for government expenditures on health in developing countries, including government reports and data from WHO and the International Monetary Fund (IMF).It is an admirable piece of work, finding that DAH has risen by 100% in the last 10 years, mostly due to rising GDP (gross domestic product), slight decreases in share of GDP spent by government, and increases in share of government health spending. At the country level, government expenditures to health decreased in many sub-Saharan African countries. Interestingly, DAH to government had a negative effect on domestic government health spending such that for every US$1 of DAH to government, government health expenditures were reduced by $0•43. On the other hand, DAH to the non-governmental sector had a positive effect on domestic government health spending.

In an accompanying editorial, Devi Sridhar and Ngaire Woods of Oxford University, call for caution in interpretation of these results. Firstly, due to poor quality data, a lot of data in the analysis was missing and had to be imputed. Secondly, NGOs are good at carrying out vertical programmes targeting specific diseases (e.g. HIV/AIDS), but not so good at health system integration. Therefore, the authors’ recommendation of standardised monitoring of government health expenditures and government spending in other health-related sectors is probably the right one.

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