Aid eligibility in a mobile, high-velocity world


Wealthy countries need to invest every penny they can to combat global epidemics. Massive inequity in access to health care means that millions of people die each year of preventable, treatable diseases like HIV, TB and malaria. But who should be eligible for global health aid? Not so easy to answer. We’re stuck with some 20th century tools that don’t fit our high-velocity, globalizing world.

This blog is thinking aloud sparked by online and offline conversations about how donor states “transition” out of middle-income countries without losing ground in the three diseases. While they try to extricate themselves, new health threats loom: heart disease and stroke head the list of global causes of death, over 65 million people were in displacement last year, and climate change is bringing back old viruses long hidden in ice, to name a few.

Currently, health aid goes to “developing countries”. The World Bank publishes each country’s GNI per capita. The OECD uses this to classify countries as either Least Developed, Lower Middle Income, or Upper Middle Income; usually only the first two of these groups are eligible for aid. (Not all donors blindly follow the OECD list: the Global Fund combines three years of GNIpc with disease burden for their eligibility list). 

But however you make the list, it’s based on three assumptions:

  • GNIpc tells you something meaningful about what a country can do about health
  • economic development is a rational linear progression that leads to lower infectious disease burden for all, and
  • infectious diseases can be controlled within national boundaries.

These assumptions have a lot of truth in them, but they aren’t ironclad.

First, GNIpc is just one number: a reductionist way to sum up a whole economy. It does not tell you about essential things a country needs to fulfill the right to health: infrastructure, technology, refrigeration, health personnel, health insurance, political stability, health of civil society; it just says that a country has money, but not where that money is or how it’s spent.

Take the United States, a wealthy country that spends more than any other on health care, with the lousiest results. Or Venezuela, an oil-rich country whose health system is crumbling (and whose demands from PLHIV for support sparked controversy at the Global Fund, which struggled with how to respond as Venezuela is not aid-eligible).

Second, the OECD list implies a rational, linear process of economic development, with countries moving progressively from least developed at one end of the scale to upper middle income on the other (and then right up to heaven, I guess). It’s a model conceived in the 1950-60s, which development economists now roll their eyes at. Economic development is not linear. Economies boom and bust, skip stages, stagnate, collapse and renew. Countries can “graduate” out of eligibility and pop back up as re-eligible a year or two later.

Third, while sure, some countries eliminate some diseases, in a globalizing world with porous national boundaries, those wins are hard to sustain. Infectious diseases are driven not by national pride, but by an urge to multiply. They love to travel. They cross borders more swiftly than development finance, and with zero bureaucracy. They fly through migrant social networks, or puddle in forgotten corners of a country far from national capitals, straddling borders. They find a happy, thriving breeding ground anyplace where there’s stark inequity. They multiply wildly among people that national governments fail to acknowledge, let alone care for.

Europe-wide HIV transmission network: a transmission network constructed by means of selected limit values for the evolutionary distance. The nodal color shows the country of origin of the infected patients.

Euro network model HIV

Yet somehow, we are stuck with metrics that allocate funds for health to precisely those national governments who fail to care for or dedicate funding to those vulnerable to infectious diseases, and who make decisions in capitals far from where epidemics thrive.

The SDGs set global targets for all countries and promote mutual accountability. Yet some of the biggest donors to global health are backsliding at home — which thanks to globalization, will make any success they fund in least developed countries a temporary win. Why are we stuck with a neocolonial paradigm in which aid-recipient countries are expected to meet global health targets that donor countries fail to take seriously?

We need a paradigm for global health aid that aligns with the vision of the Sustainable Development Goals. We have to balance country ownership, with its related emphasis on strengthening national health systems, with the flexibility to tackle dynamic, networked infectious diseases at the community level where outbreaks take fire. One key lesson from Ebola was that where bureaucracy and politics fail, community-led responses can be powerful.

What’s the solution? Perhaps in addition to national health aid, we could have regional committees that bring together diverse experts, including from affected communities, to use some part of health aid to zoom in on where the epidemics are in real time, and swiftly direct funds to smaller institutions and community-based programs that are based where the outbreak is and can respond across borders.

It sounds nice; I don’t know if it would work in practice. But our outmoded concepts of national sovereignty just seem clunky today in the mobile, shifting landscape in which HIV, TB and malaria thrive, and in which the SDGs have directed us to start thinking outside the box.


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