From lemming to leader: Moving beyond Gross Domestic Product (GDP) to bring health financing assistance into the 21st century

Abstract

Nearly 90 years after Simon Kuznets first introduced Gross Domestic Product (GDP) for the limited purpose of measuring economic growth (by measuring the monetary value of all local goods and services within a given period of time), calls continue to mount for decision-makers to stop using GDP and its derivate, Gross National Income (GNI), for purposes far beyond their original design [1].This is particularly true in the case of the development assistance architecture, where these indicators are used as proxies to measure a nation's overall wellbeing and, in some cases, eligibility for external funding [2, 3].The GNI-based classification system has recently even been suggested by some Member States as a criterion to access to medicines in the new WHO Pandemic Agreement.In recent years, increasing scrutiny of "transition" processes for countries shifting from low-to middle-income classification status has revealed that the use of these measures to determine eligibility for and allocation of aid consistently prioritizes economic growth over the health of populations [4].Yet while recognizing GDP and GNI are not fit for purpose, major health financing agencies, including Gavi, the Vaccine Alliance, the Global Fund to Fight Aids, Tuberculosis and Malaria, and the World Bank, continue to use these measures to determine eligibility [2, 3, 5].They do this in part because of ease of calculation, overall generalizability, availability of data to calculate these indicators annually and methodological simplicity and consistency across countries [6].As Gavi, among other funds, heads towards a replenishment event this spring, it may be time to call it quits on the use of these measures to allocate global health aid.Why?Because GDP-and GNI-based criteria mask inequalities within and between countries [6].As aggregate figures measuring solely economic activity [7], GDP and GNI render invisible disparities caused by gender, race, ethnicity, religion, (dis)ability, geography, socioeconomic status, and more, particularly disparities exacerbated by intersecting axes of marginalization.They also exclude a significant proportion of those in poor health living under the poverty line.Middle-income countries (MICs) collectively host 70% of the world's poor and an increasing proportion of the global burden of disease, yet are often ineligible for aid since MICs are assumed to have 'graduated' from being eligible for aid regardless of potential gaps between health expenditure and needs [8][9][10].This mismatch between economic growth and population health drives home the fact that measures of economic activity cannot be used to assess the strength of health systems and the health of the populations they serve.This status quo must be disrupted well ahead of the 2030 deadline for the Sustainable Development Goals (SDGs), as the attainment of SDG 3, Good Health and Wellbeing, hinges upon the provision of universal health

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