Global health 2050: the path to halving premature death by mid-century

Abstract

Global health 2050 (GH2050), a new report from the Lancet Commission on Investing in Health, finds that dramatic improvements in human welfare are achievable by mid-century with focused health investments. By 2050, countries that choose to do so can halve their probability of premature death (PPD)—the probability of dying before age 70—from their pre-pandemic level in 2019. We call this goal “50 by 50”: a 50% reduction in PPD by 2050. The interventions for achieving “50 by 50” will also reduce morbidity and disability at all ages.

Historical experience and continued scientific advance indicate that this is a feasible aspiration. Eight of the 30 most populous countries reduced their PPD over the last decade at a rate that would halve PPD before 2050, including countries as diverse as Bangladesh, Iran, Tanzania, and Turkey. These focused gains can be achieved relatively early on the pathway to full universal health coverage (UHC).

The path to achieving “50 by 50” runs through control of a remarkably narrow set of just 15 conditions. For currently high mortality countries, eight infectious diseases and maternal conditions are the highest priority. Seven clusters of noncommunicable diseases and injuries are important everywhere and addressing them will prove central to achieving “50 by 50” in most countries with lower initial levels of mortality.

Focused attention to health system strengthening (HSS) for primary care and first level hospitals will generate capacity to better tackle the 15 priority conditions and will be a critical step on the way to improving capacity to address all the conditions in a UHC package. Packaging interventions into 19 modules (e.g., a childhood immunization module, a module on cardiovascular disease prevention and low-cost, widely available treatment) will address the 15 priority conditions. Adopting this focused approach also invests in key areas of HSS and addresses major morbidities, such as psychiatric illness, not already covered by mortality-reducing interventions. Value for money can be assessed through a two-step process: technical cost effectiveness to assess how best to achieve module-specific goals (e.g., reduction in child mortality, reduction in cardiovascular mortality) and political evaluation of trade-offs in investing in expanding module coverage.

In many countries seeking reform, standard budgetary mechanisms have failed to successfully reorient systems toward priority interventions that improve health. This mechanism of blanket budget transfers from ministries of finance to ministries of health has not been fit to support such reorientation. The Commission concluded that this problem could be addressed by directing a substantial and increasing fraction of budget transfers to making available and affordable the specific drugs, vaccines, diagnostics, and other commodities that are currently available for control of the 15 priority conditions. Drug availability and affordability will typically require four complementary components: (i) redirecting general budget transfers to line item transfers (subsidies) for specific priority drugs; (ii) centralized procurement by government (or perhaps internationally); (iii) procurement in sufficient volumes to ensure availability when needed; and (iv) use and strengthening of existing supply chains, public and private.

Of the many intersectoral policies that governments can adopt to help achieve “50 by 50,” tobacco control is by far the most important, given the number of deaths caused by tobacco and the established and improving capacity of governments to implement tobacco policy. A high level of tobacco taxation is essential, and valuable in the short to medium term for public finance, and should be accompanied by a package of other effective tobacco control policies.

Background research conducted for the Commission points to exceptionally high ongoing levels of mortality risk from pandemics. Country performance against COVID-19 varied greatly, although eventual vaccine availability attenuated, but far from eliminated, this variability by the end of COVID-19’s emergency phase. National implementation of public health fundamentals—early action, isolation of infected individuals, quarantining of those exposed, and social and financial support for people isolating or quarantining—accounted for much of the success of the best-performing nations, such as Japan. In the next pandemic, these fundamentals will help to avert mortality while waiting for vaccine development and deployment.

The conclusions above are primarily aimed at national governments. Our final conclusion is aimed at the development assistance community. We conclude that such assistance should focus on two broad purposes. The first is to provide direct financial and technical support to countries with the least resources—to help develop health systems to better control diseases. The second is to finance global public goods, including strengthening data systems; reducing the development and spread of antimicrobial resistance; preventing and responding to pandemics; fostering global health leadership and advocacy; identifying and spreading best practices; and developing and deploying new health technologies. For both purposes, focusing efforts on the 15 priority conditions would best contribute to “50 by 50.” A decade ago, there were no malaria vaccines and the only available tuberculosis vaccine had low efficacy. Today, two partially successful malaria vaccines have been approved and three promising tuberculosis vaccine candidates are in late stage trials. These successes exemplify the enormous value in funding development of new medicines, vaccines, diagnostics, and operational research against the 15 priority conditions.

The prize of “50 by 50,” with an interim milestone of “30 by 2035” (a 30% reduction in PPD by 2035), remains a prize within reach. The most efficient route is to focus resources against a narrow set of conditions and scale up financing to develop and deploy new health technologies. Our economic analyses have shown that the value of achievable mortality declines remains high and indeed is often a substantial fraction of the value of gains in gross domestic product. Today, the case is better than ever for the value of investing in health for reducing mortality and morbidity, alleviating poverty, growing economies, and improving human welfare.

Figure 1:. Map of CIH regions with basic statistics

Figure 2:. The probability of premature death, 1970–2019: World, China, India, North Atlantic, Sub-Saharan Africa, and the United States

Note: The graph highlights the time taken for certain regions—namely the North Atlantic, China, the World, and India—to halve their PPD values to 2019 levels. Data from reference 14

Figure 3:. Life expectancy (LE) versus health-adjusted life expectancy (HALE)

Source from reference 14 Data from reference 15

Figure 4:. Country performance on the probability of premature death – level relative to per capita income, and halving time, world’s 30 most populous countries, 2019

Notes: 1. PPD is the probability of premature death, i.e., death before age 70. World average PPD was 31% in 2019. 2. The y-axis values show the number of years required to halve a country’s PPD if its rate of improvement in 2010–19 were to continue. The horizontal line drawn at 31 years indicates a halving time just adequate to reduce premature mortality by 50% between 2019 and 2050. Values above 75 years are simply indicated as ‘greater than 75’. 3. The x-axis values show a country’s deviation from the PPD that would be predicted from its income in 2019. The 2019 PPD for Italy, to take an example, was 12 and its value predicted from income was 17. Since predicted is higher than actual, the deviation is a favorable −5.

