Date of Award
Spring 2026
Language
English
Embargo Period
4-20-2026
Document Type
Dissertation
Degree Name
Doctor of Philosophy (PhD)
College/School/Department
Department of Public Administration and Policy
Program
Public Administration and Policy
First Advisor
Ashley M. Fox
Committee Members
Dr. Susan Appe, Dr. Brian Greenhill, and Dr. Stephanie Smith
Subject Categories
Health Policy | Policy Design, Analysis, and Evaluation | Public Affairs, Public Policy and Public Administration | Public Policy
Abstract
How do governments respond to the global health agenda? Does external health assistance translate to sustained domestic political commitment in low- and middle-income countries? Over the past three decades, development assistance for health has expanded, accompanied by international agreements emphasizing country ownership, alignment, and domestic resource mobilization. Yet domestic fiscal commitment to health remains uneven across countries. These questions have become more pressing as the global aid landscape enters a period of contraction, with a significant decline in development assistance, including health financing, raising concerns about the sustainability of health systems that have become reliant on external support. This raises a central question: to what extent do external financing and global governance frameworks strengthen, substitute for, or fail to influence national commitment to health priorities?
The dissertation conceptualizes government response through the framework of political commitment, distinguishing between stated, institutional, and budgetary commitment. Using a three-paper design, the project investigates how external influence interacts with domestic political and institutional dynamics to shape national responses to the global health agenda.
The first paper analyzes cross-national panel data from 2000 to 2021 to examine how aid dependence and aid modality affect domestic health spending. The findings show that external assistance has heterogeneous effects across income groups, with on-budget aid often associated with short-term substitution, while off-budget aid shows limited additive effects, and long-term spending patterns remain strongly path dependent.
The second paper evaluates whether global aid effectiveness frameworks, including the Paris Declaration (2005) and the Sustainable Development Goals (2015), altered donor behavior and recipient fiscal commitment. The results suggest that these soft-law agreements influenced aid modality, particularly increasing on-budget alignment, but had limited and inconsistent effects on domestic health spending.
The third paper uses qualitative evidence from Libya to explain why governments conform to some externally promoted priorities while resisting others. The analysis shows that domestic gatekeepers mediate global agendas and that political incentives, social norms, crisis pressures, and strategic considerations shape uneven commitment across policy areas.
Together, the findings demonstrate that global health agendas do not automatically translate into durable domestic commitment. External assistance and international agreements can shape incentives, but national political dynamics ultimately determine whether global priorities are internalized in state institutions and budgets.
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
Recommended Citation
Abdelkarim, Sana, "After the Aid Boom: Government Responses to the Global Health Agenda and Political Commitment in Low- and Middle-Income Countries" (2026). Electronic Theses & Dissertations (2024 - present). 386.
https://scholarsarchive.library.albany.edu/etd/386
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Health Policy Commons, Policy Design, Analysis, and Evaluation Commons, Public Policy Commons