A new article in PLOS Medicine says large donors have a major influence on which health issues get funded. The author says it’s an attempt by governments and others to exert more control over international agencies.

Oxford University’s Dr. Devi Sridhar says large donors have shifted to a practice called multi-bi financing.

“Multi-bi financing is funds that at first glance look multilateral. They’re given to multilateral agencies. You know, the WHO, the World Bank or new initiatives that look multilateral at the surface, but that actually have more characteristics that are bilateral in that they’re often earmarked. They’re often limited in duration. It’s this new area and it’s been growing. It’s been estimated to account for 40 percent of total multilateral funding,” she said.

Agencies like the World Health Organization are relying more on this type of funding, rather than on a standard annual budget. In fact, Sridhar said almost 80 percent of the WHO’s budget comes from voluntary contributions, which would be classified as multi-bi financing.

“Within the World Health Organization, there have been concerns raised, particularly by developing countries and emerging countries such as Brazil, over how much influence voluntary contributions are having, rather than the assessed budget – what countries are required to pay each year through kind of a U.N. formula,” she said.

Sridhar is a university lecturer in Global Health Politics and co-director of the Center for AIDS Interdisciplinary Research. She said the major donors are the U.S., Britain, Japan, the European Commission and the Bill and Melinda Gates Foundation.

“Well, what you get is actually priorities being skewed in a way that perhaps fits the priorities of the donor in question - whether it’s taxpayers - whether it’s the priorities of a particular organization. And it differs from how priorities are set within, let’s say, a body like the World Health Organization, where you have all member states come together in the World Health Assembly to decide collaboratively through deliberation what the priorities should be for the organization. So, in a way, it’s priorities being decided by the few for the many,” she said.

She said it’s also generating debate on how funds should be spent within the Global Fund to Fight AIDS, Tuberculosis and Malaria. Since the global financial crisis, donors are demanding that projects not only improve health, but be cost-effective, as well.

“So you are seeing much more reliance in actually trying to monitor these international agencies more closely - being able to decide the priorities, to realign them with those of a particular donor," said Sridhar.

Sridhar said one of the main issues is that short-term health concerns might take priority over long term objectives.

“Part of the rationale for creating the World Health Organization was that countries would compromise their short term differences in order to obtain the long term benefits of collaboration," she said. "For example, international health regulations, which require countries to report on, let’s say, disease outbreaks in their country. It’s not necessarily in the short term interest of a country to do that, but it’s in the long term collective interest of the global community for this to happen.”

She said when large donors set health priorities, input from technocrats – such as public health experts, economists and lawyers – may not be included in discussions. Also, many of the new initiatives are funded by the private sector, such as pharmaceutical companies. The question arises as to how much influence the private sector should wield.

“How actually do we include these powerful stakeholders, but in a way that controls conflict of interest? And make sure that actually public health is the primary concern – not opening new markets or profit motives,” she said.

But Sridhar did say that multi-bi financing “has shown a light on how and where multilateral institutions might do better” and bring about reforms.