Global Health 2050: The Path to Halving Premature Death by Mid-Century

Rachel Nugent: Good morning, good afternoon, good evening. I'm Rachel Nugent, one of the commissioners of this report that we'll be discussing today. Former Vice President and Director of Global Non-Communicable Diseases at RTI International, former Director of Disease Control Priorities Project, and even former CGD. We're delighted to have you here with us today, and I'll be your moderator and timekeeper. One bit of housekeeping before we start. Please put your questions in the Zoom questions function for the Q&A session that we will have after the presentations.
Without further delay, let's go. I'm going to introduce Larry Summers, who will give us our keynote. First, a little bit of background. Some might say that the global health enterprise has been going through rough times in recent years. Setbacks in some areas such as malaria and polio eradication, vaccination in general being questioned. The failure of the global community to address the pandemic equitably and COVID havoc in some countries calls for decolonization of global health, lagging progress in the SDGs.
All of these things make our jobs look very tough and along comes this new report from the investing in health team and the Lancet assuring us that the world can reduce premature death by 50% and make progress towards UHC by 2050. Are they right? This report being CIH 3.0, is the third time the charm or is this just kicking the can down the road? We have an amazing lineup of speakers today to answer that question for us, starting with the esteemed Professor Larry Summers.
I suppose it's de rigueur to say that Larry needs no introduction, but nonetheless, I'll do my job right, so they don't fire me. Larry is the Charles W. Eliot University Professor at Harvard University and the Weil Director of the Mossavar-Rahmani Center for Business and Government at Harvard's Kennedy School. He's had a bunch of other jobs, including Secretary of the Treasury, Director of National Economic Council, President of Harvard University, Chief Economist of the World Bank. Today he's going to give us his views that are reflected in the CIH report that the rest of the panel will then be discussing. Over to you Larry.

