Making Global Institutions Work by Kate Brennan

Author:Kate Brennan [Brennan, Kate]
Language: eng
Format: epub
ISBN: 9781317629610
Google: yY6QBAAAQBAJ
Goodreads: 28024462
Publisher: Routledge
Published: 2013-08-12T00:00:00+00:00

6 Global health and the new bottom billion

What do shifts in global poverty and the global disease burden mean for GAVI and the Global Fund?1

Amanda Glassman, Denizhan Duran and Andy Sumner

• The global distribution of poverty and disease

• Aid, health aid and MICs: why are we providing health aid in the first place?

• Components of a MIC strategy

• Conclusions

Up to a billion poor people, or a “new bottom billion,” now live not in the world’s poorest countries, but in middle-income countries (MICs). Not only has the global distribution of poverty shifted to MICs, but so too has the global disease burden. If we want to make global institutions work for the people who need them most, then we need to direct our attention to MICs, and the implications of this demographic shift for global health institutions.

Global health funders have even perhaps accentuated these patterns by having favored low-income countries (LICs) in their funding allocations: in 2009, 46 percent of total health aid from Development Assistance Committee (DAC) donors went to LICs, and 39 percent went to lower middle-income countries (LMICs). More strikingly, the world’s largest multilateral global health funding institutions, GAVI and the Global Fund, have set up eligibility thresholds that limit access to funding by many MICs with high disease burdens. GAVI only supports countries with a gross national income (GNI) per capita below US$1,520, which has resulted in many countries losing support. In 2000, 72 countries were eligible for GAVI support; today, 57 countries are, and only 42 countries will be eligible for support by 2020, representing half of the current eligible population. Similarly, the Global Fund has increasingly been limiting access to funding by MICs.

The decision to target most funding to LICs is based on the idea that MICs have the fiscal capacity to spend enough on health, yet prospects for large increases or reallocation in public spending on health are modest, and in many new MICs the marginal tax rates to refocus funding to health would have to be much higher. Inequality in new LMICs is a huge problem, and LMIC governments are, on average, spending $15 per capita on health. This presents the challenge for many LMICs to absorb further health investment without substantial reallocation or external financing.

This chapter examines the implications of this “new bottom billion”— the fact that up to a billion of the world’s poorest people now live in MICs—for global health efforts and recommends a tailored middle-income strategy for the Global Fund and GAVI. The chapter describes trends in the global distribution of poverty, preventable infectious diseases, and health aid response to date, revisits the rationale for health aid through institutions like GAVI and the Global Fund, and proposes a new MIC strategy and components, concluding with recommendations.

The global distribution of poverty and disease

The global distribution of world poverty

Data presented by Sumner, and Kanbur and Sumner demonstrate that there has been a change in the global distribution of poverty from LICs to MICs.2 In 1990, 93 percent of the world’s poor lived in LICs.

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