The shifting sands of health

This guest blog was written by Jim Calverley, Parliamentary Advocacy Officer (Child Health) at RESULTS UK

Kenya is one of many developing countries that has recently graduated from being a low income country (LIC) to a lower middle income country (LMIC). This should be a good thing – middle income countries are the engines of global growth and in sub-Saharan Africa in particular, economic growth is to be welcomed given that the African continent accounts for such a small proportion of the world’s imports/exports. But does the marginal economic growth from a low to a middle income country always translate into better health outcomes for the population?  Given that the highest disease burdens for child health and infectious diseases are in countries that are classified as middle income suggests not.

Photo credit: Jonathan Torgovnik/Getty Reportage

Photo credit: Jonathan Torgovnik/Getty Reportage

The line in the sand that separates the world’s low income countries from middle income status according to the World Bank falls between GNI per capita of US$1,026 to $12,475 – an overview can be viewed here. This is not the place to discuss the appropriateness of that line in the sand – both in terms of the level at which it is set and the effectiveness of using Gross National Income (GNI) in isolation as an indicator of population wealth. Nor is it the place to discuss whether just under $3 per day (the equivalent of $1,026 per annum) qualifies as being anything other than a very small amount of money.

However, what is indisputable is that the figures used by the World Bank are derived from averages: in any number of middle-income countries, there will be a significant proportion of the population that earns less than just under $3 per day (along with a small proportion that earn a huge amount more). Those averages mask huge inequalities within countries and those who are most in need. Upon graduation, the poorest people in the population do not miraculously get pushed over the line in the sand. Similarly, where there has been a gap in finances for health services in a country, that gap does not vanish on the basis that the country has graduated to MIC status. Kenya’s graduation will have future implications for the overseas development assistance (ODA) that it receives. Firstly, it is an unfortunate fact that donors are less willing to provide development assistance to MICs; irrespective of the clear health needs in these countries. Secondly, Kenya’s share of its co-financing responsibilities with Gavi will now increase by 15% per year (and 20% per year when GNI per capita goes above $1,580), which will put significant strain on health budgets. The co-financing structure can be viewed here.

RESULTS UK estimates that 45% of health services in Kenya are financed by overseas aid. Unless there is a very significant shift in priorities in Kenya, that finance gap is not going to narrow any time soon. It is the aim of all developing countries that they be self-reliant. President Kenyatta himself has in no uncertain terms identified that Kenya needs to develop its own resources to help it stand on its own two feet. However, Kenya and countries like it should be wary of the potential health precipice on which they may find themselves given that huge gaps in health financing prevail which will require both increases in domestic resource mobilisation (DRM) and ODA. ODA must remain an essential component of health financing and the challenge is to balance this with the development of DRM.  To do otherwise risks a different line in the sand being drawn: one which prevents swathes of the population from accessing basic healthcare.

For a more detailed analysis of the issues in this blog, you can read RESULTS UK’s new report called ‘Who Pays for Progress?’ here.