If you ask the proverbial ‘man on the street’ where the greatest health needs in the world are, most will think of the poorest countries. Economists and politicians who allocate development funding for health do the same. But they are wrong. It may surprise you that over half Médecins Sans Frontières (MSF)’s medical programmes are in countries currently labelled as ‘middle income’. The health needs we see there are real and desperate. But in a changing world, the international system used to categorise a population’s health needs according to their country income is no longer fit for purpose. It is certainly no basis on which to allocate health funding or to set the prices for lifesaving drugs and vaccines.
Health was at the core of the Millenium Development Goals (MDGs) and important progress was made to fight ill health and save lives. In the current Sustainable Development Goals framework that will cover the period 2015 2030, health has been relegated to only one of 17 goals. In a harsh competition for a stagnating aid envelope, health and other social sectors are likely to lose out. Considering the unfinished business of the health MDGs and major health challenges still facing many countries, health should remain high on the priority list in the development funding discussions. Credit: Médecins Sans Frontières (MSF)/Doctors Without Borders
This week, the great and the good of the international aid community gathered in Addis Ababa to discuss financing for development (FfD), including for the successors to the Millennium Development Goals. The ‘Sustainable Development Goals’, which will set global development priorities and funding for the next fifteen years, must be based on the reality of the world we live in, if they are to work: health needs rather than Gross National Income (GNI) per capita.
Given the current trend in discussions around development aid, countries will need to grapple with stagnating or shrinking Official Development Assistance to cover a wider array of sectors and objectives. An unhealthy competition between sectors and even within the health arena could ensue, with health priorities pitted against one another. Credit: Médecins Sans Frontières (MSF)/Doctors Without Borders
To start with, the highest disease burdens for maternal and child health; the three major killer infectious diseases HIV/AIDS, tuberculosis and malaria; and non-communicable diseases, are in countries classified as middle income. These countries, home to over 70% of the world’s poor and sick, find themselves on the wrong side of a statistical threshold. Yes, India may have more billionaires than the UK, but it also has the greatest number of malnourished children on the planet. Any system that groups China and the Republic of Congo in the same category needs to be looked at again.
In many countries, civil society groups play a critical role in health care delivery through direct service provision, voicing peoples concerns and needs, monitoring service quality and access, demanding better services and rights to their countrys institutions and authorities, standing by vulnerable and marginalized people. Today international funding dwindles and is increasingly funnelled through and towards central authorities and government systems, with the prime aim to build the capacity of the state and its systems. Without support, the capacity of civil society and community-based associations will decrease, despite their key role in reaching and protecting health gains. Credit: Médecins Sans Frontières (MSF)/Doctors Without Borders
Donors would have us believe that economic growth automatically translates into a reduced need for development aid for health. The reality is sadly different. Growing global health inequality demonstrates that a slight increase in national income has no bearing on the number of poor and sick, nor the accessibility or quality of health services available to them. It takes time to transform new revenues into larger health expenditure.
Effective strategies to improve peoples lives and health cannot be captured by political concepts and economic modelling only. They need to be rooted in and fed by the reality at clinic and population level. The discussions at the Financing for Development (FfD) conference in Addis and later about Sustainable Development Goals (SDGs) in New York should come up with more than new concepts and terms. Theoretic concepts- however lofty- will fail to make a difference without a critical reality check. Credit: Médecins Sans Frontières (MSF)/Doctors Without Borders
There has been a reduced interest of donors in global health solidarity over recent years.. Even impactful global health initiatives, such as the Gavi, the Vaccine Alliance, and the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), have not been spared.. For example the latter has seen GNI imposed as a criterion for eligibility, and for determining the size of allocation to countries, with interventions for recipient communities in middle income countries at risk of being cut off. Health needs and diseases are not bound by either country borders or income classification. Yet, aid allocation differs greatly according to the income status of a country, with middle-income countries assumed to be less in need of official development assistance, including for health. To make up for the shortfall, user fees and increased out-of-pocket payments policies are in some cases reintroduced by governments, despite being proven barriers of access to healthcare. Credit: Médecins Sans Frontières (MSF)/Doctors Without Borders
Frequently glossed over are the additional knock-on consequences of middle-income classification. Promotion to this ‘club’ imposes more stringent international funding restrictions, with an increase in loans and decrease in grants. It results in tighter trade and intellectual property regulations with de facto limitation on access to cheaper drugs, vaccines, medical devices and commodities. In other words, arbitrary economic classification might lead to more costly national health care bills even in countries with improved health expenditure per capita. This will translate in more health gaps that organisations such as MSF are increasingly solicited to fill.
