Distributing global health financing fairly
From one perspective, what should matter to development assistance is ‘poor people’, irrespective of their geographic location (10). Accordingly, middle-income countries should be eligible for development assistance for health (10–12). Further, the classification itself has been criticised as the threshold is somewhat arbitrary (12–14); countries above or below the same threshold differ widely with respect to health needs and the capacity to address them (9, 10).
On the other hand, obtaining middle-income status reflects a country’s increasing internal capacity to respond to its health needs, in some cases entirely without external support. The financing gaps are thus likely to be greater for low-income countries (13). Recent estimates from the World Health Organization support a view that the poorest countries are in most need of external health financing (15). The study estimated the additional investments needed to achieve the health-related sustainable development targets in low- and middle-income countries, and identified large financing gaps.
Many countries will depend on continued external financial support to strengthen their health systems. Particularly, fragile and conflict-ridden states with weak health and welfare institutions will continue to need development assistance for health (15). Further, the study argued that middle-income countries are ‘well equipped to self-finance the investment’, and that the largest financing gaps are in low-income countries (15), indicating that development assistance for health should primarily be directed to these countries.
Despite gaps in healthcare financing, most countries have the capacity to increase investments in health systems (15). Spending on health care is predicted to progress faster in upper-middle-income countries, while health spending in low-income countries is estimated to remain low (16).
This is an additional argument for giving more priority to low-income countries. Even if they experience economic growth, many are far from spending the recommended 5 % of gross domestic product on health care (17). However, middle-income countries may have difficulties in the short term in mobilizing resources to replace recent bilateral, multilateral and philanthropic support. It is therefore crucial to consider potential harms induced by shifting resources away from middle-income countries.
Views diverge about whether middle-income countries, due to their share of the world’s poorest populations, should continue to be eligible for development assistance for health. Scholars have proposed that middle-income countries should not be automatically excluded from development assistance for health per se, but that each country must be considered on a case-by-case basis, given their heterogeneity (10, 11, 13).
More recently, efforts have been made to systematically assess criteria guiding the allocation of development assistance for health. Two overarching criteria for distribution have been suggested (13, 18): ‘need’ and ‘effectiveness’. The ‘need’ criterion prescribes that development assistance for health (or aid more generally) should be allocated to countries with the greatest need. This could be measured using a range of indicators, including gross national income per capita, under-five mortality rate, the burden of disease, or income inequality.
The ‘effectiveness’ criterion prescribes that aid should be allocated to countries where the development gains, such as improvements in health, are likely to be the greatest. A simulation of the implications of eleven criteria identified that low-income countries would receive most development assistance for health given a needs-based approach linked to domestic capacity to address health needs (9). Upper-middle-income countries would receive a greater share of development assistance for health if an income-inequality criterion was given greater weight (9).
Depending on countries’ ability to pay, as measured by gross national income per capita, should we ask whether middle-income countries ought also to contribute to financing global health (13). Some of these countries, such as China, India, and South Africa, have for some time provided aid to other countries (19). These and other countries can play a significant role in the efforts to strengthen financing of health challenges, particularly those that require global collective action.