The potential impact of declining development assistance for health on population health in Malawi:A modelling study

BACKGROUND: Development assistance for health (DAH) to Malawi will likely decrease as a fraction of Gross Domestic Product (GDP) in the next few decades. Given the country's significant reliance on DAH for the delivery of its healthcare services, estimating the impact that this could have on health projections for the country is particularly urgent. METHODS AND FINDINGS: We use the Malawi-specific, individual-based "all diseases-whole health-system" Thanzi La Onse model to estimate the impact that declining DAH could have on health system capacities, proxied by the availability of human resources for health, and consequently on population health outcomes, in the period 2019-2040. We estimate that the range of DAH forecasts considered could result in a 7.0% (95% confidence interval (CI) [5.3, 8.3]) to 15.8% (95% CI [14.5,16.7]) increase in disability-adjusted life years compared to a scenario where health spending as a percentage of GDP remains unchanged. This could cause a reversal of gains achieved to date in many areas of health. The burden due to non-communicable diseases, on the other hand, is found to increase irrespective of yearly growth in health expenditure, assuming current reach, and scope of interventions. Finally, we find that greater health expenditure will improve population health outcomes, but at a diminishing rate. The main limitations of this study include the fact that it only considered gradual changes in health expenditure, and did not account for more severe economic shocks or sharp declines in DAH. It also relied on key assumptions about how other factors affecting health beyond healthcare worker numbers -such as consumable availability, range of services available, treatment innovation, and socio-economic and behavioural factors-might evolve. CONCLUSIONS: This analysis reveals the potential risk to population health in Malawi should current forecasts of declining health expenditure as a share of GDP materialise, and underscores the need for both domestic and international authorities to act in response to this anticipated trend.