Donor-driven global health programs have saved millions of lives over the past two decades, but they have also produced unintended distortions in national health priorities, according to a new book by Michael John Alastair Reid and Eric Paul Goosby, Redefining Global Health in the 21st Century.

The authors argue that many governments in sub-Saharan Africa and parts of Asia scaled back domestic health investments as external donor programs filled critical gaps in HIV/AIDS treatment, maternal and child health, and infectious disease control. In some cases, domestic health budgets shrank in real terms even as external funding increased — a phenomenon commonly described as "fiscal substitution."

This dynamic, Reid and Goosby contend, produced national health systems that became heavily donor-dependent, externally managed, and acutely vulnerable to funding shocks. The COVID-19 pandemic laid bare many of these structural weaknesses, as countries reliant on donor-supported supply chains and external technical assistance struggled to mount independent public health responses. The problem emerged despite a landmark commitment made by African Union member states in the 2001 Abuja Declaration, in which governments pledged to allocate at least 15% of their national budgets to the health sector. More than two decades later, only a handful of countries have met that target.

The concept of fiscal substitution has long been debated in global health economics. It describes a situation in which foreign aid for health partially or fully displaces domestic government spending, rather than supplementing it. While the evidence has been mixed across countries and time periods, the broader concern is that sustained reliance on external financing can weaken the incentive for governments to build self-sufficient health systems.

Major donor initiatives — including the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), launched in 2003, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, established in 2002 — have channeled tens of billions of dollars into low- and middle-income countries. These programs are widely credited with dramatic reductions in mortality from HIV/AIDS, tuberculosis, and malaria, as well as improvements in health infrastructure and supply chains.

The timing of the book's release is notable: several major donor governments have signaled flat or declining aid budgets in recent years, and PEPFAR's reauthorization process has faced domestic political headwinds, raising questions about the sustainability of programs that millions of patients depend on for continuity of treatment.

However, Reid and Goosby's work highlights the structural trade-offs that accompanied these gains. When donor funding concentrates on specific diseases or vertical programs, it can divert attention and personnel away from broader health system strengthening, primary care, and non-communicable disease management. As populations in many low- and middle-income countries age and urbanize, the disease burden is shifting toward conditions such as cardiovascular disease, diabetes, and cancer — areas that have historically received far less donor attention than infectious diseases.

Writing on Marginal Revolution, the blog that featured the excerpt, the commenter noted the book's value but questioned its pricing: at $150 for a relatively slim volume published by Elsevier, the cost may limit its reach. If the authors believe in the power of aid, the commenter suggested, they might consider making the book freely available rather than entrusting it to a commercial academic publisher.

The book is available via Amazon.