U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y i i UNLOCKING THE POWER OF HEALTHY LONGEVITY Demographic Change, Non-communicable Diseases, and Human Capital ii U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y © 2024 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved. This work is a product of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. 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Unlocking the Power of Healthy Longevity: Demograph- ic Change, Non-communicable Diseases, and Human Capital. Washington, DC: World Bank. © World Bank.” Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; email: pubrights@worldbank.org. Cover design and typesetting: Karim Ezzat Khedr, Creative Director; email: karim.ezzat@gmail.com. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CONTENTS iii Contents Tables and Figures iv Abbreviations and Acronyms v Foreword vi Report Team vii Preface: Why this report? viii Unlocking the power of healthy longevity: Key messages of this report 1 Executive Summary 5 1. Introduction: Better health throughout the life course is achievable 11 2. Healthy longevity, NCDs, and human capital: Levers for action across the life course 30 3. Advancing healthy longevity now: What countries can do 42 4. Financing for healthy longevity: Country leadership and key supporting roles for development partners 60 5. Conclusion: From knowledge to action 72 Appendices Appendix A: Data sources, methods, and analytic processes 72 Appendix B: Supplementary analytic materials 79 Appendix C: Acknowledgments 86 Appendix D: Background papers 88 Bibliography 89 iv TAB LE S AN D FI GU R E S U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Tables and Figures Figure Title Figure 1.1 Trends in global population change by age and dependency ratio, 1950 to 2050 Figure 1.2 Population and deaths by age in 1990 and 2023 and projections to 2050 Figure 1.3 Population size by age group in 1990, 2023, and 2050 and changes in total fertility rate, selected countries Figure 1.4 Global distribution of climate vulnerability Figure 1.5 Trends in probability of death at ages 0–79, 50–79, and 0–49 years from 1970 to 2019 by income region Figure 1.6 Proportion of all deaths attributable to NCDs, by country income category, 2019 and 2040 Figure 1.7 Number of adults living with major NCDs in 2019 Figure 1.8 Contribution of mortality or disability for selected major causes of death in India at various ages, 2017 Figure 1.9 Number of people (aged 15+) with NCD risk factors in 2016 and trends in prevalence Figure 1.10 Avoidable mortality as a percentage of total mortality, 2019 Figure 1.11 Projected mortality decline vs. mortality decline at the rate of top 20% of countries, Ethiopian men aged 50-69 Figure 1.12 Trends in the age distribution of avoidable mortality by sex in Colombia, 1990 and 2030 Figure 1.13 Levels in avoidable mortality, selected countries by age and sex in Latin America and Japan in 2020 Figure 2.1 Shares of total wealth, by asset type and income group, 2018 Figure 2.2 Conceptual framework to address NCDs, human capital, productivity, and wellbeing Figure 2.3 Survival among British males in 1960, 2010, and with hypothetical ideal, including years lived with disability Figure 2.4 Distribution of critical income values for LMICs in 2019, relative to reference 1990 global value Figure 2.5 Incidence rates of major CVDs in selected countries by income region Figure 2.6 Education levels and age-standardized death rates from cancers among adults aged 30–69 in India by sex, 2001–03 (left) and education levels and selected NCD and risk factors among Argentinian adults aged 18 years and older, 2013 (right) Figure 3.1 Levels of excise and other taxes on cigarettes by country income group, 2020 Figure 3.2 Prioritization of HLI-recommended NCD clinical interventions, by country income Figure 3.3 Coverage of contributory pension systems strongly depends on income level (left) and coverage levels in LMICs have changed little over 15 years (right) Figure 3.4 Survival rates and pension coverage, by education in India Figure 3.5 Sample HLI dashboards for India and Sierra Leone Figure 4.1 Intersections of demographic change, NCDs, climate change, and pandemics Table Title Table 1.1 Average annual rate of reduction in mortality between 1990 and 2019 by age (%) Table 1.2 Projected deaths vs. avoidable deaths in hypothetical scenario and with accelerated performance through- out life course Table 1.3 Economic value of avoidable mortality for 2050 as a percentage of annual income and in US$ trillion, by country income category Table 1.4 Economic value of avoidable mortality in 2019 and 2050, globally and compared to the frontier mortality rates, as % of annual income by major disease category Table 3.1 Full list of recommended NCD interventions Table 3.2 Estimated cost and impact of locally tailored, high-priority NCD package, by country income Table 3.3 Estimated distribution of cost of NCD package, by level of health system Table 3.4 Estimated increase in health care workers and facilities with HLI package Table 5.1 Summary of the HLI agenda recommendations and their impact U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y AB B R E V IAT I O NS AN D ACR O N YMS v Abbreviations and Acronyms AARC   Average annual rate of change LTC   Long-term care AARR   Average annual rate of reduction MDB   Multilateral development bank ACS   Acute coronary syndromes MDGs   Millennium Development Goals AI   Artificial intelligence MICs   Middle-income countries AIDS   Acquired immunodeficiency syndrome NCD   Non-communicable disease ASRHR   Adolescent sexual and reproductive NGO   Nongovernmental organization health rights ODA   Official development assistance BMI   Body mass index OECD   Organization for Economic COPD   Chronic obstructive pulmonary disease Co-operation and Development COVID   Coronavirus disease PCI   Percutaneous coronary intervention (also known as COVID-19) PHC   Primary health care CVD   Cardiovascular disease PPP   Purchasing power parity CWON   Changing Wealth of Nations R&D   Research and development DALY   Disability-adjusted life year SBCC   Social and behavior change DCP3   Disease Control Priorities, third edition communication EVAM   Economic Value of Avoidable Mortality SDGs   Sustainable Development Goals GDP   Gross domestic product SHI   Social health insurance GNI   Gross national income SIDS   Small island developing states GPGs   Global public goods SSBs   Sugar-sweetened beverages GPT   Generative pre-trained transformer UMICs   Upper-middle-income countries HICs   High-income countries UN   United Nations HIV   Human immunodeficiency virus UNPD   United Nations Population Division HLI   Healthy Longevity Initiative VLY   Value of a life year HNP   Health, Nutrition and Population VSL   Value of statistical life Global Practice (World Bank) VSLr   Ratio between VSL and income per HPV   Human papillomavirus capita IDU   Injecting drug use WHO   World Health Organization LICs   Low-income countries WPP   World Population Prospects LMICs   Low- and middle-income countries vi FOREWORD U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Foreword The World Bank has a long history of engaging in population issues, ranging from childhood illness, nutri- tion, fertility, and safe motherhood to the aging process. It supports countries in addressing the implications of the demographic process through analytical work, technical advice, and financing to expand health cov- erage, redesign pension systems and social security, and undertake actions that support their economies. This report follows that tradition and analyzes the steps to promote healthy longevity and enhance the quan- tity and quality of human capital through attention to the burgeoning problem of Non-communicable dis- eases (NCDs). Research began before COVID and concluded after, drawing upon lessons from the pandem- ic. The report is intended to inform policy and action at the country level. The demographic transformation is a global phenomenon, and the increasing population of the mid- dle-aged and elderly brings with it many challenges which are more acute in low- and middle-income countries where resources are more limited. The increasing number of adults calls upon countries to insti- tute the social and economic measures of ensuring their wellbeing and making them optimally productive. Health must be at the center of these concerns, not only its preservation towards the end but its optimiza- tion throughout the life-course. This report builds on a compendium of analytical papers covering the economics of avoidable mortality, long-term care, behavior change, social protection, and whole-of-government solutions to support healthy longevity. It emphasizes that a great deal of ill health globally is a result of inequities—especially poverty and gender inequities that limit or delay access to and use of health care. High out-of-pocket payments for NCDs can plunge households further into poverty or extreme poverty. Women live longer with NCD morbidities. Preserving good health increasingly depends on preventing and controlling NCDs. This is grounded not only in the demonstrated efficacy of fiscal instruments governments can use to reduce the burden of NCDs, such as excise taxes on tobacco, sugar-sweetened beverages, and alcohol, but also on the definition of the system-wide interventions that make healthy longevity possible. The proposals set out in this report are ambitious but firmly grounded in the financial realities of individual countries and emphasize that such financing should come principally from domestic sources, noting that the poorer countries will need support from external sources. There are existing instruments to operationalize most of the recommendations of the report, and attention to research and development of global public goods is a necessary adjunct. The adoption of such policies will involve not only governments but also all of society, particularly people living with NCDs and the full range of development partners. Countries are at different levels of development, but all can commit to the imperative of the life-course approach. This implies continuing the commitment to maternal and child health that was so successful for reaching the Millennium Development Goals. It is my hope that the wide dissemination and adoption of the recommendations in this report will contribute significantly to adding both years to life and life to years. Mamta Murthi Vice President for Human Development The World Bank U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y REPORT TEAM vii Report Team The Healthy Longevity Initiative (HLI) was led by Sameera Altuwaijri, Global Lead, Population and Devel- opment at the World Bank. Prabhat Jha was the lead author of the HLI report and the lead of the HLI sci- entific advisory committee. The scientific advisory committee was composed of George Alleyne, Debapriya Chakraborty, Gisela Garcia, Victoria Haldane, Paul Isenman, Seemeen Saadat, Jeremy Veillard and Daphne Wu. The HLI builds on the Non-Communicable Diseases and Human Capital Research Initiative, which was spearheaded by Jeremy Veillard. The HLI was conducted under the overall guidance of Mamta Murthi, Vice President, Human Development, World Bank. Timothy Evans and Muhammad Ali Pate, as former Directors of the Health, Nutrition, and Population (HNP) Global Practice of the World Bank, and Juan Pablo Uribe, as the current Director, helped to initiate and complete the HLI. Monique Vledder, Practice Manager, HNP Global Practice, World Bank oversaw the completion. Alexander Irwin, Christine Ro, Leslie Newcombe, Katherine Ward and Meriem Boudjadja provided editorial and writing support. Karim Ezzat and Danielle Willis provided graphics sup- port and Arlene Lucindo Fitz-Patrick, Jocelyn Haye, and Venus Jaraba provided operational support. Aart Kraay and Roberta Gatti from the Human Capital Index team joined in early consultations on the HLI. Elena Glinskaya, Gustavo Demarco, and Margaret Grosh provided input on social protection and jobs, and Daniel Halim on gender. Iffath Sharif and Gabriel Demombynes, successive Managers of the Human Capital Project, provided key additional input. Additional contributions were provided by Philip O’Keefe, University of New South Wales, Australia; John T. Giles, Lead Economist in the Development Research Group, World Bank; Susan Horton, University of Waterloo, Canada; Hoyt Bleakley, University of Michigan; and Norbert Rudiger Schady, Chief Economist of the Human Development Network, World Bank. Dean T. Jamison, Lawrence H. Summers, and Jeffrey D. Sachs provided useful comments on development finance. Adalsteinn Brown and Beverley Essue provided input from the Dalla Lana School of Public Health, Univer- sity of Toronto. The work was conducted in partnership with the Disease Control Priorities Project, led by Editor-in-Chief Ole Norheim. Any errors are the sole responsibility of the report team. The report benefited greatly from a wide variety of workshops (see Acknowledgments in Appendix C). Fund- ing for this report came from the World Bank; the Access Accelerated Trust Fund; the Centre for Global Health Research, Unity Health Toronto, Dalla Lana School of Public Health at the University of Toronto; and the Queen Elizabeth Scholars Program of the Government of Canada. viii PREFACE U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Preface: Why this report? Governments have increasingly recognized the importance of human capital, defined as the knowledge, skills, and health that people accumulate throughout their lives, enabling them to realize their potential as produc- tive members of society. Human capital is central to ambitions of greater prosperity and inclusive societies, as well as to the greater human wellbeing to which they contribute. Three major challenges to human capital and wellbeing are climate change, pandemic vulnerability, and demographic transformation. While the first two have received substantial attention, the demographic shifts occurring worldwide have attracted less. This report seeks to fill this gap, demonstrating that addressing the major Non-communicable diseases (NCDs) through a life-course approach contributes to healthy longevity and improves human capital and wellbeing. Countries continue to rebuild from the COVID pandemic, crucial in itself and as a portent of the relation- ship between infectious diseases and NCDs, and of the need to build resilience in individuals and societies. Simultaneously, the global demographic landscape stands at a crossroads, with rapid declines in fertility and rapidly aging populations holding profound implications for employment, social services, and wellbeing. This aging of populations has accelerated the rise of NCDs as the leading global cause of death. Projections suggest a global surge in deaths from 61 million in 2023 to 92 million in 2050, as well as related increases in needs for NCD-related hospitalization and long-term care. Beyond mere statistics is the grief, hardship, and suffering from death and severe disease. The world finds itself inadequately prepared for the impending NCD pandemic. This report maps out a menu of practical, cost-effective, fiscal and clinical interventions, many of which can be swiftly implemented to yield substantial benefits. With mortality and spending forecasts extending to 2050, the report underscores the imperative of prolonged interventions to fully realize the impact of a life- course approach. Its principal focus is to galvanize country-led efforts, with accelerated progress through cost-effective, pro-poor, and inclusive interventions. If low- and middle-income countries can achieve am- bitious yet feasible rates of progress, the world could avert 25 million deaths annually by 2050, effectively halving avoidable deaths and meeting the related Sustainable Development Goals. The report proposes a comprehensive, but fiscally realistic, intervention package, building on that menu and on historical successes in reducing mortality among children and mothers and combating infectious diseas- es. It is also important to extend interventions beyond health to encompass broader social protection, labor market, and long-term care policies. The report draws on the foundation of the World Bank’s Human Capital Project and Human Capital Index and synthesizes economic, epidemiological, and implementation evidence, including 18 detailed background papers. It introduces innovative analysis assigning economic value to avoid- able mortality and incorporates insights gleaned from consultations with over 90 experts conducted over a four-year span. It identifies priorities in global public goods to tackle NCDs and improve welfare. People living with NCDs are also increasingly recognized as a potent political force and can help in gaining more attention to NCDs. The billions of individuals grappling with NCDs look to their governments for support in managing their conditions and contributing meaningfully to their families, communities, and economies. Analyses alone will not be enough. Mobilizing support to move from knowledge to action is required to real- ize the astounding human and economic benefits of addressing one of the major challenges of the 21st century. The HLI Report Team, August 15, 2024 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y KEY MESSAGES OF THIS REPORT 1 Unlocking the power of healthy longevity: Key messages of this report Navigating global demographic The key lesson from centuries of demography transformations—a call for and epidemiology is clear: while death in old age strategic action is inevitable, death early in life should be rare and death in middle age need not be common anywhere. The world is undergoing a significant demographic These demographic changes intersect with the transformation, with a rapidly aging population in challenges posed by climate stress and pandem- many countries presenting opportunities as well as ic vulnerability. Approximately 40 percent of the challenges. Encouragingly, there has been remark- global population—around 3.5 billion people— able progress, with global mortality risk of death live in areas vulnerable to adverse climate effects before the age of 80 dropping from about four in that exacerbate poverty, especially among margin- five in 1970 to just over half in 2023. Child mor- alized groups. There is also a reasonable proba- tality has seen remarkable declines worldwide. This bility of another global pandemic in the medium positive trend, marked by longer and healthier term. Pandemics of respiratory pathogens, like lives, more women working, and smaller families COVID, will disproportionally harm the elderly as countries prosper, has contributed substantially and people with NCDs. These intersections could to economic growth. markedly amplify intergenerational suffering and However, these favorable trends bring with economic stagnation. them a set of challenges. The growing adult pop- Governments cannot afford to delay address- ulation, encompassing both the elderly and mid- ing these interconnected challenges. Proactive dle-aged individuals, has impacts that reverberate measures and country-driven strategic planning across societal organization, education, work dy- are essential to build resilience. While altering the namics, and health care services. The global pop- population structure significantly by 2050 might be ulation is projected to reach 9.7 billion by 2050, challenging, sustaining success in reducing prema- stabilizing thereafter. Some nations already grapple ture deaths and disabilities and enhancing overall with declines in total population; and the majority wellbeing is achievable. These are potent yet un- of countries are experiencing significant declines derused tools to alleviate poverty. in the rate of growth of population, and so in the growth of the labor force. These shifts result from Tackling the NCD challenge—a falling fertility rates and reduced premature mortal- strategic imperative ity. The one area still experiencing marked popula- tion growth is Sub-Saharan Africa. NCDs—particularly cardiovascular diseases, di- Many nations are ill-prepared for the magni- abetes, respiratory diseases, cancers, and major tude and pace of these demographic shifts, which depression—already account for over 70 percent will ripple through labor markets, immigration, and of all deaths in low- and middle-income countries social policies. Retirement ages and other institu- (LMICs) and a significant portion of disability. tional responses to changes in the age structure are NCDs are surging in low-income countries (LICs) lagging behind the rapid increase in adult popula- due to demographic shifts toward older populations tions. To navigate this evolving landscape, investing and the influence of key risk factors including to- in the health and wellbeing of the working-age pop- bacco smoking, heavy alcohol use, and obesity. ulation is imperative. Early and effective control of The share of NCDs in overall deaths—and even Non-communicable diseases (NCDs), the primary more as a share of avoidable deaths—is large and cause of adult deaths, is crucial. rising, contributing also to preventable increases in 2 KEY MESSAGES OF THIS REPORT U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y hospitalizations, long-term care (LTC) needs, and Leveraging cost-effective poverty traps for families. For example, the world interventions—the HLI agenda has over 1.1 billion smokers (who will typically lose a full decade of life compared to similar non-smok- The HLI agenda proposes proven, cost-effective ers); 1 billion people with hypertension, contribut- interventions ranging from NCD prevention and ing to cardiac death and disease; and 700 million treatment to targeted financial protection for the who are obese, contributing to diabetes. On current poor and to meet LTC needs. While recommen- trends, the global number of diabetics may double dations vary based on individual country circum- from 500 million today to over 1 billion by 2050. stances, they demand increased upfront financing, LMICs are particularly vulnerable, already bearing primarily domestic for most middle-income coun- the brunt of the NCD epidemic but without ade- tries (MICs), complemented by external financ- quate preparation and resources. ing and technical support. In addition, substantial Healthy longevity means sharply reducing concessional financing will be needed for LICs. In avoidable death and serious disability throughout the short run, excise taxes on tobacco, alcohol, and the life cycle, as well as increased levels of physical, sugar-sweetened beverages can mobilize additional mental, and social functioning through middle and revenue. In the long run, enhanced productivity and older ages, and a socially-connected, reasonably extended working lives may—other things equal— pain-free and short period of time before inevita- boost incomes and tax revenues. ble death. It is produced by action throughout the The overarching recommendation is for coun- life cycle, starting with infant health and nutrition. tries to invest in interventions for NCDs over the Countries face critical choices in responding to life course. The main thrust involves scaling up their aging populations. Vigorous action, as pro- high-impact interventions, addressing financial pro- posed in this Healthy Longevity Initiative (HLI) re- tection for the poor and LTC needs, and supporting port, can catalyze a virtuous cycle of gains in health, data and global public goods for healthy longevity. improved wellbeing, and reduced poverty. With the achievement of ambitious yet feasible rates of prog- Scaling up high-impact interventions—a fiscal, ress, LMICs could meaningfully extend billions of public health, and clinical approach lives, averting 25 million deaths annually by 2050, effectively halving avoidable mortality and meeting Leveraging fiscal instruments for health across the the related Sustainable Development Goals. life course is crucial. Tobacco excise taxation stands out as the single most effective measure, with sig- Recognizing poverty and gender equity nificant pro-poor health benefits and reasonably in the pursuit of healthy longevity rapid reductions in premature mortality. Excise taxes on alcohol and sugar-sweetened beverages The poorest within countries are most suscepti- similarly bring health benefits and can generate ble to NCDs, for example because of higher rates substantial revenues for NCD interventions and of smoking and obesity. They are also least able to other pro-poor measures at all income levels. Inte- afford treatment costs and cope with income loss. grating cost-effective clinical services into primary NCDs and their risk factors create intergeneration- health and first referral systems is also crucial and al traps of poverty, affecting children’s prospects. cost-effective—as well as preventing unnecessary So reducing NCDs increases equity. In addition, suffering and death. The sooner the integration pro- HLI-recommended responses explicitly target pov- cess begins and is scaled up, and the higher, better erty and gender equity. Women generally outlive structured, and more sustained the tax increases, men. But partly because of that, they bear high the greater the benefits. burdens of specific NCDs and experience great- HLI investments in LMICs are expected to cost er and longer periods of disability, and they have about US$220 billion in 2050, constituting about 7 fewer resources to address these challenges than percent of projected public spending on health (but men. In addition, women bear disproportionate re- significantly more as a percentage of public spend- sponsibility for caregiving which can reduce their ing in LICs). These investments would substantially employment prospects and compromise their own expand health care capacity: over 6 million more wellbeing. Expanding LTC options to reduce costs nurses, 0.8 million more doctors, and 1.7 million and care burdens on women is essential. additional health facilities. It will take time to scale U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y KEY MESSAGES OF THIS REPORT 3 up this expanded capacity, but it is important to can strengthen national systems, improve program hasten the process, primarily to accelerate health management and evaluation, and facilitate knowl- benefits, but also because the additional capacity edge sharing between countries. can support expansion of overall health services to the population. Emphasizing the needs of women, Moving from knowledge to action—a who have been relatively neglected in NCD efforts, call for collective effort and disadvantaged social groups is essential. Health interventions have been spectacularly suc- Providing financial protection and addressing cessful in reducing child and infectious disease long-term care needs—a holistic approach mortality. Similarly, NCD interventions could yield remarkable gains reasonably quickly, improving the Supporting financial protection from catastroph- lives of potentially billions of parents and grandpar- ic health expenditure is vital for inclusive healthy ents worldwide. longevity, particularly for the poor who are primar- The HLI agenda requires substantially more ily in the informal sector. Providing opportunities spending, begun and scaled up quickly to avoid cost for skill development and extending working lives headwinds, and accelerated steps to reduce pre- is crucial. In addition to existing social protection ventable disease and death. With a minimal “start- systems, expanding non-contributory or subsidized er” HLI package of interventions, cumulatively at pensions for the informal sector can enable digni- least 150 million deaths across all LMICs would be fied aging and help cover essential costs, including avoided by 2050, and about 8 million in 2050 alone. health care. Emphasizing sustainable alternatives Analysis of the economic value of avoidable mor- to residential LTC, particularly community-based tality suggests that this would correspond to over care, will contain costs, respect dignity and cultural US$3.2 trillion just in 2050, suggesting a very favor- norms, and aid women to remain in the workforce. able benefit-cost ratio of 16 to 1 for all LMICs.. This report provides a robust knowledge base, Promoting data and global public goods—a including evidence that significant progress in tack- collaborative strategy ling NCDs is possible in nearly every setting, even where delivery capacity is currently limited. How- It is essential to create and fund global public goods ever, a strong evidence base alone is insufficient. (GPGs): internationally relevant innovations, in- Building strong support at top leadership levels in cluding health tools, pricing mechanisms, joint political and other areas is crucial for adopting and procurement, scientific and operational research, advancing the proposed agenda. A coordinated, knowledge, and pro-poor intellectual property ar- whole-of-society effort involving governments, the rangements. These GPGs correspond to global chal- private sector, academia, nongovernmental organi- lenges including synergies with climate change and zations (NGOs), foundations, the media, the health pandemic preparedness and response. GPGs can community, including people living with NCDs, and expedite progress on life-course health with suffi- the global and national development communities is cient mobilization of resources from development needed. Multilateral development banks can play a partners. Expanding open data for accountability pivotal role in catalyzing country analysis and own- and monitoring, which are partly national and part- ership and sharing learnings across diverse settings. ly global public goods, is also crucial. Investments The imperative is clear: acting now on healthy in vital registration and statistical systems, cou- longevity can shape a healthier, equitable, and more pled with the use of healthy longevity dashboards, productive future for the twenty-first century. 4 KEY MESSAGES OF THIS REPORT U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y BOX  Summary of Report Structure Following this overview, Chapter 1 details the rapid demographic transformation the world faces from a shift to a much larger and older population of adults, declines in fertility, and changes in the age-structure. Paired with this demographic change, it describes the large and growing burden of NCDs and their key risk factors, notably smoking, harmful use of alcohol and obesity. It includes novel analysis of avoidable mortality that combines demographic estimates with economic value. It also compares the very large benefits in lives saved if countries were to accelerate their performance in life-course investments to match that of the top fifth of peer countries. Chapter 2 sets out the links among healthy longevity, NCDs, and human capital. It explains why levers for action are needed across the life course, suggesting key levers for action at each stage. It then provides pathways from healthy longevity to en- hanced human capital and wellbeing. Key to the welfare benefits is the relationship between NCDs and poverty. The chapter ends with why tackling NCDs is critical to increasing gender equality. Chapter 3 then addresses the country-level arenas for action in advancing the healthy longevity agenda. These include tackling NCDs with cost-effective, pro-poor interventions, as well as looking beyond the health sector to social protection, jobs, and long-term care strategies. Improving healthy longevity outcomes will necessitate stronger measurement and monitoring sys- tems, and the chapter lays out how healthy longevity dashboards can contribute to these goals. Chapter 4 presents suggestions for financing from both national governments, which must take the lead on the healthy lon- gevity agenda if it is to produce sustainable progress, and development partners and other external sources of financing. These international sources of financing are crucial, especially but not exclusively to LICs. In both LICs and MICs, they can support country efforts to accelerate the pace of scaling up of NCD and other healthy living investments, as well as in development and uptake of GPGs such as new knowledge creation and dissemination or pooled procurement mechanisms. This chapter also ad- dresses intersections with climate change and pandemic finance, and the substantial role for multilateral development banks. Chapter 5 provides a brief conclusion with key recommendations of the report. The appendices detail the analytic methods used and provide additional analyses. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y EXECUTIVE SUMMARY 5 Executive Summary This report, a product of the Healthy Longevity cardiovascular disease, diabetes, respiratory disease, Initiative (HLI), presents the rationale and recom- cancer, and selected mental health conditions—are mendations for focusing on the many opportunities responsible for at least 70 percent of deaths global- presented by healthy longevity. This summary high- ly each year and most disabilities. The majority of lights particular points from each chapter in turn. NCD deaths already occur in LMICs, where abso- lute NCD burdens are also rising fastest. Chapter 1: Better health throughout By 2050, based on current projections, there the life course is achievable will be a rise in overall deaths to 92 million from 61 million in 2023, concentrated among middle-aged Demographic transformations are reshaping the and older adults, and most of these deaths will be world, with the global population expected to reach from NCDs. The world has, over the last three years, 9.7 billion by 2050. Notably, the number of mid- largely overcome the COVID pandemic. Yet much dle-age and older adults is rising sharply, creating of the world is unprepared for the serious and con- both opportunities and challenges. Reductions in tinuing NCD pandemic of recent decades. fertility and child mortality have largely driven these Death in very old age is inevitable, but the changes, along with age-structure effects. These, also main lesson from centuries of demography and ep- known as cohort effects, relate to the relative size of idemiology is that death prior to very old age need different age groups. not be common anywhere. This report’s analysis of There are important lessons from the last few avoidable mortality suggests that about 7 in 10 of decades. The world has made remarkable progress all deaths in 2019, or 40 million, could have been in saving children’s lives. From 2000 to 2019, the avoided at the lowest observed death rates of various deaths of 65 million children under 5 were averted countries. Deaths can be avoided by applying the in low- and middle-income countries (LMICs). abundant knowledge of cost-effective ways to pre- Major global goals, like the Sustainable Devel- vent, treat, and palliate NCDs, directly and through opment Goals (SDGs), focus on reducing mortality their major risk factors, most notably smoking, obe- rates, particularly for children and from NCDs. To- sity and alcohol abuse. day, urgent new global health challenges are emerg- This report provides a unique lens on NCDs by ing, linked to rapid demographic transformation, strongly emphasizing a life-course approach. Im- with a big increase in the size of older age groups plementing this approach will increase good health and a related rise in cases of NCDs. during longer lives. This will be associated with in- Population aging carries economic implica- creased human capital (knowledge, skills, and other tions, potentially slowing growth unless there is in- individual aspects that contribute to productivity) creased labor force participation and productivity. applied over longer working lives, as well as with Countries need careful analysis for policies that bal- positive impacts on gender and income equity. ance economic demands, social services, and long- If all countries were to accelerate their progress term care costs. Migration policy becomes crucial through life-course approaches by matching the in this context, depending on the size and skill com- rate of progress that the top 20 percent of countries position of demand, and leveraging the differential have achieved for each age and sex group, cumula- stages of demographic transition across countries. tively over 500 million lives could be meaningful- Climate change adds an additional layer of com- ly extended by 2050, and 25 million lives could be plexity, particularly for countries facing both aging saved in the year 2050. This would halve avoidable populations and rapid changes in climate. deaths and help achieve the relevant SDGs. A key reason for the sluggish pace of improve- This report’s life-course approach to NCDs aims ments in health outcomes among older adults is the for not only a longer lifespan but also good health growing contribution of NCDs. NCDs—including throughout. It introduces the Economic Value of 6 EXECUTIVE SUMMARY U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Avoidable Mortality (EVAM), a new analysis to better a global scale-up in life-course health will require describe the period of life spent in good health, in or- substantial resources and effort. Innovations can der to inform priority-setting and decision-making. make investments more affordable. While it is sig- The EVAM quantifies the benefits of healthy nificantly cheaper now to save a child’s life than it longevity. It considers the acquisition and protec- was several decades ago, it is more expensive to save tion of health throughout life, comparing actual an older adult’s life. In 2019, to keep up with the top and projected mortality rates against a frontier of 20 percent of peer countries in reducing mortality low observed rates. This comparison enables quan- in children under 15, LMICs had to spend US$182 tification, albeit imperfectly, of avoidable mortality. per capita, substantially less than the US$342 need- The EVAM method estimates the economic value ed in 1990. But to achieve similar performance of avoiding deaths, emphasizing the potential gains for adults aged 50–69, they had to spend US$255, from improving life-course investments. This ap- which is more than the US$198 required in 1990. proach makes it possible to compare the economic The rising relative cost to save an adult life em- value of various rates of progress toward reducing phasizes the need for more effective interventions mortality. It suggests that substantial progress is through research and development (R&D) and oth- possible, emphasizing the importance of accelerat- er global public goods (GPGs) to bend the cost curve ing efforts to reduce NCDs. downward, as has happened for children’s health. Taking a life-course approach to NCDs pro- Chapter 2. Healthy longevity, vides an economic case for what is already clear NCDs, and human capital: Action on moral grounds, and which shone through the across the life course world’s collective response to the COVID pandem- ic: the lives of older adults are well worth saving. By acting across the life course, the world can Life-course programs, starting at a young age, to achieve a more desirable and dignified form of lon- reduce NCDs have a modest positive impact on hu- gevity that benefits individuals, households, and man capital (more education and on-the-job train- societies alike. This report defines healthy longevity ing) and enable deployment of that human capital as the state of good physical, cognitive, and social over longer working lives. Lower NCD burdens also functioning for nearly the full lifespan of an indi- reduce absenteeism and decrease age-related de- vidual. Healthy longevity is a key component of preciation of human capital, so increasing worker people’s wellbeing, and thus important in itself as a productivity. Extending working lives will be par- key objective for development. It is simultaneously ticularly important as the labor force grows more a driver of greater equity and social inclusion—so- slowly (or even shrinks) in an increasing number of cioeconomic, gender, and intergenerational. The ul- middle-income countries. This opens up the possi- timate vision is for people to live longer, healthier, bility of increased economic growth, depending on more productive, and more satisfying lives. Some of the effectiveness of government policies and of their the health and wellbeing benefits to be had in the implementation—not just in NCDs but on labor future will, rightly, be after retirement. market and other directly related issues. It depends This vision would mean that in their forma- even more on the evolution of broader underlying tive years, adolescents and young adults would be determinants of growth, including economic man- much less likely to