This study provided, for the first time, an estimated gross disbursement of Japan’s DAH and its flows. Japan’s DAH was found to be approximately 900 million USD in 2016. The main source of DAH was MOFA. According to the OECD statistics, Japan’s gross disbursements of ODA in 2016 amounted to 16.26 billion USD [28], which means that the share of DAH in ODA was about 5.5%.
In accordance with the ODA Charter, Japan has traditionally placed Asia, which has a close relationship with Japan, as a priority region [17]. Meanwhile, we revealed that approximately half of Japan’s bilateral and multilateral DAH were allocated to the African region in the study periods (Fig. 1). This finding may reflect Japan’s recent efforts to strengthen its diplomatic relations with African countries through various efforts including TICAD as well as Agenda 2063 and SDGs. For example, Japan hosted TICAD VI in Kenya in 2016 and launched the “UHC in Africa: Framework for Action” in partnership with the World Bank, WHO, the Global Fund, and the African Development Bank [32]. This is a roadmap for African countries to accelerate progress towards UHC and to monitor and assess their progress. In the same year, Japan hosted the Ise-Shima Group of Seven (G7) Summit, which was held in the aftermath of the Ebola crisis in Western Africa, providing an important opportunity for Japan to advance global health governance issues [33].
In addition, in May 2014, JICA signed, for the first time, an ODA loan agreement of up to 68.31 million USD (at current price in 2015) with the Government of the Federal Republic of Nigeria for the Polio eradication project [34]. This project aimed to contribute to the early eradication of polio in Nigeria by ensuring smooth vaccination of children under five years of age throughout the country through the procurement of polio vaccines. ODA loans to Africa in 2015 in Fig. 1 refer to this project.
This study examined the distribution of earmarked funding (bi-multi) and core funding to multilateral agencies for DAH in 2012–2016. Bi-multi funding is a resource to multilateral agencies over which the donor retains some degree of control on decisions regarding disposal of the funds. Such flows may be earmarked for a specific country, project, region, sector or theme. It is aid for bilateral functions channelled through multilateral agencies, and is therefore considered by the OECD and others as part of bilateral ODA [1,2,3].
On the other hand, core funding to multilateral agencies are used for a variety of purposes, some of which are channeled to global functions (e.g., provision of global public goods, management of cross-border externalities, and fostering of leadership and stewardship). Schäferhoff et al. (2015) estimated the total share of core funding going to global functions by agencies, as follows: WHO 62%, UNAIDS 40%, UNFPA 22%, UNICEF 12%, World Bank (International Development Association) 5%, Global Fund 10%, and Gavi 20% [23].
In Japan, core funding accounted for the majority of the DAH channeled through multilateral agencies, except for those through UNICEF and UNFPA. In particular, Japan’s core funding to WHO, which primarily focuses on global functions, has ranked 2nd in the world after the United States [35]. It may be said that Japan’s global functions in relation to the global trends is relatively high. This finding may be consistent with the direction of the Basic Design for Peace and Health, which emphasizes the strengthening of global functions based on the concept of human security. For example, at the Ise-Shima G7 Summit, Japan emphasized the promotion of aid for global functions both in the G7 Ise-Shima Leaders’ Declaration and G7 Ise-Shima Vision for Global Health [36, 37].
While the effective DAH allocation has long been discussed, it might be guided by a number of factors, including historical and traditional diplomatic relations, geographic proximity, strategic reciprocity, and trade-related considerations, particularly in bilateral aid; and not necessarily aligned with disease priorities for health aid in recipient countries and cost-effectiveness of interventions [38].
Globally, however, DAH growth has been stagnant over the past 10 years and limited financial resources are a universal constraint [39]; Japan is not exception. It is, therefore, an urgent policy issue to implement DAH strategies wisely, efficiently and effectively, while ensuring transparency.
Synergies through the human security approach
Both in the Global Health Diplomacy Strategy and the Basic Design for Peace and Health, protecting human security has been a core concept of Japanese foreign policy [4, 5]. Human security is at a convergence that combines the competing policy issues that could threaten vital core of all human lives, including infectious disease epidemics (as exemplified by the recent 2014 Ebola outbreak [10] or pandemic influenza) as well as refugee and migration crises and climate change. Human security approach thus enriches the synergy between measures to address these issues. For example, among the nearly one million Rohingyas, an Islamic minority group, living in a refugee camp in Bangladesh, there is a growing concern about a serious infectious disease epidemic, including measles, cholera, and typhoid [40]. Also, as global warming progresses, the distribution of vectors such as mosquitoes that transmit Japanese encephalitis, dengue fever, malaria, and yellow fever, may expand [41, 42]. Human security approach will also contribute to the achievement of SDGs as well as AU Agenda 2063 by building a healthy, sustainable, and stable society. An important issue in the DAH strategy for donors is therefore to consider how donors should fund their human security efforts from a limited ODA budget, and in particular what is the optimal role of DAH in this context.
