Global health 2035: a world converging within a generation

Abstract

Executive summaryPrompted by the 20th anniversary of the 1993 World Development Report, a Lancet Commission revisited the case for investment in health and developed a new investment framework to achieve dramatic health gains by 2035. Our report has four key messages, each accompanied by opportunities for action by national governments of low-income and middle-income countries and by the international community.There is an enormous payoff from investing in healthThe returns on investing in health are impressive. Reductions in mortality account for about 11% of recent economic growth in low-income and middle-income countries as measured in their national income accounts.However, although these accounts capture the benefits that result from improved economic productivity, they fail to capture the value of better health in and of itself. This intrinsic value, the value of additional life-years (VLYs), can be inferred from people's willingness to trade off income, pleasure, or convenience for an increase in their life expectancy. A more complete picture of the value of health investments over a time period is given by the growth in a country's “full income”—the income growth measured in national income accounts plus the VLYs gained in that period. Between 2000 and 2011, about 24% of the growth in full income in low-income and middle-income countries resulted from VLYs gained.This more comprehensive understanding of the economic value of health improvements provides a strong rationale for improved resource allocation across sectors.Opportunities•If planning ministries used full income approaches (assessing VLYs) in guiding their investments, they could increase overall returns by increasing their domestic financing of high-priority health and health-related investments.•Assessment of VLYs strengthens the case for allocating a higher proportion of official development assistance to development assistance for health.A “grand convergence” in health is achievable within our lifetimesA unique characteristic of our generation is that collectively we have the financial and the ever-improving technical capacity to reduce infectious, child, and maternal mortality rates to low levels universally by 2035, to achieve a “grand convergence” in health. With enhanced investments to scale up health technologies and systems, these rates in most low-income and middle-income countries would fall to those presently seen in the best-performing middle-income countries. Achievement of convergence would prevent about 10 million deaths in 2035 across low-income and lower-middle-income countries relative to a scenario of stagnant investments and no improvements in technology. With use of VLYs to estimate the economic benefits, over the period 2015–35 these benefits would exceed costs by a factor of about 9–20, making the investment highly attractive.Opportunities•The expected economic growth of low-income and middle-income countries means that most of the incremental costs of achieving convergence could be covered from domestic sources, although some countries will continue to need external assistance.•The international community can best support convergence by funding the development and delivery of new health technologies and curbing antibiotic resistance. International funding for health research and development targeted at diseases that disproportionately affect low-income and middle-income countries should be doubled from current amounts (US$3 billion/year) to $6 billion per year by 2020. The core functions of global health, especially the provision of global public goods and management of externalities, have been neglected in the last 20 years and should regain prominence.Fiscal policies are a powerful and underused lever for curbing of non-communicable diseases and injuriesThe burden of deaths from non-communicable diseases (NCDs) and injuries in low-income and middle-income countries can be reduced by 2035 through inexpensive population-based and clinical interventions. Fiscal policies are an especially promising lever for reducing this burden.Opportunities•National governments can curb NCDs and raise significant revenue by heavily taxing tobacco and other harmful substances, and they can redirect finances towards NCD control by reducing subsidies on items such as fossil fuels. Investment in strengthening health systems to deliver packages of cost-effective clinical interventions for NCDs and injuries is another important national opportunity.•International action should focus on provision of technical assistance on fiscal policies, regional cooperation on tobacco, and funding of population, policy, and implementation research on scaling-up of interventions for NCDs and injuries.Progressive universalism, a pathway to universal health coverage (UHC), is an efficient way to achieve health and financial protectionThe Commission endorses two pro-poor pathways to achieving UHC within a generation. In the first, publicly financed insurance would cover essential health-care interventions to achieve convergence and tackle NCDs and injuries. This pathway would directly benefit the poor because they are disproportionately affected by these problems. The second pathway provides a larger benefit package, funded through a range of financing mechanisms, with poor people exempted from payments.Opportunities•For national governments, progressive universalism would yield high health gains per dollar spent and poor people would gain the most in terms of health and financial protection.