Global health 2035: a world converging within a generation

Abstract

Prompted 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. The 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. •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 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. •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. The 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. •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. The 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. •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.

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Affiliated Institutions

• Harvard University US
• Gates Foundation US
• International Monetary Fund US
• Stanford University US
• Gavi CH
• Princeton University US
• Columbia University US
• University of the West Indies JM
• University of Washington US
• Lancet Laboratories ZA
• University of California, San Francisco US
• Results for Development Institute US
• University of Oslo
• Ministry of Health RW
• Banque Nationale de Gènes TN
• Harvard University Press US
• World Health Organization CH
• Peking University CN
• Public Health Foundation of India IN
• United States Agency for International Development US

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