Global Health 2035

The World Bank’s Global Health 2035 report sets out some bold ambitions for the next two decades, but they are achievable with the right investment.

Global rates of infectious diseases and mortality from reproductive, maternal, newborn, and child health in low- or middle-income states are set to fall sharply. By 2035 they should rival the current rates in the best-performing middle-income countries: Chile, China, Costa Rica and Cuba.

The World Bank report is Global Health 2035: A World Converging within a Generation.

The report makes the case that:

* The returns on investing in health are even greater than previously estimated (nine to twenty times the return for money spent)
* Within a generation—by 2035—the world could achieve a “grand convergence,” bringing preventable infectious, maternal and child deaths down to universally low levels
* Taxes and subsidies are a powerful and underused lever for curbing non-communicable diseases and injuries
* Progressive universalism, a pathway to universal health coverage (UHC) that targets the poor from the outset, is an efficient way to achieve health and financial protection.

The main reason for optimism is the huge progress that has already been made achieving health goals in the last 20 years. Technological and scientific advances continue, and poorer countries’ GDP growth means they are no longer so dependent on aid. Yet the authors argue that a new spending push is needed to prevent around 10 million deaths in low-income and middle-income countries. That means scaling up efforts to tackle HIV/AIDS, tuberculosis, malaria, neglected tropical diseases and maternal and child health conditions, and focusing spending on poor, rural populations.

For the 34 lowest-income countries, says the report, such initiatives will cost an estimated US$23bn-27bn a year in total, or around US$24 per person in 2035, around 60-70% of which would go on improving health systems. For the 48 lower-middle income countries, it would cost another US$38bn-53bn a year, or about US$20 per person in 2035. To justify that expenditure, at a time when many countries are only just recovering from the 2008-09 financial crisis, the authors have calculated a value for additional life years (VLYs) and added it to GDP growth.

If low-income economies grow as expected, using the VLY calculation, then they would need to stump up an additional 3% of annual GDP growth; for low-middle-income countries it would be 1%. But the benefits would exceed the costs by a factor of about nine, and most of the costs can be met domestically. Based on these projections, the wealthier countries could mostly self-finance the package with some non-concessional loans from the World Bank. For low-income countries, a mixture of external grants and concessional loans would be needed on top.

Fighting cancer

The report also focuses on how to nip in the bud a new and growing threat in low- and middle-income countries: non-communicable diseases (NCDs). Cancer, diabetes, hypertension and heart disease are already the biggest killers in wealthier states, but they are becoming a growing burden in poor countries too as smoking, junk food and physical inactivity take hold.

The report says ramping up preventative measures, including taxation, regulation and information, will help to ease the burden of NCDs. It also recommends a select number of essential packages for dealing with cancer, such as Hepatitis B vaccines to prevent liver cancer, although other cancers may be harder to tackle. More broadly, low- and middle-income countries should roll out a universal health coverage plan that focuses on the poor, either by covering essential diseases only or by offering a more comprehensive plan that charges wealthier patients for premium services.

Internationally, the focus should be on capacity building, providing political, legal and technical leadership, and carrying out implementation studies for clinical packages. The authors want investments in drugs, diagnostics and vaccines to rise from US$3bn to US$6bn a year by 2020, with the fight against drug-resistant bacteria a priority, but it does not say who will absorb these costs. Overall, foreign aid should support a transition away from direct financing.

These are all achievable goals, say the authors, particularly given the progress that has already been made. Yet the report’s financial calculations rely on low- and middle-income countries growing at steady rates, without financial crises, pandemics or natural disasters. Even if that happens, persuading low- and middle-income countries to allocate a bigger slice of their budgets to healthcare may prove a long-term challenge.

There is an enormous payoff from investing in health

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.

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 lifetimes

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.

Fiscal policies are a powerful and underused lever for curbing of non-communicable diseases and injuries

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.

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.

The Commission’s modelling suggests that by 2035 nearly all countries could reach the frontier of feasibility—that is, they could reduce their infectious, maternal, and child mortality rates down to those currently seen in the best-performing middle-income countries (eg, the 4C countries: Chile, China, Costa Rica, and Cuba). Quantitatively, we express this goal as “16—8—4”, referring to the target of an under-5 mortality rate of 16 per 1000 livebirths, an annual AIDS death rate of eight per 100 000 population, and an annual tuberculosis death rate of four per 100 000 population. Unprecedented opportunities exist for both national governments and the international community to contribute to the achievement of such convergence.

National opportunities

Through aggressive scale-up of existing and new tools to tackle infections and RMNCH (Reproductive, Maternal, Neonatal & Child Health) disorders, low-income countries could converge with the 4C countries by 2035. Convergence would prevent about 4·5 million deaths in low-income countries in 2035, at an annual incremental cost of around US$23 billion per year in 2016—25 and US$27 billion per year in 2026—35. Most of these incremental costs are to finance the crucial health systems components (eg, skilled health workers) that will be needed for the delivery of interventions. With use of full income approaches to estimate the economic benefits of convergence, the benefits would exceed costs by a factor of about 9. Benefits of this magnitude will only be realised if the additional funds are targeted at the correct mix of interventions (ie, if there is allocative efficiency), and if health systems are strengthened so that they can deliver health services.

The expected rise in GDP in low-income countries will allow them to finance much of the convergence agenda from domestic sources. For example, if public spending on health in low-income countries increases from its current rate of 2% of GDP to 3% by 2035, and if countries allocate two-thirds of this increase specifically to infections and RMNCH disorders, about 70% of the incremental costs of achieving convergence could be financed domestically. Domestic fiscal space could also be created by mechanisms such as increases in tobacco taxation and removal of subsidies on fossil fuels.

Most of the burden of infectious and RMNCH diseases lies in the more deprived subpopulations of middle-income countries. Our understanding of the global map of disease is therefore changing. These countries are in a better position than low-income countries to mobilise domestic finance and so they have an even greater opportunity to achieve convergence. Across lower-middle-income countries as a group, such an achievement would prevent about 5·8 million deaths in these countries in the year 2035, costing an additional US$38 billion per year in 2016—25 and $54 billion per year in 2026—35. Benefits would exceed costs by a factor of about 20. Our modelling suggests that these countries will easily have sufficient domestic resources in the next 20 years to finance the convergence agenda.

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