The paradox of success
January 24, 2014
In 1993, the World Bank published an impactful report "Investing in Health (L. Summers et al.)". The authors forecasted that the potential gains from getting the right health policies in place around the world were enormous. In December 2013, The Lancet Commission published "Global health 2035: a world converging within a generation" (Jannison, Summers et al.), forecasting 20 years in advance the unanticipated challenges in public health.

A striking aspect of their analysis is the uncovering of the paradox of success in public health over the last 20 years. The greatest success story has been the decrease from 1990 to 2010 in mortality rates in children under 5 (from 87 to 51 per 1,000 live births) and the decrease in maternal mortality ratio (from 400 to 210 maternal deaths per 100,000 live births). This was due to the reduction in the rates of infectious disease and mortality from reproductive, maternal, newborn, and child health disorders. But as low-income and middle-income countries successfully tackle communicable (infectious) diseases, their disease burden shifts to non-communicable diseases (NCDs), such as diabetes, hypertension, ischemic heart disease, stroke, obesity and cancer (Figs 1 & 2). The age-adjusted mortality rates for several NCDs are now higher in low- and middle-income countries than in high-income countries.


Fig. 1: Death by broad groups of causes across different income levels, 2011

The Lancet Commission proposes an essential package of population-based interventions (e.g. reducing tobacco and alcohol use and improving diets) as well as an essential package of clinical interventions (i.e. providing basic cardiovascular, pulmonary, neurological, and cancer care). Using a full income approach (which puts an economic value on additional years of life gained), the benefits of implementing an essential care package aEUR" to mitigate both communicable and non-communicable diseases worldwide by 2035 aEUR" could exceed the cost nine times over.


Fig. 2: Deaths from important causes across different income levels

Within a generation, with the right investments in global health, we have the ability to make the challenges in communicable diseases largely disappear and non-communicable diseases come under control. Scaling up low-cost packages of population-based and clinical interventions would delay the onset of NCDs, reduce their incidence, and manage their consequences when they occur. Health improvements have accounted for about 11% of economic growth in low and middle-income countries. The expected rise in GDP would allow those countries to finance much of the health improvement work from domestic sources, enhancing their sustainability.