The Lancet Commissions Global health 2035: a world converging within a generation Dean T Jamison*, Lawrence H Summers*, George Alleyne, Kenneth J Arrow, Seth Berkley, Agnes Binagwaho, Flavia Bustreo, David Evans, Richard G A Feachem, Julio Frenk, Gargee Ghosh, Sue J Goldie, Yan Guo, Sanjeev Gupta, Richard Horton, Margaret E Kruk, Adel Mahmoud, Linah K Mohohlo, Mthuli Ncube, Ariel Pablos-Mendez, K Srinath Reddy, Helen Saxenian, Agnes Soucat, Karene H Ulltveit-Moe, Gavin Yamey Executive summary A “grand convergence” in health is achievable within Published Online Prompted by the 20th anniversary of the 1993 World our lifetimes December 3, 2013 http://dx.doi.org/10.1016/ Development Report, a Lancet Commission revisited the A unique characteristic of our generation is that col- S0140-6736(13)62105-4 case for investment in health and developed a new lectively we have the fi nancial and the ever-improving *Denotes co-fi rst authors investment frame work to achieve dramatic health gains technical capacity to reduce infectious, child, and See Online for video infographic by 2035. Our report has four key messages, each maternal mortality rates to low levels universally by Department of Global Health, accompanied by opportunities for action by national 2035, to achieve a “grand convergence” in health. With University of Washington, governments of low-income and middle-income coun- enhanced invest ments to scale up health technologies Seattle, WA, USA tries and by the international community. and systems, these rates in most low-income and (Prof D T Jamison PhD); Harvard middle-income countries would fall to those presently University, Cambridge, MA, USA (Prof L H Summers PhD); There is an enormous payoff from investing in health seen in the best-performing middle-income countries. Harvard School of Public The returns on investing in health are impressive. Achieve ment of convergence would prevent about 10 Health, Harvard University, Reductions in mortality account for about 11% of recent million deaths in 2035 across low-income and lower- Cambridge, MA, USA (Prof economic growth in low-income and middle-income middle-income countries relative to a scenario of J Frenk MD, Prof S J Goldie MD); University of the West Indies, countries as measured in their national income stagnant investments and no improvements in Kingston, Jamaica accounts. technology. With use of VLYs to estimate the economic (Prof G Alleyne MD); However, although these accounts capture the benefi ts, over the period 2015–35 these benefi ts would Department of Economics and benefi ts that result from improved economic exceed costs by a factor of about 9–20, making the Center for Health Policy, Stanford University, Stanford, productivity, they fail to capture the value of better investment highly attractive. CA, USA (Prof K J Arrow PhD); health in and of itself. This intrinsic value, the value of Executive Offi ce, GAVI Alliance, additional life-years (VLYs), can be inferred from Opportunities: Geneva, Switzerland people’s willingness to trade off income, pleasure, or • The expected economic growth of low-income and (S Berkley MD); Ministry of Health, Kigali, Rwanda convenience for an increase in their life expectancy. A middle-income countries means that most of the (A Binagwaho MD [Ped]); more complete picture of the value of health incremental costs of achieving convergence could be Family, Women’s, and investments over a time period is given by the growth covered from domestic sources, although some coun- Children’s Health (F Bustreo MD) and Department in a country’s “full income”—the income growth tries will continue to need external assistance. of Health Systems Financing measured in national income accounts plus the VLYs • The international community can best support con- (D Evans PhD), World Health gained in that period. Between 2000 and 2011, about ver gence by funding the development and delivery of Organization, Geneva, 24% of the growth in full income in low-income and new health technologies and curbing antibiotic Switzerland; Global Health Group, University of California, middle-income countries resulted from VLYs gained. resistance. International funding for health research San Francisco, CA, USA This more comprehensive understanding of the eco- and develop ment targeted at diseases that dispro- (Prof R G A Feachem DSc [Med], nomic value of health improvements provides a strong portionately aff ect low-income and middle-income G Yamey MD); Development rationale for improved resource allocation across sectors. countries should be doubled from current amounts Policy and Finance, Bill & Melinda Gates Foundation, (US$3 billion/year) to $6 billion per year by 2020. The Washington, DC, USA Opportunities: core functions of global health, especially the pro- (G Ghosh MSc); Health Science • If planning ministries used full income approaches vision of global public goods and management of Center, Peking University, (assessing VLYs) in guiding their investments, they externalities, have been neglected in the last 20 years Beijing, China (Prof Y Guo MPH); Fiscal