Following up on a groundbreaking 1993 report from the World Bank, a new report by a Lancet Commission argues that concerted investment in health in the next 20 years can reduce infection, maternal and child mortality rates around the world to low levels.
Last year the Lancet had the good idea of establishing one of its commissions to reprise the work of the World Bank’s highly influential 1993 World Development Report (WDR) Investing in Health. To do this, it asked Lawrence Summers, the Bank’s chief economist in 1993, and Dean Jamison, the principal author of the 1993 WDR, to co-chair a new commission comprising many of the great and good of the global health community, past and present. Their report Global Health 2035: A World Converging Within a Generation is published today.
The 1993 WDR was a milestone: the world’s premier development institution for the first time applying its intellectual firepower in its flagship annual report to defining appropriate policies towards health. It was an innovative report – it popularised the use of disability-adjusted life years (DALYs) as a key methodology for assessing the relative cost-effectiveness of health interventions. And it was a controversial report – it encouraged the use of the private sector in delivering health care, and user fees as a way of financing delivery. This came in the context of the Bank’s commitment to structural adjustment, market-based policies and fiscal retrenchment.
The three key messages of the WDR were:
- Foster an environment that enables households to improve health. Pursue economic growth that will benefit the poor, invest in education, particularly for girls, and promote the rights and status of women.
- Improve government spending on health. Implement a package of public health interventions and essential clinical services that offer best value for money. This is where the DALY analysis was used to identify the most cost-effective interventions.
- Promote diversity and competition. Promote social and private health insurance and encourage public and private suppliers.
The current commission’s report is not for the faint-hearted – 58 double-columned pages with 268 footnotes, accompanied by 93 pages of appendices and 46 Excel worksheets. So this is ‘evidence-based policymaking’ par excellence, and a solid follow-up to the equally comprehensive 1993 WDR.
The report’s key innovation (akin to the DALY) is to support and popularize the concept of ‘full income’ – adding to conventional national income measures a valuation of the increase in life expectancy. On that basis it estimates that, between 2000 and 2011, 24 per cent of the growth in ‘full income’ in low and middle income countries was due to health improvements, equivalent to a 1.8 per cent per annum addition to GDP growth. Based on this methodology it concludes that ‘there is a very large payoff from investing in health’.
Its other big idea, captured in the title, is that with rising incomes in the developing world and continued improvements in health and delivery technologies, an achievable goal for nearly all countries in 2035 is to bring down infection, maternal and child mortality rates to the current levels of the four best performing middle income countries (Chile, China, Costa Rica and Cuba).
The commission reckons that this could be achieved mainly through self-financing, but the international community will need to chip in for the low income countries and through doubling support to biomedical and health systems research aimed at poor countries. Health should be assigned a higher priority within development assistance. Development of new tools to tackle the ’global crisis of antibiotic resistance should be high on the agenda’. In general more resources need to be devoted to global public goods that cannot be provided by national governments alone – including better disease surveillance and capacity to respond to pandemics, standard setting, technical leadership and knowledge sharing.
This might require more support for the World Health Organization (WHO), including ’significant organisational restructuring’ on its part. The commission recommends low-cost packages of public health and clinical interventions focused in particular on combating non-communicable diseases. Fiscal policies should be used actively to discourage risky behaviours, as well as raise resources.
Finally, attempting to distance itself from the more controversial parts of the WDR, the report treads delicately in the area of universal health coverage (UHC) by calling for ‘progressive universalism’. This is a two-pronged approach to achieving UHC.
Like the WDR it recommends public finance of a defined set of key interventions for all, particularly aimed at the health needs of the poor, but it clarifies that this time there would be no charges. Also like the WDR it envisages alongside this a ‘larger package of interventions’ financed through a variety of mechanisms (taxation, insurance, co-payments), but this time it wants the poor to have free access to this second package. It acknowledges, but does not address, the severe problems in managing such a system, including determining the eligibility for free access. This two-tier approach is therefore likely to remain controversial.
The Lancet also provides commentaries on the report by three global health leaders – Richard Horton (Lancet editor), Margaret Chan (WHO) and Mark Dybul (Global Fund) and heads of two key development institutions (Jim Kim of the World Bank and Helen Clark of the UN Development Programme). While the first group is largely favourably disposed, the latter two both focus on the commission’s failure to address the social and economic determinants of health. The report essentially argued that there are ‘complex and entrenched political obstacles’ to addressing them so it is better to focus on the health sector where a more immediate impact can be realized.
Kim and Clark argue strongly against this – they contend that there needs to be a balance between investments inside and outside the health sector if the goal of improving health is to be achieved. The global health community will need to heed these words if it wishes to find a proper place for health in the post-2015 development agenda.
The Chatham House Centre on Global Health Security has established two high-level working groups on governance and financing which will report in 2014.