# Abstract After a ‘golden age’ of extraordinary growth in the level of development assistance for health (DAH) since 1990, funding seems to have reached a plateau. With the launch of the Sustainable Development Goals, debate has intensified regarding what international financing for health should look like in the post-2015 era. In this review paper, we offer a systematic overview of problems and proposals for change. Major critiques of the current DAH system include: that the total volume of financing is inadequate; financial flows are volatile and uncertain; DAH may not result in additional resources for health; too small a proportion of DAH is transferred to recipient countries; inappropriate priority setting; inadequate coordination; weak mechanisms for accountability; and disagreement on the rationale for DAH. Proposals to address these critiques include: financing-oriented proposals to address insufficient levels and high volatility of DAH; governance-oriented proposals to address concerns regarding additionality, proportions reaching countries, priority setting, coordination and accountability; and proposals that reach beyond the existing DAH system. We conclude with a discussion of prospects for change. # Eight criticiques of the [[DAH]] system 1. Inadequate total volume of financing 2. Volatility and uncertainty of financing 3. Additionality of financing: external financing may displace rather than augment domestic financing for health 4. Proportion transferred to recipient countries: [[phantom aid]]. The OECD estimates that the proportion of ODA that qualifies as Country-Programmable Aid (targeted at specific countries and ‘over which partner countries could have a significant say’) was 78% in 2014 (OECD, 2016a). We did not find an estimate for the proportion of DAH that remains in donor countries, but studies narrower in scope support the overall critique. For example, a 2009 study of the Gates Foundation’s grants from 1998 to 2007 estimated that 40% of grant funding went to supranational organizations and 82% of the remaining amount went to US-based organizations (McCoy et al., 2009). A 2013 study on PEPFAR found that only 8% of funds went directly to governments in LMICs (Fan et al., 2013). 5. Priority setting: 3 questions: 1) how the priorities are set, 2) who should set priorities, 3) how priorities should be set 6. Coordination 7. Accountability: While discussions of accountability have tended to focus on relationships between donor and recipient governments, also significant are accountability relationships between governments and their own constituents and those between donors and recipients across societies as increasing amounts of DAH are channeled outside governmental channels. 8. Rationale: what is and what should be the rationale or justification for [[DAH]]. The foundation was built from WW2 and were initially framed as foreign aid. Now alternative framings have emerged, including 'cooperation', which implies a more equal relationship, national security; ‘[[global public goods (GPG)]]’, which emphasizes the responsibility of all states to contribute to the shared benefit of health; ‘[[health diplomacy]]’, which can include the use of DAH to achieve a donor’s other foreign policy goals; ‘investment’, eyeing future commercial relationships to be built between a donor and recipient country; ‘restitution’, which emphasizes obligations to remedy past and/or ongoing wrongs; ‘global solidarity’, based on the notion of the emergence of a global society bound together by relationships of interdependence (Commission on Macroeconomics and Health, 2001; Mackintosh et al., 2006; Frenk and Moon, 2013; Heymann et al., 2015; Kickbusch, 2016). Each of these framings implies different institutional arrangements for DAH and is reflected in various reform proposals for the DAH system. # Proposals for reforming the DAH system Divided into three categories: 1) primarily seek to address financing issues (volumes, volatility); 2) address governance issues within the existing DAH system (additionality, proportion, coordination, priority setting and accountability); 3) those that reach beyond the DAH system. ## 1. Financing-oriented proposals [[innovative financing]] mechanism: international taxes such as a levy on financial transactions (such as trade in equities or currencies), 'sin taxes' on products that are potentially harmful to health such as tobacco, alcohol, fossil fuels or some foods, a tax on every individual earning more than $1 bilion per year, or expanding the tax on air tickets currently used to fund the global health initiative UNITAID. Finally, ==earmarked contributions from the sale of products by the private sector== have been proposed to generate additional funds for health, such as (Product) Red for the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). While Product Red has raised important sums ($306 million from 2001 to 2015), it remains a very small proportion (0.8%) of the $38 billion contributed to the GFATM, 95% of which came from governments ($36.2 billion). Other proposals involve novel mechanisms for managing financial flows (rather than generating new financial flows), including: leveraging the [[International Monetary Fund (IMF)]]’s Special Drawing Rights to back bonds for development purposes; building on the GAVI Alliance’s International Finance Facility for Immunization, which frontloads financial flows by using long-term pledges from donor governments to sell ‘vaccine bonds’ in capital markets; designating a ‘swing donor’ or donor of last resort that would counterbalance unpredictable disbursements by individual donors to smooth out resource transfers; and building on the GFATM’s (or Global Fund) Debt2Health initiative, which redirects funds for debt repayment by recipient countries to domestic health investments. Finally, advocates have long urged OECD donor governments to live up to their commitments to allocate 0.7% of gross national income for development assistance and to extend their planning horizons to make aid more predictable (see e.g. Millenium Development Goals (MDG) Gap Task Force, 2013). As of May 2016, however, only seven governments had ever achieved the 0.7% target (OECD, 2016b). ## 2. Governance-oriented proposal within the DAH system At national level, proposals to improve coordination have included: Sector-Wide Approaches, General Budget Support or donor specialization in one sector, referring broadly to the principle that donors coordinate within a given country and with its government to harmonize aid with country priorities, and with each other; the ==Three Ones approach for HIV/AIDS==, referring to one action framework, one national coordinating authority and one monitoring and evaluation system for all actors involved in a country’s response to HIV/AIDS; and ==the One UN/Delivering as One initiative== to improve coordination among UN organizations within a country based on six principles – One Leader, One Budget, One Programme, One Office, One Voice for advocacy and One Fund. At the international level, initiatives and proposals include: the 2005 Paris Declaration on Aid Effectiveness, signed by more than 100 countries and international organizations and based on the five principles of ownership, alignment, harmonization, results and mutual accountability, with the follow-up 2008 Accra Agenda for Action putting additional emphasis on ownership, ‘inclusive partnerships’ and results; the International Health Partnership, started in 2007 to apply the Paris Declaration principles to the health sector, and provide better coordination for donor countries and agencies; ## 3. Proposals reaching beyond the existing DAH system ome proposals reach at least one step beyond the existing set of actors and institutions in DAH. These include the proposal for a Global Social Protection Fund for long-term resource transfers (or redistribution) to poorer countries or populations to meet basic health needs, based on an expansion of the notion of social protection beyond the nation state and possibly a transformation of the GFATM (Ooms et al., 2010a, 2010b) ==Many have also argued for the increased use of formal international law for global health (including but not limited to the purpose of resource generation)==, building on the precedent established by the 2005 WHO Framework Convention on Tobacco Control. Proposals include those for a treaty on antimicrobial resistance (Hoffman and Behdinan, 2016), research and development of new medicines focusing on the needs of the poor (Røttingen and Chamas, 2012), an alcohol convention (Sridhar, 2012), a chronic disease ‘global compact’ (Magnusson, 2009), a ‘fake drugs’ treaty (The Lancet, 2011a), an obesity convention (The Lancet, 2011b) and a Framework Convention on Global Health (Gostin, 2007). [[The track record of international law in achieving its intended effects is both mixed and difficult to assess]], however; therefore, both the problems to be targeted by treaties and treaty design itself merit careful consideration (Hoffman and Røttingen, 2014). # Discussion and conclusions What are the prospects for reform? The ‘golden age’ of rapid increases in DAH may be over, with DAH increasing only 1% per year since 2010, compared with over 11% annual growth in the decade prior (IHME, 2012; IHME, 2016). Political attention in the traditional donor OECD countries may be shifting to other global challenges, such as climate change, refugees and terrorism. Given a relatively fixed resource envelope, it becomes even more important, then, to improve other aspects of DAH. The [[power operates in multiple and interconnected ways and that different forms of power are at play simultaneously in socio-political relations|emerging powers]] may have an appetite for reform. Within the global financial institutions, they have sought a weightier decision-making role at the World Bank and IMF, or created alternate arrangements such as the [[Asian Infrastructure Investment Bank]] and [[New Development Bank (NDB)]] (formerly known as the BRICS Development Bank). However, as demonstrated in Table 1, ==DAH accounts for a small proportion of health financing in MICs. It is the LICs that have the greatest stake in strengthening the system, and will need to push for change.== While LICs, in general, will have fewer levers of influence than MICs, leadership and political alliances with like-minded development actors can wield significant power. In addition, many LICs are undergoing rapid economic growth which may change the nature of the donor–recipient relationship. Furthermore, the rationale for DAH may shift with the increased health interdependence that results from the intensified movement of people, goods, pathogens, ideas and financial resources across borders (Frenk et al., 2014). The closer the health of one country’s population is tied to that of another, the stronger the interest in ensuring healthy populations on both sides of the border. The recent Ebola and Zika health emergencies have reminded the world of these realities. Reforming a complex, entrenched DAH system will never be easy. While there are numerous problems, there is also no shortage of promising proposals for change, or of political possibility. What is needed are determined leaders who will champion reforms and invest the political capital needed to build better institutions for DAH in the SDG era.