globalHealthAndEconomyIn the recent past, much of the world's poverty was concentrated in low-income countries (LIC). However, as incomes around the world have increased, the distribution of poverty has shifted. In 1990, over 90 percent of the world's poor lived in LIC. A recent paper by Andy Sumner finds that as much as 70 percent of the world's poor now live in middle-income countries (MIC), a "new bottom billion". Over the last 15 years, many countries have moved up the income distribution to middle-income status, including China in 1999, Indonesia in 2003, and India in 2007. As more and more countries graduate from low-income status, they bring with them much of the world's poor, and often leave behind the attention of international donors.

MIC are also home to the majority of the global disease burden, along with the world's poor. Information from the World Health Organization's Global Disease Burden Database shows that MIC account for over a billion disability-adjusted life years of global disease burden, compared to 200 million in LIC. Similar trends are apparent in the distribution of the burden of women's ill-health. India and Indonesia for example have maternal morality ratios of 230 and 240 per 100,000 live births respectively. These numbers add up, considering India and Indonesia have a combined population of nearly one and a half billion as of 2010.

Yet, in spite of the concentration of poverty and disease in MIC, global health agencies continue to focus on LIC in their policies and funding allocations. In 2009, the majority of global health aid was directed to LIC, with less than 40 percent of funding directed at MIC.

In some ways, this distribution makes sense. MIC, in principle, should have enhanced capacity to spend on health that LIC simply do not. However, MIC tax yields remain low as a share of GDP, and these countries spend a smaller share of their national budgets on health compared to LIC. Public spending in lower MIC is only slightly more per capita than in LIC. Further, and most important, the most basic, cost-effective preventive public health services–like vaccines, oral rehydration therapy and deworming–are not at scale.

This trend is influenced by several factors, including (i) difficulty in redistributing wealth through high marginal tax rates on the 'wealthy' (those who earn over $13 per day), (ii) lack of budgetary priority-setting mechanisms to balance preventive public health efforts with clinical, curative interventions, and (iii) political pressures that make investments in prevention and public health unpopular—among others.

So what are the best strategies to support women's health issues in MIC? There are four key areas for leveraging better results, and most have little to do with new donor funding.

The first is to develop tailored assistance strategies for the large lower MIC countries and to eliminate the use of income per capita measures as a hard rule to allocate resources. While not all women's health issues are concentrated in MIC, the burden of disease attributable to lack of contraception, for example, is concentrated in Pakistan, India, China, Nigeria and Indonesia. Yet the obstacles to adequate coverage of contraceptive services with quality of care and attention to human rights are heterogeneous, and not only financial. Projects like the Urban Reproductive Health Initiative have rightly identified that the bulk of unmet need for contraception is in urban areas in the populous lower MIC, and have accompanied their efforts with in-depth measurement, learning and evaluation activities, which will allow for carefully tailored and more effective approaches to scale up. Similar efforts should be undertaken for maternal health and cancers affecting women.

Second, attention should be paid to pricing and procurement strategies for essential women's health products. MIC can set up regional procurement schemes to buy in bulk or negotiate with global health funders or manufacturers to secure lower MIC public sector prices. In many MIC, particularly large countries such as China and India, there are

enormous inequalities in health status and income across states and provinces, and health care markets serving the poor and the wealthy are totally segmented. Providing market data and illustrating segmentation can encourage pharmaceutical companies to use differentiated pricing within country markets, creating the conditions for lower prices in markets that serve the poor.

Priority-setting institutions are the third category of interventions. Such institutions can provide support to public sector budget decision-making processes by identifying cost-effective interventions and assuring their inclusion among publicly funded health benefits via insurance or public provision. Effective priority-setting institutions can help ensure that adequate funding is allocated to maternal care and cervical cancer screening, among others.

The final aspect of the MIC agenda relates to improved accountability mechanisms. Measuring public spending and performance, as well as creating constituencies for increased coverage of highly cost-effective women's health care, can create reputational incentives for better health results in MIC. Further, aid instruments themselves can be used to create positive incentives for improving health, such as conditioning aid against independently measured improvements in safe maternity care coverage, for example.

Overall, the landscape of global disease burden has changed. Country governments and global donors alike will need to readjust their outlook to effectively address and alleviate global disease burden, looking beyond average income to the health goals to be met.