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What can be learned from data for nancing of global health?In The Lancet today, Nirmala Ravishankar and colleagues1 valuably quantify and characterise development assist-ance for health (DAH) since 1990. This endeavour wasdiffi cult, and the investigators have had to grapplewith fragmented data for aid ows for health fromvarious bilateral and multilateral donor agencies,private philanthropic institutions, pharmaceuticalcompanies, and civil-society initiatives. But there arelimitations to what the data, so extensively massaged,can communicate.

First, there is a US-centric quality to this analysis.

Some of the non-governmental organisations (NGOs)that are treated as receiving money from the USAare, in fact, international NGOs, even though some of their constituent organisations are US-incorporated.Equally, some US-based NGOs receive money fromnon-US sources, such that the contributions of theseother sources are effectively understated. Some non-US NGOs and foundations as well as bilateral aidagencies in countries outside the Organisation forEconomic Co-operation and Development (OECD) arenot included because of scarcity of data. Over time, theexclusion of this group would impute some bias to theresults because these sources of funding have becomeincreasingly important to DAH.

Second, although the focus of Ravishankar and co-workers analysis is on DAH, I am concerned that assist-ance for health-related areas such as water and sanitationare excluded from the database. The inclusion of aid forthese areas would probably not substantially change themessages of the study in terms of the orientation of DAH.However, that nding itself would yield an interestinginsight, since the provision of clean water and sanitationwould probably do as much to facilitate good health as

does the assistance provided to direct medical care.Third, todays study underscores that much healthassistance is provided not in usable budgetaryresources, but rather as in-kind assistance (technicalassistance and commodity aid). Although Ravishankarand colleagues call attention to the questionablevaluation of drugs provided by pharmaceuticalcompanies, implicitly raising the question of value formoney, one could pose the same question with respectto the high opportunity cost of technical assistance inthe form of high-priced external experts.

Fourth, the investigators allude to the high fraction of the total assistance provided by US-based institutions inthe private sector, and the possibility that there mightbe a tax benet associated with these contributions.I would be interested to know the amount of taxexpenditure associated with these contributions since,effectively, a share of private contributions is actuallynanced by US taxpayers. A rough imputation of thesetax expenditures at, say, the corporate tax rate wouldchange the effective shares derived from the public andprivate sectors. Such an imputation would be no more

arbitrary than that associated with many of Ravishankarand colleagues calculations.Fifth, I believe a far stronger qualication is needed

with respect to the inherent articiality of some of thenumbers derived from various imputation approachesused in the study. This need for qualication relates to:pre-2002 disbursement data from the OECD creditorreporting system database; data on health spendingfrom NGOs; 2007 data for overseas spending fromNGOs, which is estimated on the basis of the growthrate from 2001 to 2006; and grants that were for morethan one area (where the grant was divided equallyacross the matched areas). It is hard to judge the fractionof different categories of results derived from suchimputation methods as opposed to when hard data areprovided by the agencies.

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Finally, although Ravishankar and colleagues reporta distinct reduction in the role of the UN agencies, Ithink this seems simply to reect the decision of theinternational community to rechannel previouslydonated resources and provide new resources throughnew entitiesparticularly the Global Fund to Fight AIDS,Tuberculosis and Malaria and the GAVI Alliancethatwere established to bypass UN agencies. But these newentities are linked indirectly to the UN system, withheavy international participation. I would be wary of overstating this reduction as an important trend, exceptto the extent that it can be seen as a no condence votein the capacity of the UN system.

This study does, however, make an important andhelpful contribution to our understanding of the

magnitude and sources of DAH. If nothing else, thecomplexities entailed in producing this report show theinadequacies and absence of compatibility in the wayin which data for aid ows are provided by the privateand government donor community.

Peter S Heller

Paul H Nitze School of Advanced International Studies,The Johns Hopkins University, Washington,DC 20016-1905, USAphellerdc@gmail.comI declare that I have no conicts of interest.

1 Ravishankar N, Gubbins P, Cooley RJ, et al. Financing of global health:tracking development assistance for health from 1990 to 2007.Lancet 2009; 373: 211324.

Thiazolidinediones and clinical outcomes in type 2 diabetesType 2 diabetes is characterised by two main metabolicdefects: target-cell resistance to the action of insulin(insulin resistance) and insuffi cient secretion of insulin by pancreatic cells (-cell dysfunction).1 Thiazolidinedione medications (rosiglitazone andpioglitazone), through modulation of the transcriptionfactor peroxisome proliferator-activated receptor ,have remarkable benecial effects on both insulin actionand -cell function.13 The clinical signicance of theseeffects is underscored by the fact that treatment withthiazolidinediones results in more durable glycaemic

control compared with other antidiabetic agents(especially sulfonylureas).4 Furthermore, the thiazo-lidinediones have several other benecial cardio-metabolic effects, including reduction of visceralfat mass, decreased systemic inammation, andimprovement in biomarkers and surrogate outcomesassociated with atherosclerosis.1,2,5,6

In clinical practice, the benecial effects of a therapyshould be considered in relation to its potential risks.Adverse effects that have been associated with bothrosiglitazone and pioglitazone include weight gain,increased incidence of fractures, uid retention,and a two-fold increased risk of heart failure.7,8 Mostimportantly, meta-analyses 911 have reported a 3040%increase in the risk of myocardial infarction in patientstreated with rosiglitazone. These ndings haveraised considerable uncertainty about the effects of

thiazolidinediones on cardiovascular disease.In The Lancet today, the rosiglitazone evaluated forcardiovascular outcomes in oral agent combinationtherapy for type 2 diabetes (RECORD) study wasspecically designed to assess the effect of rosiglitazoneon cardiovascular outcomes.12 In this open-label non-inferiority study, 4447 patients with type 2 diabeteson metformin or sulfonylurea monotherapy wererandomly assigned to either add-on rosiglitazone ormetformin and sulfonylurea combination therapy.Over 55 years mean follow-up, non-inferiority

S c i e n c e P h o t o L i b r a r y

Atheromatous artery

PublishedOnline June 5, 2009

DOI:10.1016/S0140-6736(09)61029-1

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