take up smoking, start drinking agement, education, institutions, and technology. to excess, or become obese—all activities that sig- Even more importantly, reducing prevalence, nificantly increase their likelihood of developing morbidity, and mortality from NCDs also brings NCDs. In this improved scenario, chronic ill health about improvements in human wellbeing. This would be much less likely to mar their lives, lim- comes not only through higher incomes, but also as iting their employment and income while exacting a direct consequence of being healthy. high health care and associated costs. Nor would In discussing the wellbeing impacts of address- avoidable diseases kill them prematurely. Moreover, ing NCDs, it is important to bear in mind the equity family members, usually women, would not have dimension. People living in poverty and other dis- to compromise their own opportunities to provide advantaged groups are more likely to have NCDs. protracted care. This is partly because poor people are more prone to Investments in the life course have proven fea- adopt behaviors that lead to NCDs, such as smoking sible and cost-effective in a variety of countries. But and obesity, and to have worse mental health. Poor U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y EXECUTIVE SUMMARY 7 people are also more likely not to be able to afford, interventions are not only cost-effective but also and may be far from, the diagnostic and treatment address equity, reducing financial risk, and feasi- care they need. In addition, studies show that the bility of implementation. Countries can draw on combination of high medical bills and lost income and adapt these interventions, depending on their of a breadwinner creates a high risk of personal and specific needs and capacities. Scaling up all of the family impoverishment. items in the prioritized list of interventions to cov- Addressing NCDs also reduces gender inequal- er even 80 percent of the population in all LMICs ity. This is partly because women have heavy specific by 2030 would dramatically reduce NCD mortality NCD burdens over their lifetimes, which are usual- and would be highly cost-effective—even though in ly longer than those of men. It is also, importantly, practice it would take longer in most countries to because of the societal expectation that women will get in place all the financing and capacity needed. provide care to older household members suffering For the great majority of countries, adopting all of from NCDs instead of seeking gainful employment the measures at once would involve unrealistic in- outside the household. Women also frequently ex- creases in health expenditure and institutional ca- perience greater barriers to health care for their pacity. Realistically, most LMICs will need to focus own NCDs, especially because of their often-limited initially on a subset of interventions and sequence financial means and decision-making power within the order and expansion of their coverage. Most the household, particularly in LMICs. It is for these countries will likely want to apply “progressive uni- reasons the HLI includes a strong, explicit emphasis versalism”: limiting costs by concentrating public on gender in its recommendations. financing initially on the poor and disadvantaged, In sum, reducing the prevalence of NCDs would then moving toward universal coverage of a set of also reduce socioeconomic and gender inequalities. basic services, and then adding to that set as financ- The healthy longevity approach to NCDs consistent- ing and institutional capacity permit. ly emphasizes taking account of these inequalities in The chapter also provides a framework for pri- strategies and interventions—whether in prevention oritizing NCD interventions based on three other and care of NCDs or in policies related to labor mar- criteria beyond cost-effectiveness: equity, finan- kets, pensions, or long-term care (LTC). cial risk protection, and implementation feasibility. The list of high-priority intervention includes six Chapter 3. Advancing healthy population-level prevention measures, all of which longevity now: What countries can do are highly cost-effective and relatively inexpensive to implement. The biggest and most cost-effective Countries can make major advances toward healthy gains would generally come from “health taxes”— longevity with well-chosen policies and life-course particularly taxes on tobacco. These policies are fea- interventions if implemented quickly. A key general sible to implement even in countries with weak in- message is the need to substantially accelerate NCD stitutional and financial capacity, including in those interventions, which have been underused, and to recently emerging from war or conflict. There is vast do so early. Delays in adopting interventions will evidence that health taxes reduce consumption of result in massive and preventable death and disease, these substances that sicken and kill; in the case of both before scaling up starts and in the longer run, tobacco, prolonged smokers lose an average of one because it will inevitably take a long time for scaling decade of life compared to non-smokers. Yet this up to reach full coverage. fiscal tool is greatly underused worldwide. The high A commitment to healthy longevity through a priority package also recommends other clinical life-course approach can be realized in part by con- interventions—including pulmonary rehabilitation tinuing investments in child and maternal health and treatment for chronic heart failure—and priori- and nutrition. To improve health from teen to older tizes them based on country income level. ages, Chapter 3 lists a range of 31 cost-effective, ev- Overall, fully implementing the high-priority idence-based interventions that countries can select package of interventions starting from 2023 to 2050 from and adapt in view of their unique needs and could avert up to 150 million deaths by 2050, at an constraints. The HLI recommended menu of clin- incremental cost of US$1.3 trillion (US$9,300 per ical health interventions can largely be delivered death averted). The budgetary implications of the through primary health care (PHC) systems, ide- package would be more manageable. Total cost (at ally in concert with community-based care. These 80 percent coverage) would in the longer run range 8 EXECUTIVE SUMMARY U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y from a relatively affordable 7 percent of projected own homes, with family, community, and public public spending on health in 2050 in upper-middle support. For older adults, especially women, there income countries, to a much more challenging 20 is a need for adequate access to health care. Ideally, percent in low-income countries. This cost is based ill health would be confined to a short period just on the assumption that countries invest in the pack- before the end of their lives. age constantly every year from 2023 to 2050. Given Another urgent area for country action is the that programs take some years to reach full opera- strengthening of country data systems that can help tional capacity and the cost to save a life increases set and measure progress on life-course health. Ex- over time, it is urgent that countries act now in pri- panding open data sources for widespread use is oritizing, adapting, and implementing the package, needed to help countries consider how to improve so that consequently with economies of scale, scaling their performance, including by providing data up coverage for these interventions remains feasible. with which to measure their progress and problems The HLI intervention package should be con- against those of peer countries. Essential invest- sidered a starter or catalytic package that needs to ments include supports for national vital events, be customized to local contexts. For political econ- registration systems, and improved statistical ca- omy and institutional reasons, some countries will pacity. There is also a need for healthy longevity continue NCD interventions not in the HLI list, dashboards: an innovative data visualization tool even if they are relatively less cost-effective. In ad- tailored to countries that aims to help turn data dition, over time there will be new cost-effective in- into action. It synthesizes key indicators to improve terventions (new or newly cost-effective) because of management and evaluation, and enables and en- declining prices, including from GPGs. courages countries to draw on available data to as- Moving beyond health-specific interventions, sess their performance in relation to others. policies on jobs, social protection, and LTC will also be needed to progress on the NCD and healthy lon- Chapter 4. Financing for healthy gevity agendas. In terms of employment, countries longevity: Country leadership could call on a range of policies to support older and key supporting roles for workers who wish to continue working, with resul- development partners tant benefits for their, and potentially, national in- comes. For those no longer able to work, a critical The NCD and other aspects of the healthy longevity area of social protection is non-contributory pen- agenda are ambitious, and the necessary financing sions, where fiscally feasible, for the large poor pop- will be considerable. But these investments will de- ulations in LMICs who have worked in the informal liver strong returns on investment, contributing to sector. This can help the many older adults and fami- human capital while reducing poverty. lies facing both low incomes and high out-of-pocket The time for action is now, as delaying NCD-re- medical expenses, especially in those countries far lated interventions will result in increased NCD from achieving universal health care. Additionally, death, disease, suffering, and worsening poverty. to ensure the healthy and dignified aging of people While some interventions can affect change quickly, who require LTC, countries should consider how most NCD programs take some years to establish best to bolster, oversee, and -as needed- partly subsi- the financial and institutional capacity—and need- dize community and home-based care, with less em- ed political support—for adequate national cover- phasis on sparse and expensive residential LTC. For age. Strong country ownership is essential. And it is both non-contributory pensions and LTC systems, at the country level where the bulk of the financing countries will have quite different needs and capac- will need to be mobilized. ities, and so different approaches. Well-evaluated To extend the high-priority package of recom- pilots of both, supported as appropriate by external mendations to all LMICs would cost up to US$220 funding, can help countries assess what makes the billion in 2050. The cost would be reasonably afford- most sense for them before large-scale expansion. able, at 8 percent of projected public expenditures Adults who continue working longer contrib- on health in 2050 for lower-middle income coun- ute to household income. They can also support tries, 6 percent for upper-middle income countries, children and other, needier elders by providing and 20 percent for LICs. The corresponding benefits family or community care. As they age, they can re- of life-course investments are large—corresponding tain some independence—with many aging in their to over US$3.2 trillion in economic value of avoid- U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y EXECUTIVE SUMMARY 9 able mortality in 2050. Thus, the benefit-cost ratio is large death tolls occurred among those with pre-ex- very favorable, at about 16 to 1 overall for all LMICs. isting chronic disease and that NCD sufferers are also Countries need to customize interventions to vari- likely targets for future viruses; (ii) improving data ous contexts and over time. The overall cost-benefit systems for both emergencies and routine diseas- ratio of the HLI is sufficiently high to suggest that es, including nationwide systems to monitor deaths various combinations that include most of the HLI and detect outbreaks; and (iii) the close link between interventions should be attractive investments. NCDs and the impact of pandemics adds a strong ar- The political economy of investments over the gument in favor of a cost-effective global adult vacci- life course suggests that each country would have to nation program to expand routine antigen coverage consider the benefits and demands from its citizens. and to provide surge capacity for future pandemics. Most interventions will require long-term efforts to While climate investments are essential for attain full coverage. Reassuringly, longer-term costs planetary health, they are also complementary to would fall somewhat through economies of scale plus life-course investments. Synergistic investments, benefits from investments in GPGs (health technol- such as expanding green transportation in urban ogies, good practices, and other “tools” at the global settings, can reduce carbon footprints and increase or regional level with benefits beyond borders). incentives for physical activity. Ending harmful External assistance could play an important subsidies for fossil fuels, which represent about 7 role in accelerating expenditures and policy actions percent of global gross domestic product (GDP), in the early years of scaling up NCD programs. The can free up major amounts in government budgets external financing would be available to support that can be used for health as well as climate change countries’ efforts at determining priorities, institu- mitigation and adaptation and other priorities. tional reforms, and to kick-start the scaling up of life- GPG investments are a powerful lever for im- course investments. Development partners (external proving health throughout the life course and for donors and partners of development—bilateral and amplifying the equity impact of such efforts. They multilateral organizations, foundations, and NGOs) are much needed to bend downwards the cost curve can also help in analysis and technical assistance. (reduce costs) and improve results for developing Development partners have enormous scope countries. GPGs relevant to NCD prevention and for increasing their financial assistance. Currently management include knowledge-sharing networks, just 2 percent of all official development assistance sharing of intellectual property, and global pro- for health (ODA) goes to NCDs. Development part- curement mechanisms for health commodities, as ners as well as countries should work closely with well as relevant scientific breakthroughs for NCD foundations, academia, and NGOs. The private sec- treatment. Our broad definition of GPGs also in- tor also has a major role to play in research, produc- cludes technical assistance to countries on uptake of tion, financing, and technical capacity. Stewardship GPGs. This includes possible expansion of the role of the private sector should be encouraging while of artificial intelligence (AI) in global health. AI still taking account of diverging incentives. tools could help identify new treatments and spur The HLI comes at a time when there is mo- efficiencies in delivery and quality assurance of life- mentum for a strengthening the role of multilateral course investments. Careful cross-country regula- development banks (MDBs). MDBs are well placed tion and transparent governance will be required to to use their financial, technical, and institutional curb disinformation and other harmful AI practices resources, their cross-country experience, and their and share benefits equitably. close relations with both finance ministries and Development partners should give high priori- health ministries to encourage and support coun- ty to investing in and fostering the uptake of GPGs try-owned NCD and broader healthy living initia- for healthy longevity as an important complement tives and programs. The World Bank Group stands to their financing at country level. Financing to ready to apply its full set of relevant instruments date for GPGs for elders and other adults has been to implementation of the HLI, tailored to specific grossly inadequate. While most financing for NCDs country circumstances as a part of its growing sup- at country level will come from the countries them- port for health and social protection. selves, this is not the case for GPGs. Rather, GPG Experience from NCDs suggests three priori- support is a critical area where multilateral and bi- ties for planning responses to future pandemics: (i) lateral development partners, foundations, NGOs, reducing NCDs, given that much of COVID’s very academia, and public health groups can spur trans- 10 EXECUTIVE SUMMARY U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y formation. MDBs are considering how they can best and are summarized above. give higher priority to participating in the develop- Acting on these recommendations would con- ment and application of such GPGs. tribute to three linked key outcomes: (i) reduced GPGs have helped to foster incredible im- death and disease from NCDs and improved well- provements in child survival and have driven the being; (ii) reduced poverty and gender inequality; significant decrease in the cost of saving a child’s and (iii) improved productivity, choice, and equity in life. They could help to do the same for adults. work. Drawing on the lessons from those improvements If all countries improve their performance to and applying the same energy to a life-course ap- match their best-performing peers, this could avert proach to address NCDs has the potential to con- up 25 million deaths in the year 2050, halve avoid- tribute to putting the world on a path to a more able deaths, and achieve many of the SDGs. equitable and healthy future. At both country and global levels, building strong support at top political and other leader- Chapter 5. From knowledge to action ship levels for adopting and advancing the agenda is required. That will take a strong and coordinated Prevention and control of NCDs amidst demo- whole-of-society effort that includes, within govern- graphic transformation is a grand challenge for the ments, ministries of finance, planning, social pro- first half of the twenty-first century, commensurate tection, labor, and gender among others, as well as in scale to climate change and global pandemics. championing by health ministries. That effort should The overall recommendation is for countries go far beyond governments and external partners to to invest in life-course investments for NCDs, with include academia, NGOs, foundations, the media, related reforms of labor markets, pensions, and civil society, the private sector, and the broader global long-term care. The former covers three areas: (i) and national development and health communities scaling up high-impact interventions; (ii) address- including people living with NCDs. The challenge ing specific social protection and long-term care facing all who recognize the feasibility and impor- needs; and (iii) supporting data and global public tance of healthy longevity is moving from knowledge goods for healthy longevity. More detailed recom- to large-scale, sustainable action and impact. mendations are provided in the various chapters U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 1 11 Introduction: Better health throughout the life course is achievable Demographic transformations are rapidly reshaping the world, with the global population expected to reach 9.7 billion by 2050. The number of middle age and older adults is rising sharply, creating both opportunities and challenges. The core of meeting the needs of people involves increasing good health during longer lives. Over the last few decades, the world has witnessed dle-income countries (UMICs) to about 80 years extraordinary improvements in human welfare. (Appendix B Table B4). The proportion of the world’s population living in Healthy longevity is produced across the life poverty fell from over 50 percent in 1950 to below course. This entails avoiding death and serious 9 percent in 2019, driven by particularly faster de- disability in middle age, enabling a high level of clines in poverty from about 2000 onward (World mental and social functioning through middle Bank 2022). In 1970, one in seven of all newborns and older ages, and includes a socially-connected died before their fifth birthday. By 2020, only one and reasonably pain-free, short period of time be- in 25 did. From 2000 to 2019, the world made ex- fore death (O’Keefe and Haldane 2024). Moreover, traordinary human development gains, particularly there is evidence of avoidable disability at every age in reducing poverty and child mortality. Concerted including past age 80. global action on child mortality and extreme pover- From 1970 to 2023, the global risk of death ty was catalyzed by the UN’s Millennium Develop- before age 80 fell from 79 percent to 54 percent, ment Goals (MDGs). The first MDG goal—to halve driven by improvements in mortality at younger extreme poverty between 1990 and 2015—was ages: below 50, mortality risks fell from 30 percent reached ahead of schedule. Countries’ participation to 11 percent, driven specifically by reductions in in the MDG process may have resulted in saving child mortality. Even between the ages of 50 and 79, the lives of as many 17 million additional children, when NCDs are the major causes of death, the risk beyond what would otherwise have been achieved of death fell from 71 percent to 46 percent. (McArthur and Rasmussen 2018). From 2000 to Much of the stunning reduction in child mor- 2019, the deaths of 65 million children under five tality has been related to communicable diseases. years of age were averted in LMICs. The economic There have also been some improvements on adult value of this achievement is staggering, correspond- communicable diseases, notably tuberculosis and ing to US$45 trillion (Chang et al. 2024). HIV/AIDS. The picture for NCDs is quite different. The eminent epidemiologist Sir Richard Doll For example, annual rates of progress in reducing summarized that the main lesson from 200 years of mortality from most cancers and ischemic heart dis- demography and epidemiology is that, “while death ease have been much slower than for childhood dis- in old age is inevitable, death before old age is not”. As eases and from infections (Wu et al. 2024) (Appen- he conveyed, death early in life should be rare, and dix B Table B7). And urgent new health challenges death in middle age need not be common anywhere. are emerging, linked to rapid demographic transfor- By necessity, any definition of old age will be mation and rising NCDs. Sustainable Development arbitrary. For purposes of this report, we define old Goal (SDG) 3 calls for ensuring healthy lives and age as above 80 years. Currently, global life expec- promoting wellbeing, including a specific indicator tancy in 2023 is 73 years and it is expected to in- to reduce NCD mortality at ages 30–69 by one-third crease to 77 years by 2050 (assuming the setbacks by 2030. While the goal is laudable, given current from the COVID pandemic do not change the progress, it is unlikely to be achieved on time. pre-pandemic trajectories). While the median age These extraordinary transitions are best un- of death in low-income countries (LICs) by 2050 derstood by examining changes in past and future is expected to be only 59, it will rise in upper-mid- demography and in the major NCDs. 12 CHAPTER 1 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y 1.1  Demographic shifts affecting life- 15 peaked around 2020, and by 2040 they will be course health outnumbered by 50–79-year-olds. The number of young adults aged 15–49 will rise substantially and The rise of NCDs has occurred against the back- will not peak until the turn of the century. The num- ground of sweeping demographic changes un- ber of people aged 80 or more is rising sharply and derway over the last 100 years, and, importantly, will do so until 2100. changing trajectories in the size and structure of Dependency ratios (the ratio of the sum of the populations by 2050. population aged 0–14 years and those aged 65 and The global population is expected to grow from above to the population aged 15–64) have fallen the current 8 billion to approximately 9.7 billion in sharply globally. In all regions, except in low-in- 2050 before plateauing at just over 10 billion, and come countries in Sub-Saharan Africa, dependency eventually declining by 2100 (UNPD 2022). Figure ratios will continue to increase between now and 1.1 shows the trends from 1950 to 2050, indicat- 2050, driven by falling fertility and aging. ing that the number of children below the age of FIGURE 1.1   Trends in global population change by age and dependency ratio, 1950 to 2050 Source: UNPD (2022). Note: HIC = high-income country; LIC = lower-income country; LMIC = lower-middle-income country; UMIC = upper-middle-income country. Figure 1.2 depicts the overall change in population Concurrently, by 2050, on existing projections, and deaths by age and sex group worldwide in 1990 there will be a vast increase in overall deaths to 92 and 2023 and projections to 2050. It shows that the million from 61 million in 2023. In 2050, there will “inverted V” of mostly children and young adults in be about 30 million deaths of people below age 70, 1990 has already yielded to rapid growth of popula- the same number as in 2023. By contrast, at ages tion at older ages by 2023. Between 1990 and 2023, 70–79, deaths are expected to rise from 13 to 20 there were 2 billion additional adults aged 15–69, million. As deaths increase, so will the huge bur- and another 1 billion will join this age group by dens from those sickened and from demands on 2050. The population at ages 70–79 alone will reach care in homes or facilities. 0.7 billion by 2050. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 1 13 FIGURE 1.2   Population and deaths by age in 1990 and 2023 and projections to 2050 Source: UNPD (2022) Note: Crude mortality (deaths per 1,000 population) fell from 10 in 1990 to 7.6 in 2023 and will rise to 9.2 by 2050 due to a greater contribution of deaths at older ages (which have higher death rates) in 2050 than in 2023. 1.2  Falling fertility, reduced mortality, rates, particularly in childhood, and reduced fertili- and cohort effects shape the future ty, which collectively increases labor supply of work- population ing age adults, reduces the dependency ratio, and in- creases economic output. The second phase results For most of human history, population growth from reduced family size, which reduces growth in has been slow because high fertility was countered labor supply and increases the dependency ratio. with high mortality rates, particularly in child- Much of the world, with the exception of Africa, is hood. Thus, it took most of 200,000 years of human already in the second phase (Bloom et al. 2024). history to reach a population of 1 billion (around Three main factors determine changes in the the year 1800), and another 130 years to reach 2 world’s population size and structure—declines in billion. However, from the 1950 to 2050, the global fertility, increases in life expectancy, and age-struc- population will approximately quadruple, growing ture effects—and how they vary by country. from 2.5 billion to 9.7 billion. In 1950, women worldwide had an average of Broadly, demographic changes can be thought five children and a quarter of children born would of as two phases. The first arises from reduced death die before their fifth birthday. But this fertility is now 14 CHAPTER 1 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y halved. The transition to lower fertility has been fast- members of this bulge reach reproductive age, this er in many LMICs than in the US or Europe. For creates a second, smaller boom in births. Thus, even example, the reduction from six children per wom- if total fertility rates are at replacement (meaning an to three took the US over 80 years (from 1840s a woman has about 2 births to replace biological onward) and even longer in the UK. But Bangla- mother and father), this bulge effect, sometimes desh achieved this same halving over 20 years (from called population momentum, carries on for gener- 1982 onward) and China took only 11 years (from ations. Indeed, population momentum is expected 1967 onward and even prior to the start of its “one to drive much of the growth in total population in child policy”) (Roser 2014). Today, women in many LMICs through 2100 (Bloom et al. 2010a; Bloom et LMICs, such as Brazil, Chile, China, and Thailand al. 2010b; Bongaarts and Johansson 2002). Impor- have fewer children than do women in the US. tantly, reductions in adult mortality from NCDs Reductions in fertility have been driven by have little impact on population growth because favorable changes in empowerment of women (as most families have completed their childbearing by measured by expanded access to education and the ages when adult mortality substantially rises. contraceptive technologies, and greater participa- The remarkable and rapid reduction in fertili- tion in the labor market), and declines in child labor ty paired with reduced mortality and cohort effects and child mortality. will substantially change the demographic profile of Increases in life expectancy have largely aris- the world by 2050, but variably so. Six country ex- en from reductions in infectious diseases includ- amples illustrate this diversity (Figure 1.3). Nigeria, ing those common in childhood. Improvements in the most populous country in Africa with over 210 nutrition, water, and sanitation have complement- million people, is expected to nearly double its pop- ed public health innovations. Prior to about 1950, ulation to 375 million by 2050 and to 546 million by much of the improvement in child and young adult 2100. This is driven by currently high fertility (over mortality arose from general improvements in water 5 children per woman), and with fertility expected and sanitation, and public health practices includ- to stay high. Moreover, the successive of cohorts ing basic understanding of the modes of transmis- born in Nigeria have their own population momen- sion of common infections. However, since 1950, tum. Fertility rates are expected to decline to only the major improvements have arisen from biomedi- 3 by 2050. Thus by 2050, much of Nigeria’s popula- cal innovations, such as use of antibiotics, vaccines, tion will be aged 15–49, which includes prime eco- insecticides for malaria control and related technol- nomically productive years. Uzbekistan is expected ogies (Jha et al. 2005). Since about 1960, reductions to similarly grow in population size, with a larger in adult mortality also arose in many countries due proportion at ages 15–49 years. By contrast, fertility to smoking cessation and more widespread simple rates are notably below replacement in Colombia treatments for heart attacks (Norheim et al. 2015). and cohort effects imply that the number of adults The third factor in population aging consists aged 15–49 years will fall but the number of adults of age-structure or “cohort” effects. In 2030, the aged 50–69 and 70–79 years will rise sharply. Thai- number of adults aged 50–59 years will reflect the land shows similar patterns, with modest declines death rates faced by the cohort born between 1970 in its population aged 50–69 and increases at ages and 1980 as they aged. Generally, mortality declines 70–79. China and Japan can both expect net depop- have preceded fertility declines, creating a cohort ulation by 2050 because the decline in numbers of of living children who would have otherwise died younger and middle-aged adults does not offset the in infancy or early in life at the death rates of ear- increase at ages 70–79 years. lier generations. This has led to the so-called “baby Appendix B Figure B2 provides these graphs boom” generation, or a “bulge” in the age structure for the 25 most populous countries plus other se- which works its way through the population. When lected countries. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 1 15 FIGURE 1.3   Population size by age group in 1990, 2023, and 2050 and changes in total fertility rate, selected countries Source: UNPD (2022). 1.3  Implications of future ple, pro-natalist policies are unlikely to substantially demographic change reverse the large decline in fertility in many coun- tries (Brainerd 2014). In the past, population growth was the major con- Societies have moral, political, and social ob- cern for global demography. While Africa faces ligations to all their people; and as the world ages ongoing challenges to reduce fertility, much of the rapidly, governments, global institutions, academic world has seen population growth rates decline. and civil society have obligations to try to improve Population aging is increasingly becoming the main the welfare of the far larger number of adults that concern. Future vast demographic changes up to nearly every country will have by 2050. Indeed, a 2050 are, for the most part, not avoidable; for exam- key theme of this report is that this rapid demo- 16 CHAPTER 1 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y graphic change represents an opportunity to im- These include policies to support competitive labor prove wellbeing, as well as gender and income and capital markets—equipping workers with hu- inequalities. An important opportunity exists for man capital and building infrastructure and careful- government action to achieve healthy longevity, al- ly designed trade policies (Bloom 2020). For exam- lowing individuals to live more years in good health ple, despite concern in the US that national health and stay productive and independent for longer insurance would reduce employment, the Canadian (World Bank 2021). experience showed that the introduction of health Population aging can slow economic growth if insurance from 1961 to 1975 actually increased em- it is not accompanied by an increase in labor force ployment and wages (Gruber and Hanratty 1995). participation and productivity (Bloom et al. 2010a; Conversely, countries that do not generate sufficient Onder and Pestieau 2014). Population aging can im- jobs for large cohorts of young adults are prone to pair long-term economic growth through a reduc- social, political, and economic instability as oc- tion in employment and labor productivity, higher curred in Tunisia and other settings (Bloom 2020). dependency, and lower savings and investments. An Given concerns about slowing global econom- aging population needs additional resources for so- ic growth over the next decade, there are challenges cial services, associated mostly with health systems for countries to make these investments in an era and long-term care costs and pensions (Araújo and of reduced government revenue and lower real per Garcia 2024; Rofman and Apella 2020). The effect capita income. This raises the concerns about coun- of population aging on economic growth ultimately tries becoming old before they become rich. While it depends on how population aging affects the size took 115 years for France to transition from “young” and productivity of the labor force, capital intensity to “old” (defined as the proportion of people aged and returns to capital, consumption, and asset accu- 65+ doubling from 7 percent to 14 percent), in some mulation and if careful public policy can enable lon- countries this transformation is happening in less ger, economically and social productive lives (Lee than 20 years (Araújo and Garcia 2024). Fast aging 2016; Lee and Mason 2017). is not in the future, it is already here. While future scenarios will vary by country, Migration: The 2023 World Development Re- the dramatic changes in the size and structure of port, Migration, Refugees and Societies, identified the population are likely to profoundly influence all about 184 million people across the world, including societies by creating large numbers of working-age 37 million refugees who do not have citizenship in adults in some countries, which could drive eco- their country of residence. The report concluded: nomic growth, including by expanding savings, but “Rapid demographic change is making migration also by leading to more older adults who require increasingly necessary for countries at all income lev- care (described in Chapter 3) and by influencing els. High-income countries are aging fast. So are mid- migration. Finally, future demographic changes will dle-income countries, which are growing older be- interact closely with climate change. fore they become rich. The population of low-income Economic growth: The effects of a changing age countries is booming, but young people are entering structure can increase economic growth if defined as the workforce without the skills needed in the global the “demographic dividend.” For any specific coun- labor market. These trends will spark a global compe- try, the possible dividend is driven not by popula- tition for workers” (World Bank 2023e, p xxiii). tion growth alone, but also by macroeconomic man- The report outlined advance planning for agement, labor and capital markets, savings rates, matching migrant skills from countries of origin to trade policies, and, importantly, by human capital destination countries. It argued that origin coun- accumulation (which Chapter 2 describes in some tries should manage migration for development, detail). For many LMICs where the 2050 population including facilitating knowledge transfer by their may have higher portions able to work and save, diaspora and building skills that are likely to be specific policies can expand economic growth. The globally relevant. For this report, a major consider- countries that can (i) combine effective policies to ation, identified in Chapter 3, is the need for long- create jobs while expanding publicly financed health term care and health care workers. insurance, (ii) adopt additional efforts to promote Climate change: Over 3.5 billion people, or human capital (especially for women), and (iii) en- about 40 percent of the world’s population, already sure safety nets for the poorest are more likely to see live in settings highly exposed to climate change the demographic dividend yield broader benefits. (Figure 1.4) (World Bank 2023e). Highly urban- U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 1 17 ized populations in coastal or mountainous regions such as hurricanes and floods. Many of the impact- are especially vulnerable to the effects of climate ed LMICs countries also face large burdens of aging change. By 2050, an additional 2.5 billion people, populations, including higher rates of mortality at primarily in Africa and Asia, will be exposed (In- ages 50–69. In particular, Small Island Developing tergovernmental Panel on Climate Change 2022). States face an existential crisis of rising sea levels, Additionally, an estimated 2.8 billion people will aging populations, and high NCD burdens (Box be living in countries facing extreme ecological 4.1). Climate change also affects NCDs through in- threats in 2050, compared to 1.8 billion in 2023 9 creasing exposure to heat stresses, and in worsening Institute for Economics & Peace 2023). Effects of respiratory health. Their possible mitigation is fur- climate change include heat stress, drought, water ther discussed in Chapter 4. shortages, sea level rise, and extreme weather events FIGURE 1.4   Global distribution of climate vulnerability Source: ND-GAIN (2021). 