Global Health NOW: The ‘4 Ds’ that Threaten Middle-Income Countries
Shashika Bandara, policy associate; Kaci Kennedy McDade, policy associate; Hanna Huffstetler, associate in research; and Wenhui Mao, senior policy associate, all at the Center for Policy Impact in Global Health at the Duke Global Health Institute

“In the last 2 decades, more than 30 countries moved from low-income to middle-income status, a billion people were lifted out of poverty, and there were major reductions in maternal and child mortality globally. Despite this progress, middle-income countries, where over 70% of the world’s population now live, are facing unprecedented challenges. The progress they’ve made is threatened. In particular, 4 key phenomena — which we call the 4Ds of global health transition — are rapidly reshaping the nature of health in MICs: 1. Disease … 2. Demographics … 3. Donor Financing … 4. Domestic Funding … These interlinked transitions threaten to stall or even reverse global health progress. A focus on tackling diseases or mobilizing domestic resources in isolation will not be sufficient. A ‘joined up’ strategic approach is crucial. … The 4Ds of transition are underway whether or not countries are prepared for them. Without immediate attention, we risk jeopardizing the remarkable gains made over the past 2 decades and leaving MICs behind” (6/26).