New prescriptions

IN 2000 policy wonks from governments and aid organisations agreed on what would become the Millennium Development Goals, an ambitious set of development targets for 2015. Surprisingly, the fine words prompted concerted action. From 2001 to 2010 the aid devoted to health care grew by more than 10% a year, compared with 7% a year in the 1990s. Most of the new money went on fighting the scourges on the list: HIV/AIDS, malaria, tuberculosis, and maternal and infant mortality.

The growth in health-care aid has now slowed to less than half the rate of the early 2000s. And as 2015 approaches, donors are mulling new health-care goals. Ideas will be discussed at a big meeting of the World Bank and IMF in Washington, DC, on April 11th-13th. One is to make aid money go further by increasing the use of cash incentives for patients or health-care providers. Rather than merely buy inputs such as vaccines, donors would pay for results, such as each child who is immunised.

Such schemes can improve outcomes: one in Rwanda that offered cash rewards for clinics increased the share of women giving birth in the clinic, rather than at home, by 23%. But the design and implementation need thought, says Tim Evans of the World Bank: another in the Democratic Republic of Congo that paid clinics for offering more services—more prenatal consultations and childhood immunisations, for example—made little difference, perhaps because the bonus payments were too small.

Since 2008 the World Bank has devoted $2.5 billion to programmes that pay at least partly by results. It, and other donors, are thinking of shifting more of their spending to such schemes. But even if the outcome is greater efficiency, it will not deal with a bigger problem: the growing burden of chronic diseases in the developing world.

Research by Christopher Murray of the University of Washington published on April 8th in the journal Health Affairs shows a growing mismatch between the ailments donors spend most on tackling, and those that are taking the heaviest toll. About 55% of all aid for health care in 2011, the most recent year for which global figures were available, went to areas identified by the Millennium Development Goals. Just 1% went to chronic ailments such as diabetes and heart disease, though these now account for half the years spent in bad health, or lost because of early death caused by illness, in developing countries.

Austerity in the rich world means that aid budgets are unlikely to start growing quickly again. And even if more money was forthcoming, chronic diseases are harder to target with aid programmes. A vaccine can be administered in one, or at most a few, doses and offers an easily calculated return on investment. Managing diabetes requires long-term monitoring and medication—that is, a functioning health-care system, which will have to be built by recipient countries’ governments.

It seems likely, then, that donors will continue to go for infectious diseases, leaving governments to tackle chronic ones. In a sign of the shift to come, Dr Murray reports that government spending on health care in poor and middle-income countries grew more quickly than health-care aid between 2010 and 2011. On April 11th ministers and aid specialists in Washington were due to discuss their next task: helping to ensure that by 2030 everyone, everywhere, has health care. The Millennium Development Goals look modest by comparison.