Abstract
Gross national income (GNI) per capita is widely regarded as a key determinant of health outcomes. Major donors heavily rely on GNI per capita to allocate development assistance for health (DAH). This article questions this paradigm by analysing the determinants of health outcomes using cross-sectional data from 99 countries in 2012. We use disability-adjusted life years (Group I) per capita as our main indicator for health outcomes. We consider four primary variables: GNI per capita, institutional capacity, individual poverty and the epidemiological surroundings. Our empirical strategy has two innovations. First, we construct a health poverty line of 10.89 international-$ per day, which measures the minimum level of income an individual needs to have access to basic healthcare. Second, we take the contagious nature of communicable diseases into account, by estimating the extent to which the population health in neighbouring countries (the epidemiological surroundings) affects health outcomes. We apply a spatial two-stage least-squares model to mitigate the risks of reverse causality. Our model captures 92% of the variation in health outcomes. We emphasize four findings. First, GNI per capita is not a significant predictor of health outcomes once other factors are controlled for. Second, the poverty gap below the 10.89 health poverty line is a good measure of universal access to healthcare, as it explains 19% of deviation in health outcomes. Third, the epidemiological surroundings in which countries are embedded capture as much as 47% of deviation in health outcomes. Finally, institutional capacity explains 10% of deviation in health outcomes. Our empirical findings suggest that allocation frameworks for DAH should not only take into account national income, which remains an important indicator of countries’ financial capacity, but also individual poverty, governance and epidemiological surroundings to increase impact on health outcomes.
Highlights
Human potential lost to poor health is immense
In Column (2), we demonstrate the robustness of our results when the abundance of land suitable for growing wheat relative to that suitable for growing sugarcane is used as an instrument for the poverty gaps, and when Gross national income (GNI) per capita is instrumented by a measure of GNI per capita in neighbouring countries
In Column (7), we show that results are robust when we use Group I disability-adjusted life years (DALYs) lost as measured by the Institute for Health Metrics and Evaluation (IHME) (Murray et al 2015)
Summary
Human potential lost to poor health is immense. In 2012, 39% of global potential healthy life years were lost to premature death or compromised by disability (Murray et al 2015). The aim to end the epidemics of communicable diseases and to provide universal access to basic healthcare rose to the top of the global health agenda (Brolan and Hill 2015) and is incorporated in the UN Sustainable Development Goals. To achieve this objective, Development Assistance for Health (DAH) has more than quintupled since 1990, to reach $36 billion per year in 2014 (Dieleman et al 2015)
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