Factors influencing the allocation of United States' development assistance for health, 2000-2020

Prior to the second Trump administration, the United States (US) had consistently maintained its position as the world's largest donor of development assistance for health (DAH) for a long time. However, the factors influencing US DAH remain poorly understood. A comprehensive analysis of the factors potentially determining US DAH allocation in recent decades could provide valuable insights for navigating the evolving global health financing landscape and informing future policy decisions. We analyzed how US DAH was allocated across recipient countries and how country-year allocation of US DAH was associated with a range of factors, covering disease burden, economic condition, diplomatic relationship, bilateral trade, and governance indicators. The study used data from Institute for Health Metrics and Evaluation and other sources covering 2000-2020, a period when data for most variables were available. In addition to our primary regression analysis, we conducted stratified analyses across time periods (2000-2015 vs. 2016-2020). US DAH was positively associated with burden of infectious diseases, maternal and neonatal conditions, and nutritional deficiencies, but was not significantly related to non-communicable diseases and injuries. Nursing and midwifery (per 10000) positively correlated with aid allocation, whereas other human resource variables showed no significant association with aid distribution. Diplomatic distance was negatively associated with US DAH, and trade level was positively associated with US DAH. Corruption was negatively associated with US DAH. The study reveals the complexity of the factors shaping US DAH, raising questions regarding the equity of its distribution. These findings underscore an opportunity for the global health community to shift towards better alignment of funding priorities with the specific need of developing countries, amid the uncertainty brought by the substantial policy shifts of the current US administration.