•The international community can best support countries to implement progressive universal health coverage by financing population, policy, and implementation research, such as on the mechanics of designing and implementing evolution of the benefits package as the resource envelope for public finance grows.Our report points to the possibility of achieving dramatic gains in global health by 2035 through a grand convergence around infectious, child, and maternal mortality; major reductions in the incidence and consequences of NCDs and injuries; and the promise of universal health coverage. Good reasons exist to be optimistic about seeing the global health landscape utterly transformed in this way within our lifetimes.IntroductionIn 1978, the World Bank initiated an annual flagship publication, the World Development Report (WDR),1World BankWorld Development Report.http://files.dcp2.org/pdf/WorldDevelopmentReport1993.pdfDate: 1993Google Scholar which aims to inform global thinking on a specific topic (panel 1). WDR 1993, Investing in Health (figure 1), is the only WDR so far that has focused on global health. It was the first major health report to be targeted at finance ministers and remains one of the most widely cited WDRs in the Bank's history.2Deaton A The World Development Report at 30: a birthday tribute or a funeral elegy?.in: Yusuf S Development economics through the decades: a critical look at thirty years of the World Development Report. World Bank, Washington, DC2008: 105-114Google ScholarPanel 1What are World Development Reports and why did the World Development Report 1993 focus on health?The World Bank's annual World Development Reports (WDRs), probably the world's most widely distributed economic publication, are its chief mechanism for taking stock of the evidence on a specific topic and for developing and sharing its policy messages with member countries, other development agencies, and the academic community. The reports are produced by the Bank's research community, headed by its Chief Economist, who has overall responsibility for the report.2Deaton A The World Development Report at 30: a birthday tribute or a funeral elegy?.in: Yusuf S Development economics through the decades: a critical look at thirty years of the World Development Report. World Bank, Washington, DC2008: 105-114Google ScholarWhy did Lawrence Summers, the Bank's Chief Economist in 1991–93, and Chair of this Commission, choose health as the focus of WDR 1993? Summers saw three benefits of publishing a WDR about health. First was the opportunity to amplify the Bank's strategy to combat poverty. Second, health represented an area in which a central and constructive role existed for government. Third, Summers believed that the potential gains from getting the correct health policies in place were enormous.Every year, a small team of World Bank staff and others is seconded from their regular positions to work full time authoring that year's WDR. WDR 1993 was written by Dean T Jamison, Seth Berkley, José Luis Bobadilla, Robert Hecht, Kenneth Hill, Christopher J L Murray, Philip Musgrove, Helen Saxenian, and Jee-Peng Tan, under the general direction of Lawrence Summers and Nancy Birdsall. The report's preparation was facilitated by 19 international consultations and several seminars during a 9-month period.Figure 1The World Development Report 1993View Large Image Figure ViewerDownload Hi-res image Download (PPT)WDR 1993 showed finance ministers that well-chosen health expenditures were not an economic drain but an investment in economic prosperity and individual wellbeing. It argued that allocation of resources towards cost-effective interventions for high-burden diseases offered a rapid and inexpensive pathway to improvements in welfare.Prompted by the 20th anniversary of WDR 1993, a Lancet Commission on Investing in Health was launched in December, 2012. The Commission was chaired by Lawrence Summers, the Chief Economist at the World Bank responsible for choosing global health as the focus of WDR 1993, and co-chaired by Dean Jamison, lead author of WDR 1993. The Commission aimed to consider the recommendations of WDR 1993, examine how the context for health investment has changed in the past 20 years, and develop an ambitious forward-looking health policy agenda targeting the world's poor populations.The time is right to revisit the case for investment in health. We are in the closing era of the Millennium Development Goals (MDGs). Although tremendous progress has been made towards MDGs 4–6, a very high preventable burden of infectious, maternal, and child mortality will still remain by 2015. The global development community is debating both a new set of post-2015 sustainable development goals and the positioning of health, including universal health coverage (UHC), in such goals. We are also in an era in which the landscape of global health financing is undergoing major changes. After a decade of rising aid for health—a “golden age” for global health assistance3Institute for Health Metrics and EvaluationFinancing global health 2012: the end of the golden age?.http://www.healthmetricsandevalu ation.org/publications/policy-report/financing-global-health-2012-end-golden-ageGoogle Scholar—development assistance budgets are strained. At the same time, the economic growth of many low-income and middle-income countries means that they are increasingly able to step up their domestic health investments.This evolution in the aspirations, landscape, and financing of global health is being accompanied by a rapid shift in the global disease burden away from infectious diseases and towards non-communicable diseases (NCDs) and injuries. This shift has been slower in some low-income and middle-income countries than in high-income countries, such that they face a heavy triple burden of infections, NCDs, and injuries, with tremendous health and financial consequences for households and societies. On top of these health problems, we face emerging global threats, such as antimicrobial resistance, new pandemics, emerging infections, and global climate change. Our commission set out to answer the question: how should low-income and middle-income countries and their development partners target