Lawrence H. Summers: Thanks very much. It's very good to be at this gathering. It's very good to be at a CGD event. I believe CGD makes enormous contributions to the world on many different dimensions. It's good to be reunited with the team that has worked on CIH 1, CIH 2, and CIH 3. This is something that it was almost accidental that I got myself into more than 30 years ago but has been a source of deep intellectual interest and deep personal satisfaction for me.
In the summer of 1992, when I was serving as Chief Economist of the World Bank, it was my task to decide what the next world development report would be written about. At the time, the bank had propounded on the importance of price liberalization, private sector privatization, and financial structure reform in a variety of quite helpful ways. It seemed to me that on the one hand, it had lost a bit of sight of the fact that development was fundamentally about better lives for people and there was no aspect of better lives for people that was more important than being healthy.
It seemed to me, on the other hand that the kind of techniques that an economically oriented organization like the Bank prided itself on were very applicable to the health sector, in terms of assuring that resources were most efficiently used, carrying out cost-effectiveness analysis, thinking about structures of incentives, and that it was a very important lesson that the more you care, the more important it was that you count and do careful analysis.
Motivated by those two considerations, I made the judgment that I would encourage the senior management of the Bank to accept the idea of writing a world development report on health. I very quickly made the judgment that since I wanted a team that would not be afraid of challenging conventional bank wisdom, that I wanted a team that would be substantially analytically oriented, and because I was prepared to live with a trade-off that was somewhat more pointed towards intellectual quality and somewhat less pointed towards punctiliousness about punctuality, that the right thing for me to do was to ask Dean Jamison to lead and assemble such a team.
Dean did, and we wrote the report. I had a number of fascinating experiences along the way, not just reading the report, but visiting and touring various health projects in various parts of the world. I think everyone who is involved in that effort can take great pride in it.
I believe the Bank prints 120,000 copies of that report. I believe it's also true that one of those copies was probably the most important and may have been as important as any 10,000 others. It was the one that was read by Bill Gates who concluded that there was a lot that was similar between software and global health. Both involved technological innovation, both had high fixed costs, low marginal cost aspects, both involved achieving substantial global penetration, and both could do a great deal to make the world a better place.
Bill has said that this report was important in leading him to decide to orient his philanthropy substantially around issues of global health. The report emphasized the importance of targeting specific conditions and specific areas where burdens were greatest. The report called attention at that early stage to the transcendent importance of AIDS.
Including through its emphasis on AIDS, it emphasized the theme of global public goods and the need to make investments, particularly investments in new treatment approaches that would have payoffs that were global even though the costs in them were local. One was encountering global public goods challenges.
The report highlighted the enormous damage done by substances in general and tobacco in particular. It suggested that it really was possible to make very, very substantial progress in global health. Indeed, in the decades that followed, child and maternal mortality rates were cut more than in half. It's perhaps inevitable in the modern world that successes are followed by sequels, and there was an effort in 2013, also under the auspices of the Lancet, to pull together a version of the original group with a great number of additional experts who could track what had happened in the intervening 20 years.
We wrote a report that highlighted that there had been major progress over 20 years, that that 20 years created grounds for very substantial optimism going forward, and we set what is maybe the grandest of goals. We called it grand convergence.
We observed that mortality rates all over the world had been substantially similar in 1750. Life was, in Hobbes phrase, for almost everybody, nasty, brutish, and short. We suggested that after the huge divergencies with life expectancies in some countries, twice life expectancies in other countries, with child mortality rates in some countries, 10 times child mortality rates in other countries, that we could again aspire to a converged world in terms of health indicators. This time on favorable grounds of long-life expectancies and limited mortality rates.
We set that goal of grand convergence, and we spoke about how investments in health had payoffs if you measured all of their benefits that could easily be 10 to one, some contexts even 20 to one, and that those were standard investments and that there were potentially even larger investments to be realized from investments in global public goods. We reviewed progress, it didn't live up to all our high hopes five years ago. Then the Lancet, which I guess is sequel oriented, convened our group once again about a year ago to produce the current report.
The current report, which I think extends in some very important ways the broad themes in the earlier analysis, sets a ambitious goal. The goal that this time is very calibrated to country's initial conditions. The metric we focus on is premature mortality defined as death prior to the biblical age of three score and 10. The question asked is, in each country, what is the probability that a person born on current mortality statistics would die before the age of 70? That is a number that varies widely, it is the cutting edge in certain parts of Western Europe, close to 10% in the United States, and China it is in the range of 20%. There are other developing parts of the world where it is far less favorable than that.
We believe that wherever you start, if the right choices are made, it is reasonable to aspire to cut that child mortality rate in half by 2050. That's why our slogan is 50 by 50, 50% reduction in premature mortality by 2050. As someone who has recently become a grandparent, I think of it as having a lot to do with how many people will miss the opportunity to ever meet their grandchildren because their life has been cut short. It's not enough to set goals without talking about means, and you'll hear more in the course of the panel discussion about the means, and you'll hear it with more medical granularity than an economist like me is able to provide.
I'll just conclude by talking about a few of the lessons in the report that seem most important to me. Number one, focus on a few specific conditions, particularly given all the progress the world has made in infectious disease on NCDs, and that the right approaches to a limited number of conditions can provide enormous benefits. Number two, the immense significance, it's not all that intellectually interesting to highlight, but every time I see the numbers, I am struck by the moral force that, yes, there are a whole variety of good and bad habits and better and worse public health practices. Tobacco and less tobacco is of transcendent importance for the global health prospect and for reducing premature death.
Some progress on tobacco is worth immense progress on a variety of other conditions. Some of that has to do with tax instruments. Some of that has to do with various kinds of regulatory policy. Some of that has to do with public health education. Some of it has to do with labeling, which is an aspect of regulation, but I would underscore the importance of tobacco.
Next, the report I found, and this has been a preoccupation of mine now for close to a decade. Dean and I co-authored work in the late 20 teens when the term COVID would've been something where people would've thought about a collaborative video production.
As a suggesting that on plausible calculations of the kind used by the reinsurance industry, the cumulative present value of pain that humanity would suffer from pandemics was of the same broad order as the cumulative present value of the pain associated with climate change. Yet climate change received 100 times more attention from the policy community. We had no sense that climate change was receiving excess attention, if anything insufficient attention given that it also has health costs, but it seemed to us that pandemics were receiving much too little attention.
Then we had COVID, and I will just record that it's my judgment that the odds are purely better than even that we will have another COVID scale event within the next generation. I do not believe that the world is remotely, appropriately prepared to avoid what is a catastrophe whose total social cost or mitigate a catastrophe whose total social cost I believe would be comfortably in the tens of trillions of dollars.
Finally, in terms of the conclusions that I'm going to highlight, the report focuses on assistance and the importance of targeting assistance. The point about targeting specific conditions is in many ways analogous to the point about targeting assistance. We highlight the importance of increased funding of global public good type efforts, whether that's new technologies or means for the development and dissemination of new technologies or efforts to address pandemics. We also highlight the importance of targeting resources on the most resource-scarce environments and on the environments where there is the most least risk of new funding being made fungible.
We believe that there has been some reorientation of global health assistance priorities over the years, but insufficiently in the direction of focus on the most needy environments and on the issue of global public goods. Finally, we, also in the report, emphasize the importance in a number of different respects, which I hope my colleagues will get into in the discussion of being properly nuanced about where markets work and where markets do not.
We speak of the Arrow mechanism, the idea that for many conditions, the use of government scale economies and market size to purchase cures at the top of the pipeline and then disseminate them through the system can lead to far more efficiency in the use of resources and far more effective distribution of effective treatments. My last remark. I am very much aware that for friends of a view of an inclusive, generous, humane global community, there is not a sense that all the winds are blowing in our direction in light of recent events.
I certainly can understand that, and I'm not going to argue with that conclusion. What I would note, however, is that it is the overwhelming lesson-- two overwhelming lessons of all the analysis that I've ever seen in this area. One is that the progress of technologies and their dissemination, which is not a fundamentally political thing, is something that has an enormous effect.
That, at a moment when the political winds were not blowing well, there was remarkable progress in vaccine development, the likes of which and speed of which had never been seen previously. Even in a complex environment, important aspects of progress are possible. I would also caution that it is better for each of us to think about the difference we can make rather than simply to cry the storms.
I believe that individual choices by individual policymakers can make an enormous difference in a set of local environments that cumulatively constitute global health outcomes. I hope some of the ideas in this report point to productive directions.

Rachel: Thank you very much, Larry, for those encouraging words and for the 30-year overview of the raison d'être for this report. That gives us a lot to talk about. If we can beg your indulgence for a question or two, maybe a big picture question or two, before we get into details of the report with the panelists. Thank you. Let me start with this, recognizing we're here under the auspices of CGD, a very impactful organization that you've been associated with for a very long time.
I recall, and this will be a paraphrase, I think, words of Nancy Birdsall, the founding president, a small place with a big impact, and I think that has been demonstrated many times. With your CGD Board Chair hat on, could you comment on the urgency and priority of the recommendations of this report relative to the other global development issues, the many global development issues that CGD focuses on, and whether you think there's a possibility to align development actors, especially funders, to achieve these objectives? Over to you.

