Should international aid for health support middle-income countries? International health funds tend to answer this question with ‘no’, based on the states responsibility and ability to pay, and focus on low-income countries only. The following lines try to examine this policy from a global health and human rights perspective.

Middle-income countries' burden of disease is usually tremendous and has a border crossing impact on health

The classification of a middle-income country is based on its GDP. This monetary threshold neither reflects the distribution of income and wealth in a country nor its actual ability to tackle health challenges. To base the decision of health aid exclusively on this measurement is therefore inappropriate. Middle-income countries' burden of disease is usually tremendous and has a border crossing impact on health. Taking into account that the majority of people below the poverty line live in middle-income countries, the focus to address poverty and its devastating effects on health and wellbeing should rather be on poor people than on poor countries.

Assuming that a country actually has the means to provide health coverage for its citizens makes the question whether international development aid is justified a very complex one. Supporting a country’s health systems has shown some negative effects on the government’s allocation of funds, i.e., decreasing their spending in the population’s health. Obviously, governments shouldn’t be rewarded for not assuming their responsibility. However, upon closer examination, the question of what is right or wrong doesn’t seem to be that complicated:

The focus to address poverty and its devastating effects on health and wellbeing should rather be on poor people than on poor countries

Would we refuse to care for an abandoned child, just because it is actually the parent’s responsibility? Would this change, if the parents had the money to care for the child, but still refused to do so? The parent’s behaviour certainly influences our emotions. But it should not make a difference to the decision to help the child as long as nobody else will.

We expect doctors to take an oath to treat patients regardless of their socio-economic background. This unconditional commitment to health can and should be applied on a global scale. Decisions that directly affect the ones in need should be separated from decisions we take about accountability.

Human rights allow people to retain dignity in situations of need, claiming their right instead of begging for mercy. Yes, it is a state’s duty to respect, protect and fulfil the right to health of people under its jurisdiction and it is also the international community’s duty to stand up for these people, if a government does not fulfil its responsibilities. But to use people’s health as a leverage undermines the whole idea of human rights protection: people in need should not be used to protect human rights, but human rights to protect the people.

Usually, a small economic elite with a disproportionate accumulation of power and wealth lifts the GDP to a level considered as middle-income

In addition, there are other forms of pressure, less comfortable though, that high-income countries should exert to promote human rights: The huge gap between rich and poor is a salient characteristic of many middle-income countries. Usually, a small economic elite with a disproportionate accumulation of power and wealth lifts the GDP to a level considered as 'middle-income'.

The government responsible for reallocating the country’s resources to tackle its population’s needs is usually guided by this establishment - and not by the typically weak civil society, thus maintaining or strengthening pre-existing inequalities. By trading with the privileged parties regardless of their human rights situation we further weaken the position of the civil societies and sustain inequity.

In persuading governments of middle-income countries to give priority to the subject of health, we should lead by example and use the powerful leverage of trade, put back the opportunity for profit to advocate for global health.