The long-term impact of COVID-19 on development assistance for health is still uncertain.

The COVID-19 pandemic is continuing to have an unprecedented effect on lives, livelihoods, and economies around the world. Some experts speculate that COVID-19 will become endemic, requiring a shift from an emergency response to a long-term sustainable strategy.1, 2 Modelling the impact of COVID-19 on total health expenditure and development assistance for health into the future is therefore challenging while the pandemic is ongoing.

In The Lancet, the Global Burden of Disease 2020 Health Financing Collaborator Network estimate the amount of total health expenditure and development assistance for health from 1990 to 2050, using new data sources to update previous estimates from 1990 to 2018.4, 5 They estimate funding for 2019–20 with a special focus on COVID-19, and forecast health spending for 2021–50. They report that annual development assistance for health reached US$54·4 billion in 2020, of which $13·5 billion was targeted at the COVID-19 response ($12·1 billion in new commitments and $1·4 billion reallocated from other health projects). They also report geographical inequalities in disbursements, finding that some countries with a high COVID-19 burden received less funding than less affected countries.

The new Article goes further than previous attempts at quantifying this expenditure by comparing COVID-19-related development assistance for health to non-COVID-19 development assistance for health, preventing double counting of resources by differentiating funding entities from organisations that serve as funding channels, differentiating new funds for COVID-19 from funds reallocated from other health projects towards COVID-19, and using robust statistical methods. These estimates will enhance planning and coordination of COVID-19 response policies. Policy makers and funders will now have clearer visibility of the volume and allocation of funds, enabling them to address financial gaps in the response to the pandemic. For example, countries in Latin America and the Caribbean received only 8% of the COVID-19 development assistance for health despite having 39% of the COVID-19 deaths in 2020. This is a critical gap in funding from an equity and global health perspective. Moreover, funders can see the activity of other funders, allowing them to explore collaborations or fill existing funding gaps.

However, as useful as these estimates are for policy making, they should be interpreted with caution. The methods used in the study, though robust, have limitations described elsewhere.6, 7 The estimates do not fully account for the uncertainties created by COVID-19, or the likelihood of a future COVID-19-like pandemic. COVID-19 might trigger a new age of sustained increase in development assistance for health similar to HIV between 2001 and 2010, when development assistance for health increased by 11·2% per year and annual development assistance for health tripled between 2001 and 2010. Conversely, slow economic growth in donor countries coupled with rising nationalism and donor fatigue might lead to decreased development assistance for health. Indeed, the announcement by the UK Government to cut bilateral aid to 102 countries in the middle of the pandemic shows how little is known about donor-country responses to the pandemic.

Furthermore, the models used to estimate future government health expenditure and development assistance for health rely heavily on projections of the gross domestic product (GDP). As a result, the models fail to capture important political shifts created by crises such as pandemics that could influence health spending over and above the impact of the GDP. Several countries increased investments in health relative to the GDP following national crises. China increased investments in universal health coverage after the SARS-CoV outbreak,8, 9 as did Rwanda after the genocide. Following the Asian financial crisis, Thailand increased spending but Indonesia did not. Lastly, it is not clear that the model sufficiently captured the changing frequency of outbreaks, the differential impact on the economy, and the subsequent effect on development assistance for health.12, 13

Taken together, these concerns illustrate the potential impact of COVID-19 on future government health expenditure and development assistance for health. The ultimate direction and magnitude of the impact is not certain and will depend on which of the counteracting forces prevail. It is therefore impossible to say exactly how health spending and development assistance for health will change over the next 30 years. Although these projections reflect the current state of knowledge, they might quickly become outdated as situations change and more evidence becomes available.