Skip to main content

Distributing development assistance for health: simulating the implications of 11 criteria

  • Trygve Ottersen (a1) (a2) (a3), Suerie Moon (a4) and John-Arne Røttingen (a4) (a5) (a6)

After years of unprecedented growth in development assistance for health (DAH), the DAH system is challenged on several fronts: by the economic downturn and stagnation of DAH, by the epidemiological transition and increase in non-communicable diseases and by the economic transition and rise of the middle-income countries. Central to any potent response is a fair and effective allocation of DAH across countries. A myriad of criteria has been proposed or is currently used, but there have been no comprehensive assessment of their distributional implications. We simulated the implications of 11 quantitative allocation criteria across countries and country categories. We found that the distributions varied profoundly. The group of low-income countries received most DAH from needs-based criteria linked to domestic capacity, while the group of upper-middle-income countries was most favoured by an income-inequality criterion. Compared to a baseline distribution guided by gross national income per capita, low-income countries received less DAH by almost all criteria. The findings can inform funders when examining and revising the criteria they use, and provide input to the broader debate about what criteria should be used.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Distributing development assistance for health: simulating the implications of 11 criteria
      Available formats
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Distributing development assistance for health: simulating the implications of 11 criteria
      Available formats
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Distributing development assistance for health: simulating the implications of 11 criteria
      Available formats
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
*Correspondence to: Trygve Ottersen, Department of Global Public Health and Primary Care, University of Bergen, PO Box 7804, 5020 Bergen, Norway. Email:
Hide All
Alesina, A. and Dollar, D. (2000), ‘Who gives foreign aid to whom and why?’, Journal of Economic Growth, 5: 3363.
Anderson, E. (2008), ‘Practices and implications of aid allocation’, Background Study for the 2008 Development Cooperation Forum. UN Economic and Social Council (ECOSOC).
Basu, S., Stuckler, D. and McKee, M. (2014), ‘An alternative mechanism for international health aid: evaluating a global social protection fund’, Health Policy and Planning, 29: 127136.
Berthelemy, J.-C. (2006), ‘Bilateral donors’ interest vs. recipients’ development motives in aid allocation: do all donors behave the same?’, Review of Development Economics, 10(2): 179194.
Cagé, J. (2015), ‘Improving upon the World Bank’s Country Policy and Institutional Assessment: a new performance indicator based on aid effectiveness’, Journal of Globalization and Development, 5(2): 213–233.
Ceriani, L. and Verme, P. (2013), ‘The Income Lever and the Allocation of Aid’, ECINE Working Paper Series, Society for the Study of Economic Inequality, Verona, Italy.
Collier, P. and Dollar, D. (2002), ‘Aid allocation and poverty reduction’, European Economic Review, 46: 14751500.
Consultative Expert Working Group (2012), ‘Research and Development to Meet Health Needs in Developing Countries: Strengthening Global Financing and Coordination’, CEWG on Research and Development: Financing and Coordination. Geneva: World Health Organization.
Crosswell, M. (2015), ‘Country Selectivity and Extreme Poverty’, USAID Economics Brief, USAID, Washington, DC.
Daniels, N. and Sabin, J. E. (2008), Setting Limits Fairly: Learning to Share Resources for Health, 2nd edn, New York: Oxford University Press.
Dieleman, J. L., Graves, C. M., Templin, T., Johnson, E., Baral, R., K. Leach-Kemon, A. M. Haakenstad and C. J. L. Murray. (2014), ‘Global health development assistance remained steady in 2013 but did not align with recipients’ disease burden’, Health Affairs, 33(5): 878886.
Fan, V. Y., Glassman, A. and Silverman, R. L. (2014), ‘How a new funding model will shift allocations from the Global Fund to Fight AIDS, tuberculosis, and malaria’, Health Affairs, 33(12): 22382246.
Frenk, J., Gómez-Dantés, O. and Chacón, F. (2011), ‘Global Health in Transition’, in R. Parker and M. Sommer (eds), Routledge Handbook in Global Public Health, New York: Routledge.
Frenk, J. and Moon, S. (2013), ‘Governance challenges in global health’, New England Journal of Medicine, 368: 936942.
Glassman, A., Duran, D. and Sumner, A. (2013), ‘Global health and the new bottom billion: what do shifts in global poverty and disease burden mean for donor agencies?’, Global Policy, 4(1): 1–14.
Glennie, J. (2011), ‘The Role of Aid to Middle-Income Countries: A Contribution to Evolving EU Development Policy’, Working Paper 331, Overseas Development Institute, London.
Global Fund (2016), ‘Equitable Access Initiative’, Global Fund to Fight AIDS, Tuberculosis and Malaria, [25 September 2016].
Gostin, L. O. (2014), Global Health Law, Cambridge, MA: Harvard University Press.