Lawrence: Rachel, now close to 35 years of involvement in the international community, I've seen a lot of reports. I've seen questions like the one you just asked, asked many times, and I've never heard the presenter of the report say, "Well, ours is a good report, but there are a lot of great reports and ours aren't particularly urgent and essential priorities. They're just one bit of risk for the mill." I've never heard that answer given, and I'm certainly not going to be the first to give it.
I would just say these things. One, when I look at estimates of the cumulative benefit attempting to put everything into a money metric, so valuing a year of premature death averted, or valuing a dolly created at adding it all up, I think that a substantial fraction of the highest return investments are investments in the healthcare sector. I think these are more important recommendations than recommendations about getting it better in many other sectors.
The second thing that I would say is that, look, it is a very difficult period for foreign assistance. The areas, more budgetary pressure in more countries coming from deficits and debt than at almost any time in the last generation. There is more competition for international affairs budgets coming from within, coming from security issues, I think principally of Ukraine and the Middle East and a felt need for re-armament in many countries than at any time since the Cold War ended. The pressures for nationalism are greater than at any time that I can remember, and that nationalist orientation tends to operate against international generosity. I don't feel inclined to any kind of Pollyanna.
I do remember that the political environment that produced PEPFAR, that did not come in the context of a moment or an era where the idea of a large, new global health initiative would've seemed propitious. I don't think most people would've expected that some kind of collaborative with the private sector effort with a name like Warp Speed would've proven to be as effective as it did.
I think we are seeing a world in which there are more people, frankly, with more control over resources and with a scientific orientation than they can spend in their lifetimes or their great-grandchildren can spend in their lifetimes who are at least rhetorically committed to deploying those resources in philanthropic ways and looking at ways to have maximum impact as they do it.
I think we are in a challenging environment, but I also think we have no alternative but to be putting the case and that it's a serious misreading of history to suppose that you can predict how things will unfold based on the nature of the political composition that seems to be prevailing at any moment. I am increasingly struck as I live through more history that a bit less of it is shaped by the political attitudes of current political leaders, and a bit more of it is shaped by events and ideas that I might have supposed a generation ago.

Rachel: Thank you, Larry. My takeaway is that miracles can happen, and I think that's probably comforting to me and maybe others at this moment. Do we have another few minutes with you or do you have--

Lawrence: Let's do one more question.

Rachel: Thank you. That's very generous of you. My question, moving from the big picture, and I think you've certainly given us food for thought there, too, something very specific. This is a heavily economics-oriented report published in a medical journal. Will economists pay any attention to it? If they do, what would you like to see economists do?

Lawrence: I'd like to see economists get themselves behind the broad conclusion, which is, this is high return investment relative to other stuff, and follow the logic of economics, which is that if you're a small actor in a big world, having a diversified portfolio of your interventions is unlikely to be the right thing to do, rather than deciding where the highest marginal return is and concentrating there. I'd like to see a bit less spread the butter evenly over the bread.
I don't understand why the World Bank thinks that the right thing to do is to be active, which has limited money relative to national economies in many of the countries in which it enters, why it decides that it is imperative to be involved in every sector, in every country, rather than make the best sector country combinations with the highest return, which I think will often be health investments. That is, in a way, the macro lesson.
I think the micro lesson is plan and budget in cost-effective ways. I think that economists who are prepared to roll their sleeves up and get a little bit engaged in the detail can have big effects on aspects of policy design, as the term Arrow mechanism, which came out of the malaria field, suggests as the idea of advanced price commitments as a spur to innovation, suggests as a variety of other kinds of analyses in this report, emphasizing in particular, the importance of fungibility as a caution on the one hand, and global public goods as a spur on the other would tend to suggest.
I think these are all areas where economists can make a contribution, and I think that it is helpful for part of the reason why I have stayed involved in these endeavors, is that I have become persuaded that it is helpful for health ministers to have voices that are seen as financial, and if you'll pardon my language, hard-ass, as embracing some of their preoccupations.

Rachel: Great. Thank you. I want to note CGD's involvement in some of those notable mechanisms that have been very impactful, and I hope going forward likewise. Thank you so much, Larry, for your time and your wisdom, as always. I'm going to turn to open up the panel. Larry, please stay with us as much as you can. To open up the panel discussion. We'll start with Gavin Yamey, who will share with us recommendations of the report. Gavin is the Director of the Center for Policy Impact in Global Health, based at the Duke Global Health Institute. Over to you, Gavin.

Gavin Yamey: Thanks, Rachel. Can I just check that you can see my slides?

Rachel: Yes, indeed.

Gavin: Wonderful.

Rachel: Not in slide view yet though, so I can see your notes too.

Gavin: Let me try. Is that better?

Rachel: That is not in slide view still, and you're on slide number two now. Back to slide one. Still not slide view. No. You could proceed like this.

Gavin: I probably will have to. I've tried every slide view option that there is.

Rachel: They look fine.

Gavin: Great. I'm going to kick off then. Thanks, Rachel. I'm delighted to present the seven key messages of the report. It's obviously a long report, 54 pages, 310 references, 50 authors, 22 advisors, 10 background research papers. I'm going to distill out the most important take home findings. Before I do that, let me just briefly say what I think the report is and is not. It's a high-level report led by two economists, product of discussion and debates among the folks I just mentioned, and its analysis of trends across all countries, high, middle, and low-income countries from all regions.
What it isn't is a prescription for countries. It's certainly not comprehensive. It doesn't cover everything that everyone wants us to cover, and we are the first to admit that it is not perfect. We have seven main messages, and the first message is, as you mentioned and Larry mentioned, nations that choose to do so can achieve what we're calling 50 by 50. We say that dramatic improvements in human welfare are achievable by mid-century with focused health investment.
By 2050, countries that choose to do so, that's important, could reduce by 50% the probability of premature death in their populations. That's the probability of dying before the age of 70 from a pre-pandemic 2019 baseline. We call that goal 50 by 50. We're talking about reducing the probability of premature death from 2019 to 2050. That's 31 years or less. There are two reasons why we believe that this is a feasible goal. The first is historical experience.
Since 1970, there are 37 countries that have halved their probability of premature death in 31 years or less, including seven of the world's 30 most populous countries shown here. As you can see, is a very diverse group politically, economically, geographically, and they differ in terms of their starting points. They start from high, medium or low probability of premature death. The second we do find optimistic-

Rachel: Gavin?

Gavin: -is continuing scientific advance. Dean Jamison and colleagues-

Rachel: Gavin?

Gavin: Yes.

Rachel: I'm so sorry to interrupt. We are not seeing your slides move, and I-

Gavin: Oh, okay.

Rachel: You're probably not intending to be on the first one still.

Gavin: I'm sorry about that. Do you think maybe CGD has a copy and there's a way that they could--

Rachel: You were on four.

