Rethinking country classifications towards a more equitable global health future

Overview:  

Right now, the World Bank groups countries based on income (low, middle, or high) using gross national income per person. These categories influence how funding is allocated, what research gets prioritized, and how countries are perceived.  

This OHT collaborative article questions how countries are classified in global health. The authors argue that this system is outdated and misleading because income alone does not reflect a country’s real health needs, inequalities, or ability to respond to health challenges. A more nuanced, equity-focused system is essential for tackling global health challenges, including antimicrobial resistance, infectious diseases, and future pandemics.  

The Question: 
Is income a reliable way to classify countries for global health decision-making, and if not, what should replace it?  

The Findings:   

• Income doesn’t reflect reality: countries with similar income levels can have very different health systems, disease burdens, and vulnerabilities.
• Inequality is hidden: national averages mask major differences within countries, such as disparities based on gender, geography, or socioeconomic status.
• Middle-income countries are overlooked: many countries with high disease burdens (such as tuberculosis or antimicrobial resistance) lose access to funding once they move up in income classification.
• COVID-19 highlighted the problem: the pandemic showed that income level did not predict how well countries could respond; many middle-income countries struggled due to weak health systems.
• The current system misdirects resources: it can reinforce unfair donor–recipient dynamics and fail to reach the most vulnerable populations.

The authors propose moving toward a multidimensional classification system that considers disease burden; health system capacity, such as workforce, diagnostics, and infrastructure; social determinants, including poverty, inequality, environment; and vulnerability to crises such as pandemics or climate change.   

They also recommend using more detailed, subnational data to identify who actually needs support by creating better benchmarks across countries and testing how new classification systems would affect funding and equity  

Read the article in The Lancet here.