their future investments in health to tackle this complex array of challenges?Our report proposes a new pro-poor investment plan that lays out key priorities and essential packages of interventions to accelerate the recent progress in global health and achieve dramatic gains within a generation—that is, by 2035. The report is divided into seven sections.Section 1 sets the scene by laying out the context for investment in health. We begin by briefly looking back at WDR 1993 to assess its legacy, both positive and negative, and to draw lessons that can be applied to future investment planning. We then discuss the key advances and challenges in the global health landscape in the past 20 years that have resonance for health investment. We lay out three domains of health challenges that national governments will be grappling with over the next 20 years. The first domain is the ongoing high rates of infectious disease and mortality from reproductive, maternal, newborn, and child health (RMNCH) disorders in poor populations, especially in rural regions. Since most of the world's poor people are now in middle-income countries, tackling such disorders will require focused attention, not only to low-income countries but to the lower-income and rural subpopulations of middle-income countries. The second domain, a consequence of tackling the conditions of the first domain, is demographic changes and the shift in the global disease burden towards NCDs and injuries. Increasing rates of NCDs, associated with the rise in behavioural risk factors such as smoking, alcohol consumption, and sedentary behaviour, are compounded by often weak institutional arrangements to tackle these diseases and risks. Governments in many low-income and middle-income countries that have curbed their burden of infectious mortality are now facing a growing burden of deaths from road traffic injuries, associated with increasing rates of urbanisation and motorisation. Such injuries are the world's leading cause of death among people aged 15–29 years.4WHOGlobal status report on road safety 2013: supporting a decade of action. World Health Organization, Geneva2013Google Scholar The third domain, a consequence of inadequate financial arrangements for addressing the other two domains, is the potential for impoverishing medical expenditures together with sharp and unproductive increases in health-care costs.In section 2 of our report, we examine the latest evidence on the impressive economic returns to investing in health. This evidence includes new data derived from valuation of improvements in life expectancy in monetary terms, an approach that leads to a more comprehensive concept of income called full income.5Cropper M Hammitt JK Robinson LA Valuing mortality risk reductions: progress and challenges. Resources for the Future Discussion Paper no. 11-10.http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1788975Google Scholar The notion of a change in full income includes change in GDP but goes beyond it by also including a valuation of change in life expectancy.In section 3, we briefly highlight the crucial role of a diagonal approach to tackling infections, RMNCH disorders, NCDs and injuries—that is, stronger health systems that are focused on achieving measurable health outcomes. We also stress the importance of population-based policies, especially in curbing NCDs and injuries.In section 4, we propose an ambitious, yet feasible, integrated investment plan for achievement of a “grand convergence” in health by 2035. By grand convergence, we mean a reduction in the burden of infections and RMNCH disorders in most high-mortality low-income and middle-income countries down to the rates presently seen in the best-performing middle-income countries (eg, Chile, China, Costa Rica, and Cuba, conveniently labelled the “4C” countries). We show that convergence could be achieved through enhanced investments to scale up health technologies and systems. Although our analysis suggests that the annual price tag to achieve convergence is large, with a full income approach we find that the benefits would be enormous, which makes the investment highly attractive. Our report's notion of a grand convergence in health echoes Mahbubani's recent suggestion of a “great convergence” in the global economy,6Mahbubani K The great convergence. Asia, the West, and the logic of one world. Public Affairs, New York2013Google Scholar with decreasing absolute poverty and a rising middle class.In section 5, we propose a framework to sharply reduce the burden of NCDs and injuries within a generation through scale-up of essential packages of population-based and clinical interventions.In section 6, we study the role of UHC in providing financial risk protection. We argue for public financing of progressive pathways towards UHC that are pro-poor from the outset. We also propose steps that low-income and middle-income countries can take to avoid unproductive health cost escalation.Finally, in section 7, we assess the role of international collective action in provision of technical and financial assistance to national governments; preparation for emerging risks of the 21st century (eg, pandemics and antibiotic resistance); financing of new product development; and in supporting what we call population, policy, and implementation research (PPIR).Our analyses were done by an international multidisciplinary group of 25 commissioners. We synthesised available evidence, undertook primary research on key topics, and met for three in-person consultations during the course of 8 months (in Norway, Rwanda, and the USA). Smaller subgroups of commissioners held additional consultations about specific topics with experts who generously contributed their time. The Commission co-hosted two collaborative meetings: a colloquium with the Council on Health Research for Development on sustainable investments in research and