Faulty middle-income country classification hurting donor-dependent health systems across Africa

Erroneous middle-income country classification by the World Bank is causing unintended healthcare consequences across Africa, with low-income nations facing gradual reductions in foreign aid and higher prices for essential life-saving medicines, according to officials.

Healthcare stakeholders are concerned that governments are poorly managing the transitions as multilateral donors scale down or terminate operations in the newly upgraded middle-income countries.

The mismanagement is slowly reversing gains made in the healthcare sector, particularly in the fight against killer diseases like HIV and AIDS, tuberculosis (TB) and malaria. In Kenya, health facilities are running out of key vaccines, exposing infants, pregnant women and other vulnerable populations to health risks.

The east African country is currently experiencing a shortage of at least five essential donor-funded vaccines for newborns, including the polio vaccine (oral and inactivated) and the Bacillus Calmette-Guerin vaccine for tuberculosis. The others include measles-rubella, rotavirus, tetanus, diphtheria and pentavalent.

During a session with the parliament, Kenya health ministry’s principal secretary for public health, Mary Muthoni, acknowledged the shortage of supplies largely from GAVI / the Vaccine Alliance and the United Nations Children’s Fund (Unicef), among other multilateral sponsors.

She highlighted the World Bank’s decade-long reclassification of Kenya as a middle-income country and urged the national assembly and the national treasury to budget for the funding of the programmes.

“There has been a steady reduction in donor funding for these programmes and this calls for the need to increase the Government of Kenya counterpart funding to offset the deficit, especially for these medical commodities that are critically needed,” Muthoni told the parliament.

Like most countries in Africa, Kenya heavily relies on donor funding to manage and control deadly diseases like HIV / AIDS, TB and malaria. Some of the key funders of these programmes include the Global Fund, Gavi / the Vaccine Alliance, the United Kingdom government and the United States government (the President’s Emergency Plan for AIDS Relief and USAID).

To stay focused on the poorest countries, multilateral donors like Gavi and the Global Fund have implemented transition policies that gradually phase out support after countries’ gross national income per capita surpasses a set threshold.

Besides immunisation programmes, other donor-dependent programmes that are almost coming to an end include TB, family planning and HIV / AIDS. Kenya has been receiving HIV testing kits and antiretroviral (ARV) drugs from Global Fund.

Meanwhile, cases of shortages in family planning devices like condoms have also been reported recently in Kenya, with a possible increase in unwanted pregnancies and sexually transmitted infections.

Despite efforts by the Ministry of Health officials to allay fears of an impending crisis, experts and stakeholders argued that shrinking donor funding is likely to paralyse healthcare and increase infections and fatalities.

The Ministry of Health said in a statement that it’s working on reducing donor dependency, establishing mechanisms for transitioning from multilateral donor support and exploring sustainable domestic financing options.

According to key stakeholders like health professionals, Kenya has made significant progress in the control and management of deadly diseases, but more work needs to be done to protect the burgeoning population.

The country reported around five million malaria cases and over 12,000 deaths in 2022, according to the World Health Organization (WHO). With almost 40 per cent of the country’s population living below the poverty line, it’s erroneous to classify it as middle-income. In addition, Kenya still has a relatively high HIV epidemic compared to other countries.  

Various organisations have expressed concerns about the shortage of vaccines in Kenya, warning of the dire implications, especially for children living in refugee camps in northern Kenya and adjacent countries like Somalia and Sudan. 

Officials from various organisations, including the International Rescue Committee (IRC), CORE Group Partners, Health NGO Network and WHO are urging the Kenyan governments to take urgent action to end the shortage.

“The Government of Kenya must move with speed and save children from outbreak of preventable diseases, which might result in lifelong disabilities or death. Previous outbreaks of vaccine-preventable ailments like polio and measles in Somalia, Ethiopia and Sudan highlight the urgent need for swift intervention,” said Brigid Waliuba, IRC technical coordinator for health.

Experts argued that the World Bank, whose mission is to end extreme poverty worldwide and boost shared prosperity, has often erroneously reclassified low-income countries as lower-middle-income countries.

At the inception of income classification in 1987, 30 per cent of reporting countries were classified as low-income, while three decades later in 2022, only 12 per cent fell in this category.  

The extent of this drastic decline varied from region to region, with sub-Saharan Africa’s proportion of low-income countries sharply falling from 74 per cent to 46 per cent in 2022, as economies moved to higher categories over this period.

The World Bank classification also threatens the rights to affordable healthcare in Kenya and across Africa, said the regional director of International Treatment Preparedness Coalition (East Africa), Rose Kaberia. 

“We are asking the World Bank to conduct an urgent review of how they categorize countries and ensure that country designations factor in disease burdens, such as HIV / AIDS and poverty levels,” said Kaberia.

She said shrinking donor funding will slowly but surely reverse progress made in controlling deadly diseases like HIV / AIDS at a time when Kenya is being hailed as a success story in the prevention of certain ailments.

The reality of the impending crises is yet to be appreciated, considering in the 2024 / 25 budget estimates for Kenya, the National Treasury has not allocated funds for HIV, family planning and vaccine commodities. This is despite the Ministry of Health’s request for Sh14.1 billion to cover these critical needs.