Making the Final Decade of the Sustainable Development Goals Count: An Analysis of Donors’ Subnational Approaches to Reaching the Poorest People

Although the proportion of the world’s population living in poverty has declined substantially over the last two decades, the absolute number of people that live in poverty or vulnerable conditions has remained high. Nearly 70% of the poor now live in countries classified as middle-income.3 We conducted a document review and comparative analysis of six of the largest global health donors to better understand the extent to which they incorporate subnational poverty into their allocation decisions and programming. The donors we studied were Gavi, the Vaccine Alliance (Gavi); the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund); the President’s Emergency Plan for AIDS Relief (PEPFAR); the United States Agency for International Development (USAID)—specifically, its Global Health Bureau; the World Bank’s International Development Association (IDA); and the Government of Japan. We found that most donor high-level strategy documentation allude to the relationship between poverty and health by, for example, noting the financial burden of specific diseases targeted or the disproportionate disease burdens that may fall on the poorest people. However, only two of these donors, Gavi and IDA, incorporate any subnational poverty indicators or broader subnational poverty focus that could be tracked and monitored over time. Gavi and IDA also integrate household level wealth or health expenditure data in their routine monitoring processes, though there is limited information about how much this integration influences how these two donors target aid toward the poorest communities. For the other four donors—Global Fund, PEPFAR, USAID, and Japan—subnational poverty is either not addressed or else is invoked in the context of other social or demographic factors that make certain groups of people vulnerable to disease (e.g., sex workers’ vulnerability to HIV).