14 Jan 2020
Updated transitions list projects 12 countries becoming ‘upper-middle-income’ by 2028

According to the Global Fund to Fight AIDS, Tuberculosis, and Malaria’s recently published Eligibility 2020 list, the list of countries and disease components currently eligible for Global Fund support, 131 countries are eligible to receive an allocation from the Global Fund during the 2020–2022 period. However, this eligibility does not automatically result in an allocation as countries still need to apply for Global Fund funding, in line with the application process for 2020–2022, as described in a recent GFO article (19 December 2019). The Global Fund also recently published the list of components projected to transition from Global Fund support by 2028.

The Global Fund allocates funding to countries for programs to fight the three epidemics (HIV, TB and malaria) once every three years, after raising funds through its three-year Replenishment cycle. Before the recent allocations announced in December 2019, the last Global Fund allocations were made in 2017, for country components eligible for funding for 2017–2019. The 2020 Eligibility list determines countries’ components eligible for funding from the Global Fund for the 2020–2022 period.

A country’s income category and disease burden are the main determinants for a country’s eligibility for a Global Fund allocation. The Global Fund relies on the World Bank’s income classification that categorizes countries into four income groups: low income (LI), lower-middle income (LMI), upper-middle income (UMI), and high income (HI). For the purposes of setting its co-financing requirement, the Global Fund subdivides the LMIs into two categories: lower and upper-LMIs.

The Global Fund also relies on the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) classification of disease burden as ‘High’ or ‘Not high’.

Disease burden classifications

According to the Global Fund Eligibility Policy, a country’s HIV burden is classified as ‘high’ when the national prevalence is one percent or more, or prevalence within a key population is five percent or more, and when a country is listed to receive support by the Organization for Economic Co-operation and Development (OECD) Development Assistance Committee (DAC). A country’s tuberculosis burden is classified as ‘high’ when the incidence rate per 100,000 people is 50 or more, or when the proportion of new TB-resistant cases is five percent or more of the identified TB cases. A country’s malaria burden is regarded as ‘high’ when the death rate from malaria is 12 people or more per 100,000 at risk of the disease, or the country contributes 0.25% or more to global malaria deaths, or the death rate is less than 12 people per 100,000 at risk of malaria and when more than 65 per 1,000 people at risk have the disease, or when there is a documented artemisinin (malaria drug) resistance in a country.

Income category changes

Regardless of the HIV, TB and malaria burden, all low-income and lower-middle income countries are eligible to receive an allocation from the Global Fund. However, the upper-middle income countries are eligible to receive the Global Fund allocation only if they have a ‘High’ burden of one of the three disease components. Also, upper-middle income countries are eligible for an allocation if the International Development Association (IDA) classifies them as ‘Small Island Economy Exceptions’. High-income- and the Group of 20 upper-middle-income countries are ineligible to receive an allocation from the Global Fund. Moreover, countries that the WHO has certified as malaria-free are ineligible for a malaria component allocation.

A comparative analysis of countries income status in the 2017 and 2020 Eligibility lists reveals that ten countries moved up while nine were downgraded in income category, as summarized in Table 1.

Table 1: Country income changes in 2017 and 2020
No Countries that moved up in income Income category in 2017 Income category in 2020
No Countries that moved up in income Income category in 2017 Income category in 2020
1 Bhutan lower-LMI upper-LMI
2 Cambodia low income lower-LMI
3 Comoros low income lower-LMI
4 Guatemala upper-LMI upper-middle income
5 Guyana upper-LMI upper-middle income
6 Kosovo upper-LMI upper-middle income
7 Moldova lower-LMI upper-LMI
8 Papua New Guinea lower-LMI upper-LMI
9 Samoa upper-LMI upper-middle income
10 Zimbabwe low income lower-LMI
1 Angola upper-middle income upper-LMI
2 Congo upper-LMI lower-LMI
3 Georgia upper-middle income upper-LMI
4 Mongolia upper-middle income upper-LMI
5 Nigeria upper-LMI lower-LMI
6 Syrian Arab Republic lower-LMI lower-LMI
7 Timor-Leste upper-LMI lower-LMI
8 Tunisia upper-middle income upper-LMI
9 Ukraine upper-LMI lower-LMI
Source: Global Fund’s 2017 and 2020 Eligibility Lists:

Newly ‘eligible’ countries

Five new upper-middle-income countries — Fiji, Nauru, North Macedonia, Russian Federation, and Venezuela — ­­­were the new additions to the 2020 Eligibility list. The new country components categorized as ‘eligible’ to receive an allocation in 2020–2022 period are Nauru’s TB, North Macedonia’s HIV, the Russian Federation’s HIV, and Venezuela’s malaria components. These components are eligible to receive an allocation following their disease burden classified as ‘high’, and after they were determined to be eligible for a second year in succession. Fiji had one determination of eligibility following the IDA re-classification of the country as a Small Island Economy.