Gavin: Slide five. If you could do slide five. I'm going to stop the share. Sorry about that. If you could share the slides and go from five and then I'll just tell you to move slide. Great. The second reason for optimism, Rachel, thanks for letting me know, is continuing scientific advance. Dean Jamison, who you'll hear from shortly and colleagues showed that about 80% of the decline in child mortality in low and middle-income countries from 1970 to 2000 could be attributed to the dissemination of health technologies.
Based on what is in the product development pipeline today, our own research suggests that we're going to have something like 450 new medicines, vaccines and diagnostics for infectious diseases and maternal health conditions before 2050. That is another reason for optimism. Next slide. Our second message is that sharp reductions in mortality and morbidity can be achieved early on the path to UHC. You don't have to wait for full UHC. We argue that the path to 50 by 50 is through a focus on 15 conditions shown here, ATAR infectious and maternal, and seven are noncommunicable diseases and injuries.
Those 15 conditions account for a very large fraction of the life expectancy difference between the highest reporting regions and other regions. For example, if we go back to 2019, our pre-pandemic baseline year, life expectancy was 60 years in Sub-Saharan Africa, 82 years in Western Europe and Canada. A 22-year gap. Our report shows that around three-quarters of that gap was from these 15 priority conditions.
Next slide. Our third message is that we argue that the UHC and health system strengthening agendas need a reset, and we propose what we call a modular approach. We argue that the UHC agenda has largely stalled. There has been little global progress in health service coverage since the start of the SDGs era with some exceptions. For example, the impressive rise in antiretroviral coverage and catastrophic health expenditure is going the wrong way. It is becoming more common.
We call for a reset. We argue that national governments maintain their focus on the public financing of a core set of interventions targeting these 15 priority conditions. Interventions that are fully prepaid, available to everybody, starting with those that are highest value for money, feasible to implement anywhere. We use DCP3 and the UHC compendium to identify these cost-effective interventions.
Next slide. We package these interventions into 19 modules. I've shown three examples of those modules here. These are modules for infectious and maternal health conditions. These can be delivered in primary healthcare, the routine childhood immunization module, the module for treating acute childhood illness in the pregnancy and childbirth module. You can see the high-priority interventions in each and the primary outcomes associated with each.
Along with modules that are targeting reduced mortality, there's also modules that are for improving quality of life. Rehabilitation, palliative care, child and adolescent development. They're not a prescription. Not every module, not every intervention is going to be relevant for every setting. They're really a starting point for deliberation, for local deliberation, although we expect that a substantial subset of modules will be relevant and important in most countries. They're not vertical programs. They are based on the foundations of healthcare system. They align with existing structures. We argue that focused investment on these interventions could really accelerate progress towards 50 by 50.
Our next message, our fourth message on the next slide, which Larry also mentioned, is that countries should publicly finance a short list of key medicines, vaccines, and diagnostics for these 15 priority conditions. We call this approach the Arrow mechanism, named for the late Ken Arrow, Nobel laureate, co-author of the first CIH report, who developed the mechanism as applied to malaria drugs. The Arrow mechanism has four components.
The first is redirecting general budget transfers to ministries of health to line item budget transfers for specific high-value priority drugs. The second is centralized pool procurement by government or perhaps internationally. The third is to procure large volumes to ensure availability. The fourth is to use and strengthen both public and private supply chain. The fifth message on the next slide is that tobacco is the new tobacco.
It's quite common to hear now that sugar is the new tobacco or sitting is the new smoking. We argue that tobacco is the new tobacco, that smoking remains the biggest avoidable cause of premature death in many populations worldwide. We review intersectoral policies and we argue that the most important intersectoral policy to achieve 50 by 50 is tobacco taxation. The Bloomberg Commission concluded that raising taxes on tobacco can do more to reduce premature death than any other single health policy.
Our sixth message on the next slide is that there's a high risk of another pandemic of COVID-like magnitude. In our report, we estimate that there were 23 million excess deaths during the emergency period of the pandemic, January 30th, 2020, to May 4th, 2023, almost all attributable to COVID. In a background study prepared for our report, Madhov and colleagues estimate that there's a more than 20% chance of a pandemic that kills at least 25 million people. Another way of expressing that risk is to say that on average there would be 2.5 million pandemic related deaths a year, and that's roughly the same number of deaths that are occurring annually now from AIDS, TB and malaria combined.
Next slide please. We look at the variation between countries in excess deaths during COVID. There was very large variation, particularly in the pre-vaccine period. It really suggests that public health fundamentals are going to be absolutely crucial for averting mass death in the next pandemic while waiting for a vaccine. Rapid response, identifying cases, contact tracing, isolating those who are infected, quarantining the exposed, and providing social and financial support for those who are isolating or quarantining.
Our final message on the next slide concerns the role of development assistance for health in supporting 50 by 50. We argue that there are two broad purposes, direct country support to countries that have the least resources, financial and technical for disease control and modular health system strengthening and global public goods. For example, reducing the development and spread of antimicrobial resistance, pandemic prevention and response, identifying and spreading best practices and developing new health tools in both cases, focusing on these 15 priority conditions.
Next slide. The other reason for optimism around product development is that we just finished a study showing that the way in which R&D is being done in global health, the ecosystem is becoming faster and more efficient through tools like AI and modular manufacturing and trial networks. It's another reason to be optimistic. My final slide, our analysis overall shows that there's a practical path to 50 by 50, focusing resources on high-priority conditions, scaling up financing to develop new health technologies.
We have updated estimates of the economic value of achievable mortality declines, that value is high. It's often a substantial fraction of the value of gains from economic growth itself. We say on the quote on the front of the report, "Today, the case is better than ever for the value of investing in health, for reducing mortality, morbidity, alleviating poverty, and improving human welfare." Back to you, Rachel.

Rachel: Thank you, Gavin, for that sprint through the recommendations. I'm sure the audience has read the report, so it's nice to get that review. We're going to move quickly over to Dean Jamison, the father and indeed grandfather of investing in health reports as Larry mentioned. Where is Dean now? Dean is the Emeritus Professor of the Institute for Global Health at the University of California, San Francisco. He's going to share with us what is different about this from previous reports. Over to you, Dean. We don't hear you there. Still muted. There you go.