1.4  Progress in reducing mortality Over the last five decades, survival to age 80 world- global maternal and child health) to 2019 were 3 wide improved substantially. In 1970, nearly four in percent among children below age 15 and about 1.5 five (80 percent) of those born worldwide could die percent between ages 15 and 49 (Table 1.1). For both before age 80 years. By 2023 this risk of death fell to age groups, nearly every income region matched or 54 percent (Figure 1.5). Death rates before age 50 exceeded the annual progress in high-income coun- years have declined even faster, falling from about tries (Appendix B Table B2). By contrast, the annual 30 percent to 12 percent, and at these ages, the fast- rates of decline in 50–69 and 70–79 age groups were est decline was in LICs, where death rates substan- only 1 percent, with far greater progress in high-in- tially dropped from about 1997 onwards, driven by come countries than in LMICs. Thus, in the past few extraordinarily fast declines in child mortality. decades, LMICs have been able to achieve at a faster Annual rates of mortality decline from 1990 rate the kinds of children’s health improvements that (which was the start of several major efforts on wealthy countries saw in the early twentieth centu- 18 CHAPTER 1 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y ry. By contrast, the faster improvement in mortality losing several decades of good life. Fully 24 million at older ages in wealthy countries has yet to occur would die at ages 50–69, losing about two decades in LMICs. These annual rates of improvement help of good life, and 29 million at ages 70–79, where the inform plausible targets for the future. loss of life years is smaller. Thus, while significant alterations in future Thus, securing a future for all the children population size and age structure are probably not born today requires attention not only to the nearly possible, improving wellbeing throughout the lifecy- fully avoidable deaths early in life, but also the sub- cle is possible. Consider the expected ages at which stantial avoidable proportions of death in middle the 131 million children born in 2023 worldwide (of age. Chapter 2 expands in greater detail on better whom 118 were born in LMICs) would eventually health throughout the life cycle. A historic perspec- die if 2023 age-specific death rates were to continue. tive on progress in mortality from 1970 onwards Among all births, approximately 15 million would at different ages helps set the stage to understand die before age 50 years (6 million before age 15), avoidable mortality. FIGURE 1.5   Trends in probability of death at ages 0–79, 50–79, and 0–49 years from 1970 to 2019 by income region Ages 0 to 79 Ages 50 to 79 Ages 0 to 49 Source: UNPD (2022). U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 1 19 TABLE 1.1   Average annual rate of reduction in mortality between 1990 and 2019 by age (%) Age 0 Age 15 Age 50 Age 70 Country income category (until age 14) (until age 49) (until age 69) (until age 79) World 3.3 1.4 1.5 1.3 Source: UNPD (2022). 1.5  The epidemiological shifts reshaping life-course health The rapid demographic changes underway are ac- year—accounting for nearly three-quarters of all companied by a shift in most LMICs such that deaths (WHO 2022a). Five major NCDs—cardio- NCDs are the leading cause of deaths. These chang- vascular diseases, diabetes, respiratory diseases, can- es arise both from aging—creating larger number cers, and mental health conditions (of which major of adults who are at the ages where NCDs strike— depression is the leading cause)—account for the and also from exposure to key risk factors, such as vast majority of these deaths and for three out of four smoking, alcohol abuse, and obesity. Importantly, years lived with disability worldwide (WHO 2020b). NCDs are distinguished from many infectious dis- Most NCD deaths occur in LMICs, and the propor- eases of childhood in being life-long conditions that tion of all deaths caused by NCDs is set to rise in each require ongoing treatment. LMIC category (Figure 1.6), including in LICs. Globally, NCDs cause 41 million deaths each FIGURE 1.6   Proportion of all deaths attributable to NCDs, by country income category, 2019 and 2040 Sources: Original calculations for this publication, based on WHO (2020b). Hundreds of millions of people are living with idly, and fastest in LMICs. For instance, the greatest NCDs today. Figure 1.7 shows how widespread cer- increase in diabetes prevalence is expected in mid- tain NCDs are, with over 250 million suffering from dle-income countries (MICs). On current trends, depression and over 1 billion from cardiovascular the number of diabetics globally will double from disease (predominantly ischemic heart disease and 0.5 billion today to over 1 billion by 2050 (Interna- stroke) and diabetes. These burdens are rising rap- tional Diabetes Federation (IDF) 2021). 20 CHAPTER 1 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y FIGURE 1.7   Number of adults living with major NCDs in 2019 Sources: IDF (2021); IHME (2019). Note: NCDs = Non-communicable diseases. Morbidity and risk factors for NCDs: mortality and morbidity is strong for most diseases This report emphasizes mortality as the main metric of public health importance, with only some excep- to use in prioritizing diseases and assessing prog- tions (Norheim et al. 2015). Moreover, measuring ress. Mortality comprises most of the composite mortality will be far less uncertain than trying to mortality and disability measures, such as disabil- measure disability and mortality. ity-adjusted life years (DALYs), particularly among Nonetheless, mortality does not capture all ill- lower-income countries. According to the World nesses. A deeper examination in India of the contri- Health Organization (WHO), about two-thirds of bution of life years lost to mortality and to morbid- all DALYs globally are due to mortality, but pro- ity noted that 29 percent of overall health loss was portions are higher in LICs (WHO 2020b). Impor- due to morbidity, but this proportion approached tantly, mortality does not capture all illnesses, most 90 percent for childhood malnutrition and depres- notably excluding depression (Menon et al. 2019); sion (Figure 1.8) (Menon et al. 2019). Thus, the key conditions that disable, notably depression and public attention and intervention programs need to other mental health conditions, should be priorities target selectively the conditions that are dominat- for disease control in every country (Menon et al. ed by mortality, as proposed in the HLI investment 2019). However, the correlation between premature package (Chapter 3). U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 1 21 FIGURE 1.8   Contribution of mortality or disability for selected major causes of death in India at various ages, 2017 Source: Original calculations for this publication based on Menon et al. (2019). Note: YLL = years of life lost due to premature mortality, YLD = years of healthy life lost due to disability. Neglecting key risks factors for NCDs contrib- al health—and with women’s additional responsi- utes to avoidable mortality. Smoking, obesity, exces- bilities, they would be particularly disadvantaged. sive alcohol consumption, and insufficient physical In some countries with more rigid gender norms, activity are strongly predictive of NCD mortality women may find it difficult to exercise unless they and cause morbidity by themselves (WHO 2022b). can access and afford women-only spaces for fitness. Figure 1.9 shows the prevalence of the selected risk Smoking: Smoking remains the leading avoid- factors globally and trends in prevalence in recent able risk factor for adult mortality globally, caus- decades (WHO 2020c). It is particularly import- ing over 7 million deaths or about one in ten of all ant to raise cessation rates by the world’s 1.1 billion deaths. Smoking contributes to nearly all of the current smokers (GBD 2019 Tobacco Collaborators major NCDs, not only lung cancer. The hazards of 2021). Without major increases in quitting, there smoking are uniquely high. Half to two-thirds of will be few health gains from reduced smoking be- smokers are killed by their addiction. Most smokers fore 2050 (Jha and Peto 2014). Considering the key who start early in adult life and continue to smoke risk factors shown in Figure 1.9, there has been some are eventually killed by their tobacco use. This is progress in reducing smoking and alcohol abuse but because during middle age, the death rates among there have been few advances in increasing physical smokers are about three-fold higher than those of activity, which contributes to the growing burdens similar non-smokers every year (when controlling of obesity and diabetes. While heavy alcohol drink- for differences between smokers and non-smokers ing and smoking are concentrated in men, obesity in heavy alcohol use, obesity patterns, or differenc- and inadequate physical activity are more prevalent es in educational or economic status). Therefore, in women. Obesity is driven in part by the effects up to two-thirds of the mortality among smokers of weight-gain during pregnancy (or menopause), would not occur if they had non-smoker death but more complex factors also operate. For exam- rates. Most of this excess risk arises from diseases ple, low-income families may be working multiple commonly caused by smoking. This includes dis- jobs to make ends meet, with little time for person- ease such as lung cancer, emphysema, heart attack, 22 CHAPTER 1 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y FIGURE 1.9   Number of people (aged 15+) with NCD risk factors in 2016 and trends in prevalence Source: WHO (2018); WHO (2019); WHO (2020c); GBD 2019 Tobacco Collaborators (2021); Guthold et al. (2018). Note: †aged 18+; *in 2019; **from 2000 for Obesity, Heavy episodic drinking, and Current smokers; from 2001 for Insufficient physical activty stroke, cancer of the upper digestive areas, bladder mass index (BMI) is the most widely accepted cancer, tuberculosis, and various other conditions. marker of overweight and obesity in adults, and it Every million cigarettes smoked causes approxi- is calculated as the weight in kilograms divided by mately one death (Jha 2020). the square of height in meters. For adults, WHO Smoking cessation is effective in reducing the defines overweight as a BMI greater than or equal increased risks of developing smoking-related dis- to 25, and obesity as a BMI greater than or equal to ease. Smokers who successfully quit before age 40 30 (WHO 2021b). Obesity is a major risk factor for avoid nearly all increased mortality risks of contin- NCDs such as cardiovascular disease (mainly heart ued smoking, and even those who quit by age 50 or 60 disease and stroke), diabetes, and some cancers (in- gain back some of the lost years of life (Jha and Peto cluding breast, prostate, and colon cancer) (WHO 2014). Moreover, the gains arise reasonably quickly, 2021b). Obesity is also associated with mental health just within a few years of cessation (Cho et al. 2024). conditions, including depression, and is associated Finally, given the long delay between smoking onset with raised blood pressure, increased levels of blood and disease and the far more rapid benefits from ces- cholesterol, and decreased levels of high-density li- sation, it is particularly important to help the world’s poprotein (Shekar and Popkin 2020; Romieu et al. 1.1 billion current smokers to quit. Cessation among 2017). An increase in BMI of 10 units doubles mor- current smokers will reduce mortality substantially tality from cardiovascular disease (Armas-Rojas et by 2050. By contrast, efforts to prevent youth from al. 2021). In general, however, morbidity burden taking up smoking will yield benefits only beyond starts at BMI levels regarded as “normal” and the risk 2050 (Jha and Chaloupka 1999). of cardiovascular disease and colon cancer increases Obesity: The WHO estimated in 2016 that linearly as BMI rises from about 20kg/m2 (weight in global obesity prevalence had nearly tripled since kilograms per height measured in meters squared). 1975—with more than 1.9 billion adults, 18 years Obesity is a result of impaired energy homeo- and older, overweight and of them 650 million suf- stasis: too much energy is consumed and too little fering from severe obesity (WHO 2021b). Body is expended. In addition, undetermined hormonal U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 1 23 and neurological factors lead to stored fat inducing by modifying urban design but the effectiveness of a metabolic state that maintains obesity. As a result, these interventions is unknown. some researchers believe that the source and nature Recently, drugs originally developed to treat of calories is irrelevant. However, others claim that type-2 diabetes have been approved for weight loss caloric source is important, especially if foods trig- (Garvey et al. 2022). This injectable mimics the glu- ger increases in blood glucose that lead to excess fat cagon-like peptide 1 and reduces the amount indi- deposition (Foster et al. 2003; Schwingshackl and viduals eat during meals as well as snacking between Hoffmann 2013). There is agreement that globally meals. In randomized trials, one such drug (sema- there has been a shift in food consumption, with glutide) caused a 15 percent weight loss within one populations opting for energy-dense foods with year but the majority of the weight returned after higher sugar and fat content. The processes of glo- cessation of treatment (Wilding et al. 2022). New- balization and trade liberalization play a role in nu- er drugs of this class, including some to be taken trition transition, especially in LMICs where they orally, are under development, but the current high influence modern food supply chains and introduce costs are a barrier to widespread use. Drug therapies sophisticated marketing to create an environment are likely work better if complemented by individual that promotes obesity. Concurrently, there has been behavioral change coupled with a whole-of-govern- a global reduction in physical activity. Moreover, ment or whole-of-society approach that tries to re- many LMICs, such as India, are contending simul- duce diets rich in processed and energy-rich foods. taneously with both malnutrition and obesity. The Alcohol: The excess morality from NCDs due health care costs due to obesity are increasing across to alcohol is heavily concentrated in men. Alcohol the world, but precise data from LMICs are scarce. consumption is an established risk factor for select- For example, Brazil projects a doubling of obesity-re- ed cancers—specifically esophagus, liver, upper air- lated health care costs from US$5.8 billion in 2010 to ways, colon and rectal and, in women, breast can- US$10.1 billion in 2050 (Rtveladze et al. 2013). cer (Rumgay et al. 2021). Alcohol consumption is a Childhood obesity is also increasing world- risk factor for stroke, in part because higher alcohol wide and there is evidence that obesity in child- intake uniformly raises blood pressure. In China, hood tracks through to adulthood (Simmonds et where stroke deaths are more common than isch- al. 2016). Childhood obesity may derive from ma- emic heart disease deaths, alcohol accounted for 8 ternal and household factors (Mahmoud 2022). percent of ischemic strokes and 16 percent of intrace- Malnourished and stunted children are at greater rebral bleeding strokes (a type of stroke particularly risk of becoming overweight or obese as adults if sensitive to blood pressure). The effects of alcohol on they are exposed to obesity-inducing diets or if they myocardial infarction were less certain (Millwood et adopt sedentary lifestyles. Prevention of childhood al. 2019). In meta-analyses among populations most- obesity centers on good maternal nutrition in the ly of European descent, stroke incidence rose steadily prenatal period and breastfeeding, coupled with with increasing amounts of alcohol consumed, and regulatory and fiscal measures to limit the intake of the effects on ischemic heart disease were also high- processed and high-calorie foods (WHO 2017a). er among drinkers—only slightly higher in drinkers At the individual level, the efforts to prevent whose usual intake was quite low, but approximate- and control obesity focus on behavioral changes that ly flat at higher ranges of consumption (Wood et al. are difficult to sustain once elevated body weight is 2018). Thus, while earlier studies showed apparently maintained physiologically (Kelly and Barker 2016). protective effects for ischemic heart disease, they are At the national level, fiscal policies, including taxes likely due to methodological limitations, and no clear on unhealthy foods and taxes on sugar-sweetened “safe” level of drinking exists. However, the absolute beverages have been shown to reduce consumption, increases in risk vary by age, sex, and population. especially in children. The corollary is to subsidize Thus, the key guidance is to avoid heavy alcohol use healthy foods. Regulatory policies such as front-of- including binge alcohol use, which is strongly related package warning labels have also been adopted to to cancer risk and which most significantly increases reduce the consumption of ultra-processed foods blood pressure and stroke risk. (Shekar and Popkin 2020). Changes in school feed- Blood pressure: Blood pressure is a fundamental ing programs are another approach to changing aspect of cardiovascular health that exerts an impact family food habits (Shekar and Popkin 2020). There on mortality. Hypertension is a major risk factor for have also been national policies promoting exercise cardiovascular diseases, which accounted for 32 per- 24 CHAPTER 1 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y cent of all deaths in 2019 worldwide (WHO 2020b). control have started with estimates of the costs of High blood pressure damages arteries by promoting major NCDs. These estimates have primarily relied the build-up of plaque and narrowing of blood ves- on cost-of-illness approaches or estimates based on sels. This, in turn, increases the risk of blood clots, lost output from NCDs (Bloom et al. 2011a; Jha et heart attacks, and strokes, all of which can be fatal or al. 2013). The cost-of-illness involves calculating the lead to severe disability. Hypertension coexists with sum of several categories of direct costs (i.e., actual other health conditions such as diabetes and obesi- direct or indirect expenditures) and indirect costs ty, further exacerbating the mortality risk. Reducing (mostly comprised of lost output on the assumption blood pressure and blood cholesterol paired with that if someone stops working because of an NCD. aspirin can be remarkably effective in cardiovascu- To give an illustrative idea of costs involved, the lar disease (CVD) control among the very large pop- total global cost, public and private, of CVD could ulation of adults with vascular disease (Yusuf et al. mount on average to US$20 trillion per year be- 2014). These interventions are considered as part of tween 2010 and 2030. In 2010, the cost of new cases the recommended clinical package in Chapter 3. of cancer alone amounted to US$290 billion; this Between ages 40–69 years, decreasing systolic figure is expected to reach US$458 billion in 2030. blood pressure by 20 millimeters of mercury halves Chronic obstructive pulmonary disease (COPD) death rates from stroke, ischemic heart disease and had a global cost of illness of US$2.1 trillion in 2010; other vascular causes (Lewington et al. 2002). Efforts the total is projected to rise US$4.8 trillion in 2030. to lessen blood pressure-related mortality involve life- Mental health conditions are especially costly, with style modifications—including a healthy diet, regular an expected increase from US$2.5 trillion in 2010 exercise, and stress management—as well as medica- — of which about a third was in LMICs — to US$6 tion when necessary. This is particularly challenging trillion in 2030 (Jha et al. 2013). Related approaches in resource-constrained settings where access to infor- such as those by WHO are based on the assumption mation, health care facilities, and nutritious foods as that if there were no NCDs, labor and capital would well as adherence to treatment plans affect outcomes. increase and hence output would increase (Bloom et al. 2011b). Lost output from 2011 to 2030 from 1.6  The economic value of the five NCD conditions (including mental health) avoidable mortality has been projected to be nearly US$47 trillion, in- cluding about US$13 trillion from tobacco-attribut- Major global goals, including the SDGs, emphasize able conditions (Jha et al. 2013). reducing mortality rates for various age groups, For this report, new analysis called the Eco- particularly substantial reductions in child mor- nomic Value of Avoidable Mortality (EVAM) was tality and a one-third reduction in mortality from undertaken to better describe the period of life NCDs at ages 30–69 by 2030. While progress on spent in good health, in order to inform priori- child mortality remains rapid, both goals are un- ty-setting and decision-making. likely to be met by the target date. The EVAM incorporates the acquisition and This report provides a unique lens on NCDs: protection of health throughout the life course, calling for healthy longevity across the life course, combining this with a metric of economic value which entails continued attention to child and ma- that serves as a monetary proxy for the broader ternal health and priority infectious diseases as well concept of human wellbeing (which is here synony- as accelerating progress on reducing NCDs. The mous with welfare). This approach makes it possible main social and welfare return is not just from a to compare the economic values of various rates of longer lifespan, but also a longer span of healthy life. progress toward reducing mortality. The objective is to increase both the lifespan and The EVAM is constructed in two stages. The good health during a longer life, which impacts well- first calculates the lowest observed mortality rates being—primarily through a longer working life— and based on reasonable projections, the lowest and gender and income equity. Chapter 2 describes projected mortality rates for each age group and sex this in detail, leading to discussion of country-spe- from all countries. Typically, these frontier rates are cific options in Chapter 3. To set the foundation for observed among women in Hong Kong SAR, China, those discussions, this section presents new work to Japan, and some European countries, but, in reality, quantify the economic benefits of healthy longevity. no one country or territory has a monopoly on low Previous efforts to estimate the benefits of NCD mortality. Against this frontier, the EVAM compares U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 1 25 the 2019 actual and 2050 projected mortality rates cal health services that help to achieve low mortal- and defines this as the burden of avoidable mortality. ity—can be transplanted from one country setting Since death is inevitable in very old age, the EVAM to another. Moreover, achieving the frontier rates framing defines lives that can be meaningfully ex- would imply achieving optimal past exposures to tended by reducing avoidable death prior to very risk factors and care. Therefore, some future avoid- old age. The second stage draws from the literature able deaths are already inevitable due to exposures on the statistical value of a life year (VLY) and as- and care received up to now. signs an economic value to avoidable mortality by Nonetheless, the frontier demonstrates what is estimating the percentage of annual income an indi- possible and points to the importance of efforts to vidual is willing to forgo to live in a given year at the accelerate progress in reducing mortality. For exam- frontier survival probabilities. Figure 1.10 shows the ple, it shows that 88 percent of deaths in 2019 among variation across countries in avoidable deaths using those aged 20–39 were avoidable, as were 77 percent this frontier. and 75 percent deaths of those aged 40–59 and 60– This frontier is obviously artificial, but it does 79 respectively. Sub-Saharan Africa in particular has demonstrate that every country and every age group a large number of avoidable deaths—about 90 per- could benefit by achieving the lowest observed rates. cent of deaths across age groups—due to its younger But doing that can be difficult, as it suggests that not age structure and the notable role of infectious and just the mortality rates—but also the accompanying vector-borne diseases throughout the life course. levels of income, technology, and public and clini- FIGURE 1.10   Avoidable mortality as a percentage of total mortality, 2019 Source: Chang et al. (2024). United Nations (UN) population projections es- Using the EVAM, a more realistic comparison timate a global total of 92 million deaths in 2050 (Ta- can be made against actual rates of progress achieved ble 1.2), of which about 77 million will be in LMICs in the top-performing 20 percent of each age group- (UNPD 2022). If, instead, the frontier mortality ing and sex in each year from 2000 to 2019, which rates are applied, these estimates drop to 28 million includes a substantial number of LMICs along with deaths at all ages globally, which would mean avoid- some high-income countries (HICs). Comparing ing 64 million deaths, close to 70 percent. these “top performers” to projected 2050 death 26 CHAPTER 1 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y rates yields aspirational but achievable estimates of rates for 2050 are strongly aligned with the annual how many deaths could be avoided, which, in turn, rates of progress required to achieve the SDGs by highlights the importance of strengthening efforts 2030, but with the progress rates maintained over a to realize these better rates. These top 20 percent longer, more sustained time period (Table 1.2). TABLE 1.2   Projected deaths vs. avoidable deaths in hypothetical scenario and with accelerated perfor- mance throughout life course Avoidable deaths if all countries Avoidable deaths if all countries achieved, Country income United Nations projected had, hypothetically, lowest “frontier plausibly, top 20% performance grouping deaths in 2050 (in millions) mortality” rates (in millions) (in millions (% of lowest frontier rates)) Low 9 8 5 (67%) Lower-middle 38 31 18 (57%) Upper-middle 30 19 9 (49%) ALL LMICs 77 57 32 (56%) High 15 7 4 (66%) Global 92 64 37 (57%) Source: Chang et al. (2024). Note: Percentages may not total due to rounding. Background analysis for this report suggests that even more striking when considered cumulatively. overall global progress in mortality reduction slowed Figure 1.11 illustrates the potential of deaths avoid- from the first decade of the twenty-first century to ed among Ethiopian men aged 50–69 years. It shows the second, for all age groups (Wu et al. 2024); Ap- that if Ethiopia can accelerate its mortality declines, pendix B). This suggests that more countries need to it would avoid, cumulatively, 1.6 million deaths expand life-course investments at all ages. compared to current UN projections on mortality The impact of efforts to reduce mortality are in the country. FIGURE 1.11   Projected mortality decline vs. mortality decline at the rate of top 20% of countries, Ethiopian men aged 50-69 Source: Original calculation for this publication, based on data from UNPD (2022). U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 1 27 Novel estimates based on the EVAM method- FIGURE 1.12  Trends in the age distribution of avoidable mortality by ology in several Latin American countries show a sex in Colombia, 1990 and 2030 high level of avoidable mortality at older ages—a sharp change from the scenario in 1990 when most avoidable mortality arose at younger ages. For instance, in Colombia, 58 percent of deaths in 2020 were preventable, with important differences by sex (among men, 66 percent of deaths in 2020 were avoidable as were 47 percent women’s deaths) (Figure 1.12). Similar analyses in Mexico found 71 percent of deaths in 2020 were preventable, with important differences by sex. In all countries, the 60+ years age group shows one of the highest lev- els of avoidable mortality; respiratory infections and heart disease leading the ranking of the prev- alence of chronic diseases that are responsible for most of these deaths. The EVAM analyses also permit regional com- parison. For instance, Chile is the best performing country in Latin America, showing the levels of avoidable mortality not too different from the ideal (as represented by survival in Japan). By contrast, Brazil shows the highest levels of avoidable mortali- ty (Figure 1.13). Finally, subnational level data show important spatial differences within countries such as in Colombia, differences that are now informing policy (see Box 4.2). Source: Vega et al. (2024). Note: The avoidable mortality comparisons are to the lowest level of mortality in Japanese women versus across multiple countries as in the main EVAM; however, results are similar. FIGURE 1.13   Levels in avoidable mortality, selected countries by age and sex in Latin America and Japan in 2020 Source: Vega et al. (2024). 28 CHAPTER 1 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y The EVAM makes it possible to estimate a range ue of US$61 trillion lost globally, with US$40 trillion of economic values of avoidable mortality, includ- of that total occurring in LMICs. The far more realis- ing in VLY terms, reductions in child mortality, or tic scenario of countries matching the top 20 percent specific diseases. Indeed, the EVAM, measured in of performers would result in an economic impact VLY terms, is very large. Comparing the forecast of of about 16 percent higher annual income globally, 92 million deaths globally in 2050 with the lowest with close to US$13 trillion in LMICs (Table 1.3). frontier of 27 million deaths yields an estimated eco- These estimates are broadly consistent with reviews nomic impact differential of 24 percent of annual in- of the value of reduced mortality in the US and glob- come globally. This translates into an economic val- ally (Murphy and Topel 2005; Nordhaus 2003). TABLE 1.3   Economic value of avoidable mortality for 2050 as a percentage of annual income and in US$ trillion, by country income category Country income category % of annual income with top 20% performance Value of avoided mortality with top 20% performance (in US$ trillion) LMICs 17 12.7 High 17 5.9 Global 16 18.6 Source: Chang et al. (2024). Note: LMICs = lower- and middle-income countries. The EVAM can quantify not just the hypothet- underscores the fact that reductions in child mor- ical economic value of life-course investments in tality are among the best investments ever made. coming decades, but also the actual economic value As Chapter 4 documents, future investments of the enormous reductions in child mortality seen along the life course will also yield large econom- in LMICs in recent decades. From 2000 to 2019, ic values that can build on the returns already child mortality fell by over 60 percent; during this achieved in saving children. The EVAM framework time approximately 65 million child deaths below can inform priority-setting by comparing the eco- age 5 were avoided. In 2019 alone, there were 6 mil- nomic value (also measured as a percent of global lion fewer child deaths than would have been the income) of various diseases. A background paper case at the death rates in 2000. In economic value, for this report identifies much faster accumulation this represents about US$45 trillion cumulatively, of economic value from investing early in the con- including nearly US$5 trillion in 2019 alone. This trol of CVD (Table 1.4; Verguet et al. 2024). TABLE 1.4   Economic value of avoidable mortality in 2019 and 2050, globally and compared to the frontier mortality rates, as % of annual income by major disease category Disease/year 2019 2050 All causes 23% 25% Communicable, maternal, child, and nutritional 6% 4% NCDs 13% 18% Cardiovascular 5% 7% Injuries 4% 3% Source: Verguet et al. (2024). The EVAM has some clear limitations, includ- country income, among others. These limitations ing the use of uncertain adult mortality estimates, are extensively discussed in the background papers particularly in LICs and at older ages, as well as to this report. Nonetheless, the EVAM framework assumptions made to project mortality rates and provides, for the first time, a comprehensive set of U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 1 29 aspirational and achievable estimates of avoidable Finally, as Chapter 2 describes, the EVAM does mortality by region. The HLI “starter” package of not reflect the full welfare benefits from healthy lon- health interventions recommended in this report is gevity or even human capital. It does, however, cre- compared to achievable performance, showing that ate the ability to put a monetary value on the gains while the investments would avert 150 million cu- from healthy longevity. Chapter 3 and Chapter 4 mulative deaths from 2020 to 2050 and 8 million provide greater detail on the investment package in 2050 alone, there is still room to improve. These recommended in LMICs, and Appendix B Table B5 improvements, in turn, require better interventions, provides EVAM results by country income category. including expanded investment in R&D and GPGs. 30 CHAPTER 2 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Healthy longevity, NCDs, and human capital: Levers for action across the life course Healthy longevity is increasingly threatened by NCDs, which also imperil human capital and reductions in pov- erty and inequality. To reap the full benefits of longer, healthier, and more satisfying lives, a broader life-course approach to NCD control is needed. The life-course approach emphasizes prevention determinants of economic growth for well over half as well as management of NCDs and other policy a century—or for about two and a half centuries if responses beyond the health sector, including in la- one goes back to Adam Smith’s Wealth of Nations. bor markets, social protection, and long-term care. The World Bank’s second report on the Changing It addresses behavioral risk factors for NCDs, pri- Wealth of Nations (CWON) (World Bank 2021a) marily smoking, alcohol abuse, and obesity. And focuses on the present value of the flow of increased it focuses strongly on cost-effectiveness and equi- income from human capital and complements the ty to maximize health, productivity, and wellbeing World Bank Human Capital Project’s focus on the benefits from reducing the incidence and impact of stock of human capital. As the CWON states: NCDs. As discussed below, NCDs are more com- mon among the poor, with devastating out-of- “Human capital is measured as the expected future pocket costs; and women face the double challenge earnings of the entire labor force. It is estimated as the of a higher prevalence of some NCDs and onerous total present value of the expected future labor income caretaking burdens for older family members (as that could be generated over the lifetime of the current well as children and grandchildren). working population. In other words, human capital is World Bank research analyzes healthy longevity considered an asset that generates a stream of future as simultaneously a key component of people’s well- economic benefits.” (World Bank 2021a, 146) being and thus a goal for public policy; and as a driver of greater equity and social inclusion (socioeconom- The CWON measure of human capital focus- ic, gender, and intergenerational) and of productivity es on education and health without disaggregat- as well. This chapter describes these linkages in three ing them, while related work under the Inclusive sections, focused on: (i) impact pathways between Wealth Reports of the United Nations Environment NCDs, human capital, and productivity across the Program attributes around 56 percent of the total life course; (ii) poverty and inequality dimensions of share of human capital in national wealth to educa- NCDs; and (iii) gender dimensions. tion and the remainder to health (United Nations Environmental Programme 2018). The comple- 2.1  Impact pathways of NCDs on human mentary definition of human capital, which focuses capital and productivity on the stock rather than the flow of benefits, in the Human Capital Project is: “…the knowledge, skills, A key underpinning for world’s collective response and health that people accumulate over their lives, to the COVID pandemic was unambiguous: the enabling them to realize their potential as produc- lives of older adults, including those no longer in tive members of society” (World Bank 2018, 14). the workforce, are worth saving. The impact of HLI Without the kind of interventions recommend- recommendations on prevention and treatment of ed here, NCDs are likely to negatively impact, to NCDs is closely related to the concept of “human varying degrees, both the stock of human capital capital” which has received high priority in work on and returns to human capital through several chan- U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 2 31 nels. The EVAM estimates presented in this report declines (and eventually becomes negative) in an quantify the economic value of additional years increasing number of middle-income countries of healthy life. Longer lives free of disability and (MICs). This opens the possibility of increased eco- chronic conditions increase human capital (more nomic growth, depending on the effectiveness of education and on-the-job skill acquisition) and en- government policies and of their implementation able use of that human capital over longer working -- not just on NCDs but on labor market and other lives. Lower NCD burdens also improve produc- directly related issues. It depends even more on the tivity at work and delay age-related depreciation of evolution of broader underlying determinants of human capital. Building on the Chapter 1 findings growth, including economic management, educa- about demographic changes, extending working tion, institutions, and technology. lives is particularly important as labor force growth FIGURE 2.1   Shares of total wealth, by asset type and income group, 2018 Source: World Bank (2021a). Note: OECD = Organization for Economic Co-operation and Development. Figure 2.1 shows that human capital accounts for This dramatically highlights just how disadvantaged a high share of total capital: 64 percent globally, with women are in terms both of human capital and in shares generally varying across country income cate- terms of returns to it through market work. At the gories by only a couple of percentage points. The only same time, tackling the challenge could yield signif- exceptions are the “low-income” countries group, in icant benefits. For example, CWON estimates indi- which human capital still accounts for half of total cate that in LMICs achieving gender parity would capital, and the “high-income non-OECD” catego- raise total human capital between 21 and 36 percent ry, which refers to the small group of countries with from the baseline depending on the country group- unusually high per-capita earnings from exports of ing (World Bank 2021a). petroleum or other non-renewable natural resources. The interlinkages among NCDs, human capi- Gender is an important factor. As noted in the tal, productivity, and wellbeing are well established CWON report, “human capital estimates reveal a and create a powerful impetus for action. Figure 2.2 significant disparity between the male and female summarizes how the HLI strategy for NCD preven- shares of human capital … women account for tion and management along the life course influ- less than 40 percent of human capital at all levels ences wellbeing—a key development objective with of development.” (World Bank 2021a, p 156-157). economic and non-economic elements. For exam- 32 CHAPTER 2 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y ple, addressing NCDs directly contributes to human fiscal benefits from addressing NCDs (e.g., higher capital by preventing childhood NCDs and reduc- tax receipts and bending back the cost curve of ad- ing children’s and young people’s behavioral risks dressing NCDs) permit more expenditure on health for future NCDs such as obesity. This in turn has (and other pro-poor programs), thus reducing the a positive influence on educational and, ultimately, incidence of death and disease as well as directly labor market outcomes. Addressing NCDs also en- improving wellbeing. The increased savings gener- hances human capital by increasing years of good ated by an expectation of longer life spans has a sim- health. This, in turn, permits longer working lives ilar positive effect. A key feature of the HLI NCD for those willing or economically obliged to do so. strategy is a double emphasis on poverty reduction Reducing NCD-induced poor health also increases and gender equality. Finally, both the higher pro- productivity throughout the working life. The inter- ductivity and lower and more equitable incidence action between a longer working life and increased of death and disease feed into greater and more eq- productivity throughout that working life increases uitable wellbeing. Key aspects of these linkages are the lifetime returns to human capital. In addition, discussed in more depth below. FIGURE 2.2   Conceptual framework to address NCDs, human capital, productivity, and wellbeing Source: Original figures for this publication, based on O’Keefe and Haldane (2024). Note: HC = human capital; HLI = Human Longevity Initiative; NCDs = Non-communicable diseases. Impacts on labor supply: The effect of reducing ies that NCDs impair human capital accumulation NCDs on increasing productivity is all the more and productivity, and accelerate its depreciation relevant in the large and growing number