Global health at a crossroads: Policy recommendations in light of the Lancet Global Health 2050 Report

Strupat, Christoph; Schäferhoff, Marco; Siegel, Martin; Hornidge, Anna-Katharina Research Report Global health at a crossroads: Policy recommendations in light of the Lancet Global Health 2050 Report IDOS Policy Brief, No. 5/2025 Provided in Cooperation with: German Institute of Development and Sustainability (IDOS), Bonn Suggested Citation: Strupat, Christoph; Schäferhoff, Marco; Siegel, Martin; Hornidge, Anna-Katharina (2025) : Global health at a crossroads: Policy recommendations in light of the Lancet Global Health 2050 Report, IDOS Policy Brief, No. 5/2025, German Institute of Development and Sustainability (IDOS), Bonn, https://doi.org/10.23661/ipb5.2025 This Version is available at: https://hdl.handle.net/10419/315212 Standard-Nutzungsbedingungen: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden. 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If the documents have been made available under an Open Content Licence (especially Creative Commons Licences), you may exercise further usage rights as specified in the indicated licence. https://creativecommons.org/licenses/by/4.0/ Global Health at a Crossroads: Policy Recommendations in Light of the Lancet Global Health 2050 Report Christoph Strupat, Marco Schäferhoff, Martin Siegel und Anna-Katharina Hornidge Summary At a time of global crisis and competing priorities, investing in health is among the most impactful and cost-effective decisions governments and stakeholders can make. Beyond being a fundamental right, health is a catalyst for growth, stability and resilience – particularly in uncertain times. The new Global Health 2050: the path to halving premature death by midcentury (Global Health 2050) report (Jamison et al., 2024) of the Lancet Commission on Investing in Health (the Commission) builds on a legacy of evidence-driven reports to provide strategies for making health a crosscutting enabler of the Sustainable Development Goals (SDGs). Global Health 2050 provides a roadmap for further health improvements in all countries by midcentury, arguing that by 2050 countries can reduce by 50% the probability of premature death (PPD) in their populations. The Commission calls this goal “50 by 50”. Germany has solidified its role in global health through significant investments in the health sector and by designating global health as a political priority, as demonstrated by its Global Health Strategy and the inclusion of global health as one of the core themes of the Federal Ministry for Economic Cooperation and Development (BMZ). Given this political priority, it is essential to assess the implications of the Global Health 2050 report for Germany’s global health agenda, especially as global health stands at a crossroads following the withdrawal of the United States (US) from the World Health Organization (WHO) and cuts to its global health programmes. Therefore, the aim of this policy brief is to build upon the Commission’s findings and draw from scientific evidence to provide key recommendations for Germany’s global health agenda. Five recommendations have been synthesised that align with Germany’s global health engagement and offer promising strategies to help achieve the 50 by 50 goal: 1. Sustain or ideally increase funding for the Gavi, The Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria at the upcoming replenishment conferences and strengthen Germany’s global health leadership through strong bilateral support, investments in pandemic preparedness and response (PPR) and better interministerial coordination. 2. Reconsider non-communicable diseases (NCDs) in future strategic direction of German international cooperation by reducing financial and geographical barriers to access to medicines and addressing key NCD risk factors. 3. Promote health taxes on tobacco, alcohol, and sugar-sweetened beverages that can serve as an effective strategy to improve public health and generate domestic revenue. 4. Increase funding for R&D in neglected diseases. Expand regional manufacturing, and enhance global health innovation coordination to strengthen global health security and reduce dependence on external supply chains. 5. Nepal serves as a good example of Germany’s bilateral health and social protection support: advancing the 50 by 50 goal could be achieved by strengthening national health insurance, addressing climate risks, expanding health taxes and enhancing pharmaceutical access through the Arrow mechanism. IDOS POLICY BRIEF 5/2025 IDOS Policy Brief 5/2025 2 Public background: Lancet Global Health 2050 Report The Global Health 2050 report provides a comprehensive overview, reinforcing the argument that investing in health yields strong returns and promotes broader development. The Commission concludes that substantial improvements in human welfare are achievable by mid-century with focused health investments. By 2050, countries could reduce by 50% the probability of premature death (PPD) in their