Dean Jamison: Okay, I think that's got it. Thank you, Rachel. A great start. To respond to what's different, let me just briefly recapitulate some strong common themes going from 1993. One is the power of new knowledge, new products, the fruits of science and technology. Second is the extremely high payoff to focused attention of health system resources on priority conditions.
The third point that Larry made is that the returns in terms of reducing mortality and the economically valued benefits to that are high and they can be rapid relative to the returns on other investments. Those are three important common themes, but there are really quite important differences, particularly in this last report from what has gone before.
One of those concerns, and Gavin mentioned this, but I would stress it that our concern in this report is for countries at all income and mortality levels. The previous analyses have focused on low income, high mortality, and lower-middle-income countries, but they've focused particularly on high mortality environments and the conditions that have made those high mortality.
Here, we turn to much more explicit consideration of upper-middle-income countries, and even to some extent of high-income countries. Rachel has been a leader in this. The natural consequence of that broadening of attention is to be paying a lot more attention to non-communicable diseases and certain classes of injuries.
I think one of the novel aspects of this report is not only to place those issues much more substantially on the agenda, but also to point to the fact that as with infection, there are only a relatively small number of conditions, and for most of those conditions, moderately powerful interventions to reduce harm. That focused approach that we emphasized before in dealing with infectious disease, in achieving the grand convergence that Larry talked about, that focused approach extends very naturally to the NCD arena. That's a major additional area of concern.
Second, I would say, major change is how we think about the audience and why we think about a reorientation of the audience from aid donors to national governments. There was never an exclusive emphasis by any means on focusing our messages on the aid community. In fact, there was a lot of orientation to the interests and concerns, which were then motivated, obviously by the interests and concerns of the countries they're dealing with. In part because of the changed geopolitical environment, the problems laid bare by the COVID pandemic, the problems of inequities, of inefficiencies stemming in important ways from failures of solidarity.
The reorientation of, frankly, development assistance money in very substantial amounts away from development and mortality reduction and toward dealing with the Ukraine War of western development assistance. All of these concerns led us to change the emphasis in a substantial way in who we're trying to address toward national governments and toward regional organizations. That has implications for thinking about development assistance clearly. It has important implications for how we think about and how we wrote about improving the priority setting within governments.
I think Justina will speak more to this, but one of the concerns of a purely cost effectiveness, cost per life saved or number of lives saved per million dollars spent approach to thinking about construction of a health benefits package, is that it leads to some very odd constructions and it doesn't accord well with national priorities. We've developed an approach to breaking down cost-effectiveness analysis into modules that themselves could constitute the design of a health benefits package.
There's been a lot of concern within CGD and elsewhere that we're throwing out the economic efficiency benefits of a purely cost-effectiveness-based ordering of intervention priorities, I think, quite the contrary where allowing that to come into play but at a basic technical level rather than a larger overall level. I'm thinking that Justina will probably speak more to that.
One final set of comments on what's different about this report. There's a deep concern for long-term demographic trends in two ways. One of those is related to non-communicable diseases and the aging of populations, much larger numbers of people in the age range and just there are high incidents and high mortality for NCDs. We go through the numbers on that in quite a bit of detail. Parallel to that is the hollowing out of labor force size and therefore the tax base for public finance of the health sector.
We trace the numbers on those out to 2050 with some care, point to the financing problems and the demands on health systems problems that demography with its reasonably highly predictable inevitability will be posing in the future. The problems, not surprising, are very large. We point to some directions, but not, I think, very successfully to respond to that, that aren't simply raised taxes and expand the public sector involvement in a way that will need to be much larger just to stand still. We think there's something in the way of better ways, something in part around the Arrow mechanism, but those are some differences, Rachel, that I think are quite significant from the work that has been published before.

Rachel: Dean, thank you so much. I think this demonstrates how Dean's deep thinking over the years has created challenges and great employment opportunities for health economists to try to contribute to making the world a better place. We will, in the interest of time, quickly turn to Justina Seyi-Olajide. Justina is the-- just a second. Let me turn to the right page here-- is a pediatric surgeon working in the Department of Surgery at Lagos University Teaching Hospital and a researcher focusing on improving access to safe and high-quality surgical care.
I'm going to ask Tina if she could comment, from a country perspective, how to use the modular approach, how national health planners can use this new approach, and maybe, specifically, in Nigeria as it goes through health reform, how might modular approaches be used. Thank you. Over to you, Tina.

Justina: Thank you very much, Rachel. Speaking about how national health planners can use the modular approach, essentially the approach to health systems treatment and priority setting involves breaking down health planning into distinct modules with each module focused on specific health conditions, services, and delivery platforms until a lot of the country's epidemiology resource availability and policy priorities. This approach emphasizes cost-effectiveness and efficient allocation of resources and incremental progress towards achieving the universal health coverage.
Essentially, for national health planners, they would have to identify health sector programs or interventions that are critical to the population. Examples could include modules on maternal and child health, infectious disease control, or non-communicable disease, or even emergency and trauma care. The modules can then be designed based on delivery platforms or target demographics. Modular cost-effectiveness can then be used to assess the impact of interventions within each module, identifying high-value interventions that are likely to yield the greatest health outcomes per dollar spent.
Budgetary allocations that are tailored to the needs of each modules will now be done to ensure that resources are directed towards interventions with the highest potential impact. This would also include establishing baseline spending levels and plans for incremental increases based on the available funding. Modules are then aligned with National Health Benefit Packages, ensuring that the interventions are fully prepared and available to the population with little or no out-of-pocket costs. This would ensure equity and reduce financial barriers to access care.
Now for monitoring and evaluation, each module will include performance indicators and outcomes to monitor effectiveness. For example, for maternal health, we're tracking maternal mortality, skilled birth attendance, or access to emergency obstetric care. One of the advantages of this modular approach is that it allows for flexibility and enables health planners to adapt interventions, specific regions, populations, or emerging health challenges, allowing shifts to move towards areas of increasing boarding as they evolve.
Essentially, the modular cost-effectiveness analysis approach is a two-stage process but is not unidirectional with a political stage that involves societal and political tradeoffs for definition of modules and budgetary levels, and a technocratic stage where there is optimization of intervention mix within the modules to ensure maximization of cost-effectiveness through ensuring the best mix of interventions.
For us, in Nigeria, one of the ways that the modular approach can be applied is in terms of the primary surgery module in which the priority areas as defined by our report would include road injury, maternal conditions, genital conditions, and non-communicable diseases. Surgical interventions in the modules would then be trauma and emergency surgery, emergency obstetrics care, neonatal surgery and cancer surgery, and other relevant surgical interventions for non-communicable diseases.
These can also be further broken down into more detailed interventions within the modules to ensure that they are actually better focused and locally contextualized to the needs of the population. I think I'll just stop in the interest of time. Thank you.