Health needs and diseases are not bound by either country borders or income classification. Yet, aid allocation differs greatly according to the income status of a country, with middle-income countries assumed to be less in need of official development assistance, including for health. To make up for the shortfall, user fees and increased out-of-pocket payments policies are in some cases reintroduced by governments, despite being proven barriers of access to healthcare. Credit: Médecins Sans Frontières (MSF)/Doctors Without Borders
In the majority of middle income countries, health systems do not yet make sure that the poorest and most marginalised groups have access to vital care and the withdrawal of donor support, , can result in the health funding gap mostly affecting those who need it most. Years of experience have demonstrated to us at MSF that charging patients for basic healthcare causes direct harm, can further impoverish households, and lead to the exclusion of the most needy from essential care. Yet despite being totally contradictory to universal health coverage – central to the soon to be approved SDG health goal – as donor support shrinks, such fees are now being discussed in the corridors of African Ministries of Health. The highly volatile intermediary transition period for countries moving up the economy ladder and changing category is too often grossly disregarded by economists and politicians who allocate development funding, with their focus primarily set on the long-term (system strengthening, resilience, etc.). Access to health care and people’s health will be affected if immediate existing needs are overlooked. Credit: Médecins Sans Frontières (MSF)/Doctors Without Borders
Tragically, instead of reviewing the current aid allocation logic and truly assessing health needs in countries, herds of consultants are brought in to tinker with sub-categories, move thresholds and adapt aid allocation formulas. Additional labels such as LDCs (Least Developed Countries) and FCS (Fragile and Conflict-affected states) are called to the rescue, adding exceptions to a fundamentally faulty approach, and rendering everything more complex.
Development priorities for the next 15 years and beyond must be based on the reality of the world we live in. This requires looking at poverty and health needs rather than simply Gross National Income (GNI) per capita, which often does not reflect the reality for people on the ground. Only small increase in GNI can change a classification upward and is often based on overoptimistic economic modelling, discarding economic fluctuations, setbacks and limitations in public health expenditure. Countries that graduate as Middle Income Country cant automatically and swiftly translate new revenues into health expenditures.
A more radical overhaul of the underlying approach is required, including a real-time assessment of a population’s health needs. Many serious and expensive public health crises, for example increasingly high rates of multi-drug resistant tuberculosis, currently occur in countries which, while in the middle income bracket cannot yet cope with the financial cost that these diseases impose. Without international support these countries are even less likely to meet international health targets and bring the diseases under control. In short, development aid medicine will not work if the prescription is based on a faulty diagnosis.
In recent years, the convergence of the financial crisis and a reduction in Official Development Assistance including for health, with a higher number of countries moving to middle income status, has conveniently placed the assumption of middle-income countries or MICs ability to swiftly and automatically meet the needs of their population on their own at the centre of the post-2015 development agenda and forthcoming Sustainable Development Goals (SDGs).The present predominant use of country income (Gross National Income or GNI) by donors to define aid allocation, including for health, is not fit for purpose and potentially damaging since it isnt based on the population needs, fails to reflect inequality, disease profile or access to health care. It is also delusional to think that one policy can fit all given the glaring diversities between countries falling into the macro-economic categories. The group includes Middle income countries as diverse as China, Mauritania, India or the Republic of Congo. Also the major differences within countries are hidden by using a countrys average GNI per capita.The funds allocated to health through the Development Assistance for Health (DAH) and some key Global Health Initiatives such as the Global Fund to fight Aids, Tuberculosis and Malaria (GFATM) or Gavi, the Vaccination Alliance, are starting to bear the brunt of the division of the stagnating aid envelope, affecting their capacity to fulfil their mandate in saving lives and combatting main diseases. In particular, restrictions to eligibility and level of funding based on countrys average GNI per capita are problematic. Global health Initiatives are meant to tackle disease and health needs globally, where ever the ill people are.The majority (over 70%) of the worlds poorest now reside in Middle Income Countries (MICs) which also face the highest the global burden of disease on the planet, including three of the main killer diseases (HIV/Aids, tuberculosis and malaria). MICs frequently fact a triple burden of disease: The communicable and non-communicable diseases, as well as the global health threats. Despite improved income, many Middle Income Countries are still not able to take on the huge burden of these health risks on their own.After the 2008 financial crisis, there has been a clear re-emergence of policies or donor trends favouring allocations that can give better “return of investments”, such as more loans compared to grants. There is an increasing commodification of health, linked to trade. Health services, medical supplies and medicines are seen as commodities and markets from which you can extract profit, impacting access. More and more, people using health services are seen as consumers rather than patients. Economic logic does not prioritise the needs of the most vulnerable or those who need health care most.Graduation to become a middle income country might bring extra headaches for ministries of health. Market logic gains importance, also in health. Health services, medical supplies and medicines have to be procured at higher costs. Tighter trade regulations apply with states put under economic and political pressure (from richer countries, donors, and pharmaceutical companies alike). This is especially true for countries upgraded to Middle Income Country status. Additionally, these countries face a significant reduction in international aid regardless the outstanding needs. This double negative effect creates gaps in health care. Often NGOs including MSF are asked to step in to help to fill the gaps.Equity is becoming central in development discussions, which is a welcomed trend. But equity cant be limited to equal distribution and be blind to the actual needs. Inequity cannot be captured only through the lense of the country you are in. Real equity is assistance according to needs, where ever you are.