populations – i.e., the probability of dying before age 70 years – from a pre-pandemic baseline year of 2019. The Commission calls this goal “50 by 50”. The 50 by 50 goal can be reached by focusing on 15 priority conditions, eight related to infectious diseases and maternal health and seven related to NCDs and injuries (Table 1). These conditions account for ~80% of the life expectancy gap between the best performing region (North Atlantic, which comprises Canada and Western Europe in Global Health 2050) and other regions. The Global Health 2050 report emphasises that national governments should maintain their focus on public financing of a core set of interventions that are fully prepaid, highly cost effective and available to everyone, starting with the interventions targeting the 15 priority conditions. The Commission set an interim milestone of cutting premature deaths by 30% by 2035 and shows that a practical pathway to the 50 by 50 goal is within reach. Table 1: Focus on 15 priority conditions Infectious and maternal health conditions (8) Neonatal, lower respiratory tract infections, diarrhoeal diseases, HIV, TB, malaria, childhood cluster diseases, maternal conditions NCDs and injuries (7) Atherosclerotic cardiovascular diseases, haemorrhagic stroke, NCDs strongly linked to infections, NCDs strongly linked to tobacco use, diabetes, road injury, suicide The report arrives at a critical moment, reaffirming the importance of investing in health by presenting new evidence on its value for livelihoods and economic development, as well as outlining a feasible way forward beyond the SDGs. Moreover, if investments in the 15 priority conditions succeed in halving premature deaths before age 70 by 2050, this targeted focus will serve as a valuable milestone on the path to achieving Universal Health Coverage (UHC). Some countries have already started to implement the Commission’s recommendations. For example, Norway’s Expert Committee on Global Health has embraced the recommendations of the Global Health 2050 report and national commissions are underway in several countries, including Nepal, Nigeria and the US. However, the report has also triggered a debate on how countries can best prioritise interventions at local level (Baker et al., 2024). This discussion also has to consider the need to assess how climate change could potentially jeopardise the goal of halving premature deaths by 2050 – an aspect that was not systematically assessed in the report. Nevertheless, we believe that Global Health 2050 offers important insights for Germany’s global health agenda. In the following, we outline key recommendations to strengthen Germany’s global health agenda and engagement in five areas. The recommendations align with Germany’s global health engagement and have been identified as promising strategies to contribute to the achievement of the 50 by 50 goal. Strengthen key multilateral mechanisms and bilateral engagement In Global Health 2050, the Commission puts strong emphasis on market shaping and pooled procurement to drive prices down for key medicines. It recommends fully resourcing Gavi, The Vaccine Alliance, and the Global Fund to IDOS Policy Brief 5/2025 Fight AIDS, Tuberculosis and Malaria (Global Fund) at their 2025 replenishments to ensure that their market-shaping power for priority infections can be fully leveraged. Gavi provides vaccines for major childhood diseases, while the Global Fund provides 28% of all international financing for HIV, 76% of all international financing for tuberculosis (TB), and 62% of all international financing for malaria programmes. It also invests in resilient and sustainable systems for health (RSSH), which are traditionally an important area for Germany. Gavi’s approach of pooling demand from multiple countries had a market shaping effect which transformed the market for vaccines. Likewise, three-quarters ($1.5 billion) of the $2 billion that the Global Fund invests every year for key drugs and health products is purchased through a pooled procurement mechanism (Global Fund, 2024a). From a perspective of scientific evidence, both mechanisms have proven effective in combating communicable diseases and improving child health (Boyce et al., 2021; Dykstra et al., 2019; Jaupart et al., 2019). With €1.3 billion, the German government is the third-largest donor to the Global Fund in the current allocation period 2023–2025. It is also the third-largest government donor to Gavi, including the €1.3 billion contributed during the COVID-19 pandemic. Despite the programmes’ proven positive impact, significant reductions in the contributions to Gavi and the Global Fund are planned by Germany. This would imply a significant weakening of its multilateral support for global health and would jeopardise Germany’s commitment to the health-related SDGs. The Global Health 2050 report emphasises that full funding of both mechanisms will be critical to maintain their market-shaping power to deliver key commodities to countries at affordable prices. Strong support to