development (R&D), and a meeting with the GAVI Alliance on the economic value of vaccines. We also commissioned several teams of researchers to produce background papers that informed our analysis (available online).We focused mainly on health improvements that could be achieved by the health sector. One key exception, which we discuss in this report, is population-wide interventions (eg, taxation and regulation) to address risk factors for NCDs and injuries. The Commission firmly believes that tackling the social and intersectoral determinants of health is central to achieving long-term health gains, as has been argued by several highly influential reports (panel 2). For some of these determinants, however, complex and entrenched political obstacles exist to addressing them, and for others, the effect will not be realised for a long period. For these reasons, the Commission believes that the health needs of the vulnerable will be most directly and expediently addressed by investments and action within the health sector.Panel 2Social and intersectoral determinants and consequences of better healthThree key WHO publications have advanced our understanding of these relations:•The 1999 World Health Report (WHR), the first WHR issued by WHO Director General Gro Harlem Brundtland, estimated that half of the health improvements between 1960 and 1990 in low-income and middle-income countries were from changes in two social determinants: income and education.7WHOWorld Health Report 1999: making a difference. World Health Organization, Geneva1999Google Scholar The report noted that these determinants affect health through consequences such as poor nutrition, sanitation, and other risk factors for ill health. Nevertheless, WHR 1999 argued that the health community could have the greatest effect on health by focusing on the health sector, including health systems strengthening, rather than by taking action outside this sector.•The 2001 report of the Commission on Macroeconomics and Health, chaired by Jeffrey Sachs, emphasised the importance of investment not only in the health sector but also in education, water, sanitation, and agriculture, to reduce poverty.8WHOMacroeconomics and health: investing in health for economic development. World Health Organization, Geneva2001Google Scholar By quantifying both the substantial economic consequences of better health and the costs of achieving it, the report had a hugely important role in informed advocacy for the health sector.•The Commission on Social Determinants of Health, chaired by Michael Marmot, was established by WHO in 2005 to lay out evidence for how to promote health equity through sound social and economic policies and to foster a global movement towards its achievement.9WHOClosing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. World Health Organization, Geneva2008Google Scholar The Commission made three broad recommendations: improve daily conditions; take “far-reaching and systematic action” to improve the distribution of resources to ensure “fair financing, corporate social responsibility, gender equity and better governance”; and improve data collection for better measurement of health inequities and monitor the effect of interventions in improving these inequities.To examine the context for investing in health, we begin by briefly looking back over the past 20 years, beginning with WDR 1993. We revisit the report's key messages and findings, and the criticisms that it received, to draw out the lessons for health investments that remain equally relevant today. We then review the remarkable changes in the world during the past 20 years, and the unanticipated obstacles, that have shaped today's global health landscape. We define in more detail the three major domains of health challenges, mentioned briefly earlier, that low-income and middle-income countries will be grappling with in the next 20 years. Finally, we analyse new research that provides a deeper understanding of the profound economic benefits of better health—research that we hope will lead to improved financing of the health sector.Section 1. 20 years of advances and unanticipated challengesIn the 40 years before 1993, dramatic improvements in health had already been achieved. Smallpox had been eradicated. Vaccines had driven down the number of annual deaths from measles and polio. In 1950, 28 of every 100 children died before their fifth birthday, but by 1990 this number had fallen to ten.1World BankWorld Development Report.http://files.dcp2.org/pdf/WorldDevelopmentReport1993.pdfDate: 1993Google Scholar WDR 1993 argued that these successes could be explained by scientific advances delivered by health systems, economic growth, and expanded access to education and health services. However, ongoing poverty, low educational opportunities for girls, and poor public policy decisions had prevented about a billion people in low-income and middle-income countries from fully sharing in these health gains. Health systems were facing major problems, from under-funding and misallocation of funds to an explosion of health care costs in some middle-income countries. The global HIV/AIDS pandemic had also taken hold.WDR 1993Key messagesWDR 1993 proposed a three-pronged approach to government policies, underpinned by investment in scientific research to amplify the effect of each prong.The first prong was to foster an environment that enables households to improve health. This goal could be achieved through pursuit of growth-enhancing macroeconomic policies, expansion of schooling (especially for girls), and promotion of women's rights and status through political and economic empowerment and legal protection against abuse. The report argued, for example, that providing education for girls and women would have one of the greatest payoffs for averting death and disability through improving knowledge about health and increasing contact with