Guillaumont, P. (2008), ‘Adapting Aid Allocation Criteria to Development Goals’, Essay for the 2008 Development Cooperation Forum, Clermont-Ferrand, France.
Guillaumont, P., Jeanneney, S. G. and Wagner, L. (2015), ‘How to Take Into Account Vulnerability in Aid Allocation Criteria and Lack of Human Capital as Well: Improving the Performance Based Allocation’, FERDi Working Paper, Fondation pour les Etudes et Recherches sur le Développement International, Clermont-Ferrand, France.
Institute for Health Metrics and Evaluation (IHME) (2014), Financing Global Health 2013: Transition in an Age of Austerity, Seattle, WA: IHME.
Institute for Health Metrics and Evaluation (IHME) (2016), Financing Global Health 2015: Development Assistance Steady on the Path to New Global Goals, Seattle, WA: IHME.
International Development Association (2013), ‘Annex 2. IDA’s performance-based allocation system for IDA17’, IDA, [28 Feburary 2015].
Leo, B. (2010), ‘Inside the World Bank’s Black Box Allocation System: How Well Does IDA Allocate Resources to the Neediest and Most Vulnerable Countries?’, Working Paper 216, Center for Global Development, Washington, DC.
Llavador, H. G. and Roemer, J. E. (2001), ‘An equal-opportunity approach to the allocation of international aid’, Journal of Development Economics, 64: 147171.
McGillivray, M. (2004), ‘Descriptive and prescriptive analyses of aid allocation: approaches, issues, and consequences’, International Review of Economics and Finance, 13: 275292.
McIntyre, D., Meheus, F. and Røttingen, J.-A. (2017), ‘What level of domestic government health expenditure should we aspire to for universal health coverage?’, Health Economics, Policy and Law, 12(2): 125137.
Moon, S. and Omole, O. (2013), ‘Development Assistance for Health: Critiques and Proposals for Change’, Centre on Global Health Security Working Group Papers, Chatham House, London.
Neumayer, E. (2003), ‘The determinants of aid allocation by regional multilateral development banks and United Nations agencies’, International Studies Quarterly, 47(1): 101122.
Ooms, G., Derderian, K. and Melody, D. (2006), ‘Do we need a world health insurance to realise the right to health?’, PLoS Medicine, 3(12): e530.
Ottersen, T., Kamath, A., Moon, S., Martinsen, L. and Røttingen, J.-A. (2017), ‘Development assistance for health: what criteria do multi- and bilateral funders use’, Health Economics, Policy and Law, 12(2): 223244.
Ottersen, T., Moon, S. and Røttingen, J.-A. (2017), ‘The challenge of middle-income countries to development assistance for health: recipients, funders, both or neither’, Health Economics, Policy and Law, 12(2): 265284.
Pietschmann, E. (2014), Forgotten or Unpromising? The Elusive Phenomenon of Under-Aided Countries, Sectors and Sub-National Regions, Bonn: German Development Institute.
Resch, S., Ryckman, T. and Hecht, R. (2015), ‘Funding AIDS programmes in the era of shared responsibility: an analysis of domestic spending in 12 low-income and middle-income countries’, Lancet Global Health, 3: e52e61.
Røttingen, J.-A., Ottersen, T., Ablo, A., Arhin-Tenkorang, D., Benn, C., Elovainio, R., Evans, D. B., Fonseca, L. E., Frenk, J., McCoy, D., McIntyre, D., Moon, S., Ooms, G., Palu, T., Rao, S., Sridhar, D., Vega, J., Wibulpolprasert, S., Wright, S. and Yang, B. M.. (2014), ‘Shared Responsibilities for Health: A Coherent Global Framework for Health Financing’, London: Chatham House.
Salois, M. J. (2012), ‘Biases in the distribution of bilateral aid: a regional decomposition analysis’, Applied Economics Letters, 19(2): 203206.
Salvado, R. C. and Walz, J. (2013), ‘Aid Eligibility and Income Per Capita: A Sudden Stop for MICs?’, DPAF Working Paper Series, Bill & Melinda Gates Foundation, Seattle.
Stuckler, D., Basu, S., Wang, S. W. and McKee, M. (2011), ‘Does recession reduce global health aid? Evidence from 15 high-income countries, 1975–2007’, Bulletin of the World Health Organization, 89: 252257.
Sumner, A. (2012), ‘Where do the poor live?’, World Development, 40(5): 865877.
Thomas, A. (2013), Do Middle-Income Countries Need Aid? Literature Review and Analysis of Evidence and Opinions Used in the Aid Differentiation Debate, London: Bond.
Vázquez, S. T. (2015), ‘Geographical Allocation of Aid: Lessons from Political Economy’, in B. M. Arvin and B. Lew (eds) Handbook of the Economics of Foreign Aid, Cheltenham: Edward Elgar Publishing.
Word Bank (2015), ‘Country and lending groups’, [2 March 2015].
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Health Economics, Policy and Law
  • ISSN: 1744-1331
  • EISSN: 1744-134X
  • URL: /core/journals/health-economics-policy-and-law
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
Type Description Title
Supplementary materials

Ottersen supplementary material
Appendix 1-2

 Excel (54 KB)
54 KB


Altmetric attention score

Full text views

Total number of HTML views: 20
Total number of PDF views: 191 *
Loading metrics...

Abstract views

Total abstract views: 279 *
Loading metrics...

* Views captured on Cambridge Core between 23rd March 2017 - 18th March 2018. This data will be updated every 24 hours.