From the perspective of the Global Fund, the main takeaway from the final report of the Equitable Access Initiative (EAI) is that decisions on eligibility and prioritization of resources should be based on more than just income level and disease burden. The EAI recommends that a multi-criteria framework be used instead.
The report of the EAI is dated 30 June 2016 but it was not released by the Global Fund until 12 December 2016.
For two decades, the World Bank has classified countries as low-, middle- or high-income based on gross national income (GNI) per capita. GNI has been an important factor in determining the eligibility of countries for development aid. But in recent years, the report said, it has become obvious that relying on the GNI classification has serious limitations.
In the last decade, rapid economic growth has hastened the move from low-income to middle-income status for many countries. In the process, these countries risked losing external support even though they are still home to most of the world’s poorest citizens with unmet health needs.
The EAI was launched in early 2015 by the heads of multilateral organizations engaged in global health: Gavi, the Global Fund, UNAIDS, UNDP, UNFPA, UNICEF, UNITAID, the World Bank, and the WHO. The purpose was to consider alternatives to GNI as a framework to assess countries’ need for external financial support for health.
According to the report, the 105 countries currently considered middle-income are home to more than 75% of the world’s poor, and many of them are characterized by high-levels of inequity. From a global health perspective, the largest share of disease burden is now concentrated in middle-income rather than low-income countries, a reality that GNI per capita alone cannot capture.
The report points out that the recently adopted Sustainable Development Goals (SDGs) call for achieving ambitious development and health goals with an explicit focus on equity, especially among poor and vulnerable populations. One of the unique features of the SDGs, the report said, is in their relevance for all countries regardless of economic standing. But, the report said,
“there is also a renewed commitment to ‘shared responsibility’ in investing toward a more equitable and egalitarian world, and achieving these goals through a human-rights based approach that is rooted in giving all people the opportunity to achieve their right to life and dignity. For external health financing this could mean a greater focus on the social determinants of health, reducing health disparities and the rights of vulnerable groups and key populations.”
The EAI concluded that policymakers should consider a comprehensive framework for decision-making “that accounts for countries’ position on a health development continuum, based on the analysis of countries’ needs, fiscal capacity, and policies.”
More specifically, the EAI study produced the following key findings:
- Eligibility – Policies should not only consider the level of wealth in a society, as measured by GNI per capita, but also account for health need relative to income.
- Investment priorities – A government’s resources and policies to meet its country’s health need should be taken into account.
- Equity – Context-specific analyses are relevant when assessing the level and type of support to be provided.
The Global Fund currently relies heavily on income level and disease burden to determine its policies on eligibility and to arrive at decisions on allocations to countries.
The EAI said that the weight accorded to income level in decisions about eligibility and prioritization overlooked key considerations such as (a) large variations in the distribution of disease; (b) poverty and inequality within countries; (c) the capacity of the health systems within countries; (d) the capacity of governments; and (e) governments’ policy choices towards their citizens.
According to the EAI, another concern is that the income categories themselves are too broad and consist of countries that are sometimes at very different points along the development continuum. The middle-income country category currently ranges from GNI per capita levels of $1,045 to $12,736. Middle-income countries collectively account for the largest global share of poverty and disease, and they have varying levels of development, inequity, political stability, and social issues.
“A framework not purely based on income may be better suited to ease transitions, and identify suitable health interventions,” the EAI said.
The EAI commissioned four expert analytical groups to independently explore the issue. Although their approaches differed, there were significant points of convergence in their recommendations, including (a) the use of disease metrics to capture health need; (b) accounting for inequity in income and health; and (c) accounting for a government’s capacity to domestically finance health. The groups proposed different models. However, the EAI said, all four models provided relatively similar results, “which suggests that health needs and capacities may be captured by a variety of indicators.”
In its report, the EAI described possible indicators and explored the approaches recommended by the four groups. However, the EAI did not recommend a specific framework. A news release issued by the Global Fund implied that the entire EAI report constituted a new policy framework.
The EAI said that although any classification framework depends on both the choice of underlying metric, and the choice of thresholds to group countries along common characteristics, recommending specific thresholds or grouping of counties was beyond the scope of its initiative. It said that the EAI “did not analyze the impacts of discrete funding thresholds on beneficiary country health outcomes, nor did it directly address the types of policies that might be appropriate to mitigate the impacts of eligibility transition.”
The EAI also said that while its work attempted to include inequity measures, the poor quality and the unreliability of the relevant data prevented their inclusion in the overall analysis. “A better understanding of inequity, particularly in health access and outcomes, would require more detailed sub-national analyses and to account for legal and social barriers, for which there is often no regular and reliable data collection,” the EAI said.
Finally, the EAI said that although the analysis and recommendations of its report are specific to health, the fundamental approach and characteristics could have relevance for other areas of development.
The EAI report comes too late to influence in a major way the methodology used to determine the Global Fund’s 2017-2019 allocations. Countries were told last week what their allocations are.