It is difficult to explain macroeconomics to the people I work with, and nearly impossible when you are not an economist. For me, it has been a major challenge to talk to HIV positive persons in several countries and different socioeconomic backgrounds about a particular logic around their access to life-saving drugs and the labels put on their countries by economic institutions such as the World Bank. It is the categorization of countries by their income and consequently the aid they receive.

It becomes even more painful, if you have to make the case that the principle of public health – that there is not enough money in the world to take care of everybody’s health – is basically misleading once you compare the amount of money the ‘world powers’ (and even poor families) spend on weapons. So, more often than not, the staff from multilateral institutions do not spend enough time explaining macroeconomics to the poor, or even where and when they find gaps in their lack of access to medicines.

The Paradox

The first time I faced that challenge was when AIDS Healthcare Foundation (AHF), the organization I am part of, launched the “Raise the MIC” campaign and I was to describe the objective to our colleagues and partner NGOs in Latin America. Broadly, this is what I understood about income-differentiation: World Bank classifies countries according to their National Gross Income per capita. Low income countries (LICs) are those where the average income adds up to $975 per year – $2.67 per day. Then, in a historical moment, the country announces a leap to become a middle income country, with a very small difference of 19 cents per capita to $2.86 per day, according to the World Bank Atlas method.

Now, reaching the magic number $2.86 (per day per capita) and becoming a middle-income country (MIC) is a good day for governments, especially the ruling party as the country gains access to financial resources that had not been available previously. It is a huge pat on the back because the administration must be doing something good, or heading in the right direction at least. At this point, most foreign aid starts to dwindle down from pre-MIC status levels. Maybe as a symptom of a middle-income trapped healthcare system, a kind of complacency starts emerging in the social and developmental psyche, a brief period of time that can only be described as ‘laurel resting’. Because for people living in a LIC and waking up in a MIC, paradoxically, it is an ominous day because their access to free condoms is endangered. It is a terrible day for people with HIV, as their antiretroviral (ARV) treatment is at stake. For whatever reason it may be, I was now aware that most of my audience had now begun vanishing.  “And yet” I wanted to shout at the yawning individuals “all this will massively impact your treatment!”

The HIV Situation

There are about 36.7 million people living with HIV/AIDS, of which about half have access to necessary and life-sustaining antiretroviral drugs. Progress on the issue has deepened since the discovery of the virus nearly three decades ago. Now, there are far more outreach efforts in increasing maternal health, widespread and entrenched social awareness to eliminate AIDS-related discrimination and stigma, the support of some very influential individuals and a UNAIDS declaration to end the AIDS epidemic by 2030. The rate of newly infected adults and children has declined globally by more than 35% between 2000 and 2014. Most importantly, the Millennium Development Goal 6 (A and B) have been virtually achieved.


The risk for TB grows as well as of getting malaria from a want of ARV therapy. According to the Global Fund for HIV, Tuberculosis and Malaria, those MIC countries are no longer “needy”, unless they have a high burden from any of the diseases. Without resources to support them, the ones who are most prone are in dire straits. In 2013, more than half of all pregnant women did not receive an HIV test in low and middle income countries. This is essential in post-natal HIV prevention and treatment. Migrants, internal or external, documented or not, climatic or geopolitical, are at increased risk without multi-community awareness on social exclusion and ostracization. In sub-Saharan Africa, adolescent girls and young women are twice as likely to acquire HIV as a result of gender-based violence and lack of education – 4 out of 5 women have not completed their secondary education..

Progress and Work

When asked about their categorization, the World Bank staff will claim that the categories they generate to classify LIC or MIC,are not meant to be used as labels to restrict international cooperation. They will say that, in fact, the categories are only for analytic purposes, but yet they became dogma for some agencies in the past.  These categorizations obscure the important fact that living in a MIC country does not make you a middle income person. In fact, 73% of the world’s poor live in MIC’s, yes, even when there are Louis Vuitton stores nearby. Unwittingly or not, these categorizations have done the disservice of masking the inequalities in these countries which have now, ironically, improved for the worse.

Ask Guatemala for instance. This was going to be the last year that The Global Fund would provide support for medication to HIV patients since Guatemala has graduated to a middle-income country. However due to political pressure, the support has now been extended to 2021. Furthermore, MIC countries like Mexico and Vietnam pay as much as 10 times more for common prescribed HIV drugs.  What started as an economic categorization has now turned into one that affects healthcare for the people who need it the most, whose lives are dependent on the aid they get from foreign donors.

That is why AHF has launched a campaign asking the World Bank to reconsider their current classification; to ask their staff to reassess if they truly want to put such a big decision in $2.86, which is near about the price for their morning coffee in Washington HQ and to invite Jim Kim, the Executive Director of World Bank to lend voice and say aloud that their analytic categories must change. I have to confess that it has been hard to succeed yet at the tasks at hand: to either convince World Bank staff to speak out, or convince people with HIV about the convoluted logic of classifications for international cooperation.  But then again, I renew my hopes with the New Year.

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Miriam Ruiz Mendoza
Miriam is the Director of Advocacy and Testing for Latin America and the Caribbean at AIDS Healthcare Foundation.
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