Aff airs Department, could increase overall returns by increasing their and should regain prominence. International Monetary Fund, domestic fi nancing of high-priority health and health- Washington, DC, USA related investments. Fiscal policies are a powerful and underused lever for (S Gupta PhD); The Lancet, • Assessment of VLYs strengthens the case for allocating curbing of non-communicable diseases and injuries London, UK (R Horton FMedSci); Department of Health Policy a higher proportion of offi cial development assistance The burden of deaths from non-communicable diseases to development assistance for health. (NCDs) and injuries in low-income and middle-income www.thelancet.com Published online December 3, 2013 http://dx.doi.org/10.1016/S0140-6736(13)62105-4 1 The Lancet Commissions and Management, Mailman countries can be reduced by 2035 through in- which aims to inform global thinking on a specifi c topic School of Public Health, expensive population-based and clinical interventions. (panel 1). WDR 1993, Investing in Health (fi gure 1), is the Columbia University, New Fiscal policies are an especially promising lever for only WDR so far that has focused on global health. It was York, NY, USA (M E Kruk MD); Department of Molecular reducing this burden. the fi rst major health report to be targeted at fi nance Biology and Woodrow Wilson ministers and remains one of the most widely cited School, Princeton University, Opportunities: WDRs in the Bank’s history.2 Princeton, NJ, USA (Prof A Mahmoud MD); Bank of • National governments can curb NCDs and raise WDR 1993 showed fi nance ministers that well-chosen Botswana, Gaborone, signifi cant revenue by heavily taxing tobacco and health expenditures were not an economic drain but an Botswana (L K Mohohlo MSc); other harmful substances, and they can redirect investment in economic prosperity and individual well- Chief Economist’s Offi ce fi nances towards NCD control by reducing subsidies being. It argued that allocation of resources towards (Prof M Ncube PhD) and Human Development Department on items such as fossil fuels. Investment in strength- cost-eff ective interventions for high-burden diseases (A Soucat MD); African ening health systems to deliver packages of cost- off ered a rapid and inexpensive pathway to improve- Development Bank Group, eff ective clinical interventions for NCDs and injuries ments in welfare. Tunis, Tunisia; Bureau for is another important national opportunity. Prompted by the 20th anniversary of WDR 1993, a Global Health, United States Agency for International • International action should focus on provision of Lancet Commission on Investing in Health was launched Development, Washington, DC, technical assistance on fi scal policies, regional co- in December, 2012. The Commission was chaired by USA (A Pablos-Mendez MD); operation on tobacco, and funding of population, Lawrence Summers, the Chief Economist at the World Public Health Foundation of policy, and implementation research on scaling-up of Bank responsible for choosing global health as the focus India, New Delhi, India (Prof K S Reddy DM [Card]); interventions for NCDs and injuries. of WDR 1993, and co-chaired by Dean Jamison, lead Results for Development author of WDR 1993. The Commission aimed to consider Institute, Washington, DC, USA Progressive universalism, a pathway to universal health the recommendations of WDR 1993, examine how the (H Saxenian PhD); and coverage (UHC), is an effi cient way to achieve health context for health investment has changed in the past Department of Economics, University of Oslo, Oslo, and fi nancial protection 20 years, and develop an ambitious forward-looking health Norway The Commission endorses two pro-poor pathways to policy agenda targeting the world’s poor populations. (Prof K H Ulltveit-Moe PhD) achieving UHC within a generation. In the fi rst, publicly The time is right to revisit the case for investment in Correspondence to: fi nanced insurance would cover essential health-care health. We are in the closing era of the Millennium Dr Gavin Yamey, Evidence to interventions to achieve convergence and tackle NCDs Development Goals (MDGs). Although tremendous Policy initiative, Global Health Group, 50 Beale Street, Suite and injuries. This pathway would directly benefi t the progress has been made towards MDGs 4–6, a very high 1200, Box 1224, San Francisco, poor because they are disproportionately aff ected by preventable burden of infectious, maternal, and child CA 94105, USA these problems. The second pathway provides a larger mortality will still remain by 2015. The global develop- [email protected]. benefi t package, funded through a range of fi nancing ment community is debating both a new set of post-2015 edu mechanisms, with poor people exempted from payments. sustainable development goals and the positioning of health, including universal health coverage (UHC), in Opportunities: such goals. We are also in an era in which the landscape • For national governments, progressive universalism of global health fi nancing is undergoing major changes.