Global health funders have historically focused their aid on countries with the lowest per capita incomes, on the assumption that that’s where most of world’s poor people live. In recent years, however, many large developing countries achieved rapid growth, lifting them into the ranks of the so-called middle-income countries, or MICs, even though they are still home to hundreds of millions of very poor people. Andy Sumner has called the poor people in the MICs a “new bottom billion”, as distinct from the bottom billion in poor and fragile states that Paul Collier wrote about in a popular 2007 book.
In this week’s Wonkcast, I ask Amanda Glassman, a CGD research fellow and director of our global health policy program, how global health funders should respond to the emergence of the new bottom billion. Should money that now goes to the world’s poorest countries be reallocated to reach poor people who happen to live in the new MICs? Are there other ways that the global community can help? Amanda’s answers draw on the findings of a new working paper she wrote jointly with Sumner and Denizhan Duran, and an accompanying policy brief.
I begin by asking Amanda why people in high-income countries would want to help the new bottom billion in the first place. Shouldn’t countries like China, with its trillions in foreign exchange reserves, or Nigeria, with its massive oil wealth, take care of the health needs of their own people?
“That’s the question that always comes up,” Amanda says. Many of the big middle-income countries, she says, are also vastly unequal and struggle with problems of poor governance. “If you’re concerned about people living on less than a dollar a day, then where those people are located is really relevant to deciding how you can best use your resources,” she says. About 60 percent of the world’s poor live in just five big MICS: Pakistan, India, China, Nigeria, and Indonesia, and these countries also account for a large share of the global disease burden, Amanda says.
Amanda offers four recommendations for how major health donors – mainly the GAVI Alliance and the Global Fund -- could better-target aid to poor people.
Funding agencies currently use country income thresholds as a way to decide who will get money and in what quantity. Amanda argues this is not the most effective way to reach global health goals.
“If you have certain goals in health, we think you should be allocating money based on the goal, not based on an average per-capita income threshold,” she says. For example, the Indian state of Bihar (with 82 million people) is home to a lot of very poor people who lack access to vaccinations and other basic prevention and care. “We shouldn’t just walk away and say ‘India is a middle-income country.’ Donors should figure out some new ways to work with India and improve the situation for those people in Bihar,” Amanda adds.
Besides dropping country-income thresholds as the main criteria for allocating global health funding, Amanda suggests setting up regional pooled procurement or pricing mechanisms, building evidence-based priority-setting institutions, and establishing increased accountability mechanisms. Listen to the Wonkcast, or read the brief, to hear Amanda smartly unpack each of these jargon-laden phrases!
If you have iTunes, you can subscribe to get new episodes delivered straight to your computer every week. My thanks to Alexandra Gordon and Ness Smith-Savedoff for their production assistance on the Wonkcast recording and to Alexandra Gordon for assistance in drafting this blog post.