Driving health progress during disease, demographic, domestic finance, and donor transitions (the “4Ds”)​

The global health landscape is undergoing a set of rapid and profound transitions that threaten to stall or even derail progress in global health improvement. The 4Ds project analyzes four of these major, inter-linked transitions—shifts in diseases, demography, development assistance for health (DAH), and domestic health financing:

  • The global burden of disease is shifting away from infections to non-communicable diseases and injuries, although there is still an “unfinished agenda” of mortality in poor populations from infections and maternal and child health conditions
  • There is a demographic transition involving ageing populations coupled with a bulge in the adolescent band of the population pyramid (the “youth bulge”); in some middle-income countries (MICs), like Jordan and Lebanon, migration related to conflict is also affecting this transition
  • Over the next few years, more than a dozen MICs will graduate from multilateral DAH, even though many still have large pockets of poverty and high mortality and may have insufficient domestic capacity to tackle these challenges without external assistance
  • It will cost low-income countries (LICs) and MICs an additional $371 billion annually in health spending by 2030 to reach the health-related Sustainable Development Goal targets, which will require a shift towards domestic financing of health; massively increased domestic financing will be needed, yet many countries have so far seen little mobilization of domestic resources for health.

Maintaining continued global health progress—and certainly achieving an acceleration in progress—will depend on how domestic and international health policymakers navigate these four critical transitions. These transitions cannot be managed in isolation as they are so closely tied with each other. All countries need an overarching, “joined up” strategic approach to transition that takes into account the likely shifts in disease burden and demography, how these shifts will affect health financing needs, and the mechanisms for meeting these needs.

The 4Ds project aims to generate data, evidence, and analysis to support policymakers in developing such a “joined” up strategy.  Our center is partnering with universities, think tanks, and ministries of health and finance in six transitioning MICs: Ghana, India (focusing on Uttar Pradesh state), Kenya, Myanmar, Nigeria, and Sri Lanka.

Shashika Bandara, Center for Policy Impact in Global Health
Ipchita Bharali, Center for Policy Impact in Global Health
Siddharth Dixit, Center for Policy Impact in Global Health
Hanna Huffstetler, Center for Policy Impact in Global Health
Wenhui Mao, Center for Policy Impact in Global Health
Kaci Kennedy McDade, Center for Policy Impact in Global Health
Osondu Ogbuoji, Center for Policy Impact in Global Health
Gavin Yamey, Center for Policy Impact in Global Health

Middle-income countries graduating from health aid: transforming daunting challenges into smooth transitions
Authors: Gavin Yamey, Osondu Ogbuoji, Justice Nonvingnon

The “4Ds” that threaten middle-income countries
Authors: Shashika Bandara, Hanna Huffstetler, Kaci

Health aid in transition: a review of the Global Fund to Fight AIDS, Tuberculosis, and Malaria
Authors: Marco Schäferhoff, Kaci Kennedy McDade, and Gavin Yamey

How do major health donors prepare for country exits?
Authors: Kaci Kennedy McDade, Osondu Ogbuoji, Marco Schäferhoff, and Gavin Yamey

  • Sarah Blodgett Bermeo, Associate Professor, Sanford School of Public Policy, Associate Professor of Political Science, Duke University
  • Maria Eugenia Bonilla-Chacin, Chief Economist, GFF, World Bank
  • Jesse Boardman Bump, Lecturer on Global Health Policy, Department of Global Health & Population, Harvard T.H. Chan School of Public Health
  • Erica Field, Professor of Economics, Economics Department, Duke University
  • Daniel Kress, Economist & Health Systems Expert, Former Senior Director, RTI & Deputy Director, Global Primary healthcare and Financing, Gates Foundation
  • David McAdams, Professor at Business Administration & Economics, Duke Fuqua School of Business & Economics Department
  • Myaing Nyunt, Associate Professor, Medicine and Global Health, Duke Global Health Institute (based in Myanmar/Duke)
  • Jonathan Quick, Senior Fellow & former President and CEO, MSH, former Essential Medicines Director, WHO
  • Helen Saxenian, Economist, R4D; Gavi consultant (Learning Network for Countries in Transition), formerly at World Bank
  • Seth Terkper, Ghana’s former Finance Minister, Executive Director & Founder, PFM-TAX Africa Network
  • Erik Wibbels, Robert O. Keohane Professor of Political Science, Duke University
  • Albert G. Zeufack, Chief Economist for Africa, World Bank Group

This project is funded by the Bill & Melinda Gates Foundation.


Questions? Please contact Gavin Yamey.

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