Gavi and the Global Fund will also be critical to deliver new health tools. For example, two malaria vaccines were recently approved, and three TB vaccines are currently in late-stage trials. In addition, the scientific journal Science elected Lenacapavir as its 2024 Breakthrough of the Year. Being effective in both treatment of HIV and as a pre-exposure prophylaxis, Lenacapavir may reduce global infection rates, and thereby free up resources for combatting tuberculosis and malaria (Science, 2024). The Global Fund’s ability to invest in other German priorities, such as RSSH, also hinges on the success of the replenishment. In line with Germany’s support for the Lusaka Agenda for a better integration of the global health architecture (Levine et al., 2024), Gavi and the Global Fund need to identify and exploit potential synergies arising from a growing overlap between them, for example through new technologies such as malaria vaccines and potentially upcoming TB vaccines. While countries have to assess and prioritise the optimal mix of interventions, the different funding processes and periods of Gavi and the Global Fund make the determination of the best mix of interventions in an efficient way difficult. Better integration of the multilateral mechanisms is also needed to reduce the burden of recipient countries, which currently still face high transaction costs and at times lack the necessary capacity and leadership to translate the provided support into optimal impact. Finally, Germany also invests in pandemic prevention and response (PPR) (a core priority for Germany), which aligns with Global Health 2050. The Commission estimates that there is a 48% chance in the next 25 years of a pandemic that kills at least 25 million people. Germany’s current bilateral support helps to strengthen the resilience of health systems. Germany is a key contributor to the Coalition for Epidemic Preparedness Innovation (CEPI), the Pandemic Fund and WHO’s Contingency Fund for Emergencies (WHO CEF). However, all these mechanisms remain underfunded. Overall, we recommend that the incoming German government takes the following actions: 1. Maintain or ideally increase funding to Gavi and the Global Fund at their 2025 replenishment conferences, and provide complementary bilateral support. Gavi and the Global Fund are pivotal for achieving the 50 by 50 target, IDOS Policy Brief 5/2025 as they play an important role in shaping global markets for health technologies and contribute to the strengthening of health and immunisation systems. Strong support for these mechanisms is critical to promote equitable access to health tools and ensure continued progress towards the health SDGs. (This is not to diminish the importance of other German-supported health funds, such as the Global Polio Eradication Initiative (GPEI).) Meanwhile, although Germany significantly increased its bilateral health funding during the pandemic, the funding almost dropped back to pre-pandemic (2019) levels in 2023 (OECD DAC, 2025). Going forward, it is essential that bilateral support, both technical and financial, be maintained at least at constant real terms. This ensures that health systems are strengthened through tailored, multisectoral solutions, enabling them to absorb multilateral resources. In addition, bilateral support should prioritise the poorest countries and complement multilateral efforts to strengthen health outcomes. 2. Encourage more integrated approaches between Gavi and the Global Fund. The German government should exert its influence upon the two multilateral mechanisms to promote stronger collaboration following the Lusaka Agenda. We recommend promoting the creation of a formal mechanism dedicated to ensuring integrated approaches that simplify implementation for countries and optimise value for money. The mechanism can build on initial efforts to increasingly work together (Global Fund, 2024b). Alignment around funding cycles and eligibility will be critically important. 3. Expand the international leadership for global health. The Commission emphasises the need for stronger support to WHO’s core functions (Jamison et al., 2024). Recent changes in the international system, especially the funding gap caused by the US government’s withdrawal from WHO (the US contributed ~16% of the WHO’s total revenue in the 2022–2023 biennium (Williams, 2025)), warrant resolute action. It will be more critical than ever that Germany, as one of WHO’s largest supporters, extends its funding to compensate for this substantial financial deficit. There is also need for continued investment in PPR through bilateral programmes and global mechanisms such as the WHO CEF. Second, we suggest stronger inter-ministerial coordination. Stronger collaboration between ministries (BMG, BMZ, AA and BMBF) is required to further strengthen Germany’s leadership in global health (Franz et al., 2024). In line with this approach, we recommend that Germany invests more in domestic cross-sectorial capacity to strengthen coordination between ministries