Should middle-income countries receive international aid to improve their health systems? This question is currently the subject of considerable debate, and there is no simple answer. On the one hand, health is closely related to both equity and poverty; a population’s access to health is largely dependent on economic, political, ethical and social factors. On the other hand, international aid often comes into conflict with a country’s sovereignty and internal policies.

Why the countries that have succeeded in increasing their wealth in recent decades are home to more poor people rather than before?

In recent decades, the burden of world poverty has shifted to middle-income countries, which are now home to three-quarters of the poor people in the world. The other quarter live in low-income countries, particularly sub-Saharan Africa. This means that around 50% of the poor people in the world live in China and India, which are both classified as middle-income countries. The obvious question is why the countries that have succeeded in increasing their wealth in recent decades are home to more poor people rather than before?

This conundrum can be explained by several factors, including the fact that per capita income is the indicator used by the international community to classify countries for the purposes of allocating resources. This indicator does not take into account the distribution of wealth within a country, the multiple dimensions involved in assessing its development, or the social and territorial heterogeneity characteristic of the countries in this group. Consequently, additional criteria are needed to complement per capita income and identify the structural gaps that persist in each country.  We need a more accurate picture of actual levels of development, also taking into account each county’s indebtedness. Currently, we have no reliable mechanisms to assess the impact of international aid on a country’s growth.

Poor access to health care is clearly part of a larger problem—poverty and inequity

Poor access to health care is clearly part of a larger problem—poverty and inequity—which can only be addressed by developing and implementing appropriate policies, allocating the necessary resources, and providing support that goes beyond official cooperation. The focus of development and international aid should be poor people rather than poor countries. Another question worth posing is whether aid effectiveness should be assessed in terms of quality rather than quantity.

Many middle-income countries are, in theory, capable of sustaining their own populations, providing the necessary health services including disease prevention and health system monitoring.

Nevertheless, the reality is that in many cases weak government structures, corruption and mismanagement of resources results in poor access to health services, even when the capacity to provide the necessary care is present. Moreover, given the principle of state sovereignty, international aid alone cannot bridge gaps in health access.

International aid could, however, be of great help in two ways:

1. promoting the structural development of health systems through the transfer of low-cost technology, knowledge transfer, and strengthening institutional capacities;
2. encouraging civil society organisations, social movements and media in each country to inform their citizens on their human rights and the rights of collectives.

If we want to make progress in ensuring transparency and government accountability, we need to empower communities

If we want to make progress in ensuring transparency and government accountability, we need to empower communities. The people must oblige the state to allocate resources rationally and to safeguard health access for the entire population without discrimination. An empowered population is one that is capable of monitoring resources, ensuring equality, and reducing the poverty gap in a long term and sustainable way. All of this starts with a movement inside the country itself.