A Grand Convergence in Mortality is Possible: Comment on Global Health 2035

The grand challenge in global health is the inequality in mortality and life expectancy between countries and within countries. According to Global Health 2035, the Lancet Commission celebrating the 20th anniversary of the World Development Report (WDR) of 1993, the world now has the unique opportunity to achieve a grand convergence in global mortality within a generation. This article comments on the main findings and recommendations of the Global Health 2035.

celebrating the 20 th anniversary of the WDR 1993, the world now has the unique opportunity to achieve a grand convergence in global mortality within a generation.

Investing in health
Global Health 2035 is an ambitious new investment framework to begin closing this health gap. Written by a group of economists and global health experts, Global Health 2035 argues that a convergence is possible for infectious, child, and maternal mortality. Major reductions in the incidence and consequences of Non-Communicable Diseases (NCDs) are also within reach. Their findings can be summarized in four key points:

A "grand convergence" in health is achievable within our lifetimes
Countries can learn from middle-income countries that have made wise investments in health. The report points to the "4C countries"-Chile, China, Costa Rica, and Cubawhich started off at similar levels of income and mortality as today's low-income countries. They are now among the bestperforming middle-income countries. Low-income countries can, and should, scale up existing (and new) interventions targeting reproductive, maternal, neonatal, and child health conditions, as well as infectious diseases such as Malaria, TB, and HIV/AIDS. Since the 4Cs have achieved such a remarkable mortality reduction in these areas, we know it is technologically and medically feasible. The opportunity is here, the impact on health would be immense, and the cost not unreasonable if seen in the correct perspective. The Commission estimates that for 34 low-income countries, the extra cost will be about 23 billion US dollars annually from 2016-2025, rising to around 27 billion US dollars annually from 2026-2035. For lower-middle-income countries the extra cost will be about 38 billion US dollars annually from 2016-2025, rising to around 53 billion US dollars annually from 2026-2035. These are large numbers, but what is remarkable is that the expected economic growth of middle-income countries will allow these countries to finance "convergence" entirely from domestic sources. The issue is political will and capacity to increase mobilization of domestic resources for health, to make inter-sectoral reallocations, and to improve technical efficiency (17). Low-income countries will require some external assistance, but they will be able to finance much of the incremental cost of achieving "convergence" themselves.

The returns to investing in health are even greater than originally estimated
Earlier macro-economic studies have explored and documented the national income gains from improved population health, not least increasing life expectancy. What is new in this report is that the Commission has taken what is called "full income" into account. Full income values not only economic productivity gains, but assigns also a monetary value to the intrinsic benefits of increased life expectancy. By combining demographic estimates of increasing life expectancy with the value of a statistics life (18), converted to the value of additional life years (8), the direct value of health improvements is captured in a way, and with results, that are truly noteworthy. For example, by looking only at "convergence" of under-five mortality, the increase in life expectancy could be up to 6.7 years for lowincome countries (19). This, by reflection, translates to a huge benefit measured in monetary terms. The Commission estimates that for every dollar invested in convergence-related interventions, the economic benefits are 9-20 times higher (8). That is, indeed, a remarkable return on investments. The message is clear: investing in interventions targeting infectious diseases, reproductive, maternal, neonatal, and child health conditions is not only cost-saving in the long run; it is also a very good investment.

Fiscal policies and well-designed interventions can dramatically curb non-communicable diseases and injuries
The commission also looked at emerging chronic diseases and injuries. They propose a package of essential interventions consisting of cost-effective clinical interventions for NCDs and injuries, as well as powerful public health interventions such as increasing taxes on tobacco and alcohol (in countries where this has not been done) and reducing subsidies on items such as fossil fuels, which produce air pollutants that cause NCDs. For example, a 50% tax on tobacco could prevent 20 million deaths in China and generate 20 billion US dollars additional revenue annually.

Progressive universalism is an efficient way to achieve health and financial protection
From my perspective, the most remarkable conclusion, from this commission of economists and global health experts, is that "progressive universalism"-a term coined by Davidson Gwatkin and defined as a pro-poor pathway toward Universal Health Coverage (UHC) (20)-is an efficient way to achieve health and financial protection. The first pathway towards UHC that they recommend, and which I support, makes the "convergence interventions" the key. UHC should first protect everyone "by covering essential healthcare interventions to achieve convergence and tackle NCDs and injuries. This pathway would directly benefit the poor, because they are disproportionately affected by these problems" (8). Later, and in addition, a broader package funded through a wider range of financing mechanisms can be offered.

Conclusion
In summary, there are grounds for optimism in global health. Low-and middle-income countries can: 1. Aim for convergence in mortality and life expectancy with the 4Cs, the best-performing countries, within a generation. 2. Define and scale up essential services targeting infectious diseases, reproductive, maternal, neonatal, and child health conditions, and expand the range of services targeting NCDs and injuries. 3. Merge the idea of convergence interventions and the goal of progressive realization of universal health coverage. Essential interventions are good investments, they are the first important step on the path to UHC, and they will improve both health and provide financial protection. 4. Increase revenue for health from economic growth, increased mobilization of domestic resources, intersectoral reallocations and efficiency gains. For the poorest countries, external resources are needed. 5. Justify this use of resources with reference to the fact that for every dollar invested in essential services aiming at "convergence", the economic benefits are 9-20 times higher. Now that we have a better idea of what to do, and why, the next step is to understand better how. The challenge remains: Massive health inequalities still exist across countries. The vast majority of people who die from preventable deaths caused by infectious diseases or maternal and child health conditions live in low-and lower-middle income countries. A convergence is possible, but we are not there yet.

Ethical issues
Not applicable.