An opportunity to achieve universal mortality reductions and UHC by 2035

The CIH defined grand convergence as a universal reduction in deaths from infections and maternal and child conditions down to the levels seen in the best-performing middle-income countries [1]. This would mean achieving a maternal mortality ratio (MMR) of 64 per 100,000 live births, an under-5 mortality rate (U5MR) of 16 per 1,000 live births, an annual HIV death rate of 8 per 100,000 population, and an annual TB death rate of 4 per 100,000 population (“64–16–8–4”). Global Health 2035 showed that grand convergence could be achieved through aggressive scale-up of proven health interventions, strengthening health systems to deliver these interventions, and distribution of new health technologies [7].

Five years later, in 2018, the CIH published “Alma-Ata at 40 years: reflections from the Lancet Commission on Investing in Health” (CIH 2.0) [8], which provided a mixed picture on progress. The encouraging news was that if the global trends in mortality seen in 2010 to 2016 were to continue, the global convergence targets for under-5 and HIV mortality would be achieved around the year 2035. But the worrying news was that if the rates of decline for maternal and TB mortality remained similar to 2010 to 2016, the convergence targets would not be achieved until 2067 and 2074, respectively [9].

The CIH 2.0 report also found that most LMICs, except India, could afford an “essential UHC” package of 218 health interventions from domestic public financing. However, most LICs, and sub-Saharan Africa as a region, would not be able to afford even a “highest priority package” of 108 interventions delivered in primary care (S1 Text) without substantial increases in the priority they assign to health [10]. These countries would need external financing to make up for insufficient resources. Global Health 2035 was published at a time when the International Monetary Fund (IMF) was very optimistic about the pace of economic growth in LICs and LMICs. By 2018, the projections of such growth were less optimistic. Below, we consider the newest IMF projections and what these might mean for financing UHC in the pandemic and post-pandemic era.

Both CIH reports called for a reorientation of health aid toward “global functions”—activities with cross-national benefits, such as product development for neglected diseases and pandemic preparedness. In 2013, only 23% of all donor funding for health was directed toward global functions [11]. This proportion rose in the wake of West Africa’s Ebola outbreak, but, by 2017, it had fallen again [12], suggesting that donors are prone to cycles of “panic and neglect” in funding global functions.

Threats to convergence and UHC: How COVID-19 is disrupting essential services

Above, we described a pathway to grand convergence and UHC based on aggressive scale-up of existing and new interventions through strengthened delivery systems. How might COVID-19 have affected such healthcare delivery in LICs and MICs? The illness has had a direct impact on health services: Clinics and hospitals in many hard-hit countries have been overwhelmed with patients with COVID-19. In addition, there are at least 4 main factors described in the literature that led to an indirect impact of COVID-19 on health services, although there are likely to be other more complex pathways that are yet to be delineated.

First, COVID-19 mitigation policies and patients’ fears of getting COVID-19 from healthcare settings affected service use. For example, during the first lockdown period in South Africa, there was a weekly decrease of about 48% in TB Xpert testing volumes, and the weekly number of TB positive tests fell by 33% [13]. Second, human and budgetary resources intended for managing conditions such as TB and HIV were redirected to COVID-19 testing and treatment [14]. Third, international travel restrictions and regional COVID-19 outbreaks led to temporary interruptions in supply chains for drugs, vaccines, and other health commodities [15]. Fourth, the economic consequences of COVID-19 increased financial barriers at the household and national levels to maintain routine health services [16]. In the short term, health budgets have been threatened or reduced in a number of cases, but the COVID-19 crisis also represents an opportunity to catalyze major long-term UHC financing reforms in many countries.

Evidence on the disruption of essential services has mostly come from surveys, which have shown disruptions in outpatient services, community-based care, and inpatient services [17]; HIV and TB programs [18]; and NCD diagnosis and treatment services [19]. However, there have been contextual differences in how COVID-19 has impacted health services in different LICs and LMICs. To highlight some of these differences, we have included short case studies of the impact of COVID-19 in Ghana, India, and Nigeria (S2–S4 Text).

