Investing in health: progress but hard choices remain.

e34 www.thelancet.com Vol 382 December 7, 2013 The world has changed radically since the World Development Report (WDR) Investing in Health was published 20 years ago, so it is valuable and timely to look ahead once again. The Lancet Commission’s optimistic report on investing in health confi rms my view that the best times for public health are still ahead of us. As we debate the place of health in a new generation of development goals, we must frame our case in terms that will resonate convincingly with ministries of fi nance and heads of government. This means showing how the sum of all investments committed to improving people’s health pays both economic and political dividends. The fi ndings of this Lancet Commission, which emphasise the need to quantify the value attached to extending healthy life, strengthen the economic case for investment in health. The work of this Commission complements WHO’s support for the intrinsic value attached to health and to universal health coverage. People value the assurance that when they face ill health, the services they need will be available and that they will not be fi nancially ruined by their cost. In discussions on the post-2015 health agenda, a widely held view is that we must not let the debate about the future undermine current eff orts to Investing in health: progress but hard choices remain from the current level of less than 2% to 3–4%. Governments must lead the way, but governments cannot do it alone: the private sector, international organisations, foundations, and civil society all have key parts to play. Policy makers need to harness the resources and the innovative approaches of these multiple actors, working in concert with a vibrant public sector. We also must look for solutions beyond the health sector. The Lancet Commission recognises, but chooses not to focus on, the multisectoral or social determinants of health because “complex and entrenched political obstacles exist to addressing them and...the eff ect will not be realised for a long period”. Yet one of the most successful interventions to improve child health has involved putting money in the hands of poor mothers in Mexico via conditional cash transfers. The Commission’s report also could have given greater prominence to its recommendations to tackle risk factors for non-communicable diseases through interventions such as tobacco taxation and road and air quality improvements that form the foundations of healthy societies. Lastly, the Commission’s messages on the “what” of health-service delivery could have greater impact with more attention to the ”how”. This was also a critique of WDR 1993, and it contributed to a shift in the World Bank Group towards investing in knowledge for better health-systems performance. Why, for example, are some countries able to achieve better maternal and child health outcomes than others with the same level of resources? We need to document, evaluate, and share these lessons across countries, both to save lives and to demonstrate value for money. That’s why at the World Bank Group we are placing a priority on delivery science, bringing the data and evidence on what works and what doesn’t to help countries deliver the most cost-eff ective interventions at scale. WDR 1993 helped jump-start a generation of investments that produced dramatic achievements in global health. The report of this Lancet Commission reminds us it’s time to fi nish the job in this generation, and ensure that everyone in the world has access to the aff ordable, quality care they need to lead healthy, productive lives.