Country Transition Projections up to 2040: Gavi, the Global Fund, and the World Bank’s IDA

Many countries are facing a much harsher budgetary prospect than a few years ago. For low- and middle-income countries (LMICs) in particular, domestic health expenditure is expected to plateau or contract (in real terms) for many until 2027, development assistance for health has already plateaued, and a debt crisis is looming – all likely to squeeze budgetary space for health for many years ahead. This paper updates a previous CGD mapping of potential transitions for health aid in light of up-to-date 2023 economic projections and transition policies of three mechanisms with explicit eligibility rules: Gavi, The Vaccine Alliance (Gavi); the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM); and the World Bank’s International Development Association (IDA). By “transition,” we refer to the year when a country is expected to no longer meet eligibility rules for one of the three mechanisms and for the related health aid to stop (gradually, as applicable). We find that, of 104 LMICs included in our analysis, 45 countries will be above the eligibility threshold of at least one mechanism by 2040. This is higher than expected based on projections informed by April 2017 economic prospects (26 countries), which suggests that events during the past three years have not derailed transition prospects. However, eligibility and transition policies need to respond to the reality that these countries’ budgetary space may be more constrained (e.g., by debt repayments) than in previous transition phases. There are important differences between the three mechanisms due to differences in their eligibility polices, with fewer transitions in Gavi’s and GFATM’s portfolios than in IDA’s. In addition, 60 countries are not projected to cross any eligibility threshold by 2040. This implies a commitment to supporting these countries well beyond the Sustainable Development Goals era, which may not be the policy intent of their donors. We argue that these findings call for a coordinated reexamination of the principles and content of eligibility and transition policies of the major global health financing mechanisms.