Financial Assistance for Health Security: Effects of International Financial Assistance on Capacities for Preventing, Detecting, and Responding to Public Health Emergencies

Document Type : Original Article


1 Center for Global Health Science & Security, Georgetown University Medical Center, Georgetown University, Washington, DC, USA

2 Department of Mathematics and Statistics, Georgetown University, Washington, DC, USA

3 Department of Health Systems Administration, Georgetown University, Washington, DC, USA


Health security funding is intended to improve capacities for preventing, detecting, and responding to public health emergencies. Recent years have witnessed substantial increases in the amounts of donor financial assistance to health security from countries, philanthropies, and other development partners. To date, no work has examined the effects of assistance on health security capacity development over time. This paper presents an analysis of the timelagged effects of assistance for health security (AHS) on levels of capacity.

We collected publicly available health security assessment scores published between 2010 and 2019 and data relating to financial AHS. Using validated methods, we rescaled assessment scores on analogous scales to enable comparison and binned them in quartiles. We then used a distributed lag model (DLM) in a Bayesian ordinal regression framework to assess the effects of AHS on capacity development over time.

Strong evidence exists for associations between financial assistance and select capacities on a variety of lagged time intervals. Financial assistance had positive effects on zoonotic disease capacities in the year it was disbursed, and positive effects on legislation, laboratory, workforce, and risk communication capacities one year after disbursal. Financial assistance had negative effects on laboratory and emergency response capacities two years after it was disbursed. Financial assistance did not have measurable effects on coordination, antimicrobial resistance (AMR), food safety, biosafety, surveillance, or response preparedness capacities over the timeframe considered.

Financial AHS is associated with positive effects for several core health security capacities. However, for the majority of capacities, levels of funding were not significantly associated with capacity level, though we cannot fully exclude endogeneity. Future work should continue to investigate these relationships in different contexts and examine other factors that may contribute to capacity development.