of coun- (O’Keefe and Haldane 2024). This takes several tries with declining labor force growth. And there forms. First, premature mortality shortens work is now growing evidence from LMIC country stud- life and so creates a total loss of labor supply. Giv- U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 2 33 en that more than 40 percent of NCD deaths occur (O’Keefe and Haldane 2024). Note, however, that before age 70, this is a major loss in labor supply; the appropriate comparison is “with and without” this impact is becoming increasingly important as adoption and implementation of HLI recommend- the average age of labor forces rises. Second, NCD- ed interventions and policies. Without these cost-ef- based morbidity and disability lower the productiv- fective measures there would still be a demograph- ity of labor force, with reduced work time and lower ic transition toward a higher share of older adults on-the-job productivity. Reduced productivity due in the population, with a resultant increase in the to NCDs may take the form of complete non-par- dependency ratio. There would also be more re- ticipation in the labor force (or early withdrawal), duction in revenues throughout the life cycle from unemployment, fewer hours worked, absenteeism, NCDs. Finally, there is evidence that higher levels “presenteeism” (being present at work but with low of human capital have a direct effect on both work productivity), and delayed return to work from ill- opportunities and also perceptions of wellbeing ness. Available estimates suggest that this reduced (O’Keefe and Haldane 2024). productivity has an even greater negative economic Obesity and healthy longevity: Obesity plays a impact than premature mortality from NCDs, ex- major role in the effect of health on both the total cept in some of the poorest countries (Sweeny et labor force and the productivity of the labor force al. 2015). Third, NCDs are linked with a lack of in- (OECD 2020). There is strong evidence that NCDs vestment in further accumulation of human capital and poor nutrition (including obesity as well as over adulthood, through reduction in on-the-job undernutrition among children) compromise cog- learning, including through negative behavioral nitive foundations, school attendance, learning impacts on efforts to learn. Periods out of work due outcomes, and future on-the-job training. All of to NCDs also accelerate skill depreciation (O’Keefe this negatively impacts labor market outcomes in and Haldane 2024). Fourth, in the later stages of adult life. There are also immediate effects from the life, NCDs accelerate the depreciation of human growing burden of childhood NCD mortality and capital—the result of the cumulative and accelerat- morbidity. For instance, there are important asso- ing effects of the points described above. ciations among parents’ NCDs and risky behaviors In addition, NCDs in older parents contribute and health, cognitive, and educational outcomes of to under-utilization of their adult children’s human children (O’Keefe and Haldane 2024). capital in the labor market as those adult children, To take a country example, Mexico has a strik- and particularly the women who shoulder care re- ingly high prevalence of obesity. Over 34 percent of sponsibilities for their parents. There is also a ripple adults are morbidly obese (i.e. with a BMI over 40). effect on the next generation, both because NCDs Moreover, child obesity doubled from 7.5 percent reduce the care and support that older adults provide in 1996 to 15 percent in 2016 (OECD 2020). High to their grandchildren and because NCD risk factors levels of overweight and obesity could reduce Mex- like smoking and obesity increase the chances of ico’s labor force by over 2 million full-time workers children adopting the same behaviors. And where per year because people who suffer from overweight NCDs among grandparents result in transfer of the and who experience related conditions are less like- childcare burdens to younger women in the house- ly to be employed; and, if employed, they tend to hold, it can reduce or altogether block their work op- be less productive. These conditions together would portunities, especially for formal employment. cost close to 10 percent of total health expenditure Fiscal impacts: NCDs also produce fiscal im- between 2020 and 2050, which would, according to pacts that affect human capital. In the short term, the OECD, reduce Mexico’s gross domestic product tackling NCDs increases budget revenues, initially (GDP) by 5 percent (OECD 2019a). through excise taxes on alcohol, sugar-sweetened Economic and non-economic wellbeing benefits: beverages, and especially on tobacco. Over the lon- Economists have long debated whether improve- ger run, there could well be substantial increases ments in health have a causal relationship with in labor and income tax revenues that are closely GDP growth (Bloom et al. 2024; Spence and Lewis linked to the human capital and productivity chan- 2009). The correlation between better population nels. There could also be offsetting costs due to a health and growth is clear, but separating out the growing number of people living beyond retirement two-way causal flow and the effect of other vari- ages, although the relative importance of such costs ables (particularly institutions and education) that is the subject of vigorous debate in the literature impact both health and growth remains a source of 34 CHAPTER 2 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y disagreement. The HLI does not take a position on 2.2  NCD interventions are needed whether reducing NCDs will necessarily result in throughout the life course increased overall net growth. What it does argue, however, is that implementing the HLI recommen- Historically, action to improve adult health has dations summarized in the table in concluding sec- been undervalued. Direct investments in health at tion of this report (the core of which are specific, one stage of the life course yield benefits in the other cost-effective, clinical recommendations detailed stages. For example, reducing childhood malnutri- in the next section) will, holding other things con- tion and stunting, as demonstrated by analysis of stant, raise productivity for a given demographic World Bank’s Human Capital Index, raises not only and health profile of the population. child survival but also adult survival and future While the discussion in this section has thus far earnings (Dsouza et al. 2019). focused largely on the links between NCDs, human There are also important effects across genera- capital, and productivity and healthy longevity, it is tions within the same household. The links between important also to take account of the direct impacts higher maternal mortality and increased death rates of good health on non-economic measures of well- in surviving children are well established (Scott et being at the individual and societal levels. In econ- al. 2017). And a study of six diverse MICs found omist-speak, good health has consumption value in that in households where adults used tobacco and terms of improved quality of life, over and above its alcohol, children were less likely to receive vaccina- contribution through impacts on human capital and tions and basic health treatments (Wu et al. 2021). productivity. Alternatively, Amartya Sen has argued NCDs blunt human capital at all stages of life, that health should be considered as a “function” that not just in old age. Thus, policy interventions need contributes directly to the “capabilities” that are the to address each stage of the life course. Preventing basis for the wellbeing, freedom, and dignity of peo- NCDs early in life—most notably reducing malnu- ple, over and above health’s contribution to produc- trition and childhood obesity, as well as limiting tion (Sen 1997; Nussbaum 2011). In this context, adolescent risk behaviors such as smoking—will re- the most important benefit from reducing NCDs duce adult diseases (Raghuveer 2010). Further, ear- is not economic; it is instead the impact on human ly detection of modifiable or treatable risk factors wellbeing—as an end, rather than just a means, of can limit the diseases’ harms to human capital for- development. Even in the hypothetical scenario that mation and deployment over a working life. More NCD control would lead to no income growth, in- directly, for instance, hepatitis vaccines adminis- vestments would be sufficiently justified because of tered at birth or early in life help to avoid most liver their impact on health and wellbeing. cancer later (Gelband et al. 2016). Research on the relationships between NCDs While there is, of course, great variety in life and different measures of wellbeing including in de- trajectories, what follows is a general, illustrative veloping countries has been growing (Deaton 2008; sketch of the relationship between NCDs and hu- Steptoe et al. 2015; Steptoe 2019). This research man capital over the course of a life. The seeds of consistently demonstrates that NCDs compromise healthy longevity are planted even before birth. quality of life across various wellbeing measures, in- For example, 10–15 percent of all pregnancies are cluding life satisfaction, the WHO quality of life in- affected by inter-uterine growth restriction, which dex which includes multiple domains of wellbeing, increases the likelihood of some NCDs later in life. happiness, and health-related quality of life (Lee Low birthweight may also be linked to a greater et al. 2015; Arokiasamy et al. 2015). The research risk of NCDs in both childhood and adulthood also shows a bidirectional relationship: subjective (Armengaud et al. 2021). measures of wellbeing matter for health, with lower Early childhood is another important period wellbeing increasing the risks of premature mortal- that influences health over the life course and for ity and a range of NCDs; and NCDs negatively im- multiple generations. Breastfeeding is a particularly pacting subjective (as well as objective) measures of salient example. Mothers who breastfeed have low- wellbeing. In addition, research suggests that posi- er incidence of chronic illnesses, including breast tive, subjective wellbeing may be a protective factor cancer, ovarian cancer, and cardiovascular disease for health and is associated with longer lives and (Pérez-Escamilla et al. 2023). At the same time, lower morbidity (O’Keefe and Haldane 2024). infants who are breastfed are less likely to develop into adults with diabetes, overweight, or obesity. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 2 35 A Chinese study, for example, found a significant education of 5–19-year-olds amounted to around association between breastfeeding for over a year US$210 billion each year. Investments in health for and lower BMI in 6–16-year-olds, particularly the same age group were less than 2 percent as high, 9–11-year-old boys (Liu et al. 2022). at roughly US$3 billion per year. Meanwhile, annu- Children who are breastfed also stay in school al investments in the health of under-five-year-olds longer, on average (PAHO 2015). One estimate is totaled about US$29 billion (Bundy et al. 2018). that globally, the accumulated human and econom- China has, for example, expanded health pro- ic costs of not breastfeeding add up to a US$257– grams for 5–19-year-olds with school-based nutri- 341 billion per year (Walters et al. 2019). Poor nu- tion and mental health programs to complement trition, which is broader than just the absence of additional efforts on education, such as early edu- breastfeeding, is associated with more under-five cation, e-learning, and secondary vocational train- mortality as well as more stunting, lower school ing. Youth programs in varied countries have em- attendance, and worse learning outcomes (leading ployed peer-based methods to decrease smoking or to lower incomes as adults). These factors in child- binge-drinking initiation, and to increase vaccina- hood and adolescence resound throughout the life tion of adolescents against HPV, which will avert course. An undernourished child is more likely to nearly all cervical cancers (Gelband et al. 2016). develop an NCD, such as CVD or type 2 diabetes, as Background research for the HLI examined an adult (UNICEF 2019). potential pathways through which NCDs and ed- Malnutrition includes undernutrition as well as ucation jointly affect human capital accumulation, over-nutrition, both of which lead to more death and including analysis of survey data from India, In- disease. Childhood obesity in LMICs is growing at donesia, Mexico, and the United Kingdom. The an alarming rate. It is associated with type 2 diabetes, research found that NCDs in childhood, such as coronary artery disease, mental health conditions, asthma and diabetes, are strongly associated with and other NCDs (Gupta et al. 2012). One systematic about 1.2–4.2 fewer years of completed education review found that the median prevalence of hyper- in India. NCDs in childhood lower subsequent tension related to childhood obesity was 13 percent adult height, which may be an indicator of future in HICs, compared to 36 percent in LMICs (Obita NCDs, reduced employment and hours worked, and Alkhatib 2022). Thus, avoiding malnutrition is and other life outcomes, including mental wellbe- the foundation of the extensive menu of policy op- ing (Roder-DeWan et al. 2019). tions to combat NCDs and support healthy longevity. Childhood health clearly influences vulnera- During the adolescent years, adolescent sex- bility to NCDs later in life, but there is also a sig- ual and reproductive health rights (ASRHR) out- nificant and growing burden of NCDs among chil- comes, including high adolescent birth rates, school dren already. NCDs including cancers, diabetes, dropouts, and exposure to violence, can influence and asthma are responsible for roughly one-fourth subsequent life-cycle stages (WHO 2023a). This in- of deaths between ages 10 to 24 years due to NCDs cludes women, children (especially girls), and other (Institute for Health Metrics and Evaluation 2019). vulnerable populations—for example, individuals Overall, these findings underscore the urgent living with disability and peri-urban populations need to take NCDs in childhood and adolescence facing adverse environmental exposures; it also in- seriously, as they have a large, detrimental impact cludes involuntary internal and international mi- on human capital, which could worsen without grants—facing even more challenges, compounded action. For adults as well, poor nutrition affects by extreme poverty. This also is the key period when health. It is associated with weak immune systems women are able to make autonomous decisions. Fi- and with NCDs including heart disease, cancer, and nally, emerging areas of ASRHR include avoidance osteoporosis (Kaur et al. 2019). Malnutrition in old- of smoking, and attention to obesity, menstrual er people is particularly high in LMICs. health, human papillomavirus (HPV) vaccination, As the working years wear on, it is increasingly and mental health. important to protect human capital and prevent it Given the importance of nutrition throughout from eroding. This extends beyond direct income childhood and adolescence, there is a valuable op- generation as older people influence the ability of portunity to scale up resources for children’s health loved ones to accumulate human capital them- beyond the first few years, leveraging educational selves. Not only are older parents with NCDs less investments. In LMICs in 2010, investments in the able to work, adult children who are responsible for 36 CHAPTER 2 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y their care (very often at the same time as they care disease and stroke (Jha et al. 2013). Of course, it is for their own children) also have less time and ener- not only mortality but also periods of disability pri- gy to devote to work. Healthy older people can also or to death that matter, including at older ages. An be an essential source of care for grandchildren or ideal scenario is thus one of low death rates in young for those less healthy in the household, freeing up age and middle age, paired with sharply compressed the working hours of the middle generation, partic- time before death lived in any disability state. ularly women. The key is to recognize that the interventions that create longer and healthier lives require ma- 2.3  Health and wellbeing benefits of a jor investments primarily in youth and middle life-course approach to NCDs age. This is the concept of avoidance of serious risk factors prior to middle age (mostly not smoking, Extending health longevity: Addressing NCDs would not being obese, minimizing consumption of sug- both lengthen overall life and ensure that it is mostly ar-sweetened beverages, using alcohol minimally if lived in good health, with a reasonably short peri- at all, and keeping up physical activity), plus effec- od of disability just prior to inevitable death in very tive secondary treatment for common conditions old age. Evidence demonstrating that people can live such as ischemic heart disease. longer in good health, with sickness compressed to Life-course interventions are quite feasible, just a short period before death, comes from all re- given the current state of knowledge. The Disease gions of the world. This framework is not fanciful. Control Priorities project has identified a range of It is achievable, but only with sustained investments cost-effective interventions from cradle to grave throughout the life course. Consider actual survival that provide governments with options to help them among British males in 1960 and 2010 versus a hy- customize packages of essential, effective health ser- pothetical ideal (Figure 2.3). The 1960–2010 survival vices, delivered either directly or via private provid- rate increased substantially (a gain of about 10 years ers (Gelband et al. 2016). Chapter 3 of this report of life expectancy), driven mostly by reductions in also looks in detail at NCD packages and priority smoking and widespread use of treatments for heart interventions across different country groupings. FIGURE 2.3  Survival among British males in 1960, 2010, and with hypothetical ideal, including years lived with disability Source: Original calculations using data from Office for National Statistics (2023) and mortality data from UNPD (2022). Note: No (hypothetical) levels of disability for 1960 are graphed. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 2 37 2.4  The role of innovation in the capita in 2019—just over half of the $1453 needed in life-course 1990. But to achieve similar performance for adults aged 50–69, they had to spend $1180 in 2019, a quar- Chapters 3 and 4 examine the benefits and financ- ter more than the US$914 required in 1990. At the ing of life-course investments. A relevant question is same time, the critical income for survival remained whether innovations can make investments more af- essentially stagnant for 15–49-year-olds, at the low fordable, as has happened with globally falling costs level of $400–413. Rising costs to save an adult life for computing, travel, and communication. Indeed, suggest that acting as early as possible when spend- the innovation can be measured through a metric ing will bring more health per dollar. called “critical income,” which represents how much Key reasons for the increased costs among people countries would need to spend per capita (adjusted in their 50s and older are limited use of proven tools for inflation) to be in the top 20 percent of countries in most LMICs against tobacco control; insufficient in reducing mortality for given age groups (Hum spending on NCDs, which has impeded the econo- et al. 2012). Analysis commissioned for this report mies of scale that can in turn reduce input costs; and finds that while it is substantially cheaper to save a insufficient investments in new NCD drugs and pro- newborn from dying before age 15 than it was in tocols (Jha et al. 2013). Each of these elements requires 1990, it is more expensive to save a 50-year-old from good governance and public-private cooperation dying before the age of 70 (Wu et al. 2024). As Fig- to succeed. There is a need for more effective inter- ure 2.4 illustrates, to keep up with the top 20 percent ventions through R&D GPGs to bend the cost curve of peer countries in reducing mortality in children downward, as has happened for children’s health and under 15, LMICs had to spend $800 (2017 PPP) per which Chapter 4 describes in greater detail. FIGURE 2.4   Distribution of critical income values for LMICs in 2019, relative to reference 1990 global value Source: Wu et al. (2024). Note: LMICs = low- and middle-income countries. 2.5  Poverty and inequality impacts poverty. Losing a breadwinner, whether due to death of NCDs or disability from a chronic illness, can sink house- holds into poverty. Costs can be immediate and obvi- NCDs and risk of absolute poverty: NCDs also are a ous such as catastrophic health expenditure. Indirect major cause of catastrophic health spending and loss costs can also be significant, in some cases preventing of income to households, and so are a major driver of people from obtaining care. In India, travel costs can 38 CHAPTER 2 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y amount to almost 40 percent of all out-of-pocket med- days lost (Shiri et al. 2021). NCDs limit the skills ical expenditure for people receiving kidney trans- people develop and their opportunities to exercise plants. Overall, travel costs are the primary out-of- them. A background paper for this report examined pocket expense for many Indian patients with NCDs over 100 studies and found that being overweight (Ramachandran and Jha 2013). Indirect expenses like or obese was associated with lower rates of employ- these further limit low-income people’s ability to save ment, lower income, higher rates of sickness absence, and invest in human capital. In some cases, increased and higher rates of disability pensions. Adverse labor expenditures and lost wages can force the sale of some market outcomes were also observed among those of the families’ meager productive assets or the with- suffering from depression, those with excessive alco- drawal of children from education, with significant hol use or smoking (Chakraborty et al. 2024). negative effects on future incomes and health as well. NCDs and inequality between countries: NCDs As Chapter 1 showed, there are already billions affect people unequally. People in poorer countries of adults living with major NCDs or modifiable risk are much more likely to die from certain NCDs than factors, and even larger numbers of children who, on their counterparts living in wealthier countries. For the current course, could face such risks. Thus, be- instance, compared to an individual in a high-in- yond mortality, there are even greater economic re- come country, an individual in a low- or middle-in- percussions from NCD-related ill health, which di- come country is about twice as likely each year minishes labor force participation and productivity. to die from CVD (Figure 2.5) (Yusuf et al. 2014). NCDs and inequality in labor markets: It is also Among the poorest billion people in the world clear that other NCDs and risk factors are connected (mostly in rural parts of Sub-Saharan Africa and to being worse-off in labor markets. A study showed South Asia), the mortality and disability burdens of that in LMICs, diabetes has a negative relationship NCDs often exceed those for infections. Moreover, with the employment chances of men (but did not between 19 and 50 million of those billion people find the same negative effect for women) (Pedron et incur catastrophic health expenses due to high di- al. 2019). Harmful alcohol use is associated with a rect out-of-pocket costs for treatment of NCDs and lower likelihood of employment, and greater like- injuries (Bukhman et al. 2020). And the poorest bil- lihood of taking time off work due to sickness, in lion acquire NCDs and sustain injuries at a younger studies from HICs. For instance, research from Fin- age (partly because of the population age structure) land, a country with high levels of education and and lose more years of life from these causes (partly life expectancy as well as per capita income, links because of limited access to health services) binge-drinking to a substantial increase in working FIGURE 2.5  Incidence rates of major CVDs in selected countries by income region Source: Yusuf et al. (2014). Note: CVD = cardiovascular disease; HIC = high-income country; LIC = low-income country; MIC = middle-income country. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 2 39 NCDs and inequality within countries: There are versible and can be achieved at affordable costs. also significant disparities within, as well as across, High-quality health services expanded to the poor countries. In most countries, the poor or lower-edu- can significantly help to reduce unequal health out- cated have much higher risk of death from NCDs. In comes. For example, a study of Indian men found Mumbai, the survival from cardiovascular disease is that the risk of death following a heart attack was much lower among the least-educated men for ex- 60 percent higher among the lowest socioeconomic ample (Pednekar et al. 2011). Across India from 2001 group. However, with access to treatments includ- to 2003, cancer death rates among illiterate men and ing clot-busting drugs and after adjusting for risk women were over double those of people with sec- factors like higher levels of smoking, the social gra- ondary or higher levels of education (Figure 2.6, left dient difference in death rates nearly disappeared panel; Dikshit et al. 2012). In Argentina, lower edu- (Xavier et al. 2008). This still leaves, of course, the cation level is associated with a higher likelihood of challenge of discouraging smoking and other high- having hypertension, obesity, and smoking (Figure er-risk factors for the lowest socioeconomic group. 2.6, right panel; Tumas et al. 2022). People with low There is a widespread belief that tobacco taxes hurt socioeconomic status are more likely to have to deal the welfare of the poor since they lose a greater with cancers, cardiovascular diseases, and multiple share of their income when cigarettes are more ex- NCDs. They are also less able to bear the costs and pensive. Evidence suggests that this view, promoted less likely to seek timely health care. by the tobacco industry, is not just misleading but Tacking NCDs can reduce income inequality: wrong (Box 3.3) (Paraje et al. 2024). Some NCD-related outcomes of inequality are re- FIGURE 2.6   Education levels and age-standardized death rates from cancers among adults aged 30–69 in India by sex, 2001– 03 (left) and education levels and selected NCD and risk factors among Argentinian adults aged 18 years and older, 2013 (right) Source: Dikshit et al. (2012); Tumas et al. (2022). Note: NCD = Non-communicable disease. 2.6  Tackling NCDs is crucial for bility, including ethnicity, indigeneity, illiteracy, dis- gender equality ability status, refugee or migration status, poverty, gender identity, and sexual orientation. The interac- Gender-specific aspects of NCD incidence: A major tions between gender and NCD-related ill health are axis of inequality when it comes to NCDs is gender, complex. Men smoke and drink more than women, which intersects with other dimensions of vulnera- and diabetes limits their work more for example 40 CHAPTER 2 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y (Chakraborty et al. 2024). While men have higher Gender affects not only how people provide mortality from CVD overall, men and women have care, but also how they receive it. In a study of treat- roughly equal CVD death rates at older ages, and ment for the five most prevalent chronic diseases in women tend to live longer with morbidity (Saadat Bangladesh, 53 percent of employed men had used et al. 2024; Breton et al. 2013; Rodgers et al. 2019). health care services in the past 30 days, compared Violence against women and girls is a risk factor to just 8 percent of employed women (Mahumud et for poor mental health, as well as a cause of great suf- al. 2023). The lower use among Bangladeshi wom- fering. Women bear a considerably higher burden en has to do with decision-making power, financial of depression globally, while men are more likely to capacity, and knowledge—suggesting a complex in- die by suicide (Saadat et al. 2024). Gender also plays terplay among human capital, health, and empower- a role in mental health outcomes. Due to women’s ment. In a number of LMICs, women can have lim- lived experiences across their lifecycle, especially ited health care access due to an interplay of factors in countries with greater gender inequality, women such as transportation barriers, the cost of care, and exhibit higher levels of depressive disorders com- the perceived quality of care (Saadat et al. 2024). pared to men. Women and girls are also more likely Neglect of gender aspects of NCDs: Overall, to experience gender-based violence—a major risk women’s health in relation to NCDs has been rel- factor for mental health disorders. The prevalence atively neglected and consequently less well under- of depressive disorders remains consistently higher stood. This includes women’s specific clinical needs, for women as they age; and in some cases, such as but also their role in caring for people with NCDs, Japan, there are three times more women than men whether as professionals or as loved ones. Wom- with a depressive disorder. On the other hand, mor- en and girls are disproportionately responsible for tality from self-harm is consistently higher among caring for people with serious NCDs, just as they men. Several epidemiological studies indicate that bear the lion’s share of unpaid care overall. Globally, although women attempt suicide at similar or higher women take on about 76 percent of all unpaid care rates than men, deaths remain higher among men. work—increasing to over 90 percent in countries Studies find that men are less likely than women including Mali and Cambodia (Addati et al. 2018). to seek mental health services, especially in LMICs For nearly half of women in MICs who are not in where there is still considerable stigma attached to paid work, and over one-third of those in LICs, un- mental illness, and men are more likely to use more paid care duties are the main reason for being out of violent methods of self-harm (Saadat et al. 2024). the labor market (O’Keefe and Haldane 2024). There are sociocultural reasons and modifiable The nature, intensity, and frequency of care in risk factors for men’s greater mortality at every stage the household matter for women’s employment out- of life (Chang et al. 2024). However, women are dis- comes, depending on the context. In Qingdao, Chi- advantaged by NCDs in several ways. Although na, caring for a parent-in-law, rather than a parent, women are more likely to live longer than men, is what has a detrimental effect on a woman’s paid they are less likely to be in paid work, particular- work (Liu et al. 2010). One study of how caring for ly in MICs (de Silva and Santos 2024). Similarly, in older parents affects midlife work across Colombia, lower-income countries, women’s economic partic- Indonesia, Poland, and Egypt, found that providing ipation is more limited and often restricted to infor- long-term care to older parents (many of whom had mal sectors. Due to women’s limited participation chronic illnesses) was associated with significant re- in the formal markets along with sociocultural fac- ductions in employment, hours worked, and annual tors, women’s limited financial capacity and lower earnings for both women and men. But the effect was (or missing) coverage under social protection pro- more pronounced among women and among care- grams acts as a barrier to receiving timely and ade- givers providing over 10 hours of care per week (Gat- quate health care (Guerra et al. 2008; Thorpe et al. ti et al. 2024). Such disparities lead to snowballing 2008; Stankuniene et al. 2015; Hossain et al. 2023). gaps in income, wealth accumulation, and old-age Women’s greater longevity also has specific security between men and women. Girls caring for clinical outcomes related to NCDs. It contributes to women are particularly likely to be taking on those women being more affected by dementia and blind- unpaid duties, magnifying their domestic workload. ness, as well as living longer with major NCDs, even Cumulative impact of gender inequalities: All though it lowers their comparative mortality from of this inequality compounds over time. In later NCDs in any given year. life, this can perpetuate the vicious cycle of lower U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 2 41 income, shorter life expectancy, and poorer health, of pensions than men despite living longer on aver- even as many older adults of limited means contin- age (de Silva and Santos 2024), and who thus may ue to work out of necessity. The lack of a cushion for be completely dependent on others. older people, in countries with limited public pen- Chapter 3 further describes formal and informal sion systems, can compel them to work for as long ways of reducing the impacts of gender inequalities as possible even in conditions of declining health within the framework of expanding high priority, and productivity. There are particular pressures on cost-effective interventions to the whole population. women, who tend to have lower coverage and levels 42 CHAPTER 3 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Advancing healthy longevity now: What countries can do Countries can make major advances toward healthy longevity with well-chosen, cost-effective policies and life- course interventions if implemented quickly. Previous chapters in this report showed that invest- surement, monitoring, and data to improve perfor- ing in the prevention and control of NCDs across mance of healthy longevity programs. the life course improves wellbeing, nurtures more gender-inclusive and resilient societies, boosts pro- 3.1  Tackle NCDs with cost-effective, pro- ductivity, and reduces poverty, with benefits that poor interventions extend across generations and sectors. A key mes- sage is the need to substantially accelerate NCD There is already a set of proven, cost-effective mea- interventions, which have been underused, and to sures that countries can draw on and adapt within do so early, because delay in adopting interventions their NCD and broader health and social protection will be more costly in human and financial terms. strategies to reduce NCD burdens and their human If all countries could accelerate to keep up with and economic costs (Watkins et al. 2024; WHO those countries that have been most successful at 2023d). And further investments in NCD R&D and reducing mortality, over 500 million lives could be GPGs can expand the list of cost-effective measures. extended meaningfully cumulatively by 2050, and The actions recommended here include both 25 million lives could be saved in the year 2050. This population-based NCD prevention measures and will require ongoing investment in child and mater- personal health care measures. These interventions nal health, infectious diseases, vaccine-preventable are essential for all countries to substantially acceler- diseases and nutrition, plus NCD interventions. ate their performance in reducing avoidable mortality Such approaches are consistent with aspirations for by 2050 (Chang et al. 2024; Paraje and Gomes 2022). universal health coverage (UHC). This chapter defines and estimates costs for the Options for countries incremental interventions to reduce NCDs to com- plement existing programs. The HLI intervention The menu of proven, cost-effective NCD interven- package should be considered a “starter” one, priori- tions presented in Table 3.1 builds on global evi- tizing only a small set of the most cost-effective inter- dence and analysis from the Disease Control Pri- ventions, with more NCD interventions that can be orities Project and is aligned with WHO’s work on added as they become affordable, or as innovations “best buys” (Watkins et al. 2017; WHO 2017b). It (discussed further in Chapter 4) lower the cost of cur- encompasses 31 recommended interventions. The rently cost-ineffective interventions (for example, the majority are personal health services—most of new injectable drugs for obesity). Moreover, the HLI which can be delivered through primary health care package assumes ongoing relevant investments such systems—while six are population-level prevention as the HPV vaccination against cervical cancer will interventions delivered outside the health sector. continue to be supported by existing global initiatives. Countries can draw on and adapt interventions The chapter describes policies countries can from this menu, depending on their particular cir- adopt and evidence-based interventions that they cumstances. Fiscal and regulatory approaches nota- can adapt to achieve strong gains in politically rele- bly include raising taxes on products that damage vant timeframes at acceptable cost. It highlights four people’s health especially tobacco and alcohol. Some lines of action: (i) enhanced spending on health at fiscal measures yield very quick gains. For example, the population level; (ii) cost-effective interventions higher tobacco taxes reduced consumption in Mex- to prevent and control NCDs at the clinical and ico the following year (Tobacconomics 2022); and community levels; (iii) policies for financial protec- in France, they led to a quick decline in lung cancer tion of the poor and long-term care; and (iv) mea- rates among the youngest smokers (Jha 2009). U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 3 43 TABLE 3.1   Full list of recommended NCD interventions Service delivery level Specific intervention Population-based, outside the Alcohol excise taxes health sector (risk factor reduction) Alcohol regulations Smoking regulations and social and behavior change communication (SBCC) Sodium regulations and SBCC Tobacco excise taxes Trans fat bans Community platform Pulmonary rehabilitation Health center Aspirin for suspected acute coronary syndromes (ACS) Epilepsy acute and chronic treatment Heart failure chronic treatment Injecting drug use (IDU) harm reduction measures Alcohol use screening/brief intervention Bipolar disorder chronic treatment Cardiovascular disease primary prevention especially hypertension control Cardiovascular disease secondary prevention Chronic pulmonary disease treatment Depression chronic treatment Diabetes screening/treatment Schizophrenia chronic treatment First-level hospital Heart failure acute treatment Medical management of acute coronary syndromes Management of appendicitis Management of bowel obstruction Repair of gastrointestinal perforations Repair of hernias Screening and treatment of early-stage cervical cancer Treatment of acute exacerbations of chronic pulmonary disease Referral and specialized hospital Advanced care for severe acute-on-chronic pulmonary disease Percutaneous coronary intervention (PCI) for acute coronary syndromes Treatment of early-stage breast cancer Treatment of early-stage colorectal cancer Source: Watkins et al. (2024). Note: Italics indicates items in the high-priority package. In terms of cost and the volume of care, the in most countries. Yet most countries are nowhere clinical interventions on the list represent a signif- near full implementation of these interventions. For icant proportion of what health systems can do to example, fewer than half of people with hyperten- manage NCDs. Some of the first-level hospital in- sion worldwide are receiving treatment. In LICs terventions which are not directly relevant to the like Mozambique, the figure is closer to 15 percent management of NCDs are necessary for maintain- (NCD Risk Factor Collaboration 2021). ing institutional technical capacity. Primary or sec- Scaling up all of the interventions in Table 3.1 ondary prevention of cardiovascular diseases, dia- to cover even 80 percent of the population in all betes management, and mental health care together countries by 2030 would dramatically reduce NCD address the bulk of primary care for chronic disease mortality and would be highly cost-effective. How- 44 CHAPTER 3 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y ever, for many countries, this would involve unre- and SSBs particularly influence youth, because alistic increases in health expenditure and institu- of their generally low discretionary incomes, so tional capacity. Realistically, most LMICs will need these policies can pave the way for better health