One of the things I am proudest of having done in Washington was having the idea as chief economist of the World Bank that the bank should devote its annual World Development Report to making the case for improving both the quantity and quality of global health investment. The 1993 report, produced by a team led by renowned global health economist Dean Jamison, proved more influential than I could have hoped, not least because it drew Bill Gates into the global health arena.
The report made a strong case that the benefits of the right health investments far exceed the costs. Indeed, I believe the moral and economic case for investments in health care — both prevention and treatment — is as or more compelling than in any other area in the developing world. The dramatic declines in child mortality and increases in life expectancy demonstrate that policy can make an immense difference.
Dean and I chaired a commission, timed to coincide with the 20th anniversary of the initial report, under the aegis of the distinguished medical journal The Lancet. The commission took stock of the remarkable progress made over the last 20 years and emphasized what is possible over the next generation.
The primary conclusion of our commission was that our generation has the opportunity to achieve a “grand convergence” in global health, reducing preventable maternal, child, and infectious diseases to universally low levels by 2035. We further concluded that the necessary investments would have benefits that exceeded their costs by a factor of 10. But we cautioned that grand convergence would not just happen. It would require commitments to health system reform and to new domestic and international resources that go well beyond what is in place today.
Although there is ample evidence for the value of investing in health, you wouldn’t know it by looking at how most countries allocate resources. Too many countries, particularly low- and middle-income countries, treat health services as a cost to be minimized rather than an investment to be maximized.
Yet access to health services is a core driver of prosperity. Over the last decade, improvements in health accounted for about 11 percent of economic growth in low- and middle-income countries as measured in their national income accounts. This figure is only part of the picture, as good health (i.e., living longer) has an intrinsic value on top of greater income. When the value of additional life-years is factored in, improvements in health accounted for one quarter of full-income growth in low- and middle-income countries.
Investments in health today will return huge future dividends. Our report found that providing every person with a package of essential prevention and treatment services — such as basic vaccines, family planning methods, and treatments for conditions like malaria, TB, and HIV infection — could bring infectious disease deaths to universally low levels within one generation. The impact of these services would be dramatic: The investment would return more than 10 times its cost within a generation.
However, there is a huge barrier to realizing this possibility. Around the world, the vast majority of health spending is transacted out-of-pocket, meaning that people are charged a user fee each time they fall sick or need care. Each year, an estimated 150 million people are bankrupted trying to access health care they cannot afford. Our report argued that adopting “pro-poor” pathways to universal health coverage would be an efficient way for governments to support grand convergence and also greatly reduce the burden of poverty from medical expenses. Low- and lower-middle income countries that are striving to expand health coverage, we argued, should initially focus on the diseases that are disproportionately affecting the poor.
All of this seems immensely relevant as world leaders gather in New York this week to agree on a bold new global agenda for sustainable development. The breadth of ambition embodied in the 17 Sustainable Development Goals and the associated 169 targets is truly inspiring and a tribute to the moral energy of many leaders in and out of government.
But there is the risk that, with so many priorities, there will be insufficient focus on the most important and achievable objectives. I was therefore excited when the Rockefeller Foundation asked me to work with them to develop a declaration that a broad spectrum of economists could issue underscoring the importance of global health efforts. The 266 economists who have joined our declaration come from 44 countries and at least as many political and ideological perspectives. But they are united in their belief in the importance of expanding and improving health care globally.
Our declaration was published in The Lancet last week. I hope the world listens. Millions of lives are at stake.
Lawrence H. Summers is the Charles W. Eliot University Professor and President emeritus of Harvard University. He was also secretary of the US Treasury.