For example, Japan is one of the founding partners of the Global Fund and a major donor who contributed 20.04–34.89% of DAH to the Global Fund in 2012–2016. Since its establishment in 2002, an accumulated 3.46 billion USD has been contributed from Japan [43]. At the meeting of the Sustainable Development Goals Promotion Headquarters on June 2019, Prime Minister Shinzo Abe announced Japan’s new pledge of 840 million USD to the Global Fund’s Sixth Replenishment [44]. Infectious disease control is an important DAH strategy of Japan, which covered 19.89–33.64% of Japan’s DAH shares overall between 2012 and 2016, and was mostly channeled through the Global Fund. In the context of human security approach to climate change and refugees and migrants crisis, further scale-up of DAH investments in effective infectious disease control is expected.
Note that human security approach in this context means supporting people-centered, comprehensive, context-specific, and prevention-oriented responses that strengthen the protection and empowerment of all people, adopting partnerships across sectors, developing context-sensitive solutions, and supporting the realization of a world without fear, want, and dignity [45]. Caution is needed that while human security as a rationale for linking foreign policy and health introduces significant political power, sufficient attention must be paid to the possibility that national security interests may be skewed towards health and humanitarian issues [46]. It should also be noted that treating global health issues as national security threats, rather than universal issues to be concerned with the humanity, may cause an excessive concern surrounding diseases surveillance and a divide between affected countries and non-affected countries. In the past, for example, securitization was misused as a rationale for implementing HIV-based travel, migration, and immigration control policies and laws prohibiting the entry of people living with HIV [47].
Health system strengthening for non-communicable diseases
The results also showed that between 2012 and 2016, approximately 70% of DAH were allocated to PHC, and remaining 30% to HSS. Although there are no established norms or benchmarks on the balance between PHC and HSS allocations in DAH, the High Level Task Force on Innovative International Financing for Health Systems (HLTF) proposed that approximately 15–26% of the additional resources would be required for HSS—that are broadly consistent with the above definitions—in order to achieve the Millennium Development Goals (MDGs) for low-income countries [48]. In terms of the MDGs, therefore, the balance between PHC and HSS in Japan’s DAH could be roughly reasonable. However, in today’s era of SDGs, the growing emphasis on social determinants of health makes it even more crucial that DAH strengthens health system, including institutional capacity (effectiveness of surveillance systems and laboratory networks, etc.), administrative and financial systems, and human resources development [49].
Donor-recipient countries face the challenges posed by health transition, i.e., a double burden of morbidity, mortality, and associated health care costs from increasing non-communicable diseases (NCDs) and continuing high communicable diseases [50]. PHC has played a successful role in the delivery of prevention and care interventions for communicable diseases, such as malaria, tuberculosis, and HIV/AIDS. However, it is imperative to expand the delivery of PHC in countries undergoing health transition in terms of health promotion and disease prevention and treatment in response to NCDs [51]. With limited resources, several studies suggested the need to take a diagonal approach of HSS to address NCDs, rather than disease-specific, vertical programs [52, 53]. HSS has the potential to improve the delivery of PHC in a cost-effective manner by dealing with the wide range of health problems encountered in health transition. HSS are emerging important focus of some multilateral agencies, such as the World Bank and the Global Fund (Japan’s major DAH channels), as well as the Gavi, The Vaccine Alliance.
There is an increasing debate as to why donor countries, including Japan, should invest more in NCDs [54]. A 2019 study demonstrated that recently only 1% or less of Japan’s DAH went to NCDs [39], whereas NCDs accounted for 40–50% of total disease burden in low- and lower-middle-income countries (LMICs) [55]. However, this does not imply that funds for infectious disease control should be used to scale-up to confront NCDs through HSS. Between 2012 and 2016, 31.80–48.59% of Japan’s DAH went to infectious diseases control including HIV/AIDS, which has aligned with disease burden in LMICs to some extent (or lower), where infectious disease accounted for about 40–50% of the total disease burden in LMICs [55]. Importantly, Japan’s DAH allocation should take full account of the health transition of DAH-recipient countries and make the burden of disease an important criterion for prioritizing resource allocation [12]. In the future, it will become increasingly important to promote prevention as well as treatment by focusing on HSS in recipient countries.