to choose a subset of interventions and sequence and greater opportunity over more years (Paraje their order and the expansion of their coverage. et al. 2024). Moreover, they free up the resources Most countries will likely want to apply “progressive of health systems. For example, in Bangladesh, di- universalism”: moving toward universal coverage rect care for tobacco-related diseases alone soaks of a set of basic services and concentrating public up 20 percent of all annual health spending (U.S. financing initially on the poor and disadvantaged. National Cancer Institute and WHO 2016). For instance, Mexico’s Seguro Popular expand- ed public finance of treatment for childhood and • Health taxes benefit poor people the most. breast cancers, and targeted the rollout to the poor- Some industry interests have promoted the myth est states first (Frenk et al. 2009). Chapter 4 contains that these taxes are regressive. In fact, numerous details of financing strategies within and beyond the country studies on smoking and on alcohol con- public health sector. sumption show that they are highly progressive once their health consequences are taken into ac- Leverage fiscal tools to save lives and count. It is true that the immediate tax burden is boost revenues regressive. But because the poor are more respon- sive to price, they will more often quit or cut back All six of the population-level prevention measures sharply on smoking in response to large excise in Table 3.1 are highly cost-effective, feasible, and tax increases. This also frees up money for other relatively inexpensive to implement. Many of the household uses. More importantly, given much most-cost effective policies, such as tobacco and higher tobacco-related diseases among the poor, alcohol policies, are feasible not only in countries a large and growing number of country studies with higher levels of resources, but also in coun- show that higher taxes are highly progressive in tries with lower resources or in fragile countries terms of health gains, making cigarette taxes pro- that are recently emerging from war or conflicts gressive overall (Fuchs et al. 2019). Finally, cata- (Watkins et al. 2024). strophic out-of-pocket health care costs attribut- Especially important among these are “health able to smoking often lead to the impoverishment taxes”—pro-health excise taxes levied on tobacco, of low-income families—all the more so when a alcohol, and sugar-sweetened beverages (SSBs). household breadwinner becomes incapacitated or They are crucial because smoking, alcohol, and ex- dues prematurely. A large increase in excise tax- cessive consumption of sugar (as well as salt) are es on tobacco could lift an estimated 20 million leading drivers of NCD epidemics worldwide. Taxes families from these poverty traps (Global Tobac- on such health-damaging products are powerful in- co Economics Consortium 2018). Furthermore, terventions that could avert hundreds of millions of many countries have used some of the increased early deaths (Global Tobacco Economics Consor- tax revenues for pro-poor programs, which can tium 2018), boost government revenues that can be include further health promotion. used for health and other pro-poor programs, and slow the rise in NCD health expenditures (Box 3.1) • Health taxes are underused. Many countries tax (Paraje et al. 2024). tobacco and alcohol, and increasing numbers have Three facts make the case for decision-makers targeted SSBs. But few go far enough. The oppor- to tax health-damaging products: tunities are enormous, particularly in LMICs (Box 3.1) (Verguet et al. 2015; Lane 2022). Taxes on • Health taxes raise economic efficiency. Extensive these toxic substances can bring about even more evidence from numerous countries shows that ex- change when combined with non-price measures. cise taxes are the most cost-effective tool to de- For instance, public awareness campaigns about crease consumption of tobacco and alcohol and are the benefits of quitting smoking increase public cost-effective for decreasing consumption of SSBs. support for cigarette taxes (Paraje et al. 2024). This is because affordability, which is growing in LMICs, is a primary factor affecting consumption A growing number of countries at all income levels of harmful substances. Taxes on tobacco, alcohol, have adopted policies targeting NCD risk factors U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 3 45 (Araújo and Garcia 2024). Uruguay’s aggressive to- and child health (Araújo and Garcia 2024). However, bacco control program—which includes tobacco some LICs, including Rwanda, have developed and taxes, bans on smoking in public places, and other scaled up national NCD prevention programs. Fiscal measures recommended for global adoption by the and regulatory tools can be complemented by behav- WHO—is widely considered a model (Marquez et al. ioral and social change interventions (as suggested 2019). In Sub-Saharan Africa, NCD prevention has in Box 3.2), recognizing that individual behavior is until very recently taken low priority relative to infec- embedded within structural forces that shape the tious diseases and the unfinished work on maternal context in which the behavior takes place. BOX 3.1 Impacts of consumption and taxation of tobacco, alcohol, and SSBs Globally, in 2012, the cost of tobacco use was estimated to be about US$1.4 trillion, or about 1.8 percent of the global GDP in 2012 (Pan American Health Organization (PAHO) 2022). Of this, about 25 percent is direct health care expenditure, and the rest represents indirect costs attributable to premature mortality, productivity loss due to absenteeism and presenteeism, and opportunity costs such as those of caregivers. For alcohol use, pooled results from 29 locations found that the total cost of alcohol consumption is about US$817 per adult (international dollars, purchasing power parity), or about 1.5 percent of GDP (Manthey et al. 2021). In addition to the health and economic costs, consumption of tobacco, alcohol, and SSBs is associated with reduced expenditures on food, education, clothing, and health care (Wu et al. 2021; Paraje and Gomes 2022). Worldwide, smoking prevalence has declined since the 1990s (WHO 2020c), in response to a vigorous—but still not yet ad- equate—effort by countries to implement the tax and other specific provisions of WHO’s landmark Framework Convention on Tobacco Control. However, for alcohol use, although the prevalence has decreased, per-capita volume of pure alcohol consumed has increased (WHO 2018; Manthey et al. 2019). Of the three products, SSB consumption saw the largest increase in consumption: from about 36 liters per person in 1997 to 43 in 2010 (Basu et al. 2013). This increase in global consumption, particularly of SSBs, is partly attributable to rising income in LMICs (WHO 2014). Well-designed taxation policies around tobacco, alcohol, and SSBs can reduce their consumption as well as NCD-attributable mortality, morbidity, and health care costs, while generating additional tax revenue (WHO 2014, 2017b). Despite being ranked as one of the most cost-effective interventions to reduce NCDs in the WHO list of “best-buys” (WHO 2017b), excise taxes on these harmful products are under-used in LMICs. In high-income countries, excise taxes constitute more than half of the retail price of cigarettes, but they are well below 40 percent in LMICs (Figure 3.1) (Jha et al. 2015). And given faster growth in income, the affordability of cigarettes has increased. Large, one-off increases in tobacco excise taxes are particularly effective, leading to greater reductions than comparable smaller increases spread over time, in part due to signaling to smokers’ expectations for future price increases (Irwin et al. 2018). In theory, excise taxes should be “stroke of the pen” interventions, but in practice, vested interests from the tobacco, alcohol, and SSB industries have impeded progress. For example, worldwide, the tobacco industry generates about US$50 billion in profit, or approximately US$10,000 per death caused by smoking. Tobacco-industry sponsored exploits, such as smuggling in Canada (Jha et al. 2020) are showcased around the world to deter finance ministers. Yet higher excises do not predict smuggling, but lax tax administration and corruption do (Jha and Chaloupka 1999). Coalitions of civil society and key NGOs that call out vested industry interference and ongoing evidence generation are key to sustained efforts to raise taxation. 46 CHAPTER 3 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y FIGURE 3.1  Levels of excise and other taxes on cigarettes by country income group, 2020 Source: Original calculations using data from Office for National Statistics (2023) and mortality data from UNPD (2022). Note: No (hypothetical) levels of disability for 1960 are graphed. BOX 3.2 Tools from behavioral science can strengthen NCD prevention and control Behavioral science offers insights into better preventing, detecting, and managing NCDs, by spotlighting the barriers that limit people’s ability to reach their own healthy longevity goals and by identifying feasible steps to overcome those barriers. For instance, people often believe that they are less likely than others to develop an NCD, even if they are at high risk. This influences the perceived value of screening for disease. Across cultures, medical professionals as well as patients may have biases that impede the best health outcomes. Behavioral interventions can increase the impact of traditional public health tools. Inexpensive behavioral interventions include reminders, nudges, and feedback that encourage people to stick to their medication regimens. Financial incentives have been shown in some cases to increase medication adherence, physical activity, and avoidance of addictive substances. While the effects tend to be short-lived, for certain interventions even short-term changes can be help- ful. One randomized controlled trial of Armenian 35–68 year olds tested whether several demand-side interventions would improve the rate of screenings for diabetes and hypertension. The highest impact was found among the group that received a pharmacy voucher; these participants’ screening rates for both tests increased by 31 percentage points (compared to 4 percent of control group participants going for screening) (De Walque et al. 2022). Choice architecture, which influences decision-making contexts, can help overcome present bias (i.e., the preference for a smaller reward now, like unhealthy food, over a larger reward later, such as sustained health). Another relevant concept is time inconsistency, or the tendency towards impatience when choosing between receiving benefits now and in the future, despite having patience when choosing between two points in the future to receive benefits (Rojas et al. 2023). A related type of intervention is social and behavior change communication (SBCC), which involves context-specific commu- nications to develop and maintain positive behaviors. In Accra, Ghana, the anti-smoking and girls’ empowerment program, SKY Girls involved events and social and traditional media to discourage tobacco use. Key here were the kinds of social influence that behavioral science has highlighted in relation to NCD risk factors. A study of 2,625 girls aged 13 to 16 found that living and studying in Accra during the implementation of the program was associated with an 12 percentage point decrease in their perceived pressure to smoke (Hutchinson et al. 2020). U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 3 47 3.2  Clinical interventions will lower NCD (Figure 3.2). Rapidly scaling up these interventions burdens and improve lives can also contribute to building capacities in coun- tries’ PHC systems (Hou et al. 2023; Araújo and In addition to population-level prevention, person- Garcia 2024; Chen et al. 2022). Some countries have al health care interventions are critical to reduce the made strides in strengthening NCD service deliv- impact of NCDs on lives and economies. The frame- ery within PHC (Araújo and Garcia 2024; Hou et work for prioritization of NCD personal services in al. 2023). Sri Lanka’s Ministry of Health has estab- Figure 3.2 is based on four criteria for NCD clini- lished healthy lifestyle centers within PHC, in part cal interventions: value for money, equity, financial for earlier detection of risk factors for chronic dis- risk protection, and implementation feasibility. The eases. Other countries, including Peru, have under- high-priority recommendations for serious consid- taken ambitious health care reforms, building on eration would include six clinical interventions (as the expansion of primary care toward UHC, while well as the six population-level interventions out- emphasizing the prevention and management of side the health sector and one at community level, chronic conditions (Atun et al. 2015; WHO 2017c, discussed earlier). Health ministries might consider 2017b). Evidence regarding the impacts of prima- medium-priority interventions as budgets allow. ry care approaches to managing NCDs in LMICs is limited but promising (Hou et al. 2023; Macinko et Strengthen NCD interventions at the primary al. 2009; Macinko et al. 2016; Kruk et al. 2010). health care level Community-based PHC holds promise for NCDs Rolling out priority NCD interventions within PHC, targeting populations across their life course, One way to keep down costs of primary health care can help advance overall and primary health reform is to enlist and empower communities, including agendas. It can also identify points where social care community health workers. In Viet Nam, volun- and health care can complement each other (Hou et teers are trained by retired health care professionals al. 2023; WHO 2023c). NCD clinical services will to support self-help clubs for older people. These yield the greatest impact within health systems cen- provide home care assistance, health checkups, and tering comprehensive PHC. Such systems are best other services, including social and economic sup- suited to support life-course health for several rea- port. The clubs have at least 10,000 members and sons. (i) They bring health care closest to people, es- over 16,000 caregivers (Asia Health and Wellbeing pecially the older adults who bear the largest share Initiative 2020). of NCDs and can prioritize prevention and health There is evidence that community-based PHC promotion attuned to community needs and values; programs are effective for the prevention and control (ii) they are an entry point for more specialized care of chronic diseases. Good results have been report- related to NCDs when needed, among the types of ed for tobacco cessation programs, blood pressure institutions listed in Table 3.1; and (iii) as the entry control (Jeet et al. 2017), and diabetes management point for other health care issues, they offer econo- (Kaselitz et al. 2017). In Latin America, countries mies of scale (Hou et al. 2023). that have invested in building a strong primary care This focus on integrating NCD prevention and sector have seen increased use of preventive screen- management within PHC models calls for a change ing services for breast and cervical cancer, which are in focus from the disease to the person. For exam- critical for women’s health (Almeida et al. 2018). ple, in a 2018 study from Colombia, of all the pa- Community-based PHC has delivered strong tients who sought out health care for at least one results for older adults, including in reducing socio- chronic disease, roughly half had comorbidities economic and intergenerational health inequalities (Alfonso-Sierra et al. 2018). The presence of comor- (Araújo and Garcia 2024), in some middle- and bidities tends to increase the risk of mortality from high-income countries (Hou et al. 2023). Overall, NCDs. A person-centered approach can identify countries continue to develop and expand inno- and treat these illnesses more effectively, helping to vative community-based approaches to NCDs. In reduce costs while improving service delivery. Bangladesh, the 13,000 community clinics in rural Many of the recommended NCD clinical in- areas have recently incorporated chronic disease terventions are suitable for delivery in PHC settings screening as part of their functions. 48 CHAPTER 3 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y FIGURE 3.2   Prioritization of HLI-recommended NCD clinical interventions, by country income LIC LMIC UMIC IDU harm reduction measures $57 $71 $310 Aspirin for suspected ACS $38 $72 $470 Treatment of early-stage breast cancer $24 $110 $670 Epilepsy acute and chronic treatment $100 $180 $570 Depression chronic treatment $250 $230 $540 Heart failure chronic treatment $100 $120 $820 CVD primary prevention $250 $270 $840 Pulmonary rehabilitation $100 $250 $2300 Medical management of ACS $520 $710 $1700 ICER (as a proportion Management of appendicitis $350 $680 $2200 of GDP per capita) <0.1 Heart failure acute treatment $330 $440 $2500 0.1-0.5 Asthma/COPD acute treatment $800 $780 $3300 0.5-1.0 CVD secondary prevention $640 $930 $3400 1.0-2.3 Cervical cancer screening and treatment $300 $1300 $3400 >2.3 Treatment of early-stage colorectal cancer $520 $1400 $5600 Repair of gastrointestinal perforations $420 $1600 $8200 Alcohol use screening/brief intervention $2400 $2500 $6100 Repair of hernias $1700 $4600 $5800 Management of acute ventilatory failure $4400 $2800 $6100 Management of bowel obstruction $400 $1800 $13000 PCI for ACS $10000 $5100 $8800 Asthma/COPD chronic treatment $3500 $4700 $21000 Schizophrenia chronic treatment $1800 $4800 $24000 Bipolar disorder chronic treatment $5100 $7600 $30000 Diabetes screening and treatment $2900 $8100 $37000 Source: Adapted from Watkins et al. (2024). Note: ACS = acute coronary syndromes; COPD = chronic obstructive pulmonary disease; CVD = cardiovascular disease; GDP = gross domestic product; ICER = incremen- tal cost-effectiveness ratio; IDU = injecting drug use; LIC = low-income country; LMIC = lower-middle-income country; PCI = percutaneous coronary intervention; UMIC = upper-middle-income country; $ = U.S. dollar (Watkins et al. 2017). Certain surgical services are included as expansion of surgical capacity at district levels will also help, eventually, NCD control (e.g., for surgical treatment of common cancers) (Gelband et al. 2016). Address women’s needs and expand groups are more likely to have NCDs, including their opportunities  severe cases, and to die from them. As well, being female tends to intersect with other vulnerabilities Reducing NCD Gender Bias: Gender inequalities relevant to NCDs, including less education and few- in NCD incidence, prevalence and mortality, ac- er financial resources relative to men. Women and cess to care, and financial protection often co-exist girls also may experience lower quality of care due with other dimensions of vulnerability. In poorer to gender bias in the medical profession, such as countries, multiple generations who share a home women receiving fewer and later interventions for can also share caregiving responsibilities for young heart disease relative to men (Saadat et al. 2024). and old—although these responsibilities should PHC-centered NCD programs can be tailored to- not fall automatically to women, depriving them of ward the specific needs of women and other un- employment opportunities and potentially expos- derserved groups (Saadat et al. 2024; O’Keefe and ing them to greater mental and other health risks. Haldane 2024; Araújo and Garcia 2024). At the As numerous studies have shown, disadvantaged same time, there is a need for increased research to U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 3 49 better understand sex-specific differences in chron- or other support are important for improving the ic disease symptoms such as heart disease and their quality of care as well as enhancing the quality of life progression, which, where clearly identified, need of care providers. to be reflected in provider education and training. Finally, future migration patterns may be cru- Encouraging more female participation in clinical cial to match the demand for long-term care with trials is thus important. Addressing gender-based its available supply. The World Development Report barriers also necessitates reducing gaps due to so- 2023 recommended that countries with future de- cio-economic and cultural norms that continue to mographic profiles that could produce global health play a role in delays in seeking and receiving care and LTC workers (comparable to the role the Phil- (Altuwaijri et al. 2024). ippines plays today) need to prepare for such transi- Some countries have taken promising steps tions now (World Bank 2023e). Overall, close atten- on addressing gender-based gaps in health care, tion to the interaction of human development and but progress has been mixed. In one district in ru- gender across the life course will be crucial for de- ral Thailand, in recognition of women’s geograph- veloping effective and equitable policies for healthy ical barriers to cervical cancer screenings, a free longevity (de Silva and Santos 2024). mobile screening program was implemented. It targeted women aged 25–60 who had never been Priority NCD interventions: what impact screened. Within six years, the coverage of cervi- by 2050? cal cancer screenings rose from 20 to 70 percent of women in the district (NCD Alliance 2011). On the Table 3.2 presents an analysis of a set of high-prior- other hand, Sri Lanka’s Well Woman Clinics were ity measures. Overall, fully implementing this pack- launched in 1996 to screen peri-menopausal wom- age of interventions could avert, cumulatively, up to en for breast and cervical cancers, as well as other 150 million deaths (or 2.2 billion disability-adjusted chronic diseases. Despite progress, coverage levels life years, DALYs) by 2050, at an incremental cost had fallen short of goals, reaching only 50 percent of of US$1.3 trillion. This translates to US$9,300 per 35-year-old women as of 2019 due to a severe short- death averted and US$620 per DALY averted. The age of human resources, especially midwives, which budgetary implications of the high-priority pack- remains a key obstacle (UNFPA and Sri Lanka Min- age would be more manageable. The final column istry of Health 2019). in Table 3.2 shows the total cost (at 80 percent cov- Financial protection and health insurance erage) as a share of projected public spending on geared to people with a history of employment risks health in 2050. For the high-priority package, this neglecting women and people who have toiled with- share would range from a relatively affordable 6 per- out pay. One workaround would be to support the cent in upper-middle income countries to a much entire household with health insurance, not just a more challenging 20 percent in LICs. The cost of single breadwinner. For instance, Uruguay’s health the package is calculated based on the assumption care reform of 2007 expanded insurance coverage to that countries invest in the package constantly every not only retirees, but also the children and spouses year from 2023 to 2050. Given that programs take of the formally employed (Araújo and Garcia 2024). some years to reach its full operational capacity and Similarly, social health insurance is family-based in the cost to save a life increases over time (even at a countries such as Viet Nam and Albania. low of 0.9 percent per year based on HLI estimates), In addition, interventions that reduce implicit it is urgent that countries act now in prioritizing bias, such as social and behavior change communi- and adapting the interventions based on country cation (Box 3.2) and provider training—along with needs and capacity, and implementing them, so that bringing services closer to people through integrat- consequently with economies of scale, scaling up ed PHC with community services and expanding coverage for these interventions remains feasible. universal health coverage—can help address some While the investments involved would be consid- of the existing gender gaps. Policies and programs erable, these high-priority interventions could sub- that recognize women’s roles as caregivers and pro- stantially advance the healthy longevity agenda. vide them with platforms for standardized training 50 CHAPTER 3 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y TABLE 3.2   Estimated cost and impact of locally tailored, high-priority NCD package, by country income Total cost vs. Deaths averted DALYs averted Incremental cost Projected public Total cost projected public through 2050 through 2050 through 2050 (US$ Total cost in 2050 spending on health in per capita in spending on health Country income group (millions) (millions) billions) (US$ billions) 2050 (US$ billions) 2050 (US$) in 2050 Low 9 180 51 6 28 5 20% Lower-middle 82 1,300 470 57 720 13 8% Upper-middle 55 650 830 160 2,500 61 6% All LMICs 150 2,200 1,300 220 3,300 27 7% Source: Watkins et al. (2024). Note: DALYs = disability-adjusted life years; LMICs = low- and middle-income countries. Estimates are for a simulated linear scale-up to 80 percent coverage in all countries by the year 2050. Num- bers may not add up due to rounding. Of the total cost, based on an earlier analysis physical health infrastructure: over 6 million more using similar methodology for urban India (Wu nurses, 0.8 million more doctors, and 1.7 million et al. 2020), about 80 percent would be invested in additional health facilities (Table 3.4). This major health centers and first-level hospitals, while in- increase in health infrastructure is commensurate vestment in specialized and referral hospitals only with the larger population and needs for NCD pre- account for about 3 percent of the total cost (Table vention, treatment, and palliation, and would also 3.3). Importantly, the HLI investment would en- support the relevant other goals of the health system able appropriately large increases in key human and including UHC. TABLE 3.3   Estimated distribution of cost of NCD package, by level of health system Health system level Percentage of package cost (%) Health centers 59 First-level hospitals 21 Referral and specialized hospitals 3 Community and population-based interventions 17 Source: Wu et al. (2020). TABLE 3.4   Estimated increase in health care workers and facilities with HLI package Healthcare workers and Increase in density with HLI Density in 2050 for full Increase in number with HLI facilities density Country income level Current density package by 2050 implementation of HLI package package (thousands) Nurses and midwives Low 0.97 0.27 1.23 348 (per 1,000 population) Lower-middle 1.83 0.67 2.50 2848 Upper-middle 3.87 1.05 4.92 2972 All LMICs 2.62 0.74 3.35 6168 Physicians (per 1,000 Low 0.36 0.04 0.40 56 population) Lower-middle 0.79 0.09 0.88 394 Upper-middle 2.14 0.14 2.28 394 All LMICs 1.33 0.10 1.43 843 Health facilities (per Low 4.30 0.12 4.42 159 100,000 population) Lower-middle 3.18 0.5 3.72 2320 Upper-middle 3.39 0.10 3.49 296 All LMICs 3.51 0.21 3.72 1764 Source: Watkins et al. (2024). Note: HLI = Healthy Longevity Initiative; LMICs = low- and middle-income countries U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 3 51 Successful implementation of the intervention subject to regulations, social security benefits, and package could get LMICs about halfway toward taxation. While informal and casual work is often the lowest achievable mortality (essentially, only marked by insecurity, it can also provide useful unavoidable deaths (Chang et al. 2024)) by 2050. flexibility, particularly to women and grandparents, The package is not sufficient to meet the aspiration to balance paid work with unpaid care. A study of outlined in Chapter 1, of countries accelerating Egypt, Poland, Colombia, and Indonesia found that progress in reducing mortality in every age group informal care provision to older parents was asso- to match the performance of the top 20 percent of ciated with significantly reduced labor supply, ex- countries. This would require the following prog- cept among those in the informal sector (Gatti et al. ress from the mean achieved from 2000 to 2019 2024). Allowing formally employed workers more for each age group. At ages 50–69 years, the annual freedom to set their work schedules could help to declines in mortality would need to approximately retain more workers. double from -1.5 percent (the mean observed from But the most direct way to reap economic div- 2000–2019) to -3.4 percent (observed among the idends from healthier longevity, in countries with top fifth of countries over the same time period). primarily formal jobs, is to extend the working lives The comparable accelerations needed at other ages of mature workers who want to continue earning. are at ages 0–14: mean -2.7 percent to -7.1 percent The benefits for economies could be large. It is im- in the top fifth; ages 15–49: mean -2.0 percent to portant to counter the mistaken perception that -5.9 percent; and ages 70–84, mean -1.2 percent to older workers who extend their careers take jobs -2.6 percent. While ambitious, these accelerations away from the young. This “lump of labor fallacy” are possible, especially for the younger age groups. assumes that only a finite number of jobs exist, Moreover, they have occurred in the past when so that one person’s employment reduces others’ commitment has been paired with financing and chances of obtaining their own. On the contrary, efforts to create better, faster, cheaper tools. And as evidence from nearly all high-income countries Chapter 4 outlines, asking countries to keep up with suggests that when older adults choose to work lon- the best performers is politically salient. ger, overall economic activity expands and younger workers also tend to enjoy higher employment rates 3.3  Leverage social protection, jobs, and (Böheim and Nice 2019). long-term care for productive longer lives For instance, US analysis from 1977 to 2011 with dignity shows that increased employment of 55 to 64 year olds was associated with increased employment of As countries tackle NCDs and people live longer both 20 to 24 year olds and 25 to 54 year olds, and in good health, policies for social protection, jobs, even higher income for the middle group (Munnell and long-term care will be critical to seize the relat- and Walters 2019), with similar findings in Chi- ed opportunities. This report proposes operational na (Munnell and Wu 2013; Zhang 2012). Just as recommendations for governments in the following women’s increasing take-up of paid work has not areas: (i) labor market strategies to facilitate longer necessarily detracted from men’s employment, old- and more productive working lives; (ii) pensions to er workers are not perfect substitutes for younger protect poor and vulnerable older adults, particu- counterparts. They can and often do play comple- larly in the informal sector; and (iii) expanded LTC mentary roles, as the labor market is not zero-sum options for older adults in LMICs. As with health (de Silva and Santos 2024). In addition, growth in services, strategies must be designed to address the labor force is declining in many LMICs, and in women’s distinctive challenges and needs. some the total size of the working age population is declining, including in China and Thailand, where Harness labor market policies for productive it has been declining for a decade or more. This longer lives complementarity of older and younger workers will be higher where countries follow economic policies Priorities and strategies for productive longevity will that favor inclusive growth. differ depending on the formalization of a country’s The current research points to a range of pol- labor market—the extent to which employment is icy options that hold promise, though much of the 52 CHAPTER 3 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y available evidence still stems from high-income low-skilled workers. Singapore is a leading exam- countries (de Silva and Santos 2024). This analysis ple which publicly funds individual training ac- foregrounds: (i) supply-side measures that can low- counts during working life under its Skills Future er barriers and incentivize healthy older workers to program. Experience shows the importance of continue working; and (ii) demand-side measures simple design, adequate and predictable funding, that can make it easier and more profitable for em- effective information and guidance, and support ployers to retain or hire them. for high-quality training (OECD 2019b). Supply-side approaches include the following: • Strengthen family support services. Where af- fordable, subsidizing childcare or other forms of • Make retirement rules more flexible. Relaxing care for family members can increase labor mar- partial retirement rules is commonly proposed ket participation and earnings. Affordable child- to retain older workers. Studies show that flexi- care or long-term care for sick and elderly people ble working arrangements giving workers choice can partly relieve older workers (and women) and control are linked to better health and well- from informal care duties. In Rio de Janeiro, a being. Workers favor arrangements that would lottery was used to allocate access to daycare cen- allow them to adjust the timing and speed of ters for children aged 3 and below. Access was as- labor market exit according to their preferences, sociated with sustainable increases in household achieving a glide into retirement rather than a income, due to grandparents’ higher earnings, cliff (Henkens et al. 2021; Munnell and Walters along with greater hours worked and social secu- 2019; OECD 2017). However, some evidence rity contributions (Attanasio et al. 2017). suggests that labor regulations can inadvertently dampen the hiring of older workers or be used Demand-side measures include the following: as an alternative pathway for retrenchment or early retirement. This points to the importance • Encourage pay based on performance, not se- of considering overall policy impacts (Busch et niority. Regulatory reform, information, and al. 2021). incentives can help reduce gaps between mature workers’ earnings and productivity. While this • Reconfigure social insurance. Reforms to social can face strong resistance from those already in insurance that gradually raise retirement ages and a seniority-based wage system, it sharply reduces reduce work disincentives can contribute to ex- the economic pressure to push out older, high- tended working lives for formal-sector workers. er-paid workers. Public-sector reform can lead In OECD countries, raising the age to qualify for the way in softening seniority wage practices, full retirement benefits has resulted in higher em- moving toward performance-based pay. As part ployment rates among older workers. In Austria, of a broader effort to foster the hiring of mature this led to an increase in employment of nearly 10 workers, Singapore introduced grants to firms percentage points for the affected group (Riphahn that incorporated worker performance into their and Schrader 2021; Staubli and Zweimüller 2013). wage and personnel systems (OECD 2019c). However, reforms to existing social insurance and pension systems can be controversial. • Modulate employment protections to balance flexibility and security. Governments can re- • Foster lifelong learning. Countries use various form social contributions and employment pro- instruments to increase individual access to, and tection laws to lower costs while maintaining incentives for, lifelong learning. With individual adequate social protection. This can include re- learning schemes, people choose their own op- forming systems for severance pay and entitle- tions for skills development. Voucher-based sys- ments that increase automatically with tenure. tems can help stimulate training, especially for Workers should also be better protected from workers in non-traditional or less stable forms employment shocks, such as through stronger of employment. These have had mixed success, unemployment benefits, which remain under- however, especially for hard-to-serve groups like developed in many LMICs (International La- U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 3 53 bour Organization (ILO) 2021b). Reduction in costs. For workers in the formal sector, disability, social contributions (as is done for example for sickness, and work injury insurance can also play older workers in Malaysia and Singapore) would useful complementary roles. preferably be paired with increased financing of For countries that rely on social health insur- social protection through general taxation rather ance (SHI), an inherent risk is under-coverage of than payroll taxes, which reduce incentives for those outside the formal labor force—dispropor- employment (Packard et al. 2019). tionately poorer people, women, and those be- yond working age. A number of countries (e.g., • Adapt how work is done. Investments in or- Viet  Nam, Indonesia, and China) are addressing ganizational change or infrastructure can also this challenge through full or partial subsidization have productivity payoffs. Assistive technology, of SHI premiums for poor households, older popu- mixed-age teams, and other adjustments can help lations, and other vulnerable groups. Nonetheless, workers stay healthy and engaged. A much-cited even where people are covered by SHI or entitled example is the auto manufacturer BMW’s plant to health services under general revenue-financed in Germany. There, a small investment in ergo- systems, financial protection is often shallow due nomics and workstation rotation resulted in a 7 to limited service packages, co-payment require- percent productivity increase, exceeded quality ments, and/or informal payments. targets, and reduced absenteeism on a production With respect to pensions, in richer countries, line largely staffed by older workers (European contributory pension systems have played a crucial Bank for Reconstruction and Development 2020; role in providing financial protection for health care de Silva and Santos 2024). needs, with high pension coverage of older popula- tions and in most cases adequate benefits. However, Financial protection for inclusive in LMICs, the situation is very different. First, there healthy longevity is often only very partial coverage of contributory pension schemes among the working age popula- A key element of promoting healthy longevity is tion, reflecting high levels of labor market infor- ensuring affordable health services and ensuring mality (Figure 3.3 left panel). Second, the rate of financial protection for the population. This is par- increase in coverage has, in most countries, been ticularly the case for poorer countries and popula- modest in recent decades and lags the pace of pop- tions, and as people age and face higher health care ulation aging (Figure 3.3 right panel). Under-cover- needs. In LICs, 44 percent of health spending is out age has largely continued to mirror the (often high) of pocket, compared to 21 percent in high-income share of informal workers. countries (NCD Alliance and The George Institute An additional point is that contributory pen- for Global Health 2023). Disparities also exist with- sion coverage in developing countries is typically in countries, as poor households with older family regressive, with much higher coverage among those members spend a larger share of their income on with higher incomes (almost all in the formal sec- out-of-pocket health expenditures (Kočiš Krůti- tor), higher education, and longer life expectancies. lová et al. 2021), or delay or forego care (Hossen There is also gender bias, both through lower cov- and Westhues 2010; Lena et al. 2009). In this con- erage of women and lower adequacy of pensions text, there is an important role for health insur- where they are covered due to gender wage gaps ance, pensions, and social assistance systems in and interruptions of contributions across working providing financial protection to meet health care life due to child rearing and other domestic duties. 