After a decade of rapid growth in average incomes, many countries have reached middle-income status. At the same time, however, poverty has not fallen so dramatically; as a result, most of the world’s poor now live in middle-income countries (MICs). In fact, up to a billion poor people—or a new bottom billion—live not in the world’s poorest countries but in MICs. As the global distribution of poverty has shifted to middle-income countries, so has the global disease burden.
This paper examines the implications of this for global health efforts and recommends a tailored middle-income strategy for global health funders. The paper describes trends in the global distribution of poverty, preventable infectious diseases, and health aid response to date; revisits the rationale for health aid through agencies like GAVI and the Global Fund; and proposes a new MIC strategy and components, concluding with recommendations.
Specifically, the paper recommends (1) eliminating the country income threshold as an across-the-board criterion for allocating global health funding,(2) setting up regional pooled procurement mechanisms, or negotiating a MIC public-sector price within existing procurement mechanisms, (3) building evidence-based priority-setting institutions, and (4) establishing increased accountability mechanisms to increase public spending on cost-effective, affordable health priorities.