  1. Ravishankar N, Gubbins P, Cooley RJ, et al. Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet. 2009;373(9681):2113-2124. doi:1016/s0140-6736(09)60881-3
  2. Dieleman JL, Schneider MT, Haakenstad A, et al. Development assistance for health: past trends, associations, and the future of international financial flows for health. Lancet. 2016;387(10037):2536-2544. doi:1016/s0140-6736(16)30168-4
  3. Greco G, Powell-Jackson T, Borghi J, Mills A. Countdown to 2015: assessment of donor assistance to maternal, newborn, and child health between 2003 and 2006. Lancet. 2008;371(9620):1268-1275. doi:1016/s0140-6736(08)60561-9
  4. Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other health issues? Health Policy Plan. 2008;23(2):95-100. doi:1093/heapol/czm045
  5. Piva P, Dodd R. Where did all the aid go? an in-depth analysis of increased health aid flows over the past 10 years. Bull World Health Organ. 2009;87(12):930-939. doi:2471/blt.08.058677
  6. Schäferhoff M, Schrade C, Yamey G. Financing maternal and child health--what are the limitations in estimating donor flows and resource needs? PLoS Med. 2010;7(7):e1000305. doi:1371/journal.pmed.1000305
  7. Pitt C, Grollman C, Martinez-Alvarez M, Arregoces L, Borghi J. Tracking aid for global health goals: a systematic comparison of four approaches applied to reproductive, maternal, newborn, and child health. Lancet Glob Health. 2018;6(8):e859-e874. doi:1016/s2214-109x(18)30276-6
  8. Furuoka F, Hoque MZ, Jacob RI, Ziegenhain P. An analysis of the development assistance for health (DAH) allocations for STD control in Africa. Health Econ Policy Law. 2020;15(4):458-476. doi:1017/s1744133119000197
  9. World Health Organization (WHO). International Health Regulations (2005). Geneva: WHO; 2005.
  10. Kieny MP, Evans DB, Schmets G, Kadandale S. Health-system resilience: reflections on the Ebola crisis in western Africa. Bull World Health Organ. 2014;92(12):850. doi:2471/blt.14.149278
  11. Tsai FJ, Katz R. Measuring global health security: comparison of self- and external evaluations for IHR core capacity. Health Secur. 2018;16(5):304-310. doi:1089/hs.2018.0019
  12. Bell E, Tappero JW, Ijaz K, et al. Joint External Evaluation-development and scale-up of global multisectoral health capacity evaluation process. Emerg Infect Dis. 2017;23(13):S33-39. doi:3201/eid2313.170949
  13. World Health Organization (WHO). Joint External Evaluation Tool (JEE Tool). 1st ed. Geneva: WHO; 2016.
  14. Moon S, Omole O. Development assistance for health: critiques, proposals and prospects for change. Health Econ Policy Law. 2017; 12:207-221. doi:1017/S1744133116000463
  15. Moon S, Omole O. Development assistance for health: critiques, proposals and prospects for change. Health Econ Policy Law. 2017;12(2):207-221. doi:1017/s1744133116000463
  16. Electronic State Parties Self-Assessment Annual Reporting Tool (e-SPAR). World Health Organization. Accessed August 20, 2019. Updated August 1, 2019.
  17. Joint External Evaluation (JEE) mission reports. World Health Organization. Accessed August 20, 2019. Updated August 1, 2019.
  18. Georgetown Infectious Disease Atlas – Global Health Security Tracking. Center for Global Health Science & Security. Accessed June 8, 2021. Updated June 22, 2019.
  19. Katz R, Graeden E, Kerr J, Eaneff S. Tracking the flow of funds in global health security. Ecohealth. 2019;16(2):298-305. doi:10.1007/s10393-019-01402-w
  20. World Development Indicators. World Bank. Available: Accessed October 8, 2019. Updated February 1, 2019.
  21. Hastie T, Tibshirani R. Varying-coefficient models. J R Stat Soc Series B. 1993;55(4):757-796. doi:1111/j.2517-6161.1993.tb01939.x
  22. Ravines RR, Schmidt AM, Migon HS. Revisiting distributed lag models through a Bayesian perspective. Appl Stoch Models Bus Ind. 2006;22(2):193-210. doi:1002/asmb.628
  23. Schwartz J. The distributed lag between air pollution and daily deaths. Epidemiology. 2000;11(3):320-326. doi:1097/00001648-200005000-00016
  24. Albert JH, Chib S. Bayesian analysis of binary and polychotomous response data. J Am Stat Assoc. 1993;88(422):669-679. doi:1080/01621459.1993.10476321
  25. Hoerl AE, Kennard RW. Ridge regression: biased estimation for nonorthogonal problems. Technometrics. 1970;12(1):55-67. doi:1080/00401706.1970.10488634
  26. Goldstein M. Bayesian analysis of regression problems. Biometrika. 1976;63(1):51-58. doi:2307/2335083
  27. Gelman A, Carlin JB, Stern HS, Dunson DB, Vehtari A, Rubin DB. Bayesian Data Analysis. 3rd ed. Boca Raton: CRC Press, Taylor & Francis Group; 2013.
  28. Geweke JF. Evaluating the accuracy of sampling-based approaches to the calculation of posterior moments. In: Bernardo JM, Berge JO, Dawid AP, Smith AFM, eds. Bayesian Statistics. Vol 4. Oxford: Clarendon Press; 1992:169-193.
  29. Craig AT, Sio AR. The value of joint external evaluation as a tool for country-level health security monitoring. Health Secur. 2019;17(2):166-167. doi:1089/hs.2018.0130
  30. Easterly W, Pfutze T. Where does the money go? best and worst practices in foreign aid. J Econ Perspect. 2008;22(2):29-52. doi:1257/jep.22.2.29
  31. World Health Organization (WHO). Joint External Evaluation (JEE) Tool. 2nd ed. Geneva: WHO; 2018.
  32. Gupta V, Kraemer JD, Katz R, et al. Analysis of results from the Joint External Evaluation: examining its strength and assessing for trends among participating countries. J Glob Health. 2018;8(2):020416. doi:7189/jogh.08.020416
  33. Haider N, Yavlinsky A, Chang YM, et al. The Global Health Security index and Joint External Evaluation score for health preparedness are not correlated with countries' COVID-19 detection response time and mortality outcome. Epidemiol Infect. 2020;148:e210. doi:1017/s0950268820002046
  34. Lee CT, Frieden T. Why Even Well-Prepared Countries Failed the Pandemic Test: Bad Politics Can Undermine Good Public Health. Foreign Affairs. March 29, 2021. Accessed June 10, 2021.

Articles in Press, Corrected Proof
Available Online from 01 September 2021
  • Receive Date: 28 July 2020
  • Revise Date: 11 August 2021
  • Accept Date: 29 August 2021