54 CHAPTER 3 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y FIGURE 3.3   Coverage of contributory pension systems strongly depends on income level (left) and coverage levels in LMICs have changed little over 15 years (right) Source: Palacios (2024). Note: LMICs = low- and middle-income countries; PPP = purchasing power parity. Left panel is for 2018. In India, the lowest education group has the constraints, myopia, and high discount rates of in- lowest life expectancy at age 15, due to higher death formal workers, plus the administrative challenges rates from NCDs during ages 30–69 years (Figure of collecting from them, are likely drivers of low 3.4). These lowest education groups also face poor fi- participation in such schemes (Hinz et al. 2013). nancial protection, with only 6 percent of those with no education likely to have a pension. This pattern • Introducing non-contributory social pensions of higher contributory pension coverage among the designed to ensure that those without contribu- better-off and often minimal coverage among low- tory pensions receive minimum financial support er-income groups is an almost universal phenome- at older ages (a similar financial protection effect non in developing countries (Demarco et al. 2024). can be achieved through general social assistance In response to persistent under-coverage of programs with broad coverage among older peo- contributory pension schemes, countries have di- ple) (Demarco et al. 2024). Over 80 developing versified their instruments for improving financial countries have introduced social pensions for protection at older ages, often in combination. This older people, with qualification ages typically includes the following: between 60 and 65 years old but as high as 90 (Demarco et al. 2024; Schwarz and Pallares-Mi- • Incentivizing voluntary old age savings from in- ralles 2024). There is, however, major variation formal workers through publicly financed match- across countries in the coverage of older people ing of contributions: so-called matching defined in these programs, ranging from universal cover- contribution schemes (with matches of between age for older populations (e.g., Bolivia, Botswana, 10 and 100 percent). However, coverage expan- Timor-Leste, and Georgia), to wide but non-uni- sion through this route has typically been limited, versal coverage (e.g., Philippines, Thailand, and though in a few notable cases it has been signifi- Bangladesh), to tightly means-tested coverage cant (e.g., China, Rwanda, and Korea). Liquidity (e.g., Malaysia and Egypt). U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 3 55 FIGURE 3.4   Survival rates and pension coverage, by education in India Source: Original calculations for this publication, based on data from IIPS and ICF (2021) and IIPS et al. (2020). • There is also major variation across countries in straints, is an important agenda as countries seek the adequacy of benefits, with benefits as low as 1 to strengthen financial protection against health percent of per capita GDP in India, but as high as and other shocks as people age. Taking health care 38 percent in Maldives. In many countries, social costs into account when calibrating the appropri- pension benefit levels (or general social assistance ate level of social pension benefits will be import- benefits that older people may access) are cur- ant—an approach already used in social assistance rently insufficient to provide significant financial programs that provide top-ups for people with protection for health care needs. disabilities and in countries like Thailand that gradually raise social pension benefits with age. • However, even relatively modest social pension benefits may make some difference to the health Another novel approach to improving financial pro- and wellbeing of older people. For example, in tection against health shocks at older ages is con- China, modest benefits from the informal sector sumption-based pensions, where people micro-save pension scheme led to improvements in self-re- as they consume at points of sale using digital pay- ported health, mobility, and self-care of bene- ments and related platforms. This approach is be- ficiaries, and women benefited more than men ing tried in Mexico, China, and Spain, for example (Nikolov and Adelman 2018). Reductions in con- (Hernández et al. 2017). The approach has appeal as sumption of junk food were also observed (Purun digital payments grow but to date is not widespread et al. 2023). Social pensions can also have positive and will need assessment of take-up, savings levels, spillovers on other family members, including effect on gender gaps, etc. improvements in child health and education in Achieving adequate financial protection Kenya, Brazil, South Africa, and Uganda (Arding- against health care costs remains an incomplete but ton et al. 2009; Moscona and Seck 2021; Kudrna vital agenda. Ensuring wide, adequate and equita- et al. 2022; Kudrna et al. 2024). Striking the right ble coverage of SHI or general-revenues financed balance between coverage and generosity of social health services is a priority, and budgetary subsidies pensions, while also taking account of fiscal con- will be vital to ensure inclusion of poor and vulner- 56 CHAPTER 3 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y able people. For pensions, while expansion of pen- mean replacing informal care, which is both ir- sions to informal workers and poorer populations replaceable and culturally appropriate in many is a dynamic area of policy development, there re- contexts. But adding to the portfolio of options is main large “missing middles” in most developing important for three main reasons. (i) Decent, af- countries between those covered by contributory fordable LTC is critical to the wellbeing and dig- schemes and those who receive targeted social pen- nity of many older adults, and informal care cannot sions for older people or social assistance. The most scale up to meet the full need. (ii) Enlarging the effective mix of pension and savings instruments to range of LTC options will free up many informal close the coverage gap, provide adequate financial caregivers, mostly women, to pursue paid employ- protection, and ensure fiscal sustainability will vary ment, community service, or other forms of skill according to the degree of labor market formality, development, improving their wellbeing and hu- inherited social protection systems, and other fac- man capital. (iii) Building up professionalized LTC tors. For countries with large informal sectors, real- systems in the many LMICs where they are non-ex- istically, social pensions will remain the most viable istent or weak will mean growing an important tool to expand coverage in the short term, and fiscal industry for the emerging “silver economy”—one space will be a key consideration. But this is unlike- with the capacity to provide large numbers of addi- ly to ensure adequate financial protection in fiscally tional jobs, especially for women. constrained environments. Ensuring adequacy over Research has identified four key policy di- the longer run would also require creative promo- rections for LMICs seeking to promote a range of tion of old-age savings using a mixture of financial context-appropriate, affordable, and compassionate incentives, behavioral nudges, and delivery system LTC solutions: improvements to encourage saving by informal sector workers. Layering of different instruments • Move to a balanced mix of care offerings. A and continued innovation will be needed for health mixed care system would work best in most financing and social protection systems to play an LMICs (Glinskaya et al. 2024), helping to bal- enhanced role in providing poor and vulnerable ance needs, dignity, and costs. Day care centers, populations with adequate financial protection for home and community services, and tele-assis- their health care needs as they age. tance could all form part of the mix. Sources of care are similarly varied, including faith-based Expand and diversify long-term care options for organizations, skilled volunteers, neighbors, and older adults who need care older adults themselves. Nonprofit organizations play an especially important role in LMICs (Gov- Even with gains in healthy longevity, many older indaraj and Gopalan 2024). Crucially, enhancing adults will ultimately face limitations in their func- people’s ability to age in their own homes will tional abilities, necessitating some form of LTC. benefit their mental and physical health, and a Around the world, cultural (and sometimes legal) range of creative and context-appropriate services norms often valorize family care, largely by wom- have been developed in the movement away from en, as the main way to care for older people. But institutionalization (Araújo and Garcia 2024). In changing family structures, migration, and women’s an example of formal support for informal care, increasing take-up of paid work mean that more Myanmar lends money for home adaptations, en- and more, traditional models of informal care in ex- couraging the construction of accessory dwelling tended families cannot be the only options. units for older relatives (Williamson 2015). Yet the formal care systems that would com- plement traditional models are highly limited and • Engage the private sector and strengthen gov- fragmented in nearly all LMICs (Glinskaya et al. ernment stewardship. The private sector will 2024). This can impede women’s entry into labor have a key role in building LTC provision in most markets or compel them to drop out of work; or LMICs. Most countries have opted to contract it can require them to shoulder massive loads if out LTC services to private nonprofit or for-profit they juggle paid work and care. In a vicious cycle organizations. In China, where private residen- of poor health, this overload can compromise their tial care facilities have mushroomed in the past health and wellbeing. 20 years, the government has actively encouraged Expanding LTC options in LMICs does not the private sector through construction subsi- U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 3 57 dies, tax breaks, and other policies (Feng et al. (WHO 2020a). Support can also include in-kind 2020; Feng et al. 2012). Globally, it is essential services, such as respite care, leave from work, to strengthen government stewardship and reg- and counseling. There is debate about whether to ulatory capacity to set ground rules and ensure compensate women for the typically unpaid care service quality. One worrying trend, as seen with they provide to family members. Doing so pro- some US nursing homes, is privatization and vides financial relief and helps to formalize wom- speculation for profiteering in ways that increase en’s often-unrecognized work, but also is costly costs, shrink access, erode quality, and impose a and runs the risk of entrenching unequal gender greater oversight burden on families rather than norms (Araújo and Garcia 2024). governments (Glinskaya et al. 2024). In LMICs, regulatory oversight is often lacking and of low 3.4  Leverage the power of data for priority. Recent work has clarified strategies for healthy longevity LMICs to progressively build LTC regulatory ca- pacity (Hou et al. 2023). Strengthening country measurement, monitoring and evaluation, and data capacities will be import- • Systematize LTC financing. The lack of orga- ant to track the impact of life-course health invest- nized LTC financing often dissuades firms from ments and continuously improve healthy longevity entering LMIC markets (Glinskaya et al. 2024). outcomes. In many settings where monitoring ca- This leads to access gaps, inequalities, and high pacities and statistical systems are in early stages, out-of-pocket payments (Scheil-Adlung 2015). this effort will include expanding vital registration Countries need a systematic approach to financ- and cause-of-death data through a civil registration ing, ideally working gradually toward a broad- and vital statistics system and ensuring that such based social insurance model (Glinskaya et al. data are openly available in order to encourage ac- 2024). It would make sense for public funds to countability (WHO 2021e). There should be partic- first finance a safety net for disadvantaged old- ular attention to gathering data about women, who er people (Glinskaya et al. 2024), then gradually are often not counted officially, especially in LICs or extend any additional resources to other older where more rigid gender norms persist; these gen- adults needing daily assistance. On the supply dered measurement gaps can affect policy-making, side, public financing for a LTC system often in- targeting, and health outcomes. volves supporting providers through subsidies. It is urgent to strengthen countries’ surveil- Many countries face great challenges in contain- lance and measurement capacities around NCDs ing public expenditures because they initially and healthy longevity. A recent study from India funded institutional care. On the demand side, found that 11 percent of the sample had diabetes; it subsidies or vouchers to individuals are effective then extrapolated from this to estimate that a stag- instruments for increasing the purchasing ca- gering 101 million people in India have diabetes. pacity of the poor and those with greater needs, This is significantly higher than previous figures, including women. They are also compatible with pointing to the need for improved monitoring of promoting aging in place, for example, if vouch- NCDs (Anjana et al. 2023) ers can be redeemed for home- and communi- Recent research and policy dialogue suggest ty-based care (Glinskaya et al. 2024). broad agreement among experts on basic princi- ples for NCD measurement in countries. Epidemi- • Build the LTC workforce and support fam- ological studies of major NCDs that provide local ily caregivers. Skilled human resources are a quantification of existing and new risk factors, along bottleneck for LTC services in many countries with levels and predictors of death and disability, are (Glinskaya et al. 2024; Araújo and Garcia 2024), needed in many countries. NCD data systems should and LTC jobs struggle to attract qualified work- be owned and led by countries, and there should be ers. Women are more likely to work in the care less reliance on estimates based on modeling rath- sector, and thus are more exposed to its hall- er than actual data. An important goal is to nurture marks: low wages, work overload, poor career NCD measurement systems that are fully integrated prospects, and stress (Araújo and Garcia 2024). with national statistical systems (Alleyne et al. 2024). Training to increase the capacity of informal These same principles apply to monitoring and eval- and community caregivers should be a priority uation systems, which similarly rely on good data. 58 CHAPTER 3 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y As part of this scientific innovation, open data to support country stakeholders in a wide range of should become standard for twenty-first-century settings in producing, using, and institutionalizing development. Country statistical systems and glob- their own healthy longevity dashboards, adapted to al development cooperation should adopt open data their unique epidemiological contexts and data in- as the default option for analysis and evaluation. frastructure (Haldane et al. 2024; Wu and Jha 2023). The World Bank and partners in the UN Statistical The three pilot countries are Colombia, India, Division, WHO, and other agencies could play a and Sierra Leone (with examples for India and Si- critical role in helping countries improve the sys- erra Leone in Box 3.3 and Figure 3.4). These coun- tems and effectiveness of collection and sharing of tries present a wide diversity in income, epidemiol- essential data, while also ensuring privacy. ogy, demographics, health systems, and statistical To realize the aspirations of countries accel- institutional capacity. erating performance in reducing premature mor- Building and making effective use of dash- tality to the top fifth of countries, scaling up core boards requires use of available relevant capacity. measurement of healthy longevity performance and This entails dedicated budgets and institutional ar- related interventions is essential. This requires a rangements, including strong local ownership and balance between internationally comparable indi- commitment, to maintain them and integrate them cators to maximize learning and country-specific into program management and public information. measurement to meet local knowledge needs. Keeping them as simple as possible can help to en- sure their continued use. Data tools tailored to country conditions: At the same time, efforts to create and sustain healthy longevity dashboards dashboards are an opportunity to promote robust and reliable statistical independence at a national As an important part of strengthening measure- level. Ultimately, a healthy longevity dashboard rep- ment capacity and using it effectively, countries resents a broader commitment to the health, pro- should assemble relevant and actionable data on ductivity, and wellbeing goals that underpin the in- healthy longevity in a flexible, user-friendly in- dicators. It is an opportunity to use data for targeted terface, which provides policy-makers, planners, interventions and to promote strategic approaches managers, and the public with key information on to investing in people across the life course. life-course health and human capital (Haldane et al. Overall, this chapter has shown that there is ex- 2024). For doing so, performance dashboards are tensive evidence of an effective portfolio of options a promising instrument already widely used in the for improving health at all ages, spanning the fol- private sector. Dashboards are data visualization lowing: population-level health spending; NCD in- tools that organize indicators in a single interface, terventions at the clinical and community levels; and allowing users to track performance across dimen- social protection, care, and labor policies. Drawing sions that they select. In the health field, institutions on this evidence to develop a context-appropriate are increasingly aggregating indicators through mix of options will help countries to prepare for the dashboards to monitor progress toward health demographic and epidemiological shifts associat- goals in near-real time. Such dashboards typically ed with the future needs of a large working-age or leverage vital statistics, demographic and census aging population. A healthy longevity dashboard is data, and data on program management outcomes one tool that can support rapid scale-up and assess- across a range of diseases. Dashboards have also ment of life-course interventions. Yet even the most been used to inform health and wellbeing projects sophisticated tools will have limited effect without centered around older people (WHO 2021a). sufficient financing. The next chapter explores strat- As part of the HLI, World Bank teams have egies for financing the ambitious NCD and healthy worked with national counterparts in three pilot longevity agendas set out in this report—strategies countries to design and test a methodological frame- that will ultimately pay for themselves in terms of work for country-specific healthy longevity dash- human capital gains and savings on health care costs. boards based on a life-course approach. The goal is U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 3 59 BOX 3.3 Healthy longevity dashboards for India and Sierra Leone To develop the healthy longevity dashboards for India and Sierra Leone, World Bank researchers reviewed health, economic, and sociodemographic data from international institutions for comparability of data across countries. From the global review, the researchers gathered a list of 37 indicators of the accumulation, deployment, and depletion of human capital, with a focus on NCDs. For each indicator in the dashboard, each country was assigned a score indicating its performance relative to all countries in the same income stratum. These scores are visualized in a speedometer (Figure 3.5) as very poor (score of 0 – <25), poor (25 – <50), good (50 – <75), and very good (≥75). This dashboard can be used by LMICs where local good-quality data are sparse, to monitor human capital and guide investments in NCDs and human capital. FIGURE 3.5   Sample HLI dashboards for India and Sierra Leone Source: WHO (2020c); World Bank (2021b); OECD (2021); ILO (2021a); UNESCO Institute of Statistics (2021). 60 CHAPTER 4 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Financing for healthy longevity: Country leadership and key supporting roles for development partners Meeting the healthy longevity agenda and reducing NCDs is ambitious. The necessary financing will be consid- erable requiring country-led investments and development finance, with strong attention to global public goods. Such investments will deliver strong returns on investment, contributing to human capital while reducing poverty. This chapter emphasizes the need, and potential at least 150 million deaths across all LMICs would ways, to marshal funding domestically, paying at- be avoided by 2050, and about 8 million in 2050 tention to political economy concerns. It also ad- alone. Analysis of the economic value of avoidable dresses the complementary support that external mortality suggests that this would correspond to actors should provide in order to meet shared goals. over US$3.2 trillion in economic value just in 2050 Strong country ownership is essential for successful, (Chang et al. 2024). Thus, the benefit-cost ratio is context-specific healthy longevity agendas. And it is very favorable, at about 16 to 1 overall for all LMICs. at the country level where the bulk of the financing Countries need to customize interventions to vari- will need to be mobilized. While substantial invest- ous context and over time. The overall cost-benefit ments are needed, these investments more than pay ratio of the HLI is sufficiently high to suggest that for themselves in gains in health, productivity, in- various combinations that include many of the HLI come and gender equity, and wellbeing. interventions should be attractive investments. The high-priority package will be reasonably 4.1  Country-led financing for healthy affordable over time, at 8 percent and 6 percent of longevity agendas projected public expenditures on health in 2050, for lower-middle income countries and upper-middle The recommended high-priority package across income countries respectively. For LICs, even in LMICs entails a steady increase in spending between 2050, the package would cost a sizable 20 percent 2020 and 2050, rising to US$220 billion in 2050. But of health expenditure. Thus, LICs would clearly during this period, incomes and public expenditure need external financial support and at concession- on health will also rise. Between 2020 and 2050, al (ODA) terms. In MICs, external assistance on LMIC GDP is projected to increase from US$31 tril- non-concessional terms could play an important lion to US$123 trillion, and public health expenditure role in accelerating expenditures and policy actions, would also increase. Drawing on assumptions used as it has in other sectors. That external support by the Commission on Investing in Health (Watkins could be significant, including in terms of political et al. 2024; Watkins et al. 2018), the high-priority economy, to counter the implication that all hard- package would constitute an average of about 0.2 pressed countries need to do is to put off rapid scal- percent of GDP in 2050. These projections of future ing up for a number of years until they have a lot costs are necessarily approximate. To the extent that more fiscal space. new technologies or other GPGs reduce unit costs, The HLI agenda outlines interventions that can total costs would decline. But to the extent that coun- begin quickly to major effect. Indeed, its analyses tries add other interventions, based on their specific suggests that to reduce future costs, countries should circumstances, to their NCD programs or run into accelerate progress in the life-course interventions serious implementation issues, they would increase. with the goal of matching the progress in reducing These costs must be compared to the bene- age-specific death rates by the top fifth of countries. fits. With the high-priority package, cumulatively, The combination of greater spending on NCDs U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 4 61 paired with global public good investments can also vices to the list of covered interventions as national potentially lead to cheaper future interventions, as incomes rise (Gelband et al. 2016). has occurred with child health (Wu et al. 2024). A pro-poor focus also has implications for pri- Realizing the full benefits of the HLI agenda, orities in health institutions. The recommended in- including financing additional interventions as terventions would particularly strengthen primary they become affordable, takes time. At the moment, health care and first referral hospitals, as in urban most LICs and lower-middle income countries are India and Bangladesh (Wu et al. 2020). In gener- spending relatively small amounts of their budgets al, lower-level institutions are more cost-effective on health (Watkins et al. 2024). For instance, with and reach more people, particularly the poor and the 2001 Abuja Declaration, African Union coun- disadvantaged, than higher-level facilities (World tries pledged to devote at least 15 percent of their Bank 1993). Mohalla clinics—neighborhood facil- annual budgets to the health sector. Yet a sample ities serving poor and medium-income people in of Sub-Saharan African countries has shown a far India—are an example (Tiwari 2020). lower figure: just 7 percent (Piatti et al. 2022). The Adopting the healthy longevity agenda offers neglect of NCD financing within current too-low an important way to generate at least partially off- health budgets reinforces the argument for increas- setting additional budgetary resources, with the ing the share of health in overall budgets. concurrent benefit of improving health. Specifically, Yet there are also successes to build upon: the excise taxes on tobacco, alcohol, and SSBs not only Millennium Development Goals (MDGs) triggered have health benefits but also have a highly proven large increases in expenditures across LMICs, with record of raising funds that can be used for NCD in- huge gains. For example, India spent roughly US$30 terventions, overall health, and other pro-poor pol- billion on its National Health Mission, which over 15 icy measures in countries at all income levels. For years saved the lives of about 1 million children un- example, revenues from the Philippines’ pioneering der the age of 5 (Million Death Study Collaborators cigarette excise tax enabled the country to triple the 2017). Since children who died would have lost at least coverage of poor families under its public health in- 60 to 70 years of good life, this translates to less than surance scheme (Nugent et al. 2018). US$500 per life year saved—a clearly cost-effective Despite clear evidence of their effectiveness, to- investment (Jha and Laxminarayan 2009). The addi- bacco taxes remain, as indicated earlier, underused. tional financing needed for life-course health should WHO recommends that tobacco taxes make up at be in addition to the investment in the critical ongo- least 75 percent of the retail price, yet few countries ing work to save maternal and children’s lives, while meet this threshold (WHO 2017c). Globally, 90 drawing on relevant lessons learned from that work. percent of people live in countries where tobacco Given scarce resources, countries will need taxes are lower than the recommended level (WHO to set priorities and phase in increased resources 2017c). In the medium and longer term, the signifi- to support healthy longevity, building a broad and cant positive impact of the healthy longevity agen- deep base of support to assure sustainability. The da on productivity, through the human capital, ex- principle for doing so is progressive universalism, tended working life, and other channels described which aims at universal coverage of a set of basic in Chapter 2, should contribute to generating addi- services, prioritizing poor and marginalized groups, tional tax resources. and adding more publicly financed or provided ser- 62 CHAPTER 4 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y BOX 4.1 Small island developing states Small island developing states (SIDS) face complex existential health and development threats. The interventions and policies set out in this report have special and immediate significance for the 62 million people living in these 39 states. The intersec- tion of economic, health system, and environmental vulnerabilities common to many SIDS has created an NCD crisis. In SIDS, 52 percent of people with NCDs die prematurely—among the highest figures globally. SIDS have championed a collective voice and collaborative approach to address these multi-faceted and intersecting crises. The growing burden of NCDs in SIDS is driven by a high prevalence of risk factors for developing one or more of these con- ditions. SIDS are particularly affected by commercial determinants, trade agreements, policies, and ecological situations that influence price, availability, and promotion of food, cigarettes, and alcohol (Food and Agriculture Organization, and Caribbean Development Bank 2019). As growing numbers of people living in SIDS require care to prevent or manage NCDs, health systems continue to be under-financed, under-resourced, and ultimately unable to provide models of care that support pre- vention, diagnosis, and person-centered management of NCDs in communities. Given the immediate and catastrophic threat of climate change, the very existence of SIDS is threatened. SIDS experience the highest relative losses from climate-related disasters each year (WHO 2021c). The existential threat of catastrophic disaster shapes all other challenges, including those driving the NCD crisis. In response, SIDS have come together and committed to reducing premature mortality from NCDs, determining cost-effec- tive NCD interventions, and promoting health system strengthening for universal health coverage (WHO 2021d). This work includes developing and advocating for a multi-dimensional vulnerability index to better characterize and capture the unique vulnerabilities of SIDS and guide programmatic support (United Nations 2021). Achieving these goals calls for additional and sustainable funding to strengthen capacities in SIDS and support them to face these existential threats today and in the future. The HLI agenda presents complementary actions to these ongoing efforts to improve health and wellbeing in SIDS. The political economy of going from ideas to turned on like a light switch. It will take some years action at the country level after launching programs for them to have the finan- cial and institutional capacity—and needed political The extent to which the NCD and healthy longevi- support—for adequate national coverage and reduc- ty frameworks outlined here will lead to action and tion of unit costs through economies of scale. Large- implementation depends on the mobilization of scale programs will also be able to benefit from, and whole-of-society political support. It also depends to help drive, cost-reducing GPGs as well as economies some extent on external financial and other support. of scale, thus helping “bend the cost curve down- This report supplies evidence on the health and well- ward”— lowering future costs of reducing adult being impacts of a life-course approach. The synthe- mortality, as has occurred with child survival. Gov- sis of evidence on the effects on death, disease, and ernments should look favorably on investments in related impoverishment and inability to afford treat- life-course health that will yield such benefits and ment is particularly important to health ministries compare these costs to the costs of delaying action. and national and global health communities. Other investments will, however, take time to The large fiscal outlays might make country set up appropriate high-quality and more expensive leaders hesitate. In fact, the time for action is now. services. In the case of cancer, good-quality pathol- Going beyond the economic benefits described ogy, diagnostics, treatment, safe surgery, radiothera- above, delaying NCD-related interventions will re- py, and chemotherapy have all been identified as key sult in increased NCD deaths, disease, suffering, and elements of scaling up national cancer control pro- worsening of poverty. For example, avoidable mor- grams (Gelband et al. 2016), which requires more tality from cardiovascular disease alone constituted financial outlays and a longer-frame to implement. 10 percent of global annual income in 2019, and this Civil society can play a major role in urging will rise to 14 percent by 2050. This underscores the political support. This includes coalitions of NGOs urgency of acting early on cardiovascular disease like the NCD Alliance, bringing in the many patient (Verguet et al. 2024). And NCD programs cannot be groups and the billions of people living with NCDs. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 4 63 But it also encompasses foundations, researchers and partners have allocated less than 2 percent of their policy analysts, the media, civil society organizations development assistance for health to NCDs; and working with vulnerable groups, and the population there have been even smaller proportions in bilat- at large. They all contribute to informed debate and eral financing, amounting, for example, to only 0.48 policy change. For example, in Brazil, Kyrgyzstan percent of US bilateral health funding in 2019 (Jai- and Pakistan have expanded access to insulin at af- lobaeva et al. 2021). This is far from sufficient given fordable prices, drawing upon public advocacy and the need and disease burden. Yet other global health large-scale procurement (Lepeska et al. 2021) agendas, notably the MDGs, have demonstrated the The strong cost-effectiveness of the priority inspiring progress that can be achieved with suffi- NCD interventions and the societal benefits of im- cient global mobilization of resources and effort. proved health make compelling arguments for efforts Development partners can best contribute to to mobilize whole-of-government support for tack- combating NCDs and promoting healthy longevi- ling NCDs. In almost all countries, this will require ty—and in so doing, contribute to equitable growth agreement and joint action between health minis- and wellbeing and to accelerating lagging progress on tries, finance ministries, and political leadership. Ul- the SDGs—through dual lines of action: (i) investing timately, investment in life-course health is likely to in and fostering the uptake of relevant GPGs; and (ii) pay political dividends as well as economic ones. But directly supporting country action and programs. the reality is that proposals that are viewed as affect- Terms will vary according to the source of fi- ing health rarely attract support of other parts of gov- nance and the income and debt servicing capacity ernment. This reemphasizes the role of civil society of a given country. External financing from multi- as a key part of a whole-of-society coalition, to gen- lateral and bilateral development partners in many erate ultimate approval by the head of government or cases also helps government and other domestic by central decision-making authorities “champions” in their efforts to scale up programs National NCD strategies will also involve direct and build support for increased domestic financing. action by other ministries. For instance, while the Private philanthropies are also important part- Chilean Ministry of Health spent the largest sums ners (Jailobaeva et al. 2021). Foundations can play on NCD activities in 2013, the Ministries of Sports, a strong role at the country level through direct Environment, Social Development, Interior and financing and through advocacy to help mobilize Public Safety, and National Assets also provided political support. They, along with bilateral agen- funds for health (Govindaraj and Gopalan 2024). cies, can also play an important role on GPGs for Regional and other collective action can also help NCDs, as they have for infectious diseases. Signifi- to mobilize country-level support as well as to pool cant support may also come from local NGOs, using knowledge. For example, some highly NCD-affect- their established means of resource mobilization, ed countries, notably small island developing states and, particularly in middle-income countries, from (SIDS), have gone further by joining forces to tackle domestic foundations. Support from local NGOs common challenges (Box 4.1). and foundations is also important for the advocacy needed to secure significant increases in public fi- 4.2  Support from external partners nancing for NCDs and the healthy longevity agenda. Overall, a whole-of-society approach—which Increased assistance from development partners will includes relevant coalitions from civil society, aca- also be vital to make progress on ambitious NCD demia, and the private sector—can increase buy-in and healthy longevity agendas compatible with SDG for healthy longevity strategies. Indeed, leveraging target 3.4: to reduce premature mortality from NCDs private-sector investment and know-how for healthy by one-third between 2016 and 2030. The slow longevity will be important in countries at all income progress thus far against this target, even before the levels. The private sector can mobilize substantial ad- COVID pandemic roiled health systems, suggests ditional funding and related capacity to supplement that countries and development partners continue to public sector support. In addition, it can, in some cas- under-invest in NCDs and life-course health. es, provide technological innovation and supply chain The majority of financing for NCD programs efficiencies (Watkins et al. 2024). These advantages and other aspects of healthy longevity will need to may be leveraged to foster public-private partner- come primarily from domestic resources. Howev- ships, engage industry constructively, and secure in- er, external financing can help, and in low-income creased financing and service provision in NCD and countries it is indispensable. As of now, development care-related markets (Govindaraj and Gopalan 2024). 64 CHAPTER 4 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y However, private-sector involvement requires stances—incentives that are in tension with pub- strong government stewardship. Account needs to lic health interests. Lawsuits have been among the be taken of diverging interests and of incentives strategies used to counter the influence of the tobac- for corruption and rent-seeking (Govindaraj and co and SSB industries (Gilmore et al. 2023). Gopalan 2024). Analysis of the commercial deter- Governments should exercise careful and effec- minants of health points out that many actors in tive oversight concerning private-sector involve- the tobacco, alcohol, and ultra-processed food in- ment by setting clear policy goals, establishing clear dustries (as well as fossil fuels) have incentives to regulatory frameworks, and ensuring transparent encourage consumption of health-damaging sub- reporting and benefit sharing. BOX 4.2 The relevance of multilateral development financing to healthy longevity Annual official development assistance (OECD 2022b), excluding refugee funding and support to Ukraine, averaged US$166 billion from 2019 to 2022. While this is a notable increase from a decade earlier (Prizzon and Getzel 2023), it is widely recog- nized as far from adequate to meet ongoing major global development priorities around education, health, poverty reduction, and other sectors. Moreover, additional resources will be needed to tackle the added challenges of climate change, antimicro- bial resistance, pandemic threats, and unhealthy aging and NCD burdens among other global challenges. Multilateral development banks (MDBs) are well suited to assist both low- and middle-income countries with analysis and whole-of-government, multisectoral approaches required for HLI investments (Linn 2022). MDBs can also leverage appropri- ate private-sector investment, suited to the range of products and services needed to tackle NCDs (Govindaraj and Gopalan 2023). Finally, global public goods that support cross-country direct investments can also benefit from MDB financing (Ahlu- walia et al. 2016). The World Bank is expanding its overall financing both for countries and for global public goods (Banga 2023; World Bank 2023b). It has begun engaging with countries to support their healthy longevity agendas and will continue to leverage its knowledge and financing to support the implementation of scalable solutions through its existing instruments: investment projects, development policy operations, and results-based operations. The World Bank support for healthy longevity programs can also make use of its ability to support multi-country operations. For example, to respond to the COVID pandemic, the World Bank’s multi-country Regional Disease Surveillance Systems En- hancement program, which focuses on multi-country surveillance in Western Africa, was well-placed to help its 16 member countries pivot to launch their COVID responses (World Bank 2020). The Bank has also supported 12 African countries under the Sahel Women’s Empowerment and Demographic Dividend Project since 2015. This project aims to: (i) increase women and adolescent girls’ empowerment and their access to quality reproductive, child, and maternal health services in selected areas of the participating countries; and (ii) improve regional knowledge generation and sharing (World Bank 2023d, 2019, 2023a). More recently, the World Bank has begun assisting three countries in Latin America to implement the HLI, starting with analysis of avoidable mortality (Araújo and Garcia 2023). This will lead to collaborative country reports analyzing demographic trends and the NCD burden and to proposing a costed program of cost-effective and evidence-based interventions to improve health, poverty, and gender outcomes. Based on the results of this analysis and dialogue, countries may decide whether to seek World Bank or other financing. Finally, the HLI agenda would benefit from partnership with other key MDBs, such as the Asian Development Bank and the Inter-American Development Bank, which are active in healthy longevity (Asian Development Bank 2022; Inter-American Development Bank 2023), and with the WHO and with bilateral donors and foundations, particularly on global public goods. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 4 65 4.3  Navigating the intersections of bon footprints. For example, enabling access to healthy longevity, climate change, and locally produced, unprocessed, largely plant-based pandemic vulnerability diets not only reduces carbon emissions, but may also reduce vascular disease and cancer (McCurdy The major new challenges of demographic transfor- 2022; WHO 2022c). mations, climate change, and vulnerability to pan- Importantly, the HLI agenda adopts a timeline demics co-exist. The same countries and the poorest to 2050, consistent with long-term climate change within each country are at greatest risk for each of horizons. Both agendas involve long-term planning these three global phenomena. The HLI agenda and and adaptation. However, both agendas also present its interventions provide the opportunity to build cogent arguments for the urgency of immediate ac- synergies with efforts to combat climate change and tion. They both include rethinking longer-term de- reduce pandemic vulnerability. velopment assistance and the role of GPGs. More- over, they draw upon behavioral economics and Links of healthy longevity to climate change regulatory approaches that can change individual behavior. Third, both highly cost-effective tobacco Changing climate is one of the biggest health-sec- taxes and carbon taxes are underused, with strong tor threats, and an existential threat to survival of efforts by the tobacco and fossil fuel industries to human life (WHO 2023b). Burning fossil fuels con- sway public and political opinion. Inefficient or tributes to over 75 percent of global greenhouse gas poorly targeted fossil fuel subsidies constituted emissions and 90 percent of all carbon dioxide emis- US$7 trillion, or 7 percent of global GDP, in 2022 sions, which lead to global warming and climate and are expected to increase further by 2025 (In- change (United Nations 2023). Climate change not ternational Monetary Fund 2022). Tackling the enor- only leads to biodiversity loss and extreme weather mous, vested interests of the industries requires patterns, it also has severe impacts on human health political action and careful tactics to change gov- and exacerbates poverty (Hallegatte et al. 2016). It ernment policies. Eventual removal of harmful sub- is already having significant impacts on health sys- sidies for fossil fuels can free up major amounts of tems through increased risk of natural disasters, wa- government budgets that can be used for far more ter- and vector-borne diseases, heat stress, and other productive and sustainable goals (WHO 2023e). disruptions. This is especially true amongst the most vulnerable populations of developing countries, such Links of healthy longevity to pandemic as individuals in small island nations (Box 4.1). Cli- vulnerability mate change could result in 78 million more people facing hunger by 2050 (Sulser et al. 2021) through The COVID pandemic brought healthy longevity lower crop yields. Increases in heat-related mortality challenges into focus. The pandemic revealed the and morbidity are already occurring, and future in- vulnerability of older populations, health systems, creases in the risk of accidents and impacts from ex- and economies in all countries. The pandemic caused treme weather events (floods, fires, and storms) can about 16–17 million excess deaths, or an average of be expected. Related changes in the seasonal distri- 12,000 deaths per week over the last 2.5 years—many bution of some allergenic pollen species, and virus, of these among people over the age of 70. NCD kill- pest, and disease distribution are expected as well as ers exact even more deaths: globally, cardiovascular possible changes in air quality and ozone. disease and cancer account for 100,000 and 80,000 Given the strong overlap geographically of deaths a week, respectively, just for people aged 30–69. vulnerable regions for climate change and regions The COVID pandemic was also an exam- where people live and where NCDs are increas- ple of the direct link between communicable and ingly common, the healthy longevity and climate Non-communicable diseases. COVID mortality change agendas are deeply connected (Figure 4.1). was notably higher in those with NCDs. In the UK, For example, interventions to mitigate heat stress people with three or more diseases or risk factors require strengthening health care facilities and had nearly 12 times the mortality rate of the over- delivery platforms to cope with changing burdens all population (Banerjee et al. 2020). In Cameroon, and NCDs (Watts et al. 2015), which the HLI in- diabetic adults had nearly a threefold higher risk of vestments would expand. Also, in some cases, the death from COVID if hospitalized (Nzinnou-Mbia- same measures could contribute to reducing car- ketcha et al. 2023). In LMICs, the presence of chron- 66 CHAPTER 4 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y ic diseases was particularly important in increasing epidemiological surveillance and data systems work COVID-related deaths among younger adults. In best not when designed just for emergencies but also Mexico, about 40–50 percent of COVID-related for routine diseases, including nationwide studies to deaths among adults below the age of 60 were due to monitor deaths and detect outbreaks, as is now in chronic diseases (Reyes-Sanchez et al. 2022). More place in Sierra Leone (Nolen 2022). Recognizing that recently, long COVID has emerged as a global, but the global pandemic ended outside of Africa largely as yet poorly understood, phenomenon that may due to vaccination, a key lesson from COVID is to lead to prolonged increases in NCD morbidity, in- adopt an “always-on” global adult vaccination pro- cluding poor mental health. Finally, the pandemic gram bundling routine vaccines with new vaccines disrupted NCD health services in three-quarters of and manufacturing capacity (Berry et al. 2022). A countries surveyed by the WHO (WHO 2020d). cost-effective global adult vaccination program that The catastrophic pandemic yielded some pos- builds upon the hugely successful childhood vac- itive lessons for resilience, relevant to both the cli- cination programs will be far better placed to pro- mate change and healthy longevity agendas. For vide surge capacity to vaccinate in response to new instance, it mobilized the political will for unpar- pathogens (Angus et al. 2022). Since countries have alleled global scientific cooperation, resulting in learned how to get adult populations vaccinated at vaccines and other health tools being developed at scale, it may be possible to scale up such innovations unprecedented speed. That global scientific coop- rapidly within a few years as new technologies be- eration is now much needed for GPGs to increase come available. This could be linked to novel plat- effectiveness and reduce costs of addressing NCDs. forms to reach adults with NCD-related services. A recent analysis (Madhav et al. 2023) suggests Finally, demographic change and the need for that another pandemic (killing at least 10 million peo- healthy longevity, climate change, and pandemic ple worldwide) is far more probable than assumed, vulnerability are all global challenges, and thus re- and indeed climate change may well accelerate the quire attention to GPGs and other collective glob- interaction of lethal pathogens with human popu- al action. There is a need for more effort to share lations. Reducing pandemic consequences requires learning and good practice on the development tackling NCDs, since future respiratory pathogens and scaling up use of GPGs across these, and other, are, like SARS-CoV-2, likely to raise death rates in global challenges. The next section outlines possible those with chronic diseases. In addition, improved approaches for GPGs relevant to healthy longevity. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 4 67 FIGURE 4.1.  Intersections of demographic change, NCDs, climate change, and pandemics 4.4  Accelerated development and community-based LTC, social protection, lifelong uptake of global public goods for learning, and job training. healthy longevity A key strength of GPGs is bringing down costs along with providing additional benefits. The fu- This report refers to global public goods (GPGs) as ture costs of the interventions recommended in this goods or services with global or regional benefits report would fall with the deployment of relevant beyond the country of discovery or application. As GPGs, as has occurred with falling expenses for people in all countries should be able to enjoy them, saving the lives of children under 15. This analysis international cooperation and resources are need- shows how the amount of income needed to avoid ed to develop them. The term GPGs is used broadly previously unavoidable deaths can decline with sus- here. It includes regional as well as strictly global tained scientific progress (Wu et al. 2024). public goods and covers R&D for new health tools Apart from stimulating scientific advancement, (covering drugs, diagnostics, vaccines, and proto- GPGs can lower costs by leveraging the buying cols), as well as related areas of high returns on col- power of large entities, using instruments such as lective action. From a healthy longevity perspective, medical subsidies, advanced market commitments, these include lowered LTC costs, novel forms of and bulk purchases of medicines. They can also 68 CHAPTER 4 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y bring more equity, across and within countries, to the quality of care, serving for example to check ad- the provision of NCD-related goods. Both are nec- herence to standard guidelines in management of essary to achieve the inclusive vision of healthy lon- common clinical conditions, such as asthma. gevity advanced in this report. There are obvious constraints that need to be Among key lines of research on life-course overcome to ensure that AI is relevant and help- health, partners can support operational and im- ful to healthy longevity. First, many of the training plementation research on NCD interventions and datasets that inform GPT models are from HICs LTC. There is an urgent need for a comprehensive and tend not to capture the grey literature of gov- research agenda on LTC models that are replicable ernment, NGO, and civil society reports as much as and sustainable in LMICs. Delivery research is also they capture formally published studies. Thus, very crucial to improve the integration of primary health often current GPT results are not representative, and care and LTC, which has proven elusive even in they risk being misleading with regard to LMICs or more technologically advanced economies (Araújo of other dimension of inequity such as gender, par- and Garcia 2024; Hou et al. 2023; Chen et al. 2022). ticularly in the lowest-income countries. Leading Innovation encompasses general technologies AI-technology firms can make a deliberate decision with potential applications for global health, includ- to substantially expand the input training data to ing shared artificial intelligence (AI) tools as well as include LMIC datasets and experiences. Efforts to specific technologies to reduce NCD burdens. For in- identify, call out, and remove fake news items gen- stance, mobile technologies offer promise for expand- erated by AI, particularly those with disinformation ing outreach and screening programs and delivery of and misinformation on health, are needed. Ensuring mental health services. Indeed, GPGs are particularly transparency in the input data and training datasets needed for mental health conditions, a field that does is also a reasonable global standard. not have the same widely documented evidence base Moreover, the benefits from AI-triggered dis- of implementing consistently effective tools and in- coveries, such as new drug targets or repurposing terventions as, for instance, smoking and cardiovas- of drugs need to shared widely and avoid creating cular disease. One example of the cost-effectiveness rent-seeking opportunities for selected companies. of mental health interventions comes from Iran, Various scientific consortia have signaled such in- which has been transitioning toward a more com- tentions (Melliou 2023). Transparency about who prehensive model for addressing mental health con- funds AI and who stands to profit from its uses can ditions. It has been estimated that each healthy life also help build trust. Similarly, global stewardship year gained through this new approach will only cost of AI is needed. The mechanisms to do so are being about US$800 (Hosseini Jebeli et al. 2021). actively debated by global organizations. AI could be harnessed to accelerate efforts on There is also great scope for GPGs to address NCD control and for global health in multiple ways, the major NCDs. Consider the example of cancers, including disease diagnosis using mobile-based which account for about 4 million deaths globally just telemedicine, given its ability to quickly analyze and at ages 30 through 69 (Gelband et al. 2016). Cancers organize vast amounts of medical data. For example, are common to countries of all income levels, and in Sierra Leone, generative pre-trained transformer hence a GPG agenda would have global applicability. (GPT) methods have proven comparable to du- To give some examples, R&D for health tools al-physician diagnosis of the causes of death (Wen could lead to improved diagnostics of estrogen lev- et al. 2024). AI tools could be linked to personal els for people with breast cancer. Global efforts for cellular or wearable devices to provide customized efficient procurement and cost reductions of key health promotion advice. AI is already playing a inputs for recommended interventions could make powerful role in drug discovery and development, pathology tests and other relevant goods more af- including in identifying promising molecules, key fordable, as has occurred with infectious disease proteins and other biologics that can then be test- control commodities. Technical networks for can- ed in clinical trials. Moreover, AI can also inform cer control could expand on international and re- repurposing of drugs for new purposes. However, gional collaborations that already exist for many as- much of the attention is focused on diseases and pects of cancer care, to foster institutional twinning conditions in HICs, and less on low-cost drugs or and other collaborations among LMICs. repurposing of existing compounds that are widely Within countries, peer-based professional stan- applicable in LMICs. Finally, AI could help improve dards could improve the quality of care delivered to U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 4 69 patients. Other in-country pathways for GPGs would The high economic returns of GPGs provide include harmonization of specific treatment guide- a compelling reason to reverse this neglect. Eval- lines, tracking of national cancer burdens, clinical tri- uations of R&D in high-income countries have als, and development of widely practicable low-cost demonstrated outstanding returns. In the US for ex- technologies. Finally, the sharing of global intellectu- ample, medical advances producing 10 percent re- al property related to cancers could involve licensing ductions in mortality from cancer and heart disease arrangements or tiered pricing favorable to LMICs. alone are estimated to add roughly US$10 trillion to More broadly, GPGs can connect adult health the US national wealth. And the average new drug efforts throughout the life course to pandemic pre- approved by the US Food and Drug Administration paredness. The emergence of new technology from yields benefits worth many times its cost of develop- the COVID pandemic, notably messenger RNA ment (Murphy and Topel 2003). technology, generated new vaccines for adults that GPGs need institutional and governance ar- could dramatically reduce the morbidity and mor- rangements. These, in turn, require multi-stake- tality related to cancer and cardiovascular disease, holder and expertise-driven coalitions. Models such as well as several infectious diseases. Clinical trials as the Tropical Disease Research Program at WHO are underway of injectables for blood pressure con- and the Consultative Group on International Agri- trol that would replace daily tablets with twice-year- cultural Research provide examples and insights on ly injections. This could improve treatment adher- how to do this (WHO 1997). ence (Berry et al. 2022), another useful arena for Foundations are also important for assembling development of NCD GPGs. financing, intellectual inputs, and political support for Despite the innumerable benefits of GPGs GPGs. GPGs could be attractive for MICs, or when for transforming life-course health, there is broad done in partnership with possible reprogramming agreement that there has been significant under-in- of some developmental assistance towards R&D and vestment. Because of this and the crucial impor- other GPGs. For example, the African Development tance of GPGs, the World Bank’s new vision gives Bank plans to spend US$3 billion to expand African much increased emphasis to GPGs (World Bank pharmaceutical capacities (African Development 2023b). Global health funders have tended to sup- Bank 2022). Enhanced structures for GPGs would be port reactive and country-specific efforts, rather aided if there were a way to identify and recognize than globally beneficial preparation for the demo- part of the spending by HIC research institutions on graphic and health challenges evident on the hori- global health that is not already eligible for reporting zon. In 2017, international funding for health that as ODA, at least as part of a supplementary category included a very broad definition of global functions to ODA. This calls for a more detailed study of GPG accounted for 24 percent of all ODA for health plus priorities, implementation, and funding. Since NCDs international R&D spending for poverty-related are the leading causes of death in every region of and neglected disease (Schaferhoff et al. 2019). Re- the world, R&D and GPGs could well be supported view of the 10 NCD-focused projects financed by and financed by research agencies in HICs. Opera- the World Bank that started between its 2016 and tional research efforts such as the Global Alliance 2020 fiscal years shows that only four included for Chronic Diseases have tried to leverage research global functions (in the form of outbreak prepared- funding agencies in countries of all income levels ness and response) (Govindaraj and Gopalan 2024). (Global Alliance for Chronic Diseases 2023). 70 CHAPTER 5 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Conclusion: From knowledge to action This report comes at a critical moment in global development. It is linked to dominant global concerns, climate change and pandemics, that have recently acquired even more urgent salience. The report has identified demo- graphic transformation, which shapes prevention and control of NCDs, as a grand challenge for the first half of the twenty-first century. The report acknowledges the universal desire for high-impact interventions for NCDs, (ii) address healthy longevity, and it cites the role of NCD con- financial protection and long-term care needs for trol in ensuring both longer lives and less sickness, the poor and vulnerable, and (iii) support data and allowing for greater productivity and wellbeing. This global public goods for healthy longevity. Specific research shows that it is possible to sharply reduce recommendations are provided in each chapter of excess mortality, especially through prevention and this report, such as those for financial protection, control of NCDs throughout the life course, while affordable LTC options, using the HLI agenda to ad- adopting an equity lens. Ultimately, if all countries vance UHC and help meet the SDGs, and linkage to improve their health performance to the level of interventions to combat climate change and reduce their most successful peers, billions of lives could pandemic vulnerability. be meaningfully extended, and avoidable mortality HLI recommendations would contribute to could be halved by 2050. achieving three linked key outcomes: (i) reduced The report’s overall main recommendations is avoidable death and disease from NCDs and im- for country-specific and investment, with strong proved wellbeing; (ii) reduced poverty and gender support from development partners and the private inequality; and (iii) improved productivity, choice, sector, in life-course measures to prevent and man- and equity in paid work or in household or commu- age NCDs, with complementary reforms of labor nity care for children or adults needing care. Table markets, pensions, and long-term care. The main 5.1 summarizes the relevance of these main recom- recommendations cover three areas: (i) scale up mendations to HLI outcomes. TABLE 5.1   Summary of the HLI agenda recommendations and their impact Reduced avoidable Reduced Improve productivity, death and disease poverty choice, and equity from NCDs and and gender in paid (and Instruments/Key outcomes  improve wellbeing inequality  household) work Adopt high impact fiscal, public health, and clincial interventions Levy health excise taxes to reduce disease and raise fiscal resources    Integrate cost-effective, high-impact clinical services in primary and first-referral facilities    Provide financial protection and address long-term care needs Adopt financial protection strategies for the poorest and most vulnerable including women -   Lower cost and expand availability of long-term care, including community-based care    Promote data and global public goods Invest in data systems, open data, and dashboards to track performance and provide accountability    Create and fund global public goods for healthy longevity    Note: Somewhat Strongly U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y CHAPTER 5 71 Moving from knowledge to action: This report provides a knowledge base for action approach behind the healthy longevity and NCD that is considerable and of proven high impact. A control agendas and adapting it to their specific in- strong evidence base is not enough, however. dividual situations. The realization of that prospect At both the country and global levels, what is is eminently feasible. required is building strong support at top levels of Demography may not be destiny, but the ongo- political and other leadership for adopting and ad- ing demographic transitions demand a focused and vancing this agenda. It will take a strong and coordi- forward-thinking approach to seize the benefits of nated whole-of-society effort. This includes within older populations. This report presents such an ap- governments, ministries of finance, social protec- proach and the supporting evidence for it, to enable tion, labor, and gender, as well as championing by countries to adopt and adapt the approach to their health ministries. And the effort required goes far individual country situations and to urge develop- beyond governments and external partners to in- ment partners and the wider global community to clude the private sector, academia, NGOs, founda- provide support at both country and global levels. tions, the media, the broader global and national The world can celebrate the remarkable progress development communities, and health epistemic in health and wellbeing that started near the end of communities including people living with NCDs. A the twentieth century. The challenge facing all who strengthened role for the multilateral development recognize the feasibility and importance of healthy banks can encourage and support country owner- longevity is to help realize highly effective interven- ship and seed learnings across many settings. tions, leading to remarkable gains in human welfare This effort has been sustained by the prospect during the first half of the twenty-first century. of countries, especially LMICs, adopting the basic 72 APPENDIX A U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Appendix A: Data sources, methods, and analytic processes Key Data sources used to establish a trend using a regression model; this trend is then interrupted by an intervention at Demography: United Nations, Department of Eco- a known time-point (Bernal et al. 2016; Kontop- nomic and Social Affairs, Population Division antelis et al. 2015). The difference in the trend be- (UNPD 2022). World Population Prospects 2022 fore and after the intervention quantifies the effect (UNPD 2022). of the intervention. In our analysis, we define the interruption point as 2010 to examine if there are Disease incidence and prevalence: World Health notable differences in the rate of mortality decline Organization (WHO) (WHO 2020c); Institute of in the second decade of 2000 compared to the first, Health Metrics and Evaluation, Global Burden of using the logic that trends which had been estab- Disease 2019 (IHME 2019). lished from 2000–2009 should accelerate after 2010 if more attention was given to health and action on Cause of death: WHO, Global Health Estimates health during the second. The analysis includes all 2019 (WHO 2020b). countries and was performed by grouping countries by income (World Bank 2020 classification) (World Gross domestic product (GDP): World Bank, World Bank 2021c), World Bank region, SDG region, and Development Indicators 2022 (World Bank 2023c). membership in the Organization for Economic Co-operation and Development (OECD). Methods Rates of progress in cause-specific mortality reduction Rates of progress in mortality reduction during 2000–09 and 2010–19 We measure rates of progress in cause-specific mor- tality decline from a list of 20 major diseases and We use interrupted time-series (ITS) analysis to ex- conditions using the standard average annual rate of amine any significant difference in the rate of change reduction (AARR) calculation for the period from in mortality rates between the two decades of 2010– 2000 to 2019 (UNICEF 2007). The 20 diseases and 19 and 2000–10. An ITS design provides a robust conditions were selected based on expert consulta- quasi-experimental design that affords a high level tion, primarily due to the high burden of mortal- of certainty of evidence to evaluate the longitudinal ity from these causes and areas of public interest effects of interventions where a randomized con- and funding in the past. The list of 20 diseases is trolled trial is not possible (Bernal et al. 2016). In an presented in Table A1. Data on causes of death, by ITS analysis, a continuous series of observations on country, age, and sex were obtained from the WHO an outcome of interest for a population over time is Global Health Estimates (WHO 2020b). U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y APPENDIX A 73 TABLE A1   List of diseases and conditions selected for studying rates of progress, classified by disease group Communicable, maternal, perinatal and nutritional conditions Non-communicable diseases (NCDs) Injuries Tuberculosis All cancers Road injury HIV/AIDS Tobacco-attributable cancers* Falls Diarrheal diseases Infection-attributable cancers† Drowning Childhood-cluster diseases Stomach cancer Suicide Malaria Breast cancer Respiratory infections Cardiovascular diseases, excluding stroke Maternal conditions Stroke Neonatal conditions Respiratory diseases Note: *Mouth and oropharynx, esophagus, trachea, bronchus, lung, and larynx cancers. †Liver, cervix uteri, and corpus uteri cancers. AIDS = acquired immunodeficiency syndrome; HIV = human immunodeficiency virus. All diseases and conditions are defined based on the WHO Global Health Estimates (WHO 2020b) unless stated otherwise. Economic value of alcohol use, and injuries (Luy 2016). avoidable mortality (EVAM) To provide context and assess the feasibility of achieving the frontier mortality rates, we created a Avoidable mortality scenario (called “rapid progress”) in which coun- tries experience fast but plausible mortality reduc- Avoidable mortality comprises deaths that may be tions from 2019 to 2050. Specifically, we calculated prevented through public health or prevention inter- the historical average annual rate of change (AARC) ventions that reduce incidence (preventable mortal- for all country-sex-age mortality rates between 2000 ity) and those that can be avoided through curative and 2019, and applied the top 10th percentile AARC health care interventions that reduce case-fatality to all countries from the years 2020 to 2050. (treatable or amenable mortality) (Nolte and McKee 2003; OECD 2022a; Rutstein et al. 1976). We pro- Economic value of mortality reduction pose estimating avoidable mortality as the difference between current (estimated/projected) mortality We first define the economic value of remaining life- levels from the World Population Prospects 2022 time income for an individual at age a with current (UNPD 2022), and unavoidable, or frontier mortal- annual survival probabilities and annual income. ity levels, which are the lowest mortality levels that We then identify the point at which she is indiffer- can be obtained for each age given past and current ent between continuing under the current survival technologies and knowledge. Frontier mortality lev- probability and a hypothetical scenario where she els are estimated as the lowest contemporary mortal- forgoes a proportion of this year’s income in ex- ity rates at each age in either sex, obtained from the change for higher survival probability (no avoidable Human Mortality Database for the years 2000–2019 mortality) that year. The economic value of avoid- and projected to 2050 (Barbieri et al. 2015; Human able mortality in a given year is thus measured as Mortality Database 2022; Wilmoth et al. 2021). We the maximum percentage of annual income an in- apply a single age-year-specific frontier to all coun- dividual is willing to forgo to live that year at the tries and to both males and females, consistent with frontier survival probabilities. our belief that all populations have the opportunity We closely followed the recommendations to reach the frontier with the necessary resources, made by the Harvard Benefit Cost Analysis Refer- even though it may be more challenging for some ence Case (Robinson et al. 2019). We set the ratio than others. We compared both male and female between value of statistical life (VSL) and income mortality to the lowest sex-specific mortality rate, per capita (VSLr) at 160 (the ratio comes from a which in all cases is female mortality. Most of the sex United States VSL of $9.4 million and gross nation- differences in life expectancy has been shown to be al income (GNI) per capita of $57,900), and income due to non-biological factors, namely gender differ- elasticity of 0.8 when extrapolating across countries ences in health behavior and risks, such as smoking, with higher GNI per capita than the United States, 74 APPENDIX A U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y and 1.2 for countries with lower GNI per capita. lationship was mathematically studied by Hum and We apply a lower bound constraint for the VSLr at colleagues in 2012 using the Michaelis-Menten en- 20. We choose to estimate income using GNI per zyme kinetics (Hum et al. 2012). Treating income capita expressed in 2017 international dollars and as the substrate that is catalyzed to increase surviv- adjusted for purchasing power parity (PPP), as rec- al, Hum and colleagues investigated the change in ommended by the reference case. Data on GNI per the level of income that is needed to achieve half capita (PPP constant 2017 International $) between of the period-specific maximum survival (“crit- 2000–2021 came from the World Bank (World Bank ical income”). Here, we extend the 2012 analysis 2023c); income levels for 2050 are projected using by Hum and colleagues to assess the trend in the the OECD projected country-specific growth rates critical income for ages under 15, 15–49, and 50–69 between 2021 and 2050 for listed countries (OECD from 1990 to 2019. We redefine critical income here and G20 countries), and the world average growth as the income needed to achieve 80 percent of the rate during the same time period for all remaining global maximum life expectancy. countries. The annual discount rate is 3 percent. The Using data from the WPP (UNPD 2022), we economic value of avoidable mortality is presented used country specific population by age groups as a percentage of annual income. (both sexes) and country-specific deaths by age- We present the results by the World Bank’s geo- groups, to derive a survival rate for children aged graphic regions, with China and India presented 0 to 14, adults 15 to 49, and seniors 50 to 69 from separately. We focus on the years 2000, 2019, and 1990 to 2019. For this analysis, we included only 2050, which represent the beginning of the era of countries with a population of over 7 million major international investment in global health, (which covers 99.9 percent of the world population current conditions just prior to the COVID pan- in 2019). GDP per capita (PPP, constant $2017) was demic, and future projections. We also discuss es- sourced from the World Bank (World Bank 2023c). timates for 2021, which is the latest observed year We used five-year averages to limit the influence of available from World Population Prospects (WPP) sudden, dramatic, changes in health or economic (UNPD 2022) and reflects the unique mortality development in that country. profile during the COVID pandemic. We adapted the Michaelis-Menten model for For cause-specific EVAM, we used cause of age-specific global critical income estimates (kinc) death data from the WHO Global Health Estimates and maximal survival rates such that: for 2000–2019 for 31 causes of death (WHO 2020b) to quantify the avoidable mortality for each cause of death, for 2000–2050 for 113 countries over six world regions (China, Eurasia & the Mediterra- nean, High-income, India, Latin America & the Caribbean, Sub-Saharan Africa). We then applied the value per statistical life approach as described above to assign economic values to these estimates of avoidable mortality. Critical income We used a mixed effect model to calculate the global, as well as country-level, critical incomes for In 1975, Samuel Preston, in a classic paper, showed all countries in the analysis. We also calculated the that life expectancy is related to national income income required to achieve 80 percent of the max- (Preston 1975). He found that life expectancy in- imal health in high income countries—which is, creases with national income per capita in poorer mathematically, four times the critical income. Us- countries, but plateaus at higher income levels. He ing the country-level critical incomes derived from also noted an upward and lateral shift in the curve the mixed-effects model, we ranked the top coun- over time, indicating that for the same level of in- tries with the lowest critical income values for each come, life expectancy increases over time. This re- age-grouping. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y APPENDIX A 75 NCD investment packages Intervention selection and aggregation systems), so out-of-pocket costs currently paid by households would be shifted to governments and The starting point of this analysis is a set of inter- accounted for in our estimates. ventions recommended in the third edition of the We primarily sourced unit cost data for the clin- Disease Control Priorities series (DCP3) (Jamison ical interventions from DCP3 systematic reviews of et al. 2018). The DCP3 covered a particular health cost and cost-effectiveness studies. Since NCD cost- topic (e.g., tuberculosis, cancer screening, neuro- ing studies are few, we selected the highest-quality logical disorders) and synthesized the evidence in study that we identified that most closely reflected a series of recommended interventions that (i) pro- the medical components of the intervention in ques- vide good value for money, (ii) are feasible to imple- tion. All costs were updated to 2020 US dollars us- ment in LMICs, and (iii) address a significant cause ing procedures recommended by the Global Health of death or disability. These criteria were applied Costing Consortium (Vassall et al. 2017). They were to systematic reviews of economic evaluations of then extrapolated to other countries in two stages. health interventions done in LMIC settings, supple- First, we decomposed costs into traded and non- mented by other information such as clinical and traded components. Traded components were as- implementation studies and expert judgment. The sumed to be constant across countries. Nontraded DCP3 final list of recommended interventions was components were adjusted based on ratios of gross separated into 218 health sector interventions and national income (GNI) per capita across countries. 71 inter-sectoral interventions. For this analysis, we Unit costs were then multiplied by the popu- selected 30 interventions that are proven to reduce lation requiring each intervention and further by mortality from NCDs and can achieve meaning- the target coverage level of the intervention each ful impacts by 2030 (Table A2). Our analysis looks year. For example, the cost of an intervention cost- at both clinical and inter-sectoral interventions ing US$20 per patient-year that addressed a chron- through a benefit-cost lens. ic disease with a prevalence of 1 million cases and a current coverage of 30 percent was calculated as Modeling intervention costs US$20 * 1,000,000 * 30% = US$6,000,000. The “in- cremental” cost of increasing coverage of that inter- Our cost estimates build on those done for the vention by a certain amount would be calculated as DCP3 and the NCD Countdown 2030 report (NCD the difference in coverage year over year. We defined Countdown collaborators 2022; Watkins et al. 2020). full coverage of each intervention as 80 percent of Costs borne by governments in implementing the the population covered by the year 2030, consis- inter-sectoral policies were estimated on a per-cap- tent with DCP3 and WHO assumptions (Jamison ita basis, using published costing studies or grey lit- et al. 2018; Stenberg et al. 2017). Epidemiological erature (e.g., government budget reports). For the and demographic data used to estimate population clinical interventions, the focus was on unit costs in need were taken from the WHO (WHO 2020b; (e.g., cost per patient-year of chronic treatment, WHO 2020c), WPP (2022 edition) (UNPD 2022), cost per episode for acute care, etc.) to health care and Global Burden of Disease 2019 Study (IHME sector. All interventions were assumed to be public- 2019). Coverage data were taken from the literature, ly financed (i.e., through universal health coverage WHO, or expert opinion. 