It’s time to re-think the use of the “LMIC” category
By Anna Palmer
On July 1st of every year, the World Bank classifies each country into one of four income groups – low, lower-middle, upper-middle, and high. Classifications are based on Gross National Income (GNI) of the previous year, which is the total amount of money earned by a nation’s people and businesses.
In 2022, countries earning <US$1,045, US$1,046-12,965, and >US$12,695 per capita were considered “low”, “middle”, and “high” income, respectively. Based on these classifications, there are currently 137 “low- and middle-income countries” (LMICs). Approximately 84% of the world’s population lives within these countries.
These income categories were initially developed by the World Bank as an analytic tool to organise data on countries’ economic performance.
Yet, the use of the LMIC categorisation has become ubiquitous in the field of global health. A quick search on PubMed reveals that there were almost 1,000 articles published with LMIC in the title within 2022 alone. Its use is so normalised within global health that authors hardly ever justify why they use this categorisation in their work, and their peers rarely question it.
This begs the question, what value (or harm) does the LMIC categorisation bring to global health?
Often, the LMIC categorisation is used as an umbrella term for “low-resource settings”. Countries falling into the LMIC category are often assumed to have fewer resources to provide adequate healthcare for their citizens.
However, what constitutes a “low-resource setting” is complex and not well operationalised.
Government healthcare expenditure (which has been linked to national level income) represents one factor influencing resource scarcity. However, there are a myriad of other interrelated factors that contribute to resource scarcity also – including health service delivery mechanisms, physical and social infrastructure, availability of knowledge, and availability of human resources.
Distilling the definition of “low-resource settings” down to national level income undermines the complexity of other factors that give rise to “low resource settings” and ignores the context within which resource scarcity arises.
As such, the value of the LMIC categorisation in identifying “low-resource settings” within global health is questionable.
Questionable utility is not the only reason to be concerned about the use of the LMIC category. The use of the LMIC vs. high-income country (HIC) dichotomy also perpetuates an othering narrative.
Much of the practice and vocabulary of global health today has origins within colonial medicine. Dichotomies, such as “First World” vs. “Third World”, and “developed” vs. “developing” have historically been used to instill a sense of hierarchy and superiority between countries and regions.
Such terms originated in European and North American institutions, with only vague definitions. The perceived differences between countries in these dichotomies were not founded in evidence and were influenced by racist and colonial thinking.
The LMIC categorisation is much less vague in its definition. However, its frequent use as a synonym for “Third World” and “developing country” associates it to these harmful dichotomies.
Continuing to use the LMIC-HIC dichotomy, without adequate justification, only reinforces negative biases and stereotypes associated with older dichotomous terminologies.
In addition to being othering, the LMIC category is also homogenising.
As mentioned at the start of this article, 84% of the world’s population lives in LMICs. Using the LMIC category means placing the overwhelming majority of the world’s population in one category.
This begs the question – what do all these people actually have in common?
Lumping LMICs together means grouping countries like Burundi (GNI per capita of US$220) with countries like Malaysia (GNI per capita of US$10,710), where there is a ~50-fold difference in GNI per capita. From an economic perspective, this is a very crude grouping.
From a health perspective, grouping countries like Burundi and Malaysia together feels even more inappropriate, given the tremendous differences in culture, history, and societal structures.
With no common characteristics defining populations in LMICs (apart from national level income <US$12,695), one could easily relabel this group as simply “the majority of the world”.
When talking about this topic, a question that is often asked is - what term should we use instead of LMIC?
I think this is a natural question to ask (not too long ago, I also asked this question). The language of public and global health is continually developing, with many problematic and hurtful terms being replaced by more considerate, inclusive and/or neutral terms.
However, I think that looking for an appropriate synonym for LMIC misses the point. The real question is - what does the LMIC-HIC dichotomy really represent?
Categorisation is an unavoidable tool of our profession. However, the way we form categories, and what these categories represent (explicitly and implicitly) is important.
As someone very early on in their career, I have much more to learn about this topic.
However, I thought it might be useful to share some of the things I am actively trying to think about when I find myself inclined to write or speak about LMICs:
How does what I am writing or speaking relate to a countries’ national income?
Am I equating LMICs to “low-resource settings”? If so, along which dimension(s) are resources scarce?
Does what I am writing or speaking about apply to all 137 LMICs?
Is there a more specific categorisation that would convey my point? E.g. a specific geographic region or country, a specific group of people with a common (and relevant) characteristic
What are some of the potential biases and stereotypes that could be influencing my inclination to use LMIC?
Changing how we write and speak about global health is something all of us can do. And while language is only the tip of the iceberg in the decolonising global health movement, it can be a steppingstone towards deeper conversations about the problems ingrained within the field of global health.
This article was written based on discussions from EPIB 677: Critical Perspectives on Global Health and was deeply influenced by Lencucha & Neupane, Khan et. al, and van Zyl et. al. I’d like to thank Dr Alissa Koski for providing feedback that improved this article.
Anna Palmer (she/her) is a PhD Candidate in the Department of Epidemiology, Biostatistics, and Occupational Health at McGill University. She is interested in the relationship between climate change, health, and social inequities. Her doctoral research aims to examine the impact of extreme weather events on the incidence of child marriage in over 100 countries.