International Decision Support Initiative, Imperial College London, St Marys Hospital, 10th Floor QEQM Wing, South Wharf Road, W2 1NY, London, UK.
Department of Global Health and Population, Harvard TH Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.
Health Policy Plan. 2018 Feb 1;33(suppl_1):i4-i13. doi: 10.1093/heapol/czx140.
International institutions provide well over US$10 billion in development assistance for health (DAH) annually and between 1990 and 2014, DAH disbursements totaled $458 billion but how do they decide who gets what, and for what purpose? In this article, we explore how allocation decisions were made by the nine convening agencies of the Equitable Access Initiative. We provide clear, plain language descriptions of the complete process from resource mobilization to allocation for the nine multilateral agencies with prominent agendas in global health. Then, through a comparative analysis we illuminate the choices and strategies employed in the nine international institutions. We find that resource allocation in all reviewed institutions follow a similar pattern, which we categorized in a framework of five steps: strategy definition, resource mobilization, eligibility of countries, support type and funds allocation. All the reviewed institutions generate resource allocation decisions through well-structured and fairly complex processes. Variations in those processes seem to reflect differences in institutional principles and goals. However, these processes have serious shortcomings. Technical problems include inadequate flexibility to account for or meet country needs. Although aid effectiveness and value for money are commonly referenced, we find that neither performance nor impact is a major criterion for allocating resources. We found very little formal consideration of the incentives generated by allocation choices. Political issues include non-transparent influence on allocation processes by donors and bureaucrats, and the common practice of earmarking funds to bypass the normal allocation process entirely. Ethical deficiencies include low accountability and transparency at international institutions, and limited participation by affected citizens or their representatives. We find that recipient countries have low influence on allocation processes themselves, although within these processes they have some influence in relatively narrow areas.
国际机构每年提供超过 100 亿美元的卫生发展援助（DAH），1990 年至 2014 年，DAH 支出总额为 4580 亿美元，但它们如何决定谁得到什么，以及用于什么目的？在本文中，我们探讨了平等获取倡议的九个召集机构如何做出分配决策。我们为九个在全球卫生方面具有突出议程的多边机构提供了从资源动员到分配的完整过程的清晰、简洁的描述。然后，通过比较分析，我们阐明了这九个国际机构所采用的选择和策略。我们发现，所有审查机构的资源分配都遵循类似的模式，我们将其归类为五个步骤的框架：战略定义、资源动员、国家资格、支持类型和资金分配。所有审查机构都通过精心设计和相当复杂的流程来做出资源分配决策。这些流程中的差异似乎反映了机构原则和目标的差异。然而，这些流程存在严重的缺陷。技术问题包括缺乏足够的灵活性来考虑或满足国家的需求。尽管经常提到援助效果和资金使用效率，但我们发现，无论是绩效还是影响都不是分配资源的主要标准。我们发现，对分配选择产生的激励因素几乎没有正式考虑。政治问题包括捐助者和官僚对分配过程的非透明影响，以及将资金指定用于完全绕过正常分配过程的常见做法。道德缺陷包括国际机构问责制和透明度低，以及受影响公民或其代表的参与有限。我们发现，受援国本身对分配过程的影响力较低，尽管在这些过程中，它们在相对狭窄的领域内有一定的影响力。