76 APPENDIX A U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y TABLE A2  Interventions considered in this analysis Intervention cluster Specific interventions Interventions outside the health sector Tobacco excise taxes (risk factor reduction) Alcohol excise taxes Smoking regulations and information/education/communication Alcohol regulations Sodium regulations and information/education/communication Trans fat bans Outpatient cardiometabolic Diabetes screening/treatment and respiratory disease care Cardiovascular disease primary prevention Aspirin for suspected acute coronary syndromes Cardiovascular disease secondary prevention Heart failure chronic treatment Chronic pulmonary disease treatment Outpatient mental, neurological, Injection drug use harm reduction measures and substance use disorder care Alcohol use screening/brief intervention Depression chronic treatment Bipolar disorder chronic treatment Schizophrenia chronic treatment Epilepsy acute and chronic treatment First-level hospital cardiometabolic Medical management of acute coronary syndromes and respiratory disease care Heart failure acute treatment Treatment of acute exacerbations of chronic pulmonary disease First-level hospital surgical care Screening and treatment of early-stage cervical cancer Management of bowel obstruction Management of appendicitis Repair of hernias Repair of gastrointestinal perforations Referral hospital services Percutaneous coronary intervention for acute coronary syndromes Advanced care for severe acute-on-chronic pulmonary disease Treatment of early-stage breast cancer Treatment of early-stage colorectal cancer For the non-health sector interventions, there 2014), which used an offset parameter that was ap- are two major types of costs that are borne outside plied to the estimated economic benefits from im- the government/health care sector. The first type proved health (see below). For tobacco and alcohol is the cost to firms of implementing government policies, the offset value was 0.9, and for sodium regulations. Again, we used literature-based esti- and trans-fat policies, it was 0.5. mates of these costs and extrapolated them across countries, like we did for the clinical interventions Modeling intervention health and (above). The second type of cost is the forgone con- economic outcomes sumer surplus due to taxes and regulations on un- healthy products. We used recommendations from We quantify improvements in health as a reduc- US-based regulatory impact analyses to inform our tion in mortality and disability rates following the approach 9 (U.S. Food and Drug Administration scale-up of an intervention. To do this, we used U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y APPENDIX A 77 a population model we developed for the NCD Country-specific HLI dashboards Countdown 2030 report (NCD Countdown col- laborators 2022). In brief, this model combined Selecting indicators demographic projections (including population counts and all-cause mortality rates) (UNPD 2022) The healthy longevity dashboard is an ongoing effort with cause-of-death data (WHO 2020b)and dis- to develop and refine a suite of indicators that bring ease incidence and prevalence rates (IHME 2019). together relevant data to measure and monitor coun- The baseline projection that we used as a reference try progress towards healthy longevity. As part of for calculating intervention-specific health gains these efforts, a common framework for healthy lon- was calibrated to the UNPD medium projections, gevity and harmonized approach has been proposed representing a business-as-usual scenario for inter- (O’Keefe and Haldane 2024). Under this approach, vention implementation. indicators were selected that map to the overarching Changes in disease-specific mortality and dis- HLI conceptual framework and that can be distilled ability rates were a function of (i) the effectiveness across three key actions and ten related domains to of the intervention on these outcomes, and (ii) the be prioritized when developing a healthy longevity change in intervention coverage. Effectiveness data dashboard (Table A3). This approach allows us to were usually taken from clinical trials, favoring identify indicators that map to data infrastructure meta-analytic estimates when available. Interven- maturity in a given country, while ensuring compa- tion-specific effectiveness parameters are detailed rable and consistent conceptual underpinnings. in the online appendix to the background paper and Indicators of context and HLI Indicators. Details in the Github link below. We multiplied each litera- of the selection of indicators are provided in the rel- ture-based effect size by 0.70 to account for imper- evant background paper (Haldane et al. 2024). fect implementation in real-world settings (NCD Countdown collaborators 2022). Performance Score To calculate the economic value of reduced mortality and disability, we multiplied projected DA- To assess the performance of a country relative to LYs by the standardized time series estimates for the other countries with respect to an indicator, we value of a DALY that were used throughout the Co- normalized the data across countries to calculate penhagen Consensus project (Jha et al. 2013). One the score based on two approaches: percentile rank potential benefit of tobacco and alcohol taxes is a approach and z-score approach. Details of the two gain in revenue for governments. We took a societal approaches are described below. In both approach- perspective on costs and benefits, so these revenue es, the study country is compared with other coun- gains are fully offset by additional costs to consum- tries that fall under the same income stratum as the ers—i.e., they are, functionally, transfer payments. study country, based on the 2021 World Bank coun- All input data, including citations of the litera- try classification (World Bank 2021c), and have a ture used to estimate the cost of each intervention, population of more than 7 million (or 0.1 percent of are available at https://github.com/Disease-Con- the world population) in 2021, based on the World trol-Priorities/CCC. Population Prospects (UNPD 2022). A score of 100 percent indicates best performance, 50 percent indi- cates average performance, and 0 percent indicates worst performance relative to the other countries. 78 APPENDIX A U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y TABLE A3   Key actions and related domains when developing a healthy longevity dashboard Human capital accumulation, Declining human capital accumulation, Life course stage Intensive human capital accumulation deployment, and depreciation accelerated depreciation and depletion Key action 1. Promoting enabling factors for 2. Ensuring adequate prevention and 3. Creating supportive conditions for human capital accumulation control of NCDs across the life course healthy and productive aging Supporting domains • Disease prevention • NCD risk factors and behaviors • Healthy population • Education outcomes • NCD management • Productive aging • Youth focus • Reducing avoidable mortality • Wellbeing in old age • Gender norms Percentile rank approach. In the percentile rank is computed based on the z-score. This approach approach, the score for an indicator is represented assumes that the indicator values are normally dis- by its percentile rank. The percentile rank is calcu- tributed and a z-score for a country is calculated us- lated using the standard formula: ing the standard formula: , where M is the number of values below the , where x is the value for the study country, µ value for the study country, R is the number of val- is the mean value across all countries, and is the ues equals to the value for the study country, and Y standard deviation. is the total number of values. Based on the z-score, we then used the z-table For indicators where a higher value indicates to obtain the percentage of countries that are per- better performance, such as life expectancy and forming below the study country. This percentage is employment rate, the percentile rank is directly in- used as the score for indicators where the higher the terpreted as the score, whereas for indicators where value, the better the performance, such as life ex- a lower value indicates better performance, such as pectancy. For indicators where the lower the value, mortality and morbidity rate, the score is further the better the performance, such as mortality rate, calculated as 1 – percentile rank. We use “P” to de- the score is further calculated as 1 – calculated per- note the score calculated based on this approach. centage. The score calculated using this approach is Z-score approach. While the percentile rank denoted by “Z”. approach provides the performance of a country Based on the scores calculated from the two relative to all other countries, it does not take into approaches, we assigned the study country into account the distribution of the indicator across one of four quartiles: <25%, 25–<50%, 50–<75%, countries. To take into account the distribution, in- and ≥75%. cluding the mean and standard deviation, a score U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y APPENDIX B 79 Appendix B: Supplementary analytic materials This appendix includes the following supplementary analytic materials that were used in developing this report and its recommendations. Figure/Table Figure B1 Country classification used in this report, based on the 2020 World Bank income classification Table B1 Population in 1990, 2023, and 2050 by country income category Table B2 Average annual rate of reduction in mortality between 1990 and 2019 by age and income region (%) Figure B2 Population by selected age groups, 25 most populous countries and Colombia and Sierra Leone, 2023 and 2050 Figure B3 Annual rates of change in mortality rates, by country and age groups, 2000–2019 Table B3 Demographic changes, by age group from 1990 to 2050 Table B4 Median age at death, projections by country income category from 2022 to 2050 Table B5 Economic value of avoidable mortality as % of annual income and in US$, by income region for 2050 Table B6 Economic value globally of avoidable mortality as percentage of annual income, by disease Table B7 Rates of progress in mortality decline 2000–19, by diseases and country income category FIGURE B1   Country classification used in this report, based on the 2020 World Bank income classification Source: World Bank (2021c). 80 APPENDIX B U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y TABLE B1   Population in 1990, 2023, and 2050 by country income category Category by income Population in 1990 (millions) Population in 2023 (millions) Population in 2050 (millions) Low 295.1 737.2 1,329.6 Lower-middle 2,020.7 3,486.4 4,502.2 Upper-middle 1,978.7 2,561.2 2,564.0 All LMICs 4,294.4 6,784.8 8,413.9 High 1,001.7 1,231.0 1,258.8 World 5,316.2 8,045.3 9,709.5 Source: UNPD (2022). TABLE B2   Average annual rate of reduction in mortality between 1990 and 2019 by age and income region (%) Age 0 Age 15 Age 50 Age 70 Country income category (until age 14) (until age 49) (until age 69) (until age 79) Low 4.2 2.6 1.5 1.1 Lower-middle 3.6 1.5 1.3 0.9 Upper-middle 5.1 1.7 1.8 1.4 High 3.2 1.7 1.8 2.0 World 3.3 1.4 1.5 1.3 Source: UNPD (2022). FIGURE B2  Population by selected age groups, 25 most populous countries and Colombia and Sierra Leone, 2023 and 2050 Low-income countries Lower-middle-income countries U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y APPENDIX B 81 Lower-middle-income countries (continued) Upper-middle-income countries 82 APPENDIX B U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y High-income countries Source: UNPD (2022). FIGURE B3   Annual rates of change in mortality rates, by country and age groups, 2000–2019 0–14 years 15–49 years 50–69 years 70–79 years Source: UNPD (2022). U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y APPENDIX B 83 TABLE B3  Demographic changes, by age group from 1990 to 2050 Population in 1990 Population in 2023 % change Population in 2050 % change from 2050 Age group (millions) (millions) from 2023 to 1990 (millions) to 2023 0–14 1,749 2,011 +15% 2,010 +<0.0% 15–49 2 689 4,013 +49% 4,463 +11% 50–69 677 1,502 +122% 2,089 +39% 70–79 146 359 +146% 688 +92% 80+ 55 160 +193% 459 +186% Source: UNPD (2022). TABLE B4   Median age at death, projections by country income category from 2022 to 2050 Region and income group 2022 2030 2040 2050 Low 40 42 52 59 Lower-middle 64 66 70 72 Upper-middle 73 76 79 82 High 80 82 84 86 World 69 72 75 78 Source: Chang et al. (2024), based on UNPD (2022). TABLE B5   Economic value of avoidable mortality as % of annual income and in US$, by income region for 2050 % of annual income in US$ with Value of avoided mortality with Country income grouping 20% top performance top 20% performance (in US$ trillions) Low 17 0.1 Lower-middle 18 4 Upper-middle 16 8 All LMICs 17 13 High 17 6 Global 16 19 Source: Chang et al. (2024). Note: LMICs = lower- and middle-income countries. 84 APPENDIX B U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y TABLE B6  Economic value globally of avoidable mortality as percentage of annual income, by disease Disease/year 2019 (%) 2050 (%) Communicable, maternal, child, and nutritional 6.3 3.9 Infectious and parasitic 5.1 3.0 Maternal and neonatal 1.1 0.7 Nutritional deficiencies 0.1 0.2 NCDs 13.1 17.5 Cardiovascular 5.2 7.0 Ischemic heart 2.6 3.8 Stroke 1.9 2.1 Other cardiovascular 0.7 1.1 Diabetes mellitus 0.6 1.0 Digestive 1.1 1.2 Cirrhosis of the liver 0.7 0.7 Other digestive 0.4 0.5 Malignant neoplasms 3.4 4.4 Breast cancer 0.2 0.4 Cervix uteri cancer 0.2 0.2 Liver cancer 0.3 0.3 Mouth and oropharynx cancers 0.2 0.3 Esophagus cancer 0.2 0.2 Stomach cancer 0.4 0.2 Trachea, bronchus, lung cancer 0.9 1.0 Other malignant neoplasms 1.2 1.9 Respiratory diseases 1.2 1.5 Chronic obstructive pulmonary 0.9 1.1 Other respiratory 0.3 0.4 Other Non-communicable 1.7 2.5 Injuries 3.6 3.2 Intentional injuries 1.1 1.0 Unintentional injuries 2.4 2.2 Road injury 1.2 1.1 Source: Verguet et al. (2024). U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y APPENDIX B 85 TABLE B7   Rates of progress in mortality decline 2000–19, by diseases and country income category Male Female Fastest Slowest Fastest Slowest Disease/ Diseases/ Region Age AARR Region Age AARR Region Age AARR % Region Age AARR condition category conditions group % group % group group % All Causes UMICs 0–14 4.6 UMICs 70+ 0.7 UMI 0–14 4.6 HICs 70+ 0.9 Communicable, Tuberculosis UMICs 70+ 6.3 LICs 70+ 4.1 HICs 50–69 6.3 HICs 70+ 3.3 maternal, perinatal, and HIV/AIDS HICs 15–49 8.1 UMICs 15–49 1.9 LICs 15–49 8.0 UMICs 15–49 2.4 nutritional conditions Diarrhea UMICs 0–14 6.9 HICs 0–14 4.1 UMICs 0–14 7.2 HICs 0–14 4.1 Childhood- UMICs 0–14 9.1 LICs 0–14 5.2 UMICs 0–14 9.2 HICs 0–14 5.3 cluster Malaria LICs 0–14 6.3 LMICs 15–49 0.4 LICs 0–14 6.4 LMICs 15–49 1.1 Respiratory UMICs 0–14 6.5 HICs 0–14 4.5 UMICs 0–14 6.5 HICs 40–14 4.5 infections Maternal LMI 15–49 5.8 HICs 15–49 0.6 Neonatal UMICs 0–28 4.8 HICs 0–28 2.2 UMICs 0–28 4.8 HICs 0–28 2.1 conditions days days days days Non- All cancers HICs 50–69 1.8 LICs 70+ -0.2 UMICs 50–69 1.2 LICs 70+ -0.2 communicable diseases Tobacco- HICs 50–69 2.1 LICs 70+ -0.4 UMICs 50–69 1.3 LICs 70+ -0.7 attributable cancersa Infection UMICs 50–69 4.1 HICs 70+ 0.3 UMICs 50–69 2.2 HICs 70+ 0.4 attributable cancersb Stomach HICs 50–69 3.9 LICs 70+ 0.5 UMICs 50–69 3.4 LICs 70+ 0.8 cancer Breast cancer HICs 50–69 1.5 LICs 70+ -1.2 Cardiovascular HICs 70+ 2.3 UMICs 70+ -0.2 UMICs 50–69 2.5 LICs 70+ 0.2 (excluding stroke) Stroke HICs 50–69 3.4 LICs 70+ 0.9 HICs 50–69 3.9 LICs 70+ 0.7 Respiratory UMICs 50–69 4.8 HICs 50–69 0.7 UMICs 50–69 5.3 HICs 50–69 -0.3 diseases Injuries Road injury HICs 15–49 3.5 LICs 70+ -1.2 HICs 70+ 3.7 LICs 70+ -1.0 Falls LICs 50–69 1.1 UMICs 70+ -2.3 LICs 50–69 1.3 UMICs 70+ -2.3 Drowning UMICs 0–14 6.2 LICs 0–14 2.7 UMICs 0–14 7.6 LICs 0–14 2.8 Suicide UMICs 50–69 3.7 HICs 15–49 0.5 UMICs 15–49 6.2 HICs 15–49 -0.3 Source: WHO (2020b); Wu et al. (2024); original estimates for this publication, Note: AARR = Average annual rate of reduction; AIDS = acquired immunodeficiency syndrome; HICs = high-income countries; HIV = human immunodeficiency virus; LICs = low-income countries; LMICs = lower-middle-income countries; UMICs = upper-middle-income countries. aMouth and oropharynx, esophagus, trachea, bron- chus, lung, and larynx cancers. bLiver, cervix uteri, and corpus uteri cancers. 86 APPENDIX C U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Appendix C: Acknowledgments This report benefited greatly from ideas, technical Co-Chairs: George Alleyne, Daniel Dulitzky, Timo- inputs, and critical review from a broad range of in- thy Evans, and Rachel Nugent dividuals and organizations. Contributions to spe- Participants: Francisca Akala, Jean-Louis Arcand, cific chapters are acknowledged in the Bibliograph- Adriana Blanco, Sarbani Chakraborty, Pedro Con- ical Note. Reviewers for the background papers are ceicao, Erica Di Ruggiero, Vivek Goel, Sue Horton, noted below. In addition, valuable input was provid- Alexander Irwin, Dean Jamison, Prabhat Jha, Alex- ed by participants in a series of workshops. ey Kulikov, Jeremy Lauer, Aakash Mohpal, Miri- am Schneidman, Daniel Sellen, Jeremy Veillard, Reviewers for Background Papers Stéphane Verguet, and Daphne Wu Specific thanks and respect go to the following peo- 3. Healthy Longevity Initiative Technical ple for independently reviewing the background Workshop I papers for this report: Shambu Acharya, Tanima Ahmed, Faiza Benhadid, Indu Bhushan, Mukesh May 18–20, 2022, in Mexico City. Sponsored by Insti- Chawla, Damien de Walque, Beverley Essue, Ian tuto Nacional de Salud Pública and the World Bank. Forde, Linda Fried, Michele Gragnolati, Cristian Herrera, Sue Horton, Phillip James, Chris Kurkow- Co-Chairs: George Alleyne, Sameera Altuwaijri, ski, Patrick Petit, Usha Ram, Gonzalo Javier Reyes Michele Gragnolati, and Prabhat Jha Hartley, Akshar Saxena, Helen Saxenian, Norbert Participants: Tonatiuh Barrientos, Luis Benveniste, Schady, Victoria Strokova, Jeff Sturchio, Cornelis Diego Cardoso, Debapriya Chakraborty, Angela Van Walbeek, V R Muraleedharan, and Feng Zhao. Chang, Beverly Essue, Gisela Garcia, Elena Glinska- ya, Ramesh Govindaraj, Daniel Halim, Nedim Ja- Workshops and Consultations ganjac, Dean Jamison, Julian Jamison, Venus Jaraba, Blanca Llorente Anaas, Hugo López Gatell, Claudia 1. NCDs and Human Capital Workshop Macias, Norman Maldonado, Laura Vivian Mendo- za Ardila, Ellen Moscoe, Ana Maria Munoz Bou- December 6–7, 2018, in Washington D.C. Spon- det, Phillip O´Keefe, Truman Packard, Guillermo sored by the World Bank. Paraje, María Luisa Latorre Castro, Eduardo Lazca- no Ponce, Luz Myriam Reynales, Seemeen Saadat, Chair: George Alleyne and Tim Evans Belen Saenz de Miera Juarez, William Savedoff, Participants: Jean-Louis Arcand, Kathryn Gilman Gretchen Stevens, Florence Theodore, Angela Vega Andrews, Zelalem Debebe, Michele Gragnola- Landaeta, Jeremy Veillard, Stéphane Verguet, David ti, Dean Jamison, Prabhat Jha, Aart Kraay, Jeremy Watkins, Daphne Wu, and Feng Zhao Lauer, Aakash Mohpal, Rachel Nugent, Dena Rin- gold, Sanam Roder-DeWan, Rosa Sandoval, Miriam 4. HLI Dashboards Workshop Schneidman, Jeremy Veillard, and Stéphane Verguet September 20–22, 2022 in Bogotá, Colombia. Spon- 2. Non-Communicable Diseases and Human sored by the World Bank. Capital Analytic Work and Key Messaging Workshop Co-Chairs: Gisela Garcia and Jeremy Veillard Participants: Sameera Altuwaijri, Debapriya July 9–10, 2019, at the Dalla Lana School of Public Chakraborty, Beverley Essue, Victoria Haldane, Health at University of Toronto. Sponsored by the Cristian A. Herrera, Prabhat Jha, Maria Luisa La- Access Accelerated, the University of Toronto, and torre Castro, Seemeen Saadat, Gretchen Stevens, the World Bank. Angela Vega, and Daphne Wu U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y APPENDIX C 87 5. Healthy Longevity Initiative Technical Workshop II October 26–28, 2022, in Washington D.C. Spon- sored by the World Bank. Chair: Sameera Altuwaijri Participants: George Alleyne, Meriem Boujadja, Angela Chang, Debapriya Chakraborty, Gisela Gar- cia, Elena Glinskaya, Sundararajan Srinivasa Gopal- an, Ramesh Govindaraj, Victoria Haldane, Daniel Halim, Anselm Hennis, Alexander Irwin, Paul Isen- man, Prabhat Jha, Toni Joe Lebbos, Ellen Moscoe, Ana Maria Munoz Boudet, Philip O’Keefe, Guiller- mo Paraje, Seemeen Saadat, Gretchen Stevens, Jere- my Veillard, Stéphane Verguet, and David Watkins 6. HLI Analytic Meeting February 8–9, 2023, in Washington D.C. Sponsored by the World Bank. Chair: Sameera Altuwaijri Participants: Rythia Afkar, George Alleyne, De- bapriya Chakraborty, Daisy Demirag, Gisela Garcia, Anselm Hennis, Alexander Irwin, Paul Isenman, Prabhat Jha, Bente Mikkelsen, Seemeen Saadat, If- fath Sharif, and Michael Weber 7. Economic Value of Avoidable Mortality March 16–17, 2023, in Toronto. Sponsored by the World Bank and University of Toronto Co-Chairs: Dean Jamison and Prabhat Jha Participants: George Alleyne, Sarah Bolongaita, De- bapriya Chakraborty, Angela Chang, Ryan Hum, Alexander Irwin, Paul Isenman, Gretchen Stevens, Stéphane Verguet, and Daphne Wu 88 APPENDIX D U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Appendix D: Background papers Theoretical base and economic costs Long-term care 1. O’Keefe, Philip, and Victoria Haldane. Towards 11. Araújo, Natalia Aranco, and Gisela M. Garcia. a framework for impact pathways between non- Health and long-term care needs in a context of communicable diseases, human capital and healthy rapid population aging. longevity, economic and wellbeing outcomes. 12. Glinskaya, Elena, Xiaohui Hou, Zhanlian Feng, 2. Chang, Angela Y., Gretchen A. Stevens, Diego S. Marco Angrisani, Guadalupe Suarez, Jigyasa Cardoso, Bochen Cao, and Dean T. Jamison. The Sharma, Drystan Phillips, et al. Demand for and economic value of avoidable mortality. supply of long-term care for older persons in low- 3. Verguet, Stéphane, Sarah Bolongaita, Angela Y. and middle-income countries Chang, Diego S. Cardoso, and Gretchen A. Ste- vens. The economic value associated with avoid- Gender able mortality: a systematic assessment by cause of death across regions. 13. Gatti, Roberta, Daniel Halim, Allen Hardiman, 4. Wu, Daphne C., Debapriya Chakraborty, Ryan and Shuqiao Sun. Gendered responsibilities, el- Hum, Prabhat Jha, and Dean T. Jamison. Rates of derly care, and labor supply: evidence from four progress in mortality decline, 2000–2019. middle-income countries. 5. Alleyne, George, Timothy Evans, Alec Irwin, 14. Saadat, Seemeen, Meriem Boudjadja, and Sa- Prabhat Jha, and Jeremy Veillard. Enhancing human meera Altuwaijri. Gender gaps in health and capital and boosting productivity by tackling non- well-being of older adults: A review of the burden communicable diseases: results of a research initiative. of non-communicable diseases and barriers to healthcare for women and men. Behavior change Prioritizing action 6. Rojas, Ana Maria, Ana Maria Munoz Boudet, Ellen Moscoe, Julian Jamison, and Carlos Rumi- 15. Watkins, David, Sali Ahmed, and Sarah Pickers- allo Herl. Behavioral aspects of healthy longevity. gill. Priority setting for NCD control and health 7. Paraje, Guillermo, Prabhat Jha, William Sa- system investments. vedoff, and Alan Fuchs. Taxation of harmful 16. Govindaraj, Ramesh, and Sundararajan Srini- products, including tobacco, alcohol and sug- vasa Gopalan. Control for non-communicable ar-sweetened beverages, and related topics. diseases for enhanced human capital: the case for whole-of-society action. Financial and social protection and jobs 17. Haldane, Victoria, Gisela M. Garcia, Tahir Bock- arie, Daphne Wu, Cristian A Herrera, Maria 8. Demarco, Gustavo, Johannes Koettl, Miglena Luisa Latorre Castro, Debapriya Chakraborty, Abels, and Andrea Petrelli. Adequacy pensions Beverly Essue, Prabhat Jha, and Jeremy Veillard. and access to healthcare: maintaining human Healthy longevity initiative: a performance dash- capital during old age. board for decision-making in low- and middle-in- 9. de Silva, Sara Johansson, and Indhira Santos. come countries. Productive longevity: what can work in low- and 18. Wu, Daphne C., and Prabhat Jha. Assessing hu- middle-income countries? man capital, non-communicable diseases, and 10. Chakraborty, Debapriya, Daphne C. Wu, and healthy longevity in low- and middle-income Prabhat Jha. Exploring the labor market out- countries: healthy longevity dashboard and the comes of the risk factors for non-communicable case for India. diseases: a systematic review. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y BIBLIOGRAPHY 89 Bibliography 1. Addati, Laura, Umberto Cattaneo, Valeria Esquivel, and Isabel jendra Pradeepa, Nikhil Tandon, Ashok Kumar Das, Shashank Valarino. 2018. Care work and care jobs for the future of decent Joshi et al. 2023. “Metabolic non-communicable disease work. Geneva: International Labour Organisation (ILO). health report of India: the ICMR-INDIAB national cross-sec- 2. African Development Bank (AFDB). 2022. A New Frontier for tional study (ICMR-INDIAB-17).” Lancet Diabetes & Endocrinol- African Pharmaceutical Manufacturing Industry. Abidjan: AFDB. ogy 11 (7): P474–89. 3. Agus, David B., Aurélia Nguyen, and John Bell. 2022. “COVID-19 11. Araújo, Natalia Aranco, and Gisela M. Garcia. 2024. “Health and and other adult vaccines can drive global disease prevention.” long-term care needs in a context of rapid population aging.” Lancet 401 (10370): P8–10. in Unlocking the Power of Healthy Longevity: Compendium of 4. Ahluwalia, M. S., L. H. Summers, A. Velasco, et al. 2016. Multilat- Research for the Healthy Longevity Initiative. Washington, DC: eral Development Banking for This Century’s Development Chal- World Bank. lenges: Five Recommendations to Shareholders of the Old and 12. Ardington, Cally, Anne Case, and Victoria Hosegood. 2009. “La- New Multilateral Development Banks. Washington, DC: Centre bor supply responses to large social transfers: longitudinal ev- for Global Development. idence from South Africa.” American Economic Journal: Applied 5. Ahluwalia, Montek S., Lawrence Summers, Andrés Velasco, Economics 1 (1): 22–48. Nancy Birdsall, and Scott Morris. 2016. Multilateral develop- 13. Armas Rojas, Nurys B., Ben Lacey, Monica Soni, Shaquille ment banking for this century’s development challenges: five Charles, Jennifer Carter, Patricia Varona-Pérez, Julie Ann Bur- recommendations to shareholders of the old and new Multilat- rett et al. 2021. “Body-mass index, blood pressure, diabetes eral Development Banks. Washington, DC: Center for Global and cardiovascular mortality in Cuba: prospective study of Development. 146,556 participants.” BMC Public Health 21 (1): 963. 6. Alfonso-Sierra, Eduardo, Axel Arcila Carabalí, Janet Bonilla Tor- 14. Armengaud, J. B., C. Yzydorczyk, B. Siddeek, A. C. Peyter, and res, Maria Luisa Latorre Castro, Alexandra Porras Ramírez, and U. Simeoni. 2021. “Intrauterine growth restriction: clinical con- Lenis Urquijo Velásquez. 2018. “Situación de multimorbilidad sequences on health and disease at adulthood.” Reproductive en Colombia 2012-2016: informe de investigación.” [Multi- Toxicology 99: 168–76. morbidity situation in Colombia 2012-2016: investigation re- 15. Arokiasamy, Perianayagam, Uttamacharya Uttamacharya, port]. Washington, DC: World Bank. Kshipra Jain, Richard Berko Biritwum, Alfred Edwin Yawson, 7. Alleyne, George, Timothy Evans, Alec Irwin, Prabhat Jha, and Fan Wu, Yanfei Guo et al. 2015. “The impact of multimorbidity Jeremy Veillard for the World Bank Group Human Capital on adult physical and mental health in low- and middle-in- Project. 2024. “Enhancing human capital and boosting pro- come countries: what does the study on global ageing and ductivity by tackling non-communicable diseases: results of a adult health (SAGE) reveal?” BMC Medicine 13: 178. research initiative.” in Unlocking the Power of Healthy Longevity: 16. Asia Health and Wellbeing Initiative. 2020. “The Intergener- Compendium of Research for the Healthy Longevity Initiative. ational Self-Help Club (ISHC) Development Model.” July 31, Washington, DC: World Bank. 2020. https://www.ahwin.org/helpage-vietnam-ishc/ 8. Almeida, Gisele, Osvaldo Artaza, Nora Donoso, and Ricardo 17. Asian Development Bank (ADB). 2022. “Adapting to Aging Asia Fábrega. 2018. “La atención primaria de salud en la Región de and the Pacific.” Asian Development Bank. January 11, 2022. las Américas a 40 años de la Declaración de Alma-Ata.” [Pri- 18. Attanasio, Orazio, Ricardo Paes de Barro, Pedro Carneiro, Da- mary health care in the Region of the Americas 40 years after vid Evans, Lycia Lima, Pedro Olinto, and Norbert Schady. 2017. the Declaration of Alma-Ata]. Revista Panamericana de Salud “Impact of free availability of public childcare on labour supply Pública 42: e104. and child development in Brazil.” Impact Evaluation Report 58. 9. Altuwaijri, Sameera, Seemeen Saadat, Meriem Boudjadja, New Delhi: International Initiative for Impact Evaluation. 3ie. Charlotte Pram Nelson, Amparo Elena Gordillo-Tobar, Mirai 19. Atun, Rifat, Luiz Odorico Monteiro De Andrade, Gisele Almei- Maruo, and Priyadarshani Rakh. 2024. “Achieving gender eq- da, Daniel Cotlear, Tania Dmytraczenko, Patricia Frenz, Patrícia uity in health: key areas of focus under Universal Health Cov- Garcia et al. 2015. “Health-system reform and universal health erage.” Gender Thematic Policy Note Series: Evidence and Practice coverage in Latin America.” Lancet 385 (9974): 1230–47. Note. Washington, DC: World Bank. 20. Banerjee, Amitava, Laura Pasea, Steve Harris, Arturo Gonza- 10. Anjana, Ranjit Mohan, Ranjit Unnikrishnan, Mohan Deepa, Ra- lez-Izquierdo, Ana Torralbo, Laura Shallcross, Mahdad Nour- 90 BIBLIOGR APHY U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y sadeghi et al. 2020. “Estimating excess 1-year mortality asso- 32. Böheim, René, and Thomas Nice. 2019. “The effect of early ciated with the COVID-19 pandemic according to underlying retirement schemes on youth employment.” IZA World of conditions and age: a population-based cohort study.” Lancet Labor: 70v2. 395 (10238): 1715-1725. 33. Bongaarts, John, and Elof Johansson. 2002. “Future Trends in 21. Banga, Ajay. 2023. “Remarks by World Bank Group President Contraceptive Prevalence and Method Mix in the Developing Ajay Banga at the 2023 Annual Meetings Plenary.” World Bank. World.” Studies in Family Planning 33 (1): 24–36. October 13, 2023. https://www.worldbank.org/en/news/ 34. Brainerd, Elizabeth. 2014. “Can government policies reverse speech/2023/10/13/remarks-by-world-bank-group-presi- undesirable declines in fertility?” IZA World of Labor: 23. dent-ajay-banga-at-the-2023-annual-meetings-plenary. 35. Breton, Marie-Claude, Line Guenette, Mohamed Amine Am- 22. Barbieri, Magali, John R. Wilmoth, Vladimir M. Shkolnikov, iche, Jeanne-Francoise Kayibanda, Jean-Pierre Gregoire, and Dana Glei, Domantas Jasilionis, Dmitri Jdanov, Carl Boe, Tim- Jocelyne Moisan. 2013. “Burden of diabetes on the ability to othy Riffe, Pavel Grigoriev, and Celeste Winant. 2015. “Data work.” Diabetes Care 36 (3): 740–49. Resource Profile: The Human Mortality Database (HMD).” Inter- 36. Bukhman, Gene, Ana O. Mocumbi, Rifat Atun, Anne E. Beck- national Journal of Epidemiology 44 (5): 1549–56. er, Zulfiqar Bhutta, Agnes Binagwaho, Chelsea Clinton et al. 23. Basu, Sanjay, Martin McKee, Gauden Galea, and David Stuckler. 2020. “The Lancet NCDI Poverty Commission: bridging a gap 2013. “Relationship of soft drink consumption to global over- in universal health coverage for the poorest billion.” Lancet 396 weight, obesity, and diabetes: a cross-national analysis of 75 (10256): 991–1044. countries.” American Journal of Public Health 103 (11): 2071–77. 37. Bundy, Donald AP, Nilanthi de Silva, Susan Horton, George C. 24. Bernal, James Lopez, Steven Cummins, and Antonio Gasparri- Patton, Linda Schultz, Dean T. Jamison, Amina Abubakara et ni. 2016. “Interrupted time series regression for the evaluation al. 2018. “Investment in child and adolescent health and de- of public health interventions: a tutorial.” International Journal velopment: key messages from Disease Control Priorities, 3rd of Epidemiology 46 (1): 348–55. Edition.” Lancet 391 (10121): 687–99. 25. Berry, Tamsin, Paul Blakely, Henry Lishi Li, Romina Mariano, and 38. Busch, Fabian, Robert Fenge, and Carsten Ochsen. 2021. Do Gabriel Seidman. 2022. One Shot to Prevent Disease and Prepare Firms Hire More Older Workers? Evidence from Germany. CESifo for Future Pandemics: Identifying the Most Promising Adult Vac- Working Paper No. 9219. Munich: CESifo Network. cines and Injectables. The Global Health Security Consortium. 39. Chakraborty, Debapriya, Daphne C. Wu, and Prabhat Jha. 26. Bloom, David E. 2020. “Population 2020.” International Mone- 2024. “Exploring the labour market outcomes of the risk fac- tary Fund. March 2020. https://www.imf.org/en/Publications/ tors for non-communicable diseases: A systematic review.” fandd/issues/2020/03/changing-demographics-and-eco- Social Science & Medicine - Population Health 25: 101564. nomic-growth-bloom. 40. Chang, Angela Y., Gretchen A. Stevens, Diego S. Cardoso, Bo- 27. Bloom, David E., Alfanso Sousa-Poza, and Uwe Sunde. 2024. chen Cao, and Dean T. Jamison. 2023. “The economic value “Introduction to the Handbook.” In Routledge Handbook on the of avoidable mortality.” in Unlocking the Power of Healthy Lon- Economics of Ageing, edited by David E. Bloom, Alfanso Sou- gevity: Compendium of Research for the Healthy Longevity Initia- sa-Poza and Uwe Sunde, 1–18. Abingdon, Oxon; New York, tive. Washington, DC: World Bank. NY: Routledge. 41. Chen, Xinxin, John Giles, Yao Yao, Winnie Yip, Qinqin Meng, 28. Bloom, David E., Dan Chisholm, Eva Jané-Llopis, Klaus Prettner, Lisa Berkman, He Chen et al. 2022. “The path to healthy ageing Adam Stein, and Andrea Feigl. 2011b. From Burden to “Best in China: a Peking University-Lancet Commission.” Lancet 400 Buys”: Reducing the Economic Impact of Non-Communicable (10367): 1967–2006. Disease in Low- and Middle-Income Countries. Geneva: World 42. Cho, Eo Rin, Ilene K. Brill, Inger T. Gram, Patrick Brown, and Pra- Health Organization. bhat Jha. 2024. “Smoking cessation and short and long-term 29. Bloom, David E., David Canning, and Günther Fink. 2010a. “Im- mortality.” NEJM Evidence 3 (3). plications of population ageing for economic growth.” Oxford 43. de Silva, Sara Johansson, and Indhira Santos. 2024. “Productive Review of Economic Policy 26 (4): 583–612. longevity: what can work in low- and middle-income coun- 30. Bloom, David E., David Canning, and Jocelyn E. Finlay. 2010b. tries?” in Unlocking the Power of Healthy Longevity: Compendi- “Population Aging and Economic Growth in Asia.” In The Eco- um of Research for the Healthy Longevity Initiative. Washington, nomic Consequences of Demographic Change in East Asia, edit- DC: World Bank. ed by Takatoshi Ito and Andrew Rose, 61–89. Chicago: Univer- 44. De Walque, Damien, Adanna Chukwuma, Nono Ayivi-Gue- sity of Chicago Press. dehoussou, and Marianna Koshkakaryan. 2022. “Invitations, 31. Bloom, David E., Elizabeth Cafiero, Eva Jané-Llopis, Shafi- incentives, and conditions: A randomized evaluation of de- ka Abrahams-Gessel, Lakshmi Reddy Bloom, Sana Fathima, mand-side interventions for health screenings.” Social Science Andrea B. Feigl et al. 2011a. The Global Economic Burden of & Medicine 296: 114763. Non-communicable Diseases. Geneva: World Economic Forum. 45. Deaton, Angus. 2008. “Income, Health, and Well-Being around U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y BIBLIOGRAPHY 91 the World: Evidence from the Gallup World Poll.” Journal of Eco- Sun. 2024. “Gendered responsibilities, elderly care, and la- nomic Perspectives 22 (2): 53–72. bor supply: evidence from four middle-income countries.” 46. Demarco, Gustavo, Johannes Koettl, Miglena Abels, and An- in Unlocking the Power of Healthy Longevity: Compendium of drea Petrelli. 2024. “Adequacy pensions and access to health- Research for the Healthy Longevity Initiative. Washington, DC: care: maintaining human capital during old age.” in Unlocking World Bank. the Power of Healthy Longevity: Compendium of Research for the 59. GBD 2019 Tobacco Collaborators. 2021. “Spatial, temporal, and Healthy Longevity Initiative. Washington, DC: World Bank. demographic patterns in prevalence of smoking tobacco use 47. Dikshit, Rajesh, Prakash C. Gupta, Chinthanie Ramasundar- and attributable disease burden in 204 countries and territo- ahettige, Vendhan Gajalakshmi, Lukasz Aleksandrowicz, Ra- ries, 1990-2019: a systematic analysis from the Global Burden jendra Badwe, Rajesh Kumar et al. 2012. “Cancer mortality in of Disease Study 2019.” Lancet 397 (10292): 2337–60. India: a nationally representative survey.” Lancet 379 (9828): 60. Gelband, Hellen, Rengaswamy Sankaranarayanan, Cindy L. 1807–16. Gauvreau, Susan Horton, Benjamin O. Anderson, Freddie Bray, 48. Dsouza, Ritika, Roberta Gatti, and Aart Kraay. 2019. “A Socio- James Cleary et al. 2016. “Costs, affordability, and feasibility of economic Disaggregation of the World Bank Human Capital an essential package of cancer control interventions in low-in- Index.” World Bank Policy Research Working Paper No. 9020. come and middle-income countries: key messages from Washington, DC: World Bank Disease Control Priorities, 3rd edition.” Lancet 387 (10033): 49. European Bank for Reconstruction and Development (EBRD). 2133–44. 2020. Economic inclusion for older workers: Challenges and re- 61. Gilmore, Anna B., Alice Fabbri, Fran Baum, Adam Bertscher, sponses. London: EBRD. Krista Bondy, Ha-Joon Chang, Sandro Demaio et al. 2023. “De- 50. Feng, Zhanlian, Chang Liu, Xinping Guan, and Vincent Mor. fining and conceptualising the commercial determinants of 2012. “China’s rapidly aging population creates policy chal- health.” Lancet 401 (10383): 1194–213. lenges in shaping a viable long-term care system.” Health Af- 62. Glinskaya, Elena, Xiaohui Hou, Zhanlian Feng, Marco Angri- fairs 31 (12): 2764–73. sani, Guadalupe Suarez, Jigyasa Sharma, Drystan Phillips, et 51. Feng, Zhanlian, Elena Glinskaya, Hongtu Chen, Sen Gong, al. 2024. “Demand for and supply of long-term care for older Yue Qiu, Jianming Xu, and Winnie Yip. 2020. “Long-term care persons in low- and middle-income countries.” in Unlocking system for older adults in China: policy landscape, challenges, the Power of Healthy Longevity: Compendium of Research for the and future prospects.” Lancet 396 (10259): 1362–72. Healthy Longevity Initiative.  Washington, DC: World Bank. 52. Food and Agriculture Organization (FAO) and Caribbean De- 63. Global Alliance for Chronic Diseases (GACD). 2023. “Global velopment Bank (CDB). 2019. Study on the State of Agriculture Alliance for Chronic Diseases.” GACD. https://www.gacd.org/. in the Caribbean. Rome: FAO. 64. Global Tobacco Economics Consortium. 2018. “The health, 53. Food and Drug Administration of the United States (FDA). poverty, and financial consequences of a cigarette price in- 2014. Food labeling: Nutrition labeling of standard menu items crease among 500 million male smokers in 13 middle income in restaurants and similar retail food establishments. Washing- countries: compartmental model study.” BMJ 361: k1162. ton, DC: FDA. 65. Govindaraj, Ramesh, and Sundararajan Srinivasa Gopalan. 54. Foster, Gary D., Holly R. Wyatt, James O. Hill, Brian G. McGuckin, 2024. “Control for non-communicable diseases for enhanced Carrie Brill, B. Selma Mohammed, Philippe O. Szapary, Daniel J. human capital: the case for whole-of-society action.” in Un- Rader, Joel S. Edman, and Samuel Klein. 2003. “A Randomized locking the Power of Healthy Longevity: Compendium of Re- Trial of a Low-Carbohydrate Diet for Obesity.” New England search for the Healthy Longevity Initiative. Washington, DC: Journal of Medicine 348 (21): 2082–90. World Bank. 55. Frenk, Julio, Octavio Gómez-Dantés, and Felicia Marie Knaul. 66. Gruber, Jonathan, and Maria Hanratty. 1995. “The labor-mar- 2009. “The democratization of health in Mexico: financial in- ket effects of introducing National Health Insurance: evidence novations for universal coverage.” Bulletin of the World Health from Canada.” Journal of Business & Economic Statistics 13 (2): Organization 87 (7): 542–8. 163–73. 56. Fuchs, Alan, Maria Fernanda González Icaza, and Daniela Paula 67. Guerra, Ricardo O., Beatriz Eugenia Alvarado, and Maria Victo- Paz. 2019. Distributional Effects of Tobacco Taxation: A Compar- ria Zunzunegui. 2008. “Life course, gender and ethnic inequal- ative Analysis. Washington, DC: World Bank. ities in functional disability in a Brazilian urban elderly popu- 57. Garvey, W. Timothy, Rachel L. Batterham, Meena Bhatta, Silvio lation.” Aging Clinical and Experimental Research 20 (1): 53–61. Buscemi, Louise N. Christensen, Juan P. Frias, Esteban Jódar et 68. Gupta, Nidhi, Kashish Goel, Priyali Shah, and Anoop Misra. al. 2022. “Two-year effects of semaglutide in adults with over- 2012. “Childhood obesity in developing countries: epidemiol- weight or obesity: the STEP 5 trial.” Nature Medicine 28 (10): ogy, determinants, and prevention.” Endocrinology Reviews 33 2083–91. (1): 48–70. 58. Gatti, Roberta, Daniel Halim, Allen Hardiman, and Shuqiao 69. Guthold, Regina, Gretchen A. Stevens, Leanne