Approach to support domestic resources and private investment
More effective health spending is needed in developing countries, and they should use all available resources. Recognizing this need, SDG 17 aims to strengthen domestic resource mobilization and improve domestic fiscal capacity for tax and other revenue collection [56]. In addition, under the 2015 Addis Ababa Action Agenda, countries pledged to achieve the SDGs, largely using domestic resources [57]. These are also recognized as common understanding to achieve UHC at the joint session of Finance and Health Ministers at the Osaka G20 Summit this year as well as at TIVAD VII [2, 3].
On the other hand, a recent study estimated that achieving UHC would require an increase in annual per capita health spending of more than 100 USD by 2030 in LMICs [58]. More spending may be needed, especially as the country develops economically and prices rise. This figure is much larger than DAH alone can cover. While taking into account the country’s own priorities, it is the most important strategic challenge for donors to consider how DAH can support the use and mobilization of domestic resources and how it can intervene in ways that reduce investment risks for the private sector [12].
For multilateral aid, the Global Financing Facility (GFF) and Global Action Plan for Healthy Lives and Well-Being for All is a new approach that leverages domestic resources as well as ongoing funding from private and public sources. Japan is one of the 10 donor countries of GFF as of May 2019. The first commitment, a pledge of 50 million USD, to the GFF by the Government of Japan was announced at the UHC Forum 2017 [59].
In addition, donors should be aware of the potential for the implementation of DAH to impair the ability of DAH-recipient countries to properly plan health budget disbursements, and should seek ways to avoid it. A 2016 study by the World Bank and other institutions found that the costs of using parallel systems of DAH and domestic resources were more than four times higher than relying solely on national financial systems and skills transfer [60]. Also, there is an evidence of negative correlation between DAH and domestic resources; DAH may constrain the domestic health budget and cause its significant portion substituted out of the health sector [61, 62]. Decision-making and implementation of DAH should consider how financial flows in DAH-recipient countries interact with each other.
Limitation
While ODA system is well-known, many complexities are involved in its use. This study made use of DAH on gross disbursements rather than commitments as disbursements are actual distributions of committed aid funds, while the commitments are amount the donor agreed to make available to. In some cases, disbursements could be more volatile than commitments, conditional on specific country events (e.g., political instability), and absorptive capacity during any one year [63].
As noted in the previous study [31], it is difficult to draw a strong conclusion about the share of PHC and HSS for several reasons. First, there is a lack of global agreement on measurable indications for PHC and HSS. It also includes the lack of normative descriptions of the share of DAH by donors for PHC and HSS. The method developed in the previous study (and used in this study) can be reproduced using OECD/CRS data and may serve as a useful method to track future donor resources allocated to PHC/HSS.
Our estimates of DAH are not necessarily comparable to those of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, which also provides an alternative source of data on DAH [39]. IHME uses rather complicated mathematical procedures to classify aid based on a ‘word search’ of project/program content, rather than the long-established coding procedures followed by donors for the OECD/CRS data base. IHME estimates tend to be relatively large in value than our estimates based on the OECD coding procedures. For example, in Japan, a DAH of 2016 was estimated to be 895 million USD in this study, while IHME estimates was 1100 million USD (at constant price in 2018) [39]. This may be because the IHME’s estimation method using word search allows some consideration even in areas, such as ‘agriculture’ (CRS code 310), ‘water and sanitation’ (140), and ‘education’ (110) that the OECD coding procedures based on the CRS code does not consider as ‘health’ (120 + 130). In addition, in the OECD coding, there are 17 focus areas in the field of health, while IHME classifies health into 7 focus areas. IHME also provides very important data, although the methods of estimation and classification are different. However, this study adopted the OECD coding procedures, whose categorization is more familiar and straightforward for policy makers and government officials in Japan to understand.
This study used only data from Japan over a five-year period, and therefore does not provide long-term trends of DAH or comparisons with other countries, or any consideration from the perspective of Japan’s relative position in global health diplomacy. This is our next research scope.
