Developing countries, home to 84 percent of the world’s population and 92 percent of the burden of disease, have only 29 percent of global gross domestic product and 16 percent of health spending. In the past three decades, levels of and contributors to global health aid have increased at an unprecedented pace, with an emphasis on funds for HIV/AIDS; maternal, newborn, and child health; malaria; and tuberculosis. Development assistance for health — financial contributions from public and private institutions to low- and middle-income countries to help improve health and health systems — nearly quintupled from 1990 to 2012 (from $5.7 billion to $28.1 billion). DAH is now provided by more than 170 major global health agencies and organizations, 15 percent of which are private entities (such as the Bill and Melinda Gates Foundation), other not-for-profit organizations, and public-private partnerships. Governments are still the largest source for DAH. While increased DAH is essential and welcome, these system developments raise numerous ethical questions. Are the resources sustainable, and do expenditures target correct priorities? Who should decide, and how should these decisions be made? The United Nations, in a 2010 meeting of the General Assembly, initiated a series of debates to explore ways to move the development agenda forward and build on lessons learned during the U.N.’s fifteen-year Millennium Development Goals effort. Agenda-setting for these debates has been global; stakeholders in over eighty-five countries have held conferences and workshops, and the U.N. has invited stakeholders to participate online in global thematic conferences. Several published reports have detailed initial findings. But these discussions have failed to address fundamental ethical questions adequately or to ask whether DAH conforms to basic principles of global justice. The existing DAH system grew out of the post-World War II period of reconstruction and decolonization in which neoliberal principles of national interests, charity, or enlightened self-interest guided foreign aid from donors to recipients within a hierarchical and asymmetric relationship. Empirical evidence on donor priorities suggests that these motivations persist today. Of total health spending, 2.7 percent is in lower-middle-income countries, and 26 percent is in low-income countries; the poorest countries thus depend most heavily upon DAH and suffer most from asymmetries in information and in power vis-à-vis the donor community. To expand global health equity, the DAH system should abandon the power-based donor-recipient dichotomy and replace it with the principle of equal respect for all people’s capabilities. The global justice theory of provincial globalism and its shared health governance (SHG) framework offer an alternative and much better approach to DAH. A shared health governance approach rejects global justice views that rely on individual or social contracts purporting to be mutually beneficial. Individuals and groups are often not in fact free to negotiate effectively: donors can deploy their disproportionate financial and technical resources and diplomatic prowess to influence recipient country health programs and privilege donor interest, not recipient country health needs. With shared health governance, donors and global, national, and subnational agencies and communities can jointly reform the current foreign aid scheme of DAH