The potential impact of COVID-19 on grand convergence

How might this health service disruption, and the economic consequences of COVID-19, affect progress on grand convergence? Developing a probabilistic forecast of the most likely post-pandemic health trends would be incredibly challenging and fraught with uncertainty since the pandemic and its effects are still evolving. In addition, specific experiences at country and regional levels will vary from the global average, depending on the local impact of (1) the level of disruption to health services; (2) COVID-19 containment policies; (3) the application of new technologies (e.g., COVID-19 vaccines); (4) the country’s economic recovery; and (5) the political commitment to public sector spending on health, which could allow many countries to get back on track or even exceed pre-pandemic progress [20]. For example, the Severe Acute Respiratory Syndrome (SARS) epidemic in China sparked political changes that reinvigorated public finance of healthcare and the country’s move toward UHC [20].

In light of the challenges in developing long-term forecasts, we instead did an exploratory modeling analysis using stylized perturbations in historical (2009 to 2019) trends in global TB and HIV mortality rates, U5MR, and MMR, reflecting a plausible range of pandemic severity and duration. This modeling should be seen as a “what-if” exercise rather than a statement of the most likely future path. The objective of our modeling exercise was to understand, quantitatively, how much the pandemic might throw the world off track for grand convergence and what sort of acceleration in progress would be needed to get back on track. We first projected what would have happened under a “no COVID” scenario (i.e., continuation of mortality levels and trends observed over 2010 to 2019) and then under 3 different disruption scenarios (minor, moderate, and severe). We used existing evidence to develop the parameters for these 3 scenarios [21–24]. All 3 assumed a 5% increase in mortality for TB and HIV, U5MR, and MMR in 2020 and 2021 (we call this the “affected phase”). For the post COVID-19 period (from 2022 onward), our minor, moderate, and severe scenarios employ different assumptions regarding the average annual rate of change (AARC) in all-ages mortality rates (Box 1).

Fig 1 shows the summary results of our analysis, reported at the global level. The figure shows the historical trends in the TB and HIV mortality rates, U5MR, and MMR, the trends that would be seen under the 4 scenarios S0, S1, S2, and S3, and the grand convergence targets. S2 Table shows our analysis disaggregated into LICs and LMICs. We also calculated the AARCs needed to achieve each of the 4 targets and compared these values to historical data from best-performing countries to assess feasibility.

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Fig 1. Projected global HIV, TB, and U5MRs and the global MMR under 4 different scenarios (S0–S3).

Data sources that we used to estimate historical mortality rates from 2000 to 2019 included all age mortality rates for HIV and TB from the Institute for Health Metrics and Evaluation’s Global Burden of Disease Study (2000–2019) by country and year (http://ghdx.healthdata.org/gbd-results-tool); U5MR from 2000 to 2019 from the World Bank by country and year (https://data.worldbank.org/indicator/SH.DYN.MORT); MMR from 2000 to 2017 from the World Bank by country and year (https://data.worldbank.org/indicator/SH.STA.MMRT); and population estimates from the United Nations Population Division (https://population.un.org/wpp/). GC, grand convergence; MMR, maternal mortality ratio; TB, tuberculosis; U5MR, under-5 mortality rate.

https://doi.org/10.1371/journal.pmed.1003675.g001

The economic impact of COVID-19: What it means for financing UHC

Global Health 2035 argued that the grand convergence agenda could—and should—be financed primarily through domestic resources. In all LICs and LMICs, the principal means of increasing domestic health spending is greater economic growth, which, in turn, leads to larger contributions to taxation-based and social insurance–based financing systems. As their economies grow, governments also have the option to increase health spending faster than the rate of growth in general government expenditure (in LICs and LMICs, the share of GDP devoted to government health expenditure has increased by about 0.75% annually since 2000 [32]). The CIH analyses have found that these 2 mechanisms—economic growth and health budget reprioritization—would be sufficient to finance grand convergence–related interventions in LMICs. Most LICs would require external assistance to raise sufficient resources to finance grand convergence [8].

As noted previously, the growth prospects in LICs and LMICs have worsened since the publication of Global Health 2035. In October 2020, the IMF released projections of GDP growth over the next several years, factoring in countries’ COVID-19 recovery potential [33]. Most economies are expected to rebound fairly quickly as long as the pandemic is brought under control in 2021. However, since economies are expected to contract substantially in 2020, maintaining historical rates of growth over 2020 to 2035 would result in lower spending on health by 2035 relative to what could have been achieved had there not been a pandemic. For example, an LIC that has historically achieved 4% GDP growth annually would increase its GDP by 87% in 2035 relative to 2019. If that same country’s economy contracted by 5% in 2020 and remained stagnant in 2021, then resumed its 4% annual growth rate, it would only be able to increase its GDP by 65% in 2035 relative to 2019. Lesser growth in GDP by 2035 would result in less money for health, all else equal.

