Chapter 1.4 looks into official development assistance. Official development assistance (ODA) is provided by governments or multilateral development banks (MDBs) to support economic development in other countries. Key learning includes that

• ODA is critical to achieving the United Nations Sustainable Development Goals (SDGs) in the world’s poorest countries

• The lowest-income countries typically receive less ODA than comparatively wealthier countries due to their limited capacity to absorb additional funds.

• MDB funds are best utilized when they are invested in under resourced areas, such as global or regional public goods, and when they are well-aligned with domestic policies and national goals.

• ODA success (i.e. resources having a meaningful impact on development outcomes) depends on

• – Prioritizing the right long-term development challenges

• – Effective domestic governance and an active role for national-level stakeholders

• – Transparency around ODA activities

• – Continuous assessment, evaluation, learning and improvement.

• ODA and financing institutions must adjust to new challenges such as climate change

• – moving away from a sector-by-sector approach, addressing trends and emerging themes and delivering innovative and agile financing mechanisms.

Chapter 3.10 evaluates innovative financing for neglected diseases. Neglected diseases (NDs) account for about a fifth of the global burden of disease and affect over a billion people. They are neglected because the pharmaceutical sector does not consider it profitable to develop treatments for them. This reflects that fact that NDs are most prevalent in low- and middle-income countries with relatively low purchasing potential. Key learning includes that

• Global pharmaceutical research and development (R&D) invests a disproportionate share of innovation, activity and resources in low burden diseases and fosters significant inequities.

• A range of push and pull incentive mechanisms have been developed to delink the cost of research from market profitability and promote innovation in areas of need.

• – Reduce the upfront costs by subsidizing R&D pre-discovery (push incentives) and

• – Offer a reward post-discovery (pull incentives)

• The evidence on the effectiveness and reach of incentive schemes is scant and more needs to be done to understand the relative cost-effectiveness of the different incentive mechanisms and the extent to which they mitigate inequalities in innovation and access to new medicines.

• A global, unified governance framework for needs assessment and resource allocation could usefully

• – Carry out systematic comparison of the relative needs associated with NDs globally

• – Assess the costs and benefits of addressing these

• – Set priorities for the coordinated global allocation of funding and targeted incentive mechanisms, and

• – Consider payment mechanisms that will translate research into market launches.

The pressure on health donors and aid-dependent governments to reach the end of AIDS has been managed in part through the rising dominance of discourses and tools grounded in cost-effectiveness. This chapter analyzes cost-effectiveness tools used to prioritize HIV financing at the national level, and finds that the tools can be a double-edged sword for marginalized communities and interventions. While cost-effectiveness analysis can be used to make a case for prioritizing investment in HIV services that reach key populations, these tools can also be used to reinforce epistemological exclusion of those populations due to lack of quantitative data that demonstrates their needs. Cost-effectiveness is sometimes also used to exclude other values, principles, and knowledge produced through qualitative methods. This chapter examines how cost-effectiveness analyses play out for key populations in some national investment cases, and explores whether human rights norms offer alternative principles of decision-making. It finds that while cost-effectiveness analysis can contribute towards ensuring that states fulfill the right to health, if not explicitly balanced against other human rights principles, cost-effectiveness may reinforce neoliberal values and a model of the market in which small, marginalized populations are set up to lose the competition for prioritization.