the health system. WDR 1993 also framed violence against women as a major global public health issue requiring urgent action.The second prong was to improve government spending on health, particularly by targeting public spending towards a specific set of diseases and interventions. WDR 1993 combined cost-effectiveness analysis with burden of disease assessment to specify a set of “minimum packages” of cost-effective public health interventions (eg, HIV prevention and immunisations) and clinical services (eg, treatment of childhood illnesses). The report argued that these packages would have enormous potential to avert deaths and reduce disability, especially among the world's poorest billion people (the so-called “bottom billion”).10Collier P The bottom billion: why the poorest countries are failing and what can be done about it. Oxford University Press, New York2007Google Scholar For example, WDR 1993 urged countries to scale up the six vaccines included in the Expanded Programme on Immunization (EPI) to achieve 95% coverage, and to consider adding iodine, vitamin A, and vaccines against hepatitis B and yellow fever. “In most developing countries,” the report argued, “such an ‘EPI Plus’ cluster of interventions in the first year of life would have the highest cost-effectiveness of any health measure available in the world today.” The report claimed that countries could reduce their disease burden by doubling or tripling their spending on such cost-effective packages. It recommended that these packages should be publicly financed, and urged donors to increase development assistance for health (DAH) to help cover the costs of these packages in low-income countries.The third prong was to promote diversity and competition in the supply of health services and inputs. Although governments should finance the essential packages, these publicly financed services might in some cases be best provided by non-governmental organisations or the private sector. The “remaining clinical services” would need to be financed privately or through publicly mandated social insurance within a strong government regulatory framework.The report made a strong case that the international community should devote more resources to health. It recommended that health funding should be immediately restored to 7% of official development assistance (ODA); such funding had declined to 6% of ODA in 1986–90. It called on donors to provide an additional US$2 billion per year (1993 US dollars) to “finance a quarter of the estimated additional costs of a basic package in low-income countries and of strengthened efforts to prevent AIDS”. WDR 1993 endorsed the call from WHO's Global Program on AIDS to increase funding for HIV/AIDS prevention activities by a factor of 10–15.Although the primary focus of WDR 1993 was the health sector, the report also emphasised the importance of intersectoral action, particularly the value of linking health with water and sanitation, food regulation, and education. It argued forcefully for action on tobacco control, including tobacco taxation, bans on smoking in public places, and public education campaigns. It proposed measures to combat climate change, such as promotion of clean technologies and greater energy efficiency.Impact and influenceWDR 1993, which itself was influenced by the powerful ideas contained in the Declaration of Alma-Ata, is credited for having helped to place health firmly on the global development agenda. It laid the groundwork, along with initiatives such as the Commission on Macroeconomics and Health (CMH) and the MDGs, both established in 2000, for many of the key global health milestones of the past 20 years.By proposing a vision for health improvement, a broadly applicable method for informing health policy priorities (combining disease burden with cost-effectiveness analysis), and an agenda for action, the report put pressure on other international agencies to respond. One response was the launch of the WHO's World Health Report (WHR) series in 1995. Several WHRs have been influenced by WDR 1993.A 1993 editorial in The Lancet argued that WDR 1993 could provide a “cure for donor fatigue” at a time when “international public health is drifting”.11The LancetWorld Bank's cure for donor fatigue.Lancet. 1993; 342: 63-64Abstract PubMed Scopus (12) Google Scholar However, although annual DAH doubled between 1990 and 2001, from US$5·8 billion to $11·0 billion in 2001 (data from 3Institute for Health Metrics and EvaluationFinancing global health 2012: the end of the golden age?.http://www.healthmetricsandevalu ation.org/publications/policy-report/financing-global-health-2012-end-golden-ageGoogle Scholar, converted to 2011 US dollars), there is no evidence to prove that WDR 1993 played a part in this rise. A much more rapid increase in DAH occurred in the period after the year 2000, in the wake of the CMH and MDGs. WDR 1993 might, however, have had a role in creating a climate for innovation in global health financing that influenced new funding mechanisms such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Feachem R, Global Health Group, University of California, San Francisco, personal communication).One identifiable effect of the report is that it motivated Bill Gates to invest in global health through the Bill & Melinda Gates Foundation.12United NationsUnited Nations Special Session on Children. Guest speeches: Bill Gates, Jr, Co-founder of the Bill & Melinda Gates Foundation.http://www.unicef.org/specialsession/press/02espbillgates.htmDate: 2002Google Scholar, 13Specter M What money can buy.New Yorker (New York). Oct 24, 2005; (accessed Feb 21, 2013).http://www.michaelspecter.com/2005/10/what-money-can-buyGoogle Scholar In a 2002 speech to a United Nations Special Session on Children, Gates said:12United NationsUnited Nations Special Session on Children. Guest speeches: Bill Gates, Jr, Co-founder of the Bill & Meli