and other stakeholders. The planned evaluation of the German government’s Global Health Strategy in 2025 will be an opportunity to formalise this collaboration. Third, we recommend that Germany continues advocating for global health in plurilateral fora, such as the G7 and G20, by developing collaborative proposals targeting critical health challenges such as pandemic preparedness, while pushing for increased funding and sustainable financing for global health initiatives (Strupat et al., 2023) Strategic approach to NCDs NCDs are a major contributor to premature mortality and the global life expectancy gap. In the Global Health 2050 report, the Commission highlights that, according to estimates from the WHO Global Health Estimates (2021), the World Population Prospects (UN Population Division, 2024) and Karlsson et al. (2024), NCDs and injuries from accidents account for about 43% of the global life expectancy gap, while infectious diseases account for around 35%. Nevertheless, the fight against NCDs seems to play a minor role in the BMZ core theme strategy “Health, Social Protection and Population dynamics” (BMZ, 2023). BMZ’s investments in global health amount to roughly €1 billion annually. As shown in Figure 1, the primary beneficiaries of this funding are multilateral organisations such as Gavi and the Global Fund, along with initiatives aimed at enhancing basic healthcare services and strengthening health systems (investments that may also benefit NCDs). IDOS Policy Brief 5/2025 Figure 1: Distribution of BMZ commitments to global health in 2024 Note: The information provided is based on 2023 and 2024 commitments of BMZ’s bilateral and multilateral development cooperation. Nongovernmental commitments are not included. Commitments in non-health sectors may not be included (e.g. commitments related to nutrition or WASH) even if they also affect global health or the determinants of health. Date: 06/03/2025. Source: BMZ MeMFIS Förderbereichschlüssel Gesundheit However, financial support specifically for the prevention and control of NCDs has seen a significant decrease, dropping from about €53 million in 2023 to around €26 million in 2024, which represents about 2.5% of the total annual contributions in 2024. NCDs account for a larger portion of the life expectancy gap than infectious diseases, worldwide and in almost all WHO sub-regions. Figure 2 shows the fraction of mortality under 70 years attributable to NCDs for some of the BMZ partner countries for the year 2019. In 14 out of the 17 countries, NCDs account for over 50% of deaths in people under 70 years of age. Investment in health systems and primary health care can effectively contribute to mitigating NCDs (WHO, 2013). However, it may be beneficial to more explicitly emphasise the relevance of health systems and primary care for NDCs in future strategies to enhance efforts towards achieving the 50 by 50 goal. Many NCDs, such as cardiovascular diseases, hypertension, diabetes, asthma and chronic obstructive pulmonary disease, are chronic conditions that require continuous monitoring and affordable medicines for effective treatment. Lowthreshold access to ambulatory health services and subsidised medicines, at least for lowerincome households, are therefore critical to prevent episodes of acute illness, hospitalisation, disability and premature mortality. Treatment of chronic NCDs place a very high financial burden on affected households, and leads to forgone care and unmet need because of financial constraints. IDOS Policy Brief 5/2025 Figure 2: Proportion of under 70 deaths attributable to NCDs Source: Authors’ calculations, based on WHO data (2021) We suggest the following two entry points to strategically address NCDs better in the future: 1. Reduce financial and geographic barriers to the access of diagnostics and medicines. The diagnosis, treatment and control of NCDs requires consistent access to health services and medicines. Efforts to improve access to diagnostics and medicines should be evaluated on a regular basis to ensure that the resources spent are used in a meaningful way. The Commission argues that centralised procurement of a focused set of highly subsided drugs can improve the availability and affordability of key drugs, including for NCDs, thereby reducing private out-of-pocket expenditures (Jamison et al., 2024). They propose the establishment of the “Arrow” mechanism, which involves direct subsidy of drugs and pooled purchasing. This mechanism can be funded in various ways, including domestic resource mobilisation. At the time of writing this policy brief, efforts were ongoing to establish such a mechanism in Nigeria to subsidise NCD drugs, antibiotics and antimalarials. We recommend offering technical and financial support to countries that are interested in the creation of domestic Arrow mechanisms. 