Health financing seen from the global level: beyond the use of gross national income.

For several decades, International development and financing institutions have considered gross national income (GNI) the economic touchstone for assessing and evaluating countries’ eligibility for development assistance. TheWorld Bank first developed the metric in 1960s as the basis for decisions on concessional financing through International Development Association (IDA). Since its establishment, the IDA has approved concessional financing worth around $312 bn to low-income countries (LICs), a term referring to economies below a certain GNI per capita threshold. The critical comparative advantage of GNI as a metric is its simplicity: it is a standardised statistic that is annually estimated for most economies and captures the level of wealth generated in that year. Historically, this aggregate level of wealth has been considered a useful proxy for the level of development. As a result, this universal, simple, standardised indicator, has been adopted to guide decision making in other financing institutions, but also more broadly, in global health. Key multilateral health financers and development agencies that disburse about 75% (Global and Donor Financing, 2012) of available external financing for health, base their eligibility, allocation and co-financing policies on GNI per capita levels [Equitable Access Initiative (EAI), 2016].