We note that while economic growth is a major driver of public sector spending on health, the relationship is not always a linear process, and, throughout history, there have been step changes in public financing that have often followed major crises. We previously mentioned China after SARS; other recent examples include Rwanda post-genocide and Thailand after the Asian financial crisis. The COVID-19 pandemic might provide additional motivation to increase public sector health spending in nations that have historically underspent (such as India and Nigeria).

We revisited the analyses done in the first 2 CIH reports through the lens of the pandemic and the IMF’s most recent projections of economic growth in LICs and LMICs. The starting point for our analysis was a list of 120 non-COVID-19 health interventions that would form a model essential health intervention package implemented through a UHC system [34]. As described by Blanchet and colleagues, these 120 interventions were adapted from the 3rd edition of Disease Control Priorities (DCP3) and underwent additional scrutiny as to the feasibility of their delivery amidst COVID-19–related disruptions.

We used the DCP cost model to generate estimates of the annual per capita cost of this package of 120 health interventions across 32 LICs and 47 LMICs (categorized as in the previous CIH reports) [26]. We then combined these cost estimates with population projections from the 2019 World Population Prospects to estimate the cost of the package in each country by 2035, assuming 95% coverage [35]. Previous modeling studies showed that this level of coverage would be required for these interventions to ensure the grand convergence, and related Sustainable Development Goal (SDG) targets would be achieved [36]. We then projected total domestic resources available for health by triangulating GDP growth projections from the IMF, estimates of the share of GDP devoted to public sector spending on health from WHO, and projection methods and assumptions detailed in previous CIH analyses [37].

Table 1 summarizes the findings of our analysis. By 2035, LICs would only be able to finance about a third of the costs of the package through domestic sources unless they assign substantially higher priority to health than now seems likely. LMICs would only be able to finance a little less than half. With either income group, there would inevitably be some countries with stronger growth that would be able to fully finance the package, whereas the costs would probably be out of reach for other countries. A detailed analysis of country-by-country costs was outside the scope of this report.

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Table 1. Cost and affordability of essential non-COVID-19 health interventions in 2035.

https://doi.org/10.1371/journal.pmed.1003675.t001

Greater prioritization of health within government budgets could make the package affordable for the average LIC or LMIC. If the average LIC or LMIC increased its share of GDP devoted to public sector spending on health by 8.5% and 5.0% annually, respectively, it could afford the package by 2035. Although WHO’s health accounts database shows that most countries have not achieved this rate of growth in health spending historically, several countries have. Over 2000 to 2010, Rwanda, Ghana, and Togo increased the share of GDP devoted to health by over 10% annually. Across all LICs and LMICs, the 90th percentile country increased health spending by 5.1% annually over 2000 to 2018 [28].

Our assessment of the affordability of an essential health intervention package is somewhat more pessimistic than the analysis featured in Global Health 2035, which focused only on grand convergence interventions (which comprise about half of the costs of the package featured in Table 1). Our findings are broadly similar to those of Alma-Ata at 40 years, whose primary healthcare (PHC) package included interventions that addressed both grand convergence conditions as well as NCDs and injuries.

One implication of the 3 CIH analyses, taken together, is that as LICs and LMICs develop their health system responses to epidemiological and demographic transitions, they will face increasingly difficult trade-offs as to which types of interventions they can justify financing through UHC systems. Development partners continue to focus on support for grand convergence conditions—rightly so, for equity reasons. However, without a balanced approach to UHC that includes building capacity to address NCDs and injuries, countries may find themselves further behind on population health indicators as the residual burden of grand convergence conditions is addressed. Indeed, as shown in Alma-Ata at 40 years, age-specific death rates for NCDs and injuries are increasing, rather than decreasing in some LICs and LMICs (as compared to HICs, where they continue to decrease). These trends suggest that health inequalities across countries could become even more pronounced beyond 2035 if national governments and development partners focus solely on financing and implementing grand convergence–related interventions.