2. Address key NCD risk factors more prominently in future strategic direction. Individual behavioural factors such as tobacco and alcohol consumption, physical inactivity and unhealthy diets are well-established risk factors for many NCDs (WBGU, 2023). In addition to these, the prevalence of environmental risk factors has also risen significantly in recent years, including air and water pollution, exposure to hazardous chemicals, and urban crowding. To effectively address these NCD risk factors, a systematic link to the holistic One Health approach is recommended, integrating human, animal and environmental health policies to enhance NCD prevention (Amuasi et al., 2022). Additionally, urban planning should be strategically linked to NCD prevention, where developing greener, less polluted urban environments through increased green spaces and stricter pollution controls can significantly reduce NCD rates (Zhang et al., 2023; Fazeli et al., 2022). Similarly, establishing a link between promoting sustainable energy and the reduction of NCD risks is critical. Encouraging the adoption of renewable energy sources, not only minimises emissions but also lowers NCD rates by reducing environmental stress and mitigating air pollution (Karim et al., 2024; Landrigan, 2017). Health taxes: a promising way to improve domestic health financing Complementary fiscal regulatory interventions could play a crucial role in accelerating progress towards the 50 by 50 goal. Excise taxes on tobacco, alcohol and sugar-sweetened beverages present an effective policy solution to address the dual challenges of improving health and closing fiscal gaps. These taxes can improve public health by reducing harmful consumption, thereby lowering future healthcare costs, while simultaneously generating additional revenue. For example, a 50% price increase on tobacco, alcohol and sugar-sweetened beverages is projected to IDOS Policy Brief 5/2025 prevent 27.2 million, 21.9 million and 2.2 million premature deaths, respectively, over the next 50 years (Task Force on Fiscal Policy for Health, 2019). With sufficient political will to overcome entrenched industry interests, they are relatively quick to implement. Moreover, when factoring in consumption changes and subsequent health benefits, the impacts of these taxes can be progressive, disproportionately benefiting lowerincome groups (Chaloupka et al., 2019; Verguet et al., 2015). Achieving full population coverage and prepayment for the recommended interventions targeting 15 priority conditions in 63 lowand lower-middleincome countries, as described in the 50 by 50 goal, requires significant investment. By 2050, scaling up these interventions to full coverage would necessitate an average increase in health spending equivalent to 1.1% of 2019 GDP in lowincome countries and 2.0% of 2019 GDP in lowermiddle-income countries (Jamison et al., 2024). Health taxes have the potential to generate additional revenue equivalent to 0.6–0.7% of GDP (Lane et al., 2022), which, if directed toward healthcare, could close 30–50% of the financing gap to achieve the 50 by 50 goal. Germany’s leadership in the Addis Tax Initiative demonstrates its commitment to improving tax policy and administration in partner countries. Furthermore, the current prioritisation of strengthening domestic revenue mobilisation (DRM) as a cornerstone of sustainable development financing, makes the promotion of health taxes a natural and complementary approach to achieving cobenefits. German development cooperation is actively involved in various programmes aimed at improving financial governance and increasing domestic revenue in partner countries. The following activities should be considered to reduce harmful consumption and safeguard health spending amidst tightening fiscal constraints: 1. Strengthen health taxes for public health and revenue mobilisation. Support partner countries in implementing and optimising health taxes on tobacco, alcohol and sugar-sweetened beverages as a key component of DRM and public health strategies. With excise tax systems already in place in most countries and 87% of the global population living in countries with tobacco taxes – many set too low – there is significant room for increasing rates and expanding coverage. To maximise impact, health taxes should be part of a multi-sectoral strategy, for example, aligned with the WHO Framework Convention on Tobacco Control, which includes measures such as restricting availability, banning advertising, and promoting public awareness. 