Rachel: Thank you, Tina. Thank you. It's great to get those specifics because that's really where this report needs to go and is going into country planning and being presented to people across a range of countries. That's a great way for us to start thinking about it. Thank you, Tina. I'm going to turn now to Sanjeev. Sanjeev is Senior Fellow Emeritus at CGD and former Deputy Director of the IMF's Fiscal Department. Sanjeev, always the core question that's on everybody's mind, how does this get financed? How does the Global Health 2050 agenda get paid for? Over to you.

Sanjeev: Thank you, Rachel. It's a very important question because when you look back at the second CIH report, I don't think we really achieved the targets for raising resources. Let's see. What is the potential increase in health spending if low and middle-income companies were to implement 15 priority implementations by 2050? The commission has estimated that achieving full coverage will require an additional 2% of GDP in low-middle-income countries and 1% of GDP that is 2019 GDP or low-income countries. Essentially what that implies is that this expenditure in these countries would have to double.
Now let's look at what the current spending is. Current spending on health in these countries remains low. Public health expenditures in low and low-middle-income countries have stagnated at below 2% on average of GDP, roughly half of what these countries spend on education sector. Donor rate has similarly plateaued at around 1% percent of GDP for over two decades before the pandemic. While there was a temporary increase in aid during COVID-19, preliminary data indicates the return to pre-pandemic levels.
As Larry pointed out, looking ahead, the outlook for healthcare appears bleak given fiscal pressures on donor countries and shifting geopolitical priorities. As donor countries focus on reducing their own debt and debt-to-GDP ratios, and some of these countries are projected to reach 100% in the next couple of years. They're also increasing spending on defense and aging population.
Against that background, it seems highly unlikely that there'll be a significant increase in health aid to low and low-middle-income countries in the foreseeable future. What does that mean? It means that the countries will need to rely increasingly on their own resources, which are generally more stable. We know that external aid is volatile and is often aligned more with global agendas than with national priorities as identified in the CIH report.
To generate these internal resources, these countries will need to increase revenues. According to some of the IMF estimates that these countries could raise between 5% to 8% of GDP over a period of time. Of course, not right away, but what this estimates suggest is that there is a potential. People will say, "Oh, this is too much. Countries may not be able to do it," but there is a precedent for such increases.
Between 1990 and 2011, tax revenues in these regions grossed by an average of 2% to 4% of GDP, but this revenue growth has started to stagnate between 2012 and 2020. There are some low-income countries which are collecting less than 10% of GDP in tax revenue. Of course, this limits their capacity to provide essential funding for social sectors and development. The estimates that people have prepared, they suggest that if you want to help these countries to grow, they must need to mobilize at least 50% of GDP in tax revenues because that will help support growth-enhancing investments and also allow for progressive taxation.
Here, of course, the essential strategy would have to be broadening the base of value-added tax which has played a key role in countries that have successfully raised revenues. Of course, then there is the thing about enhancing the design of personal income taxes including implementing higher taxes on capital income such as interest, dividend, and capital gains. This suggestion applies not only to low-income and middle-income countries, it applies also to high-income countries. Then, what Larry said and what Dean has also said, taxing tobacco could also contribute to revenue to the budget while reducing premature mortality. Although, if taxation of tobacco lowers consumption of tobacco, then, of course, the tax base was also eroded over the time. It doesn't provide a stable tax base.
Other potential revenue sources include excise duties on alcoholic beverages, unhealthy foods, for example, sugary drinks and plastic waste. I think when we talk about generating more resources, we should not overlook the importance of efficient spending to generate fiscal space for health budget. I think this point was also emphasized by Larry. The first thing the health ministry would need to do is to ensure that the budgeted health funds are fully utilized, which is not always the case, particularly in Sub-Saharan Africa.
Understanding in health sector is estimated to result in a loss of $4 per person based on cost in 2020 prices, equivalent to what these countries currently spend on per capita basis on primary healthcare, so one can create a lot of fiscal space or budget space for health from existing resource allocation. Then, as a report points out, there is a scope for improving procurement processes of drugs and other health commodities, which are often inefficient and duplicative. Better coordination and consolidation and bigger processes could free a substantial resources.
Furthermore, strengthening priority-setting processes and establishing institutions to direct spending toward high-impact interventions could also increase the effectiveness of health spending. Finally, before I conclude, there's a need to reassess the issue of energy subsidies, which tend to benefit, generally, wealthier households. In 2022, global fossil fuel subsidies amounted to about $7 trillion with nearly 80% attributed to underpricing of environmental impacts. The remaining 20% are explicit subsidies, which have also increased since 2020.
Reducing these subsidies would not only generate additional revenue for governments, but would also mitigate global warming and reduce air pollution, thereby improving the health status of the population. I'll stop here, Rachel. Thank you.

Rachel: Thank you very much, Sanjeev. It's really encouraging to hear that there are sources of increasing the government purse for health. I'll just note that the countries that have increased health, what's called healthcare taxes now, taxes on tobacco, sugary substances, et cetera, have been more often surprised at the increases, the higher levels of revenue they've obtained. No country has so far seen an erosion from increasing tobacco taxes and erosion of revenue. There's a lot there that can be pursued.
Thank you so much, Sanjeev. We'll turn now to Eduardo. Certainly last but not least at all, Eduardo González-Pier is Senior Technical Director for Health Financing at the Palladium Group and Global Fellow at the Wilson Center. Over to you, Eduardo, please tell us how this report applies to emerging markets and what they might do with it. You're going to have to represent all emerging markets for us here.