Global distribution of COVID-19 vaccines

One major obstacle to the deployment of vaccines to LICs and LMICs is “vaccine nationalism”—the hoarding of vaccine doses by rich nations through their bilateral purchase agreements with vaccine manufacturers [38]. The Canadian government has purchased enough doses to vaccinate all of its citizens 6 times over, and the United States and United Kingdom are not far behind, buying enough doses to vaccinate all their citizens 4 times over. The new COVID-19 Vaccine Global Access Facility (COVAX)—a global collaboration to provide equitable access to COVID-19 vaccines, with funding from the COVAX advanced market commitment—hopes to be able to distribute 2 billion doses to LICs and LMICs by the end of 2021. This would be enough to vaccinate about 15% to 20% of the population of each country with a 2-dose regimen. At the time of writing this, the Facility has purchased 2.7 billion doses [39] and argues that it is therefore on course to meet its 2021 targets.

Unless there is concerted action to redress this inequity, the lack of vaccine deployment to LICs and LMICs will impede their recovery from COVID-19 and their achievement of grand convergence and UHC. Rich nations need to (i) step up their commitments to COVAX, including to the COVAX advanced market commitment that is funding vaccine purchases for LICs and LMICs; (ii) donate their extra doses to COVAX; and (iii) agree to share the vaccine manufacturing know-how with LICs and LMICs. And the manufacturing of the vaccines needs to be quickly globalized, building on the example of the Serum Institute of India, which is manufacturing the University of Oxford/AstraZeneca vaccine. The institute initially gave doses to COVAX for distribution to LICs and LMICs until India’s surge required doses to be used only domestically (the institute will supply doses again to COVAX in late 2021). It increasingly looks likely that China will play a key role in providing COVID-19 vaccines directly, such as CoronaVac (made by the Chinese firm Sinovac), as well as development assistance for health (DAH) more broadly, to LICs and LMICs.

Insufficient manufacturing of COVID-19 vaccines and challenges to distribution of vaccines are 2 other bottlenecks to achieving global vaccine herd immunity. The Serum Institute of India, one of the largest vaccine manufacturers, produces 70 million doses every month, and it is expected to increase its capacity to produce 100 million doses per month from July 2021 [40]. Manufacturing in the US and other high-income nations is expected to ramp up in 2021 to produce enough doses to cover not just their own nations but to donate doses to COVAX or directly to LICs and LMICs. These countries will require easy to deliver, affordable vaccines in large quantities to cover their populations. The US has recently joined other nations in supporting an intellectual property waiver on COVID-19 vaccines, which could give the green light to LICs and LMICs to start manufacturing their own vaccines (this would also require technology transfer and support for scaling manufacturing facilities and capacity). Distribution challenges in some LICs and LMICs include insufficient health workers, the cold chain requirements, and reaching people in urban slums and hard-to-reach regions [41]. To date, licensed vaccines remain efficacious against all known variants of concern. Nevertheless, there remains the possibility that new variants could evade vaccine-induced immunity.

Mobilization of domestic and external health financing

Both domestic health financing and DAH will play a critical role in getting countries back on track to reach grand convergence and UHC.

LICs and LMICs need to keep health spending at the top of their agendas. The pandemic and the measures to control it (e.g., stay-at-home orders) have had an economic impact on various sectors, with rising levels of unemployment, poverty, and income instability and inequality [42]. Countries are bound to face competing priorities over the next few years, and domestic resource mobilization and budgeting will need to carefully assess spending priorities to ensure that levels of public sector spending on health are not negatively impacted. The challenges will be particularly acute for countries with ongoing fiscal weaknesses, such as low tax revenues and high aid dependence and debt levels [43]. In order to ensure that domestic resources for health continue to support grand convergence and UHC, key priorities for country governments include the following:

