Multi-bilateral aid for disease control
| Published date | 01 June 2023 |
| DOI | http://doi.org/10.1177/01925121211061241 |
| Author | Carie A Steele |
| Date | 01 June 2023 |
| Subject Matter | Original Research Articles |
https://doi.org/10.1177/01925121211061241
International Political Science Review
2023, Vol. 44(3) 387 –402
© The Author(s) 2022
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DOI: 10.1177/01925121211061241
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Multi-bilateral aid for disease control
Carie A Steele
Northern Arizona University, USA
Abstract
A growing portion of aid directed through multilateral channels is earmarked for specific recipients and
purposes, giving donors greater control, also known as multi-bilateral aid. This project examines competing
explanations of donors’ use of this multi-bilateral aid for different problems within the same sector,
specifically development aid for disease control. Using explanations from the literature on multilateralism
and principal-agent dynamics, I compare donors’ use of multi-bilateral and bilateral delivery of disease-
specific foreign aid. The results suggest that while donors deliver a greater portion of aid through multi-
bilateral channels for larger, more complex problems, they are reluctant to delegate issues that most affect
their populations.
Keywords
Multi-bilateral aid, foreign aid, development aid for health, development aid and disease control
Introduction
In 1959, the World Health Organization (WHO) devised a plan to eradicate smallpox. Although
the plan initially relied on donor countries to distribute the vaccine and provide funding directly
to recipients, they later adopted a more centralized campaign due to lack of resources and under-
funding. Under the revised plan, donor states provided nearly half of the $300m required to
eradicate smallpox through the Voluntary Smallpox Fund and the Smallpox Eradication Unit in
the WHO. Smallpox was eradicated in 1980 as a result of this coordinated effort (Levine and
Kinder, 2007).
Soon after smallpox was eradicated, HIV/AIDS gained international attention. By 1994, the
international community established the Department of HIV/AIDS within the World Health
Organization, followed by the Joint United Nations Programme on HIV/AIDS in 1995, and the
Global Fund to Fight AIDS, Tuberculosis, and Malaria in 2002. During the State of the Union
Address in 2003, President George W Bush (2003) challenged the United States to lead the fight
against HIV/AIDS and to ‘turn the tide of AIDS’. Despite the United States’ inaugural pledge to
Corresponding author:
Carie A Steele, Department of Politics and International Affairs Northern Arizona University, 5 East McConnel Drive,
PO Box 15036, Flagstaff, AZ 86011, USA.
Email: Carie.Steele@nau.edu
1061241IPS0010.1177/01925121211061241International Political Science ReviewSteele
research-article2022
Original Research Article
388 International Political Science Review 44(3)
the Global Fund, and numerous multilateral organizations, US policies mandated unilateral
action for a menu of activities similar to those engaged in by multilateral organizations (Institute
of Medicine, 2007).
These two cases suggest a common question within the study of international relations: under
what conditions do donors choose multilateral channels for aid? Previous studies examining when
donor states choose to direct aid through multilateral channels generally seek to explain differences
between bilateral and multilateral aid, relying on a clear distinction between the two: bilateral aid
conceptualized as aid given directly to a foreign government, while multilateral aid is given to a
multilateral organization and allocated by that organization in support of its independent agenda.
However, over the past 25 years, the practice among donors of earmarking aid given through mul-
tilateral organizations for specific recipients, purposes, sectors, and activities has led to the rise of
a new category of aid—multi-bilateral aid. Multi-bilateral aid now accounts for more than 50% of
multilateral funds, and as much as 70% or more for some organizations, including the WHO
(Reinsberg et al., 2015; WHO, 2019).
In theory, multi-bilateral aid enables donors to pool resources and coordinate activities through
multilateral channels while also maintaining control of aid decisions and pursuing a unilateral
agenda. But in reality, we know little about why donors choose multi-bilateral aid. While many
studies of multi-bilateral aid compare it to multilateral aid, I compare multi-bilateral aid allocations
to bilateral aid. Specifically, I examine under what conditions donors use multi-bilateral aid to
address public goods problems in the empirical context of global infectious disease control.
Global infectious disease control is the cooperative effort to limit and control the spread of dis-
eases caused by bacteria, viruses, fungi, and parasites. It includes a wide variety of programmatic
activities such as disease testing, immunization and treatment programs, parasite exclusion and
elimination, etc. It is a uniquely relevant case for studying when donors choose multi-bilateral aid
because solutions are agreed upon and diseases vary in their incentives for cooperation. In addi-
tion, global infectious disease control requires large-scale interventions. Global interventions
require funding, co-ordination, and resource mobilization that is beyond the power of any single
actor. Despite the clear benefits of multilateralism for infectious disease control, donors use a vari-
ety of channels for disease-specific aid, providing important variation to examine the incentives to
use multi-bilateral aid.
I model multi-bilateral aid for infectious disease control and compare it with bilateral alloca-
tions in order to shed light on when and why donors choose to use multi-bilateral aid. The results
suggest that donors use multi-bilateral aid to capitalize on the benefits of coordination within a
very specific set of issues that benefit from large-scale coordinated interventions, but in many other
areas where coordination could improve outcomes they continue to use other channels.
The use of multi-bilateral aid
Multi-bilateral aid is defined as aid given through multilateral channels that is both voluntary and
earmarked (Reinsberg et al., 2015). The rise of multi-bilateral aid represents donor countries’
efforts to balance the competing pressures of control over aid and the benefits of coordination.
Numerous studies find that donor countries use foreign aid to buy influence in recipient countries
(Alesina and Dollar, 2000; Dollar and Prichett, 1998; Dreher et al., 2011; Kaufmann and Wang,
1995; Vreeland, 2011). This is most easily done through the use of bilateral aid, over which donors
maintain significant control. However, a growing volume of literature and international policy
consensus suggests that aid effectiveness is tied to coordination among donors and recipients.
Donors can coordinate efforts by directing aid through multilateral organizations. Although this
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