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Original Investigation |

The Relationship of Health Aid to Population Health Improvements

Eran Bendavid, MD1,2; Jay Bhattacharya, MD, PhD2
[+] Author Affiliations
1Division of General Medical Disciplines, Stanford University, Stanford, California
2Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
JAMA Intern Med. 2014;174(6):881-887. doi:10.1001/jamainternmed.2014.292.
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Importance  International aid to the health sector is an important component of all health spending in many developing countries. The relationship between health aid and changes in population health among aid recipients remains unknown.

Objective  To quantify the relationship between health aid and changes in life expectancy and mortality in children younger than 5 years (under-5 mortality) among aid recipient nations.

Design  Cross-country panel data analysis of the relationship between measures of health aid, life expectancy, and under-5 mortality. Using difference models for longitudinal data with fixed effects for countries and years, we estimated the unique relationship between health aid and changes in life expectancy and under-5 mortality, controlling for gross domestic product per capita, urbanization, and total fertility rate.

Setting and Participants  A total of 140 aid-recipient countries between 1974 and 2010.

Exposure  Annual amount of development assistance directed to the health sector in constant 2010 US dollars.

Main Outcomes and Measures  Improvements in under-5 mortality and life expectancy in the period following aid receipt.

Results  Between 1974 and 2010, each 1% increase in health aid was associated with 0.24 months greater increase in life expectancy (95% CI, 0.02-0.46) (P = .03) and a 0.14 per 1000 live births faster decline in the probability of under-5 deaths per 1000 live births (95% CI, 0.02-0.26) (P = .02). The association between health aid and health improvements has strengthened over time, with the closest association occurring between 2000 and 2010. Health improvements associated with health aid are measurable for 3 to 5 years after aid disbursement. These findings imply that an increase of $1 billion in health aid could be associated with 364 800 fewer under-5 deaths (95% CI, 98 400-630 000).

Conclusions and Relevance  International aid to the health sector is related to increasing life expectancy and declining under-5 mortality. The benefits from aid appear to last for several years and have been greatest between 2000 and 2010, possibly because of improving health technologies or effective targeting of aid.

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Figure 1.
Health Improvements in the Decade From 2000 to 2010 by Total Health Aid Quartile

A, Mean increase in total life expectancy. B, Mean reduction in mortality rate for children younger than 5 years (under-5 mortality), defined as the probability of death before age 5 years per 1000 live births. Lowest health aid quartile, 1; highest quartile, 4; error bars represent 95% confidence intervals.

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Figure 2.
Association Between Quartile of Total Health Aid and Changes in Life Expectancy and Mortality Rate for Children Younger Than 5 Years (Under-5 Mortality) by Decade Between 1980 and 2010

The quartiles are calculated from the total health aid between 2000 and 2010 (1 is the lowest health aid quartile; 4 is the highest). A, Life expectancy. B, Under-5 mortality. A positive association with improving life expectancy and declining under-5 mortality is most apparent between 2000 and 2010, suggesting that preexisting trends in the association between health aid and health improvements do not explain the association in the 2000s.

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Figure 3.
The Strength of the Association Between Health Aid and Health Improvements With Increasing Time Lag Between Aid Disbursement and Health Outcome

Each point graph point represents the coefficient (error bars, 95% confidence intervals) on aid from a regression of the change in life expectancy or mortality rate for children younger than 5 years (under-5 mortality) on lagged health aid. The x-axis indicates the lag. The graph shows a gradual decline in the relationship of aid with both outcomes, suggesting a lasting relationship between health aid and health improvements.

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