Global Health 2050: A Q&A with Dr. Lia Tadesse Gebremedhin

Amid rapid shifts in the global landscape, how can we reinvigorate global health? In October 2024, the Lancet Commission on Investing in Health published a new report offering a roadmap for countries at all income levels to achieve dramatic improvements in human welfare by 2050. By prioritizing health investments in 15 key conditions, nations could reduce the risk of premature death (before age 70) by 50%—a strategy the Commission refers to as the “50 by 50” approach.

AlignMNH sat down with Dr. Lia Tadesse Gebremedhin, a former member of our international Steering Committee, the former Minister of Health for Ethiopia, and one of the paper’s co-authors, to talk about the implications this paper could have on global health, and on maternal, newborn, and child health specifically. Dr. Gebremedhin is the current Executive Director of the Harvard Ministerial Leadership Program and a Visiting Lecturer on Global Health and Population at Harvard University. This interview was conducted in December 2024 and has been edited for clarity.

1. In your opinion, what are the most critical findings from this publication? Which findings have the most significant implications for global health, particularly maternal, newborn, and child health? And how do these findings translate into actionable steps for different actors in the MNCH field, such as policymakers, global health organizations, and healthcare providers?

The central message of this report primarily is that it shows improvements in reducing mortality by 2050 by up to 50% are achievable. But, of course, there’s an if—it’s possible if there’s an intentional decision by countries and the global health community to make those right investments and decisions. The report is essentially saying that the probability of dying before 70 years of age can be reduced and we can also make dramatic improvements to human welfare, to improving the well-being of our communities. This is based on two main reasons:

1. The evidence that there has been historical progress in the past few decades. Countries have had reductions of 50% in premature deaths in the last 30 years or less.
2. The scientific evidence that there’s more and more innovation and dissemination of new technologies. We currently have around 450 new medicines, vaccines, and diagnostics that are expected in the development pipeline. Between the 1970s and 2000, based on the advent of newer technologies, we saw a dramatic reduction in mortality. Our projection is based on this scientific evidence showing that this can be achieved.

The other central message is that to achieve these goals as a global health community, countries need to prioritize. They cannot be achieved by investing in everything. Prioritizing the 15 conditions as defined in this paper (eight infectious diseases and maternal health conditions and seven non-communicable diseases, including mental health and injuries) will bring a sharp reduction in mortality and morbidity. Prioritization will not be exactly the same for every country; it must be context-based.

One important consideration is having some level of reset on the universal health coverage (UHC) and health systems strengthening agenda. Investing in health systems has been the key focus for achieving UHC in the Sustainable Development Goal (SDG) era, and it has brought some progress; but we have seen that progress has stalled both in terms of coverage and in terms of catastrophic health expenditures still becoming more common. Our recommended approach to health systems strengthening should really focus on these priority interventions, and the investments in health systems should be to ensure that they provide the full comprehensive set of these 15 interventions. That will, of course, have an impact on other issues as well, but if we invest in those, not just in blanket health systems strengthening, then we can have more impact.

2. Of the 15 priority health conditions, eight are infectious and maternal health conditions and seven are NCD and injury-related conditions. Can you elaborate on what is included in the category of “maternal conditions?”

In general, those infectious and maternal health conditions were defined using the WHO global health categories of country-level causes of death. That showed that these priority conditions contribute to a large amount of the life expectancy gap between the better-performing countries and those that are lagging.

When we are talking about maternal health conditions, those include the primary pregnancy and childbirth issues of antenatal care, safe delivery, management of complications of labor, and routine postpartum care. If you include child health conditions in that, then it includes certain immunizations, and also the treatment of childhood illnesses like lower respiratory infection, malaria, and acute malnutrition.

Despite the substantial progress that was made in maternal and child health in the last decades, these issues still account for a large share of the life expectancy gap between sub-Saharan Africa and other regions. It is unacceptable that there is such high mortality when we have clear, simple interventions. Complex interventions aren’t necessarily needed to avert maternal mortality, but still, we see women dying due to lack of access or lack of quality.

3. While the paper touches on global trends, how do sub-national inequities impact the realization of the health goals outlined in the paper?

The report does essentially focus on national-level data (for some countries, projections or estimated global estimates have been used when there were limitations) and global trends. Sub-national data is difficult to find, though there are some initiatives working on providing sub-national data, like the Institute for Health Metrics and Evaluation (IHME), where the sub-national global burden of disease estimates are being analyzed for some countries.

We expect the sub-national analysis to be the responsibility of countries when they go in to develop implementation plans. In many countries, the sub-national level, disaggregated data may be there, and in some it may not, but countries must take a deeper look because there are sub-national disparities that could change the implementation and design of interventions.