Figure 5:. Percent change in income, value of mortality change, full income in France and the United States from 2000–2019

Source from reference 20

Figure 6:. Projected increase in annual heat-related deaths due to climate change compared to the 2015 baseline

Note: The graph presents estimates under two Representative Concentration Pathways (RCPs): RCP 4.5, a ~2.4°C increase in global temperatures by 2100 compared to 1850–1900, and RCP 8.5, a ~4.3°C increase, as per the IPCC Fifth Assessment Report from reference 42. As of 2024, global temperatures have already risen between 1.25°C and 1.5°C from 1850–1900 (Hausfather, 2024). Source from projections adapted from reference 37

Figure 7:. Global and frontier probability of premature death (PPD), 1950–2021

Note: Probability of premature death (PPD) was defined as dying before age 70 years. The frontier is the lowest PPD ever observed. Countries with a population below 3 million in 2019 were not considered for being a frontier. Data source from reference 11 . Source from reference 79

Figure 8:. Seven high-population countries that achieved a halving of PPD in the last half century over 31 years or less

Notes: PPD = Probability of premature death Source from reference 14 Data source from reference 11

Figure 9:. Sex differences in the rate of decline in PPD, 30 most populous countries, 2010–19

Source from UN World Population Prospects 2024

Figure 10:. Life expectancy gap compared to the North Atlantic region attributable to priority conditions, 2019

Note: Life expectancy in the North Atlantic was 82 years in 2019. The priority conditions are I-8 plus the NCD-7, as defined below. The priority infections and maternal health conditions (I-8) are neonatal conditions, lower respiratory infections, diarrheal diseases, HIV/AIDS, tuberculosis, malaria, childhood-cluster diseases and maternal conditions. The priority NCDs and injuries (NCD-7) are atherosclerotic cardiovascular diseases, hemorrhagic stroke, NCDs strongly linked to infections, NCDs strongly linked to tobacco use, diabetes, road injury and suicide. Source from reference 80 Data from reference 11 and 15.^,

Figure 11:. Life expectancy gap compared to the North Atlantic attributable to individual I-8, 2019

Note: Life expectancy in the North Atlantic was 82 years in 2019. The full bars show the total life expectancy gap. Red parts show life expectancy gap accounted for by the cause indicated on the y-axis. Green+red parts show the cumulative contribution of the causes indicated at and above each bar on the y-axis to gap. Gray part shows the proportion not accounted for. Source from reference 80 Data from reference 11 and 15 ^,

Figure 12:. Life expectancy gap compared to the North Atlantic attributable to individual NCD7, 2019

Note: Life expectancy in the North Atlantic was 82 years in 2019. The full bars show the total life expectancy gap. Red parts show life expectancy gap accounted for by the cause indicated on the y-axis. Blue+red parts show the cumulative contribution of the causes indicated at and above each bar on the y-axis to gap. Gray part shows the proportion not accounted for. Source from reference 80 Data from references 11 and 35 ^,

Figure 13:. Hemorrhagic stroke, sources of change in deaths from 2000 to 2019, ages 50–69, by CIH region

Note: Mortality rate in year 2000 is expressed per 100,000 population per year. Negative rate of change in the figure indicates decline and a positive rate of change indicates increase.

Figure 14:. Prevalence of stunting among females in selected countries

Figure 15:. Mathematics test scores relative to Singapore, PISA 2022, selected countries

Source from reference 84

Figure 16:. Current levels of government tax revenue and health spending, by country

Note: Data are from the reference 145. The most recent values for each country with complete data (n=126) are plotted here.

Figure 17:. Crude death rate, 1990–2021 and projections to 2050

Note: COVID-19 years (2020–2022) were omitted. Working age is defined as ages 15–64 years. Data Source from reference 11

Figure 18:. P-score by month: Italy, United States, India and Japan — April 2020 to October 2023

Note: The graph highlights the time taken for certain regions—namely the North Atlantic, China, the World, and India—to halve their PPD values to 2019 levels. Data source: Excess deaths data were downloaded from Our World in Data. Projected deaths were based on deaths in 2019 and the annual change (averaged between 2015–2019) from reference 35 . Annual projected deaths were divided by 12 (i.e., death baseline were assumed to be uniform across each year). P-Scores were calculated by dividing excess deaths by the projected deaths.

Figure 19:. Framework for the phases of the pandemic cycle

Figure 20:. ODA+: Evolution of DAH+ disbursements, 2013–2022

Notes: Gross disbursements. Constant 2021 prices (USD billions). Sources: The CIH uses the term DAH+ to refer to official development assistance (ODA) for health and private (philanthropic) development finance to health as defined by the Organisation for Economic Cooperation and Development (OECD)’s Development Assistance Committee (DAC). DAH+ also includes donor funding for neglected disease product development. Data for our DAH+ analysis comes from two sources: the OECD DAC’s Creditor Reporting System (CRS) database, and the Global Funding for Innovation for Neglected Diseases (G-FINDER) database. See also: reference 50

Figure 21:. Total ODA disbursements to Ukraine and Sub-Saharan Africa

Notes: Disbursements. Constant price in 2022 (USD millions). p= Preliminary figures. Source from reference 267

Figure 22:. Country-specific funding for the I-8 conditions

Notes: Gross disbursements. Constant 2021 prices (USD) Source from reference 50