• Prioritization of health in their budgets to ensure that health gains and progress toward UHC are not reversed: Although in the short run it may appear that the health sector is receiving large amounts of additional resources, in many countries, there are concerns that there may be substantial reprogramming of health outlays that cannot be sustained in the long run. The COVID-19 pandemic has shown, perhaps more starkly than ever, why it is so critical for nations to continue to prioritize health spending and, equally as important, to prioritize spending whose value for money (in terms of health impact or financial protection) is highest. As the experience of China after SARS has shown, pandemics can lead nations to reinvigorate their commitment to health. Countries that have been successful at curbing COVID-19 could use this opportunity to accelerate their trajectory to grand convergence and UHC. It is quite possible that other countries will follow suit—including even countries like the US that have, historically, had a lukewarm commitment to UHC [44].
• Planning and budgeting for health, which needs the careful attention of ministries of health: Such planning includes determining the most cost-effective priorities, improving spending efficiency, and allowing for flexibility in redirecting spending for emergencies, including procurement of COVID-19 vaccines [45]. Accountability and expenditure tracking mechanisms can help to improve transparency and avoid leakages of scarce resources. At a broader level, finance and planning ministries will need to step up efforts to stabilize funding in the long-term through multiyear programming and planning [46].
• Greater attention to tax policy: This will be critical to ensure sustainable revenue generation in the long run through measures such expansion of the tax base, improving tax compliance and administration, and diversifying sources of government revenues, including exploring the potential for imposing health taxes (e.g., taxes on alcohol, coal, and tobacco) [47,48]. Countries should renew their commitments to the 2015 Addis Tax Initiative and take actionable steps to enhance domestic revenues [49]. Research has shown that people are willing to pay higher taxes in exchange for health and education services that visibly improve their lives; however, this willingness usually requires strong social contract, as has been observed in countries in Southeast Asia and Latin America in particular [50].
• Investment in the right health interventions: The CIH noted that “countries in all regions and at all income levels, such as China, Ethiopia, Bangladesh, Mexico, and Thailand, have consistently made smart health investments and have helped to set global standards for the level of health that can be achieved at relatively modest cost” [8]. This conclusion still holds true in the COVID-19 era. The DCP3 model list of essential UHC interventions can provide a helpful starting point for countries to review their current investments and deliberate on health benefit package reforms that make better use of scarce resources [10].
• Engagement of the private sector, which consumes a large fraction of resources used for health in many LICs and LMICs: WHO and UN have recently called for an “all hands-on deck” approach and called for improved performance of the private sector, such as in expanding the health workforce and strengthening supply chains [51,52].

During the acute crisis phase, donors responded rapidly to country needs. The International Aid Transparency Initiative found that in the first 7 months of 2020, commitments to health increased compared to the same period in 2019, driven in particular by multilateral funders such as the World Bank [53]. However, given the economic impacts of COVID-19 on donor nations, future DAH flows could be under threat. Official development assistance (grants and concessional loans) has historically been the most stable external resource in developing countries during past crises [54]. Maintaining DAH will be critical for grand convergence and UHC during the COVID-19 crisis. Particular priorities for donors are the following:

• Funding global functions, especially strengthening national and global preparedness for the next pandemic, including developing and stockpiling medical countermeasures; accelerating the development of new health technologies for the “convergence conditions” (HIV, TB, malaria, and maternal and child health); and shoring up WHO’s core capacities. Even before COVID-19, there was a very strong case for using donor financing to make these preparatory global investments, such as in tackling antimicrobial resistance and strengthening pandemic preparedness, because of positive international externalities [55]. Strengthening surveillance capacity, response capacity, and regulatory capacity in low- and middle-income countries is a way to strengthen national health systems while simultaneously addressing global problems. These investments have global spillovers.
• Providing debt relief, including through mechanisms such as “debt to health swaps” (in which a creditor agrees to waive all or part of an outstanding debt obligation if the debtor government invests the funds instead into the health sector) [56].
• Providing DAH to (a) strengthen PHC systems in very resource constrained environments; and (b) selectively strengthen PHC in MICs for activities with high cross-border externalities, such as pandemic preparedness, control of antimicrobial resistance, and cross-border disease control (e.g., malaria elimination activities).

Strengthening of primary healthcare delivery systems

Finally, strengthened PHC is the backbone for nations to respond to COVID-19, maintain essential non-COVID-19 services, and accelerate progress toward grand convergence and UHC in the post-COVID-19 recovery phase. The 2018 Astana Declaration that UN member states endorsed, arising from Global Conference on Primary Health Care, argued that “strengthening primary healthcare (PHC) is the most inclusive, effective and efficient approach to enhance people’s physical and mental health, as well as social well-being, and that PHC is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals” [57]. Allen and Dambha-Miller argued that the pandemic has revealed “areas where progress is needed most” [58]:

• improved coordination between PHC, public health, and other specialties;
• expanding access to PHC services, including for NCDs (S5 Text), including through telemedicine (S6 Text);
• deeper investment in prevention, integrated, team-based primary care, and care of long-term illnesses; and
• the removal of user fees and a guarantee of “comprehensive services without financial hardship.”