Changes in eligibility status

Five countries’ malaria components – Egypt,  Kyrgyzstan, Syrian Arab Republic, Tajikistan, and Uzbekistan ­— are ‘not eligible’ in the 2020 Eligibility list, whereas they were ‘eligible’ in the 2017 Eligibility list. These countries have already been determined as malaria-free. Armenia’s HIV, Guyana’s malaria, Kosovo’s HIV and TB, and Guatemala’s malaria and TB components moved from ‘eligible’ in the 2017 Eligibility list to ‘transition’ in the 2020 Eligibility list for two reasons. First, their related disease burdens are ‘Not high’, and second, all these countries, except Armenia, grew economically, with their income status moving from upper-LMI to upper-middle income.

Inversely, some countries’ disease components that were transitioning are now once again ‘eligible’, indicating a worsening of those countries’ economies. These are: Cuba’s HIV, Iraq’s TB, Surinam’s TB and Turkmenistan’s TB components. Similarly, Ecuador’s malaria, Jordan’s TB, and Tunisia’s TB components changed from ‘not eligible’ in 2017 to ‘eligible’ in 2020. This was due to the increase in malaria and TB burden in Ecuador and Jordan, respectively. However, in Tunisia the change results from a downgrade from upper-middle income to upper-lower middle income. Such reverse movement calls into question these countries’ (other than Tunisia) preparedness for transition. (See GFO article about this discussion after the Global Fund's 42nd Board meeting in November 2019.)

Transition from Global Fund support

The Global Fund’s Sustainability, Transition and Co-financing policy aims to encourage countries to progressively move away from reliance on donor funding to greater levels of domestic financing of their health programs. A country or disease component may transition from Global Fund support if it meets one of three possible scenarios: a country of its volition declines the Global Fund’s support, when the disease component is ‘ineligible’ based on the Global Fund’s Eligibility Policy, or after a country receives the final allocation from the Global Fund.

All countries that were eligible for an allocation for the 2017–2019 period were included in the 2020 list except Albania, Palau, and Panama. Albania’s HIV and TB components were allocated Transition Funding during the 2017–2019 period following the country’s upgrade to upper-middle-income status in 2015. Similarly, both Palau and Panama are upper-middle income countries with low burdens of HIV, TB, and malaria.

According to the updated projected transition list, two main transition pathways exist for countries to move away from Global Fund funding: a lower-middle income country with a ‘not high’ disease burden moves to upper-middle income status, or an upper-middle income country with any disease burden moves to high-income status.

The Global Fund projects that a total of 17 disease components from 12 lower-middle income countries will move to upper middle-income status by 2028. These countries and disease components are as follows:

Table 2: Lower-middle income countries projected to move to upper-middle income status with
‘Not high’ disease burden
No Country Disease components
Moved to upper-middle income status in 2018 – 2020 and eligible for Transition Funding in 2020 – 2022
1 Armenia HIV
2 Guatemala TB and malaria
3 Guyana Malaria
4 Kosovo HIV and TB
Projected to move to upper-middle income status in 2020 – 2022 and eligible for Transition Funding in 2023 – 2025
1 Bolivia Malaria
2 Eswatini Malaria
3 Philippines Malaria
4 Sri Lanka HIV
Projected to move to upper-middle income status in 2023 – 2025 and eligible for Transition Funding in 2026 – 2028
1 Bhutan HIV and malaria
2 Cabo Verde HIV, TB and malaria
3 Egypt TB and malaria
Source: Global Fund’s list of components for transition by 2028:


Similarly, the Global Fund projects that 16 disease components from 11 upper-middle income countries will move to high income by 2028. These countries and disease components are as follows:

Table 3: Upper-middle income countries projected to move to high income status
No Country Disease components
Ineligible for allocation in 2020–2022
1 Costa Rica HIV
2 Malaysia HIV
3 Mauritius HIV
Ineligible in 2023–2025
1 Dominica HIV and TB
2 Grenada HIV and TB
3 Guyana HIV and TB
Ineligible in 2026–2028
1 Dominican Republic HIV
2 Gabon TB 
3 Kazakhstan HIV and TB
4 Lebanon HIV
5 St. Vincent & the Grenadines HIV and TB
Source: Global Fund’s list of components for transition by 2028

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