2. Enhance technical assistance and integration into DRM strategies. Integrate health taxes into broader DRM initiatives by providing technical assistance and capacity building, helping partner countries design tax structures suited to their economic and policy contexts. With its expertise in Good Financial Governance (BMZ, 2025), German development cooperation is well-positioned to support this integration through initiatives within BMZ and international platforms such as the International Tax Compact. These efforts will strengthen fiscal sustainability while advancing public health goals. Innovation systems: research, development & manufacturing In Global Health 2050, the Commission highlights the need to invest in R&D for neglected diseases, arguing that such investments strongly contribute to reductions in mortality and that they also pay off economically. For example, the projected returns on investment in late-stage clinical trials and manufacturing in India, Kenya and South Africa would be as high as $21–67 per dollar invested (Schäferhoff et al., 2022). At the same time, 80% of the decline in the under-5 mortality rate from 1970–2000 across 95 lowand middle-income countries can be explained by the diffusion of new health technologies (Jamison et al., 2016). Germany made important commitments to important R&D initiatives (e.g. the European & Developing Countries Clinical Trials Partnership), especially through the German Federal Ministry of Education and Research (BMBF). However, IDOS Policy Brief 5/2025 funding for R&D in neglected diseases dropped from $54 million in 2021 to $34 million in 2023, reaching its lowest level since 2016 (Impact Global Health, 2024). Despite this decline, studies suggest that the current development pipeline is likely to yield a suite of new tools – including a tuberculosis vaccine – that could have a dramatic positive impact on global health. However, these tools will only be launched if donors provide funding for their development. Industry investments in R&D in neglected diseases only accounted for 13% of all funding between 2007 and 2022. Due to high risk and comparatively low profits, companies have little incentives to engage in R&D in neglected diseases. In addition, R&D investments need to be better coordinated to reduce inefficiencies and prioritise the development of new tools. Both the Lancet Commission and the German Advisory Council on Global Change (WBGU), emphasise the need to build manufacturing capacity across regions to enable lowand middleincome countries to self-produce their medicines, including their own medical countermeasures in a forthcoming pandemic. Germany strongly supports the establishment of regional manufacturing capacity and contributes about €790 million to the African Union’s (AU) goal of producing more pharmaceuticals and 60% of the vaccines needed on the continent by 2040. (This commitment is part of the Team Europe Initiative to promote vaccine production in Africa (MAV+), which totals €1.9 billion.) As part of this engagement, Germany is also the largest contributor to the African Vaccine Manufacturing Accelerator and provides bilateral support to multiple countries such as Ghana, Rwanda, Senegal and South Africa. The BMG and BMZ also support WHO’s mRNA technology transfer hub in South Africa. These are important contributions to the creation of distributed manufacturing capacity. The lack of this capacity was a substantial barrier in the response to the COVID19 pandemic. While the early emphasis was on building vaccine production capacity (including “fill & finish”; especially mRNA-vaccines), the ambition has become broader and today includes advancing production of traditional vaccines, diagnostics, and drugs. We recommend that Germany should take the following actions: 1. Pursue collaborative and innovative funding mechanisms. Funders, product developers and researchers need to collaborate and explore new mechanisms for investing in R&D. One concrete and tested example, which is promoted by academics (Ridley et al., 2024) and non-governmental organisations alike, is the Priority Review Voucher (PRV) – a pull incentive to reward developers of a new health product for an eligible neglected or rare disease with a tradeable voucher that grants priority review of a second product candidate. We believe that a PRV should be created in Europe, hosted by the European Medicines Agency. Introduced in 2007, the US PRV programme had awarded more than 60 vouchers by 2024, contributing to the development of new drugs for neglected diseases, such as Chagas and tuberculosis. US vouchers were sold for US$100 million each, creating a substantial, though insufficient, financial incentive for developers. An EU voucher would provide an additional incentive of $100–200 million, which investors say would be a meaningful stimulus. We suggest that the German government, spearheaded by the BMBF, explores and promotes the introduction of an EU voucher programme. 2. Global and regional R&D coordinating mechanisms should be strengthened to prioritise and advance high-impact innovations. One key step for Germany would be to support the development of WHO-endorsed “target product profiles” (TPPs). TPPs outline the desired “profile” or characteristics of a target product and are critical for developers to understand unmet need and for funders to make informed investment decisions. WHO maintains a TPP database (WHO, 2025) but for many disease areas, TPPs are not available or are outdated. 3. Develop manufacturing strategy and expand support for regional manufacturing to other product types. The German investments for regional vaccine production are important and should continue. However, African countries have