4. AlignMNH has made concentrated efforts to share best practices in maternal and newborn health. What role can the sharing of best practices play in accelerating progress towards global health goals?

Best practices have always been key in terms of disseminating or scaling-up interventions that have been impactful in limited settings. With more and more innovations coming up, be it technological or system-based, this would be a great opportunity to share and promote best practices. Again, what I really like about this report is the idea of focusing on a set of interventions. Even though 15 priorities is still a lot, the modular approach that’s recommended is showing us within each intervention or priority you can again choose based on cost-effectiveness and impact. Countries must make evidence-based decisions towards prioritization of those interventions. Sharing best practices will have a big role in contributing towards the evidence-based decision making needed when countries move forward with implementation.

5. The paper highlights the importance of commodities in improving health outcomes. How can countries ensure the availability and affordability of essential health commodities, including global public goods, such as vaccines and diagnostics?

Earlier I spoke about the need for countries to prioritize within the 15 interventions. But in the paper, we do talk about how commodities should have higher weight than other interventions. It’s clear that having essential commodities available at a price that’s affordable or free to communities is a big bottleneck to achieving access and quality health care. That has been the experience for most countries, including my own experience as a Minister of Health. We had so many investments in infrastructure and in the health workforce, but the continuous unavailability of medicines and commodities was a huge barrier to ensuring that the services were delivered with quality. A very good example in Ethiopia is on maternal and newborn health: we provide the services for free, but because of limitations in availability of commodities, patients end up either paying for them, or it becomes a barrier to providing care. When you look at the overall out-of-pocket expenditure and catastrophic expenditure, the highest percentage of catastrophic expenditure is from commodities.

There is a recommendation on commodities outlined in the paper called the Arrow Mechanism (p. 28). The Arrow Mechanism is proposed to ensure sustainability in availability of commodities by; redirecting general budget transfers to ministries of health to line-item budget transfers for specific priority drugs, implementing centralized pooled procurement by government or other entities depending on context, procurement of large volumes and strengthening supply chains. It also emphasizes for commodities to be financed publicly. We know that for many countries, 100% public financing of commodities may not be possible, but partly financing priority interventions and having the procurement managed by government is possible. Rather than having fragmented ways of procuring, this mechanism helps to earmark budgets for prioritized commodities with pooled procurement.  For example, in Ethiopia, we have centralized procurement through the government’s pharmaceutical procurement agency under the Minister of Health, which has many benefits.

6. As a former Minister of Health, what are the key implications of these findings for governments? How can these findings be integrated into health plans and budgets?

Governments typically have many priorities to address. This paper helps us to revisit those priorities and our investment. We are all working with limited resources. How do we invest those resources for the most impact? The cost-effectiveness of our interventions is something that this report will help us to assess in our national plans. It does not offer a prescription for every country, but gives evidence that we cannot invest in everything the same way. We should focus on what would bring the most impact in terms of reducing mortality and improving quality of life.

For example, blanket investments in the health workforce will not work. You have to decide: Where do you invest more in workforce? Where do you invest in commodities? It is also about having countries work on enhancing domestic financing for health. This is not a new idea, but countries need to work more towards enhancing domestic investment. To increase the government expenditure on health, the government’s revenue must be improved with tax reforms and looking at efficiency. Public financial management is a key opportunity for countries to better utilize their limited resources.

There’s also a big focus in the paper on tobacco taxes, as tobacco still causes such a high portion of mortality. This approach is critical to reducing mortality, but it’s also a key approach to increasing government revenue.

The report also highlights that countries must focus on emergency and pandemic preparedness. There is a projection that another pandemic could come in the next 10 years. The good thing is that with this approach to health system investment, countries would also be better prepared to respond to shocks.

7. As we approach the deadline for the SDGs, how can we build on their momentum to achieve even greater progress? How does this paper help contribute to post-SDG priority-setting?

There was momentum with the Millennium Development Goal (MDG) era and we have seen some progress in the SDG era, but more recently, we have stalled in reaching our goals. The COVID-19 pandemic and other global challenges, especially humanitarian crises and conflicts, have only further set us back.

We have enough evidence of what’s working and this paper helps us refocus on accelerating progress. The key message I keep coming back to is the issue of prioritization and how we invest in interventions that can have the maximum impact. It is the responsibility of the global community to ensure that we make progress and narrow disparity gaps in every region. This report will not cover everything that needs to be in a post-SDG health agenda, but it will definitely contribute towards how we set our priorities.

This report has given me a lot of hope and optimism that despite the challenging time we are in globally, if we really work together and collectively agree on the same agenda, significantly reducing mortality and morbidity is possible.