Wealth redistribution policies to mitigate the impact of development assistance defunding: a retrospective evaluation and forecasting analysis up to 2030

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BACKGROUND: The ongoing decline in funding for humanitarian and development assistance stands in stark contrast to the global rise in wealth concentration and widening socioeconomic inequalities. This study aimed to assess whether the implementation of wealth redistribution policies-proposed in recent high-level international agreements to support development-could mitigate the health impact of the current official development assistance (ODA) defunding crisis. METHODS: We conducted an integrated retrospective impact evaluation and forecasting analysis using longitudinal panel data from 59 low-income and lower-middle-income countries. First, we estimated the association between per-capita ODA and mortality outcomes from 2002 to 2021 using two-way fixed-effects multivariable Poisson regression models with robust standard errors, adjusting for key demographic, socioeconomic, and health-system covariates. We did extensive sensitivity and triangulation analyses to assess the robustness and plausibility of the findings. We then evaluated ten wealth redistribution policies with validated country-level microsimulation models to forecast mortality outcomes under alternative wealth redistribution scenarios versus the current defunding scenario from 2026 to 2030. FINDINGS: In comparison with the baseline ODA category, high ODA funding was associated with a 24% reduction in age-standardised all-cause mortality (rate ratio [RR] 0·76; 95% CI 0·67-0·87) and a 33% reduction in under-5 mortality (0·67; 0·50-0·89). Forecasting analyses showed that, in comparison with the current ODA funding reductions in the 59 selected low-income and lower-middle-income countries, all ten wealth redistribution policies were associated with millions of averted deaths by 2030: overall, the lowest number of averted deaths was 6 591 984 (95% uncertainty interval 4 884 075-8 374 138) for a 3% crypto tax applied to the top 10 000 holders, while the highest number of averted deaths was 29 509 934 (20 273 842-38 603 961) for a 3% wealth tax on ultra-high-net-worth individuals; in children younger than 5 years, the corresponding numbers of averted deaths were 1 312 912 (802 926-1 785 121) for a 3% crypto tax applied to the top 10 000 holders and 3 464 607 (1 235 930-5 609 331) for a 3% wealth tax on ultra-high-net-worth individuals. INTERPRETATION: The implementation of wealth redistribution policies proposed in recent high-level international agreements could mitigate the health consequences of the current ODA defunding crisis, avert millions of deaths, and support the achievement of the UN Sustainable Development Goals, particularly those related to health. FUNDING: Spanish Ministry of Science and Innovation.

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