Table 4.

Costs and consequences of large-scale investment in health systems by the Lancet Commission on Investing in Health, Disease Control Priorities, 3rd edition (DCP3), and WHO

	Lancet Commission on Investing in Health21	DCP350,54	WHO 201711
Countries included	34 low-income and three (large) lower-middle-income countries*	34 low-income and 49 lower-middle-income countries*	67 low-income, lower-middle, and upper-middle-income countries individually estimated and then aggregated†
Key definitions and intervention range covered	Grand convergence interventions lead to very substantial cross-country convergence in under-5, maternal, tuberculosis, malaria, and HIV/AIDS mortality and in the prevalence of neglected tropical diseases	21 packages (table 1) identified in terms that include intersectoral and health sector interventions (72 distinct intersectoral interventions and 244 distinct health sector interventions); EUHC are health sector interventions in the 21 packages (covered in national health accounts and potentially included in benefits packages); a highest priority subset of EUHC (HPP) includes a limited range of interventions against non-communicable diseases, injuries, and cross-cutting areas such as rehabilitation and palliative care, in addition to the grand convergence interventions	Investments were modelled for 16 SDGs, including 187 health interventions and a range of health-system strengthening strategies (the latter of which included investments required to achieve target levels of health workforce, facilities, and other health-system building blocks); two scenarios were modelled, a progress scenario (in which coverage is limited by the absorptive capacity of current systems to incorporate new interventions), and an ambitious scenario (in which most countries achieve high levels of intervention coverage and hence SDG targets)
Intersectoral action for health	Extensive discussion of intersectoral actions for health but not included in modelling grand convergence	Intersectoral interventions defined as those typically managed and financed outside the health sector; each of the 21 packages contains the intersectoral interventions deemed relevant; the costs and effects of intersectoral action on mortality reduction are not explicitly modelled	WHO 2017 scenarios include some finance of intersectoral interventions from the health-sector perspective, as well as their effects on mortality
Intervention coverage	Full coverage defined at 85%; rates of scale-up defined using historical data on so-called best performers among similar groups of countries	Full coverage defined as 80%; the HPP differs from EUHC not in coverage level but in the scope of interventions included	Full coverage defined as 95% for most interventions in the ambitious scenario, with a range from 53% to 99% depending on intervention
Estimated additional costs (including requisite investment in health system capacity)
Low-income countries	US$(2011)30 billion annually between 2016 and 2030	HPP: US$(2012)32 billion in 2030; EUHC: US$(2012)70 billion in 2030	US$(2012)64 billion in 2030
Lower-middle-income countries	US$(2011)61 billion annually between 2016 and 2030	HPP: US$(2012)97 billion in 2030; EUHC: US$(2012)190 billion in 2030	US$(2012)185 billion in 2030
Estimated deaths avertedद
Low-income countries	4·5 million deaths averted per year between 2016 and 2030	2·0 million deaths averted in 2030	2·9 million deaths averted in 2030
Lower middle-income countries	5·5 million deaths averted per year between 2016 and 2030	4·2 million deaths averted in 2030	6·1 million deaths averted in 2030
Benefit cost analysis undertaken	Yes	No	No

EUHC=essential universal health coverage. HPP=highest priority package. SDGs=Sustainable Development Goals.

^*Separate estimates for the low-income and lower-middle-income country groups are provided.

^†Reported results are for all included countries combined.

^‡DCP3 reports the number of premature deaths averted (ie, deaths younger than 70 years).

^§Averted deaths included stillbirths averted in the reports by the Lancet Commission on Investing in Health²¹ and WHO¹¹ but not in DCP3.^53,57

^¶In the Lancet Commission report²¹ and DCP3, the reported deaths averted included only deaths averted in children actually born and women actually giving birth. Family planning averts unwanted pregnancies and hence potential deaths of women and children that would have occurred as a result of those averted pregnancies. The difference is large. For low-income countries, results of a sensitivity analysis in Global Health 2035²¹ showed that the more comprehensive estimate was 7·5 million deaths averted rather than the 4·5 million deaths averted shown in this table. WHO’s 2017 estimates¹¹ of deaths averted are based on the larger and more inclusive number. Ambitious scale-up of family planning services accounted for 50% of averted child and maternal deaths and more than 65% of averted stillbirths in the WHO analysis (Stenberg K, Department of Health Systems Governance and Financing, WHO, personal communication). Sources: Jamison et al (2013),²¹ Boyle et al (2015),⁵⁸ Watkins et al (2017),⁵⁷ Watkins et al (2017),⁵³ and Stenberg et al (2017).¹¹