The start of the 21st century was a period of landmark investments in the health of people in the world’s poorest countries. Unprecedented challenges, including a raging HIV/AIDS epidemic and increasing child-death rates, inspired the creation of transformative multilateral health organizations including Gavi, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

New analysis from ONE shows that without this surge in international financing and innovation for health, at least 669 million people worldwide would have needlessly died between 1990 and 2016 from some of the most deadly infections and preventable diseases. (Proportionally, countries saved US: 219 million lives / UK: 46 million lives / GER: 28 million lives / FR: 25 million lives / NL: 17 million lives /CAN: 16 million lives / IT: 8 million lives). These lives should be celebrated as a testament to what is possible. But progress will not continue, and could be reversed, without radical new commitments, activism and innovation.

Worryingly, the ambition of some world leaders has atrophied in recent years, and the intensity of civic activism has waned. Donor assistance for global health in sub-Saharan Africa has flat-lined since 2014 and domestic resources are not keeping pace with demand. We are severely off track for key 2030 health targets in the countries at greatest risk. In less than 50 years, there will be more young people in Africa than in all G20 countries combined. Investing in this huge “human capital” boom – ensuring that this population is healthy, educated and empowered – could lead to rapid and sustained economic growth. However, failing to protect our health gains could quickly thwart this potential.

At this very moment, the world does not have a modern, costed, and implementable plan for delivering health for all over the next decade. Alarmed by this, German Chancellor Angela Merkel, Norwegian Prime Minister Erna Solberg and Ghanaian President Nana Addo Akufo-Addo called upon Dr Tedros Adhanom Ghebreyesus as head of the World Health Organization to develop a roadmap to achieve the 3^rd Sustainable Development Goal by 2030. In its new report, ONE assesses efforts to date and calls for an ambitious plan with time-bound, measurable commitments to reach key global health targets by 2030.

Key facts from the report: Investments in global health have saved the lives of millions of people

• Between 1990 and 2016, 669 million lives were saved globally through increased assistance for health.
• The top five government (USA, UK, J, GER, FRA) donors alone saved 323 million lives alone between 1990 and 2016, private, and private and foundation spending saved another 87 million.
• Development assistance for health (DAH) increased from $20.4 billion USD in 2000 to a peak of $56 billion USD in 2013. It totaled $51.8 billion USD in 2015. (All figures in USD based on 2017 purchasing power parity).
• Without increased investments, there would have been 17 million more deaths in sub-Saharan Africa (SSA) in 2015 alone.
• Between 2000 and 2015, maternal mortality in SSA fell by 15 percent, under-five deaths declined by nearly one-third, and AIDS-related deaths dropped by nearly 40 percent.
• Every country in sub-Saharan Africa saw gains in life expectancy between 2000 and 2015, a stark contrast from the “lost decade” of the 1990s.

  But the fight’s not won yet…

• In 2016, nearly one million people died from HIV/AIDS globally, another 1.9 million people became newly infected with the disease; about two-thirds of these deaths and new infections occurred in sub-Saharan Africa.
• In 2016, 5.6 million children globally died before their fifth birthday – half of them in sub-Saharan Africa.
• If the goals for HIV, TB, Malaria, and maternal and child deaths are missed, over 650 million additional lives in sub-Saharan Africa are at risk by 2030. To date, no country in sub-Saharan Africa is on track to reach these goals.
• By 2034, Africa will have a larger workforce than India or China.

 What will it take to reverse this trend and win the fight against preventable diseases?

A new plan must build on past progress but it will fail if it stops there: The next decade in global health must look different from the last. Donor spending on health must be matched by greater domestic spending on health. Efforts to combat specific diseases must be matched by efforts to set up the strong health systems needed to treat these diseases over the long-term. High-level political commitments for health must be matched by informed and persistent citizen engagement to ensure that results are delivered.

 Mobilizing more money for health

• Low-income countries must spend more on health. They should increase fiscal space for health with support from partners, with the explicit target of increasing spending to $112 per person by 2030 and a focus on countries’ primary healthcare systems. Increasing taxes, pre-payment for health services or health insurance coverage are possible options.
• Donors must ramp up work through PEPFAR, the Global Fund, Gavi, and others at increasingly ambitious levels. Moreover, we cannot keep relying on the same six countries to contribute the overwhelming majority of resources. New donors like China and countries in the Middle East, as well as the private sector absolutely must step up.
• The AU must reassess the Abuja commitment for health financing and propose a new benchmark by the 2020 AU Summit, with renewed political commitments.
• Governments and donors should explore new ways to structure support in order to leverage more domestic investments in health.
• Governments and donors should test and evaluate new financing models, like the Global Financing Facility, a multi-stakeholder partnership that supports efforts to improve the health of women, children and adolescents.

Deliver more health for the money

• Countries must invest in their healthcare workforce, including by providing more ­­­­flexible career paths and non-traditional points of entry for health workers, particularly in rural and under-served communities, to help address staffing shortages.
• Countries must increasingly focus investments on primary health care, and systematically define and cost a package of essential health benefits for citizens.
• Governments and donors must empower citizens, particularly those in marginalized groups, to inform the programs intended to reach them.
• Governments should open their budgets, including health procurement data to allow citizens’ unfettered access to budget implementation reports.
• Governments, CSOs and international institutions should experiment with new social accountability tools, like citizen and community health scorecards.

 The world has several key moments to reinvest in global health through 2020:

• 2018, November 6: Global Financing Facility replenishment in Norway
• 2018-2019: World Health Organization Financing Campaign
• 2019: Global Fund to Fight AIDS, Tuberculosis and Malaria replenishment in France
• 2020: Gavi, the Vaccine Alliance replenishment (host country tbd)