When it comes to getting aid right, an all-too-familiar problem seems to be balancing the priorities of rich governments with what communities actually want.
The latest study to explore the limits of donor funding assesses the system of financing for health research.
Widespread concerns about HIV/AIDS, maternal mortality and flu pandemics have driven up health funding around the world over the past couple of decades, says Oxford University researcher Devi Sridhar. Last year, funding for the provision of health services was an estimated $27.8 billion, while around $3 billion went to research in 2010.
But how is that money channelled and spent?
"Everyone is chasing the money," Sridhar quotes a former African health minister as saying, "...reputable universities, the U.N. agencies, partnerships, civil society groups - so who is doing what developing countries really need, rather than what donors want?"
What developing nations really need are better health systems to improve primary care for communities - that's at least the impression Sridhar got from talking to their ministers. It's a priority that fits into the wider global push for universal health coverage.
Yet so much health funding still revolves around a single issue.
Compared with HIV/AIDS , which received estimated funding of $10 billion in 2007, less sexy public health problems like malnutrition (which got about $300 million in 2007) and diabetes struggle, Sridhar says.
"There's another kind of logic happening, a political logic that overrides that technocracy (the expertise of health experts)," Sridhar told AlertNet. "Even if we have good data on morbidity and mortality, how much are they actually playing into decisions on where we should put our money?"
WHO SETS PRIORITIES?
In her paper, "Who sets the global health research agenda? The challenges of multi-bi financing", Sridhar looks at how donors are increasingly routing non-core funding that they have earmarked for specific sectors, projects, countries or regions through multilateral agencies such as the World Health Organisation (WHO) or the World Bank.
She also looks at the rise and rise of international health initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Global Alliance for Vaccines and Immunisation (GAVI). Most of these organisations, unlike the WHO with its broad objective of "the attainment by all people of the highest possible level of health", have narrow mandates relating to a specific concern.
Why does this matter? Well, it can result in skewed priorities.
Sridhar warns in her paper, published in PLOS Medicine, of "the risk that difficult choices about priority-setting in health will be made in the marketplace of global initiatives, rather than in the community that will have to live with those choices."
"Developing country health ministers have alleged that this funding mechanism imposes the priorities of powerful states and institutions on poorer countries, whose populations have little recourse to demand accountability or to influence these priorities," she adds.
Another risk is that this kind of financing may favour short-term gains over longer-term public health goals. And it could also erode global capacities to create, collate and disseminate information - the cornerstone of research.