Most of the world's poorest people now live in middle-income countries rather than low-income countries. The total disease burden has also shifted to middle-income countries, where they face a high burden from diseases like tuberculosis, measles, HIV/AIDS, and vaccine-preventable diseases. While population sizes are larger in middle-income countries, disease burdens are also high due to lagging public health prevention programs and relatively poor vaccination performance compared to their economic status. Many middle-income countries will struggle to self-finance their immunization programs based on projected costs. A new, tailored strategy is needed to address disease burdens in middle-income countries.

1. Global Health and the New Bottom Billion
Input into thinking about policy implications for
adult vaccination in middle-income countries
Amanda Glassman
Director of Global Health Policy
Center for Global Development
September 2013

2. Most of the world’s poorest people live in middle-income countries
Global Distribution of World Poverty
•
In 1990, over 90% of the
world’s poor lived in lowincome countries (LIC)
•
Now, more than 70% of the
world’s poorest people live in
middle-income countries
(MIC)
•
% of World’s Poor, $1.25/Day
Most of the “new bottom
billion” live in stable, nonfragile MIC
Source: PoVCal
Source: Sumner, 2011
2

3. Even more of the world’s poor will live in MIC over time
Number of LIC & MIC, 2000-2025E
•
Moss and Leo (2011) project
that there will be only 20 LIC
in 2025
Sources: Moss and Leo, 2011; World Bank, 2011
*If China is excluded
63
92
2003
61
93
2008
43
101
2009
40
104
2010
35
110
2025 (estimate)
Although the number of LIC
continues to fall, global
poverty, defined as total
number of people living
under US$1.25 or $2 per day
remains around 1 bn to 2 bn,
respectively*
MIC (Countries)
2000
•
LIC (Countries)
20
130
3

4. Total burden of disease has also shifted to MIC
Total Burden of Disease (DALY), All Causes (MMs), 2010
2,000
1,724
1,800
1,600
DALYs (MMs)
1,400
1,112
1,200
1,000
800
600
462
400
346
266
284
200
0
Low income
Lower middle
income
(net of PINCI)
PINCI
Source: Institute for Health Metrics and Evaluation – GBD 2010 Data
Upper middle
income
Total MIC
High income
4

5. MIC as a group has the greatest disease burden associated with tuberculosis
Number of Cases of Tuberculosis (MMs), 1990-2009
Number of Cases (MMs)
15
1990
10
5
7.75
2.06
3.50
1.58
2009
10.80 9.93
7.00
1.74
1.47
1.20
0.41
0.19
0
Low income
Lower middle
income
(net of PINCI)
PINCI
Upper middle
income
Total MIC
High income
Burden of Disease Associated with Tuberculosis (DALY) (‘000), 2010
36,479
40,000
27,913
DALYs (‘000)
30,000
20,000
12,746
5,016
10,000
3,550
500
0
Low income
Lower middle
income
(net of PINCI)
PINCI
Upper middle
income
Total MIC
Source: World Health Organization Statistical Information System (WHOSIS), 2011; IHME – GBD 2010 Data
High income
5

6. Disease burden related to measles is concentrated among the PINCI, while
that of HIV / AIDS is equally concentrated among PINCI and upper MIC
DALYs (‘000)
Burden of Disease Associated with Measles (DALY) (‘000), 2010
10,000
8,000
6,000
4,000
2,000
0
7,910
6,976
2,495
793
Low income
Lower middle
income
(net of PINCI)
141
PINCI
Upper middle
income
10
Total MIC
High income
DALYs (‘000)
Burden of Disease Associated with HIV / AIDS (DALY) (‘000), 2010
60,000
50,000
40,000
30,000
20,000
10,000
0
51,025
29,271
20,881
10,906
19,238
1,127
Low income
Source: IHME – GBD 2010 Data
Lower middle
income
(net of PINCI)
PINCI
Upper middle
income
Total MIC
High income
6

7. In the case of vaccine-preventable diseases, MIC, particularly PINCI, have a
much higher burden than LIC
Total Burden of Disease Associated with Vaccine-Preventable Diseases (DALY) (‘000), 2010*
18,000
15,595
16,000
13,652
14,000
DALYs (‘000)
12,000
10,000
8,000
6,695
6,000
4,000
1,631
2,000
312
50
0
Low income
Lower middle
income
(net of PINCI)
PINCI
Upper middle
income
Total MIC
High income
Source: IHME – GBD 2010 Data; World Health Organization Global Disease Burden Database, 2008
Note: Vaccine preventable diseases includes pertussis, poliomyelitis, diphtheria, measles, and tetanus; *poliomyelitis
data is from the WHO and is 2004 data
7

8. The shift of disease burden to MIC is driven by population size, but also by
lagging effort on public health prevention programs
Number of DTP3 Unvaccinated Children (‘000), 2010
20,000
18,135
Number of People (‘000)
18,000
PINCI have the
largest number
of DTP3
unvaccinated
children
16,000
14,000
12,000
14,440
10,000
8,000
6,000
5,477
4,000
2,434
1,262
2,000
652
0
Low income
Lower middle
income
(net of PINCI)
PINCI
Upper middle
income
Total MIC
High income
Source: World Health Organization Statistical Information System (WHOSIS), 2011
Note: DTP-3 vaccination rate pertains to 1 year olds, calculated by multiplying the crude birth rate, life table survivors
at the age of one, and the total population, divided by 100. The period is 2005-2010
8

9. Many MIC have relatively poor vaccination performance
DTP3 Vaccination Coverage and GDP per Capita in LIC and Lower-MIC
6000
Maldives
Colombia
5000
Dominican Republic
Azerbaijan
Namibia
Jordan
GDP per Capita
4000
3000
Morocco
Armenia
Swaziland
Egypt
Congo
Indonesia
2000
Honduras
Bolivia (Plurinational State of)
Philippines
Republic of Moldova
Nigeria
Pakistan
1000
Ghana
India
Senegal Zambia
Kenya
Haiti
Timor-Leste Bangladesh Rwanda
Zimbabwe
Guinea
Ethiopia Nepal
Niger
Sierra Leone
Liberia
Uganda
0
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DTP3 Vaccination Coverage
Source: World Health Organization Statistical Information System (WHOSIS), 2011
Note: Line represents the income per capita threshold between LIC and MIC, which is $1,006 according to the most
recent World Bank definition
9

10. Over the past 20 years, PINCI have done relatively poorly on different
dimensions of quality and coverage of DTP3 vaccination
Spatial Distribution of Own Vaccination Performance
Range
nd
59 - 69
< 38
69 - 79
38 - 49
79 - 90
49 - 59
> 90
Source: Own calculations on OECD, WHO and WDI data.
Graphic: Glassman, et al. / Vaccine 31S (2013)
10

11. Although most LIC and MIC governments spend less on their own vaccination
programs, some mostly self-finance
Spatial Distribution of Own Vaccine Financing and Management
Range
nd
43 - 57
< 14
57 - 71
14 - 29
71 - 86
29 - 43
> 86
Source: Own calculations on OECD, WHO and WDI data.
Graphic: Glassman, et al. / Vaccine 31S (2013)
11

12. However, judging from existing levels of spend and projected costs, many MIC
will face challenges in self-financing their immunization programs
Vaccine Spending per Child by Income Group
Vaccine Spending per Child
Spending versus estimated cost of a full package of WHO recommended routine immunization schedule
Estimated cost of a full package of WHO recommended routine immunization schedule
$80
$69
$70
$62
$60
$50
$38
$40
$30
$25
$20
$8
$10
$1
$0
Low income
Lower middle
income
Upper middle Medecins sans
income
Frontieres
Saxenian and
Hecht
High income
Source: LIC/LMIC/UMIC/HIC spending based on own calculations from WHOSIS; cost of a WHO-recommended load of
vaccines based on Medecins Sans Frontieres (2012) report includes 1 BCG, 3 oral polio vaccine, 3 DRP, 2 measles, Hep B,
Hib, PCV, rotavirus and rubella. The Saxenian and Hecht (SH) figure of $62 includes new vaccines in addition to the WHOrecommended load: HPV, Japanese encephalitis, pentavelent, pneumo, yellow fever and typohoid
12

13. A new, tailored MIC strategy needs to be developed
• Eliminating income thresholds as an across-the-board eligibility criteria
– Working in poorer regions in populous MIC
• Setting up regional pooled procurement schemes as at PAHO, or creating a
MIC window at GAVI
• Building evidence-based priority-setting institutions in MIC
• Establishing better measurement and accountability mechanisms
• Providing technical support to MIC
13

14. Sources
• Glassman A., Duran, D., and Sumner, A., “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?” CGD Working Paper 270
(Washington: Center for Global Development, 2011).
http://www.cgdev.org/publication/global-health-and-new-bottom-billionwhat-do-shifts-global-poverty-and-global-disease
• Sumner A. (2010) Global Poverty and the New Bottom Billion. IDS Working
Paper.
• Edward P., and Sumner A., “The Future of Global Poverty in a Multi-Speed
World: New Estimates of Scale and Location, 2010-2030” CGD Working
Paper 327 (Washington: Center for Global Development, 2013).
http://www.cgdev.org/sites/default/files/future-of-global-poverty_1.pdf
14

15. Contact
• Amanda Glassman
– aglassman@cgdev.org
– @glassmanamanda
– www.cgdev.org
15

16. APPENDIX
16

17. Total MIC fare worse than LIC on ARV coverage of HIV positive people
Number of People Infected with HIV and not receiving ARV Treatment (‘000), 2008
18,000
16,829
Number of People (‘000)
16,000
14,000
12,000
10,000
8,138
8,000
6,315
7,171
6,000
3,343
4,000
1,315
2,000
0
Low income
Lower middle
income
(net of PINCI)
PINCI
Upper middle
income
Source: World Health Organization Statistical Information System (WHOSIS), 2011
Total MIC
High income
17