# Abstract One of the most important gatherings of the world’s economic leaders, the G20 Summit and ministerial meetings, takes place in June, 2019. The Summit presents a valuable opportunity to reflect on the provision and receipt of development assistance for health ([[DAH]]) and the role the G20 can have in shaping the future of health financing. The participants at the G20 Summit (ie, the world’s largest providers of DAH, emerging donors, and DAH recipients) and this Summit’s particular focus on global health and the Sustainable Development Goals offers a unique forum to consider the changing DAH context and its pressing questions. In this Health Policy perspective, we examined trends in DAH and its evolution over time, with a particular focus on G20 countries; pointed to persistent and emerging challenges for discussion at the G20 Summit; and highlighted key questions for G20 leaders to address to put the future of DAH on course to meet the expansive Sustainable Development Goals. Key questions include how to best focus DAH for equitable health gains, how to deliver DAH to strengthen health systems, and how to support domestic [[resource mobilisation as one of the defining characteristics of policy networks|resource mobilisation]] and transformative partnerships for sustainable impact. These issues are discussed in the context of the growing effects of climate change, demographic and epidemiological transitions, and a global political shift towards increasing prioritisation of national interests. Although not all these questions are new, novel approaches to allocating DAH that prioritise equity, efficiency, and sustainability, particularly through domestic resource use and mobilisation are needed. Wrestling with difficult questions in a changing landscape is essential to develop a DAH financing system capable of supporting and sustaining crucial global health goals # Moving forward ## [[Question]] 1: in which areas should [[DAH]] be focused to support equitable health gains? A fundamental task is for donors to critically reflect on the appropriate criteria to ensure equitable allocation of DAH. ==Moving away from eligibility based solely on national income, to criteria that include burden of disease, country readiness, and within-country socioeconomic conditions, among other factors, will be essential for addressing systemic inequities==. Considerations of how to target aid to the poorest and most vulnerable within each country will be paramount. Potential strategies to do this might include using the size of the population living below the poverty line instead of total population size in allocation formulas and strategies; focusing on subnational units in which the poor or disadvantaged disproportionately live; tailoring health programmes to the unique health and health-care delivery problems in rural areas and slums or among sex workers, ethnic minorities, and other disadvantaged groups; funding research and development that focuses on health problems that most affect the poor; and funding high-impact multisectoral programmes that aim to alleviate poverty. Unique responses are also required for countries facing challenges of fragility, conflict, and violence, whether due to acute, short-term events; protracted situations, as in Syria and Yemen; or increasingly, susceptibilities related to climate change. Many of the poorest global citizens live in countries that are considered middle-income. Evaluating how to encourage health gains for individuals most in need, and how to engage with governments that have an increasing amount of resources but have not directed them to the poorest or most vulnerable is of utmost importance. In middle-income countries with more resources for health, this allocation might include identifying the right combination of technical assistance and policy dialogue to provide optimal support, even where levels of DAH are lower. ==There might also be other non-traditional roles for donors in these contexts, such as focusing on market shaping interventions, working across countries to ensure sustainable access to affordable essential medicines, or advocacy.== [[Insights]] This is what TBI has been doing with [[access to medicines]] and ultimately [[access goods]]. Critical reflection on the optimal role of [[DAH]] in financing [[global public goods (GPG)]], including research and development of new drugs and vaccines, developing global systems to prevent and respond to large-scale epidemics, efforts to combat antimicrobial resistance, and measures to mitigate the impacts climate change has on health and health delivery systems, is also needed. This reflection requires consideration and a willingness for high-income countries especially to invest in public goods. ## [[Question]] 2: How can development partners deliver [[DAH]] to strengthen health systems? In particular, the emphasis in the SDGs on broader determinants of health makes it even more crucial that DAH strengthens essential health system enablers, such as laboratory networks and systems, surveillance systems, and public health workforce development. These important system inputs provide a robust foundation for functional public health delivery systems that can identify and respond appropriately to the routine needs of multiple disease areas and to complex health emergencies, as well as public health systems that can promote and incentivise prevention. The G20 should consider how to channel investments so that they strengthen within country data systems and institutional capacity to use and manage data for effective decision making. Reliable vital registration systems to track births and deaths are valuable for providing social services, developing tax systems, and coordinating the health system. Strong routine health information systems can be used to track care, identify gaps in care, and respond when services are absent. Health surveillance systems to track outbreaks will enable and improve preparedness for local epidemics and global pandemics. ## [[Question]] 3: how can [[DAH]] support domestic [[resource mobilisation]] and transformative partnerships? The Global Financing Facility is a recent example of innovative and collaborative financing, in this case in support of reproductive, maternal, newborn, and child health. Grants from the Global Financing Facility intend eventually to leverage domestic funding in addition to ongoing funding mobilised through private and public sector sources, including the World Bank, UN agencies, the Global Fund, Gavi, and capital markets. The Global Action Plan for Healthy Lives and Well-Being for All also leverages new ways of working through joint advocacy, joint financing of health system strengthening, alignment around a single agenda, and unlocking innovative approaches to financing, including through blended financing arrangements. For example, in [[Nigeria]], the Gates Foundation and the Dangote Foundation contributed funds for primary health care but with an agreement to gradually transition to government financing. This model has already led to some states fully financing primary health care from state government resources. Although domestic government spending remains too low in many countries, these examples highlight how a diversity of partners can come together to support global health goals. Although these innovations risk being merely new packaging of old products, what could make them most valuable is the ability to align with country priorities and leverage new resources rather than replace existing resources. In addition to considering how DAH and innovative partnerships might support domestic resource mobilisation, the G20 has to also grapple with the reality that no health gains or health system improvements are sustainable if these do not align with a country’s own priorities. Aligning donor spending with a country’s own priorities requires, whenever possible, that recipient countries lead endeavours to reach global health goals. # Conclusion The global health challenges and expansive set of global health goals in the SDGs require a new approach to address pending questions about how DAH can better prioritise equity, efficiency, and sustainability, particularly through domestic resource use and mobilisation and strategic partnerships. Priority areas for discussion include how to focus DAH for equitable health gains; how to deliver DAH to strengthen health systems to efficiently use limited resources; and how to promote domestic financing for sustainable impact. Although not necessarily new issues, the changing global context requires new answers. Wrestling with these difficult questions is essential to develop stronger health financing systems capable of reaching and sustaining crucial global health goals.