Eduardo: Thank you, Rachel. It's a good question. I think Dean already mentioned that this report has a strong focus on middle-income countries just because of the measure of premature mortality. It might be useful just to remember a little bit some of the features about emerging markets and why this report can be especially relevant for them. There's many definitions of emerging markets. We're mostly talking about countries we're trying to transition, either from low-middle-income status to upper-middle-income status. Sometimes from upper middle-income status to high-income cap status.
We usually think about the BRICS, Brazil, Russia, India, China, South Africa, but I think there's more. One possibility is looking at the IMF definition of what it's meant by emerging markets. Take away the advanced economies as the IMF defines them and the low-income countries. We're talking about 50 to 60 countries that can be classified as emerging markets.
Another possibility is to look at the equity markets, the emerging markets index. They are very specific about these 24 countries that constitute emerging markets. Now, what are these features that make it so interesting I think for the report? I would mention four of them. Number one, these are countries which tend to be associated with FASCO. They're growing above average, and I think that's very important to what Sanjeev just said, and so did Dean. The tax base is expanding. That makes it particularly important for them to decide to pursue the 50 by 50 because they simply might be able to afford the 50 by 50.
There are also countries which are undergoing rapid industrialization, urbanization, fast growth of consumer spending. With that, they're facing emerging risk factors that could come with sedentarism, new diets associated to processed foods. Increasing prevalence of obesity, overweight, and the associated NCDs. These are also countries which are going through this double burden of disease. They still face the infectious disease, vaccine-preventable conditions, but now they're seeing the health systems burdened by NCDs, diabetes, mental health.
They tend to have overwhelmed health systems, mostly by this emergence of NCDs. That has translated in very large out-of-pocket payments, which haven't been compensated or addressed through public budget response. Something that can allow the health system, at least on the public side, to develop at the rate that the system is required them. Let me go through five of the seven messages that Gavin gave us. Think about why emerging markets are so relevant to them.
Message number one, which are the countries that have a higher chance of deciding to go for the 50/50 approach. Well, it might be emerging markets because they simply might have the tax base, the fiscal space to actually pay for this. These are countries that even if they don't start from a very high mortality base, it's been shown that they can reach the 50% reduction within the reasonable amount of years in terms. Of the second message, these are also countries which are struggling with UHC. Sometimes they've stalled. They're not doing very well with the indicators of UHC, so, a very strong message for them is, "You don't have to wait for UHC. You can still do the progress around reduced mortality, independent on how far ahead you're in the 2030 agenda."
I also think that the report is very clear about putting together these 15 priority conditions with its 19 modules, which are very much matched by this double burden of disease. It is about tackling at the same time, both the infectious diseases plus the 7 NCDs, including the injuries, which categorize the profile of health needs in developing countries. Tobacco, and I would add, most of the health taxes, are particularly relevant because it is associated with this new lifestyles which come along with increasing purchasing power of consumers in emerging markets.
Then I think the development assistance for health agenda is also very important because these are countries that are also transitioning away from dependence. They need to find the funds to do both, move towards total ownership, total reliance of domestic spending, and they need to mobilize resources to both substitute or work on the financial protection agenda and also strengthen their health systems towards providing these very essential services. There's many features about emerging markets that make it, I think, some of the best candidates to respond to this report with very productive strategies. Dr. Pier. Rachel. Thanks.

Rachel: Eduardo, thank you so much for that. There's a lot of food for thought and a lot of countries that we hope will be picking up some of those messages. We are blessed with a little bit of time for audience questions, not as much as we would have liked, but we do have a few questions, and I'd like to turn to Gavin. We have an audience question I'll read, and then interpret maybe a little bit with moderator prerogative. The question is, we know that using a systematic approach to scaling up can advance global health goals, but they're underutilized. I think meaning systematic approaches are underutilized. Can you suggest ways to mainstream this knowledge?
I think maybe because you focused a lot on disseminating this report to potential users, influential users, you could talk a little bit about mainstreaming the messages, especially the modular approach and some of the innovative ideas about premature mortality and how countries can hang on to these messages. Go ahead, Gavin.

Gavin: Thanks, Rachel. Great question. That's right. The next phase of this report really is trying to socialize the mainstream the messages. That's really in a number of different ways, we have been very lucky to have the opportunity, for example, to brief some of the agencies. Justina, Dean, and I spent a couple of days last week briefing the World Bank Health Nutrition Population team, PEPFAR, the USAID Global Health Bureau. USAID is kindly now organizing for us to do briefings with some of their specific country missions.
We are working with a number of different bilateral agencies as well. Several bilateral agencies are now putting out reports on what Global Health 2050 CIH 3.0 means for their development assistance. Last week, the Danish committee on Global Health published that report. The Swedes are going to do something similar early next year. Germany is putting out a report on what this means for Germany's CIH, so, that's terrific. Then the last thing I'll say is that at the country level, obviously, we think that there is a lot of value in the key messages that we shared today around modular health system strengthening, around focus, around some of the financing aspects that Sanjeev talked about.
We are now working with a number of different country governments on national commission processes that will play out over the next year, Nigeria, Nepal, China, hopefully, I think, Mexico. That's the next phase of this work.

Rachel: Fantastic. Great to hear. I'm sure the Lancet team is also excited to see this moving forward very deliberately. I'm going to invite any other of the panelists to comment on that question and then turn to Justina with another audience question. Any other comments? Okay, thank you. Justina, we have a question from an audience number and I'll read it to you. Why introduce the term modular approach to health systems strengthening in the report when diagonal approach to health systems strengthening, which we have heard and learned about over years, also emphasizes similar focus on disease and conditions? Do you want to take that on?

Justina: Thank you very much for the question. I'll just speak to it and any other member of the panel want to talk after me, I will upgrade. The modular approach to health system strengthening in our report emphasizes a specific flexible framework for planning and advocating resources within health systems, and it distinguishes it from the diagonal approach, which also integrates disease-focused and system-wide improvements, but follows a different conceptual focus.
For example, the modular approach while focusing on organizing health systems into discrete models, aligned with conditions, self-service delivery platforms, or interventions that are adaptable and designed to target priority areas using evidence-informed budgets and strategies to ensure clarity and focus. The diagonal approach, from my understanding, combines vertical and horizontal interventions leveraging disease-specific programs to strengthen the broader health system capacity. It emphasizes leveraging disease-focused investments to improve the general health system.
The modular approach is anchored in a forward-looking evidence-driven prioritization of interventions and services, while the diagonal approach focuses on integrating disease-specific gains, which might not always align with the specific condition-based targets of the 50 by 50 goal. We introduced the modular approach because it targets premature mortality by focusing on 15 high burden conditions, provides a clear pathway to address these priorities through specific interventions.
It makes it easier for policymakers and health planners to budget, implement, and evaluate interventions effectively, and it conduct contrasts a bit with the broader scope of a diagonal approach. It defines specific modules allowing for greater adaptability to local contexts, such as prioritizing non-communicable diseases in middle-income countries, or maternal health in low-income settings.
While the diagonal approach has similarities in terms of its integration of disease-specific and systemic improvements, the modular approach, I would say, offers a more structured context-specific framework that is tailored towards the 50 by 50 goal. Then summarily, it operationalizes the resource allocation and service delivery in a way that is both pragmatic and adaptable. I'll just just stop there. I don't know if any other person in the panel want to make a comment on that. Thank you.

Rachel: Justina, thank you. It's quite clear that you have given a lot of thought to the modular approach and how to apply it, and we'll have to keep watching what you're doing in Nigeria too. I think this will be really interesting to see. Any other comments on that question before we move on to another audience question? Okay, I'm going to turn to a comment from an audience member, I think, will be appreciated by the commissioners, which is that the report doesn't advocate for vertical health programming.
That's clear to the viewer, but they believe that a few issues in the report could be highlighted even more in the executive summary, and that is keeping the focus on comprehensive primary healthcare while prioritizing the 15 conditions. Then secondly, redefining HBPs, health benefit packages, to prioritize full domestic funding for these conditions with necessary local adaptation.
I think that's a reinforcement of a lot of what you've been saying, what the report is saying. We appreciate the comments from the audience member to highlight those issues. Let me move to a question for Dean which doesn't come from an audience member, but I really would like to hear his views on this, which is how much scientific innovation of importance, how much is-- sorry, let me start again. How important is scientific innovation to the Global Health 2050 agenda? Dean, over to you.

Dean: Well, I would answer that in two ways, Rachel. One is around the new product side of the scientific agenda, and Gavin spoke to that. There is a lot in the pipeline, as Gavin stressed. We'll see a TB vaccine that works a lot better than BCG in all likelihood, soon. There are three pretty far along in the pipeline. We're seeing malaria vaccines. We'll see broader spectrum drugs to deal with malaria. There are a lot of product advances, that I think we can count on clearly in the area of infectious disease anyway, will make a big difference. There's some discussion of the anti-obesity drugs very briefly in the report.
The questions about cost reduction are very important there. Probably there will be improvements in diagnostics and drugs, improvements in the sense of cost reductions usability, improvements in a range of those. I think that we'll see a simplification of the agenda over the coming decade or two that will make it technically much more feasible. There's a second element of scientific innovation that we haven't discussed as much. We've touched on from time to time under the label of PPIR, policy, population, and implementation research.
What works, what doesn't, what policies work, what don't. For example, how would you better utilize second-line drugs against resistant tuberculosis? There are lots of alternative ways you might go about doing that, assuming you had a good drug. Or with respect to the Arrow mechanism, what are the basics of the out-of-pocket financial gains that you might expect from implementation of a drug subsidy mechanism like that in Nigeria or in Mexico?
The basic information on out-of-pocket expenditures for drugs is quite limited. It's real, it's strongly suggestive that it's extremely important in terms of the adverse financial consequences for many households. It's a skimpy literature and it doesn't provide much guidance on how you would orient a program of public subsidies for drugs taking into account financial protection.
How well would it work? We have a very good example in the malaria field from the AMFM, which was carefully evaluated and found rapid implementation. In that case, a crowding out through the price mechanism of malaria monotherapies by highly subsidized combination therapies, which was the purpose of the program, strongly suggesting that an Arrow-type mechanism could work. I think we'll need that kind of guidance about what's working and what isn't working.
The new product development agenda, I think, needs to be complemented and we're not seeing the kind of progress in development of that agenda that we are on the products itself. It's an area where more could be done, more should be done.

Rachel: Thank you, Dean. That's great. I don't want to leave any audience questions unanswered. Eduardo, in a minute, can you explain how the full income approach can be applied to halving PPD, cutting in half PPD? Maybe a minute and a half if they give us the time. Over to you.

Eduardo: Thank you, Rachel. Very quick. Full income is something that has been part of the commission investment board, I think since the first one. Full income is about the full accounting of the economic benefits of health gains. The typical one is healthier people are more productive and they live longer, they tend to increase income. There's the other side of the accounting, which is, how much is longevity worth to society? There's ways to account for that. There's statistical ways of understanding the willingness to pay for living longer. Basically, when you put full income, you make the investment case much stronger. If you're talking to ministries of finance that want to talk about rates of return on investment, then you're competing against other needs for the budget. I think that putting together full accounting of benefits of health makes a big difference. That is an innovation that I think it's worth noting out of the several reports of the commission.

Rachel: Fantastic. Well done. I don't think anybody else could explain that concept in less than a minute. We are at the end of our time. I want to thank CGD, the incredible production team, Rosie, Shannon and others. I want to thank all the panelists. Want to thank Larry for the very thought provoking keynote and everyone who helped in organize this, and especially the audience for joining us here today. We look forward to future discussions of this. Have a very nice day or evening. Goodbye.