Despite the major strides made in the fight against COVID-19 over the past year, the end of the pandemic feels distant in many places around the world. The crisis in India, where in May 2021 alone more than 350,000 people lost their lives to the pandemic, and more recent surges in Latin America, Eastern Europe, and in parts of sub-Saharan Africa and the United States, underscore that fact dramatically. Low vaccination rates outside of high-income countries (and in some pockets within high-income countries), increasing infection rates around the world, and the threats posed by the Delta variant and other still-emerging, highly-transmissible viral variants mean that much work remains to be done. That work will require substantial investments on the part of governments and in some cases, by donors.

The question then, is how those investments should be targeted. How can we think about the future of COVID-19 development assistance for health? Should development assistance for COVID-19 be sent to the poorest countries, or to countries where the pandemic is causing the most health burden? Or would that approach be too simple? As India's experience with COVID-19 has shown, where the pandemic is currently the worst in the world can change quickly and seemingly unpredictably.

"How can we think about the future of COVID-19 development assistance for health?"

Encouragingly, in response to COVID-19 donor spending on health has already increased substantially; between 2019 and 2020, overall development assistance for health grew an unprecedented 35.6 percent, according to new research from the Institute for Health Metrics and Evaluation. Despite this dramatic increase, however, this spending may not have gone to the places that most needed support. 

The regions that received the most development assistance for health for COVID-19 in 2020 were not necessarily those where the pandemic caused the most deaths. The most striking example is in the Latin America and the Caribbean Global Burden of Disease super-region, where roughly 34 percent of COVID-19 deaths occurred in 2020, yet it received only 7.7 percent of the development assistance for health that flowed to countries in 2020.

Indeed, development assistance for health for COVID-19 in 2020 more closely matched historical trends in development assistance for health. Prior to COVID-19, the bulk of development assistance for health—more than one quarter of total funding in 2018—went to sub-Saharan Africa. In contrast, Latin America received just 3 percent of total development assistance for health that year.

Meanwhile, according to IHME's September 14 COVID-19 estimates, the three most populous countries in the Latin America and Caribbean region—Brazil, Colombia, and Argentina—had some of the highest estimated daily COVID-19 infection rates in the world—24, 11 and 24 per 100,000. The countries' cumulative death numbers were 741,764 (Brazil), 142,821 (Colombia), and 113,532 (Argentina). For comparison, at its height on December 19, 2020, the infection rate in the United States (when it was the world leader in estimated total COVID-19 deaths) was 160 per 100,000, or an estimated 480,913.

While other forms of COVID-19 spending in 2020, such as development bank loans, helped populations weather the pandemic, the point remains: it's very possible that where development assistance for health went in 2020 wasn't necessarily where it might have had the most impact on reducing COVID-related deaths.  

That said, a narrow focus on COVID-19 deaths and infections risks overlooking the widespread pain the pandemic has caused, and which development assistance for health may have helped mitigate in 2020. After all, development assistance for health encompasses a range of health-related programs and activities, from support for country-level coordination to treatment funding.

Nonetheless, COVID-19's indirect negative effects have been significant. That list is both exhausting and well-trod, from economic losses at the household level, to overtaxed health systems, to the pandemic's effect on mental health.

And to be clear, our work on COVID-19 developmental assistance for health doesn't yet take into account 2021's developments. Those include the enormous progress made in COVID-19 treatment, and vaccine development and distribution. However, 2021 has also brought setbacks as well, including new variants and vaccine hesitation in some places. Going forward, estimates of vaccination coverage can help policymakers pinpoint the regions and countries where the need for vaccines and COVID-19 funding may be greatest.

However, there are several clear issues with using estimates of regional vaccination coverage to inform policy. The first is that some countries—such as Malta and the Maldives—have vaccinated high percentages of their small populations. Another complication is the fact that some countries with high (United Arab Emirates) and low vaccination coverage percentages (Venezuela) may be artificially driving their respective regional averages up or down.

A third complicating factor is that there are a number of countries with low vaccination numbers that are also not projected to see many deaths related to COVID-19 over the coming months, so relying on estimates of vaccination coverage alone to determine where aid should be sent may be insufficient. According to IHME's September 14 COVID-19 estimates, 3.3 percent of Madagascar's population of almost 27 million people have been vaccinated, but the country is only projected to see a 0.8 percent increase in deaths by December 1, 2021. On the other hand, cumulative total COVID-19 deaths in Bolivia—a landlocked country which has vaccinated almost 36 percent of its population—are projected to grow 3.3 percent by December, so it can use all the doses it can get.

Over the past year COVID-19 has shown both the immense usefulness of health data and estimates, as well as data's shortcomings. COVID-19 spending data can be combined with other health estimates to give policymakers a fuller, more nuanced view of where spending has gone and where it has been most effective so far. In other words, we have many pieces of the puzzle. The trick is putting them together correctly.

EDITOR'S NOTE: The authors are employed by the University of Washington's Institute for Health Metrics and Evaluation (IHME), which produced the development assistance for health research described in this article. IHME is a partner on Think Global Health. All statements and views expressed in this article are solely those of the individual author and are not necessarily shared by their institution.

To fully account for the impact of the pandemic, all COVID-19 estimates include the total number of COVID-19 deaths, which is greater than what has been reported. To learn more about IHME's methods of estimating total COVID-19 deaths, please see our special analysis. Many thanks to IHME's Ian Cosgwell, Hayley Stutzman, Juan Solorio, and Christopher Troeger for their help with the estimates and figures.