Columbia International Affairs Online: Working Papers

CIAO DATE: 12/2011

Global Health and the New Bottom Billion: What Do Shifts in Global Poverty and the Global Disease Burden Mean for GAVI and the Global Fund?

Amanda Glassman, Denizhan Duran, Andy Sumner

October 2011

Center for Global Development


After a decade of rapid growth in average incomes, many countries have reached middle-income status. At the same time, however, poverty has not fallen so dramatically; as a result, most of the world’s poor now live in middle-income countries (MICs). In fact, up to a billion poor people—or a new bottom billion—live not in the world’s poorest countries but in MICs. As the global distribution of poverty has shifted to middle-income countries, so has the global disease burden. This paper examines the implications of this for global health efforts and recommends a tailored middle-income strategy for global health funders. The paper describes trends in the global distribution of poverty, preventable infectious diseases, and health aid response to date; revisits the rationale for health aid through agencies like GAVI and the Global Fund; and proposes a new MIC strategy and components, concluding with recommendations. Specifically, the paper recommends (1) eliminating the country income threshold as an across-the-board criterion for allocating global health funding,(2) setting up regional pooled procurement mechanisms, or negotiating a MIC public-sector price within existing procurement mechanisms, (3) building evidence-based priority-setting institutions, and (4) establishing increased accountability mechanisms to increase public spending on cost-effective, affordable health priorities.