Interesting article in the Lancet on the use of GDP/GNI as the base for inter country comparisons, this time on health.
Rethinking country classifications towards a more equitable global health future
Esmita Charania esmita.charani@uct.ac.za ∙ Tlangelani Makamua ∙ Sheetal Silalb,c ∙ Ramanan Laxminarayand ∙ Marc Mendelsona
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(26)00457-5/abstract?dgcid=raven_jbs_etoc_emailIntroduction
The World Bank classification of low-income, middle-income, and high-income country groups, that uses gross national income per capita, shapes financing, research priorities, and political narratives. Existing evidence suggests that income alone is a poor proxy for health needs, system capacity, and vulnerability, particularly where rising national wealth coexists with persistent poverty and high disease burden. This gross national income-based classification that remains deeply embedded in global health governance obscures health system realities, masks inequities, and misdirects resources. In this system, low-income and middle-income countries (LMICs) are routinely treated as a homogeneous block, despite the fact that they represent nearly two-thirds of the world's countries and 84% of its population, the majority of whom are in middle-income countries (MICs). National averages conceal profound heterogeneity driven by intersecting inequalities related to gender, race, geography, age, migration status, and the environment These blind spots distort global priorities and systematically overlook vulnerable populations.
The COVID-19 pandemic exposed the inadequacy of income as a proxy for preparedness; many MICs, despite moderate gross national income, lacked basic infrastructure, workforce, and fiscal resilience to mount effective responses.6 Similar mismatches persist across communicable diseases, including tuberculosis, HIV, malaria, vaccine-preventable diseases, and antimicrobial resistance, where high burdens remain concentrated in countries no longer eligible for sustained international support.7,8 Recent global health reforms increasingly acknowledge these failures. The Lusaka Agenda and related initiatives call for equity-focused metrics that better reflect disease burden, system capacity, and vulnerability.9 Established frameworks such as WHO's social determinants of health and the Multidimensional Poverty Index demonstrate that complex deprivation can be measured beyond income alone. Operational examples already exist: the Global Fund incorporating disease burden and system capacity into allocation decisions; climate vulnerability indices integrating social and environmental risk; and water, sanitation, and hygiene (WASH) programmes, which increasingly use subnational data to target interventions and demonstrate impact.
Income-based classifications continue to create systemic blind spots (panel). Challenges such as antimicrobial resistance, WASH inequities, and maternal mortality cannot be understood through income alone; they require multidimensional indicators of vulnerability and resilience. These pitfalls have tangible consequences, reinforcing donor–recipient hierarchies and mischaracterising countries as either responsible stewards or problematic hotspots.
Full article:
Charani E, Makamu T, Silal S et al.
Rethinking country classifications towards a more equitable global health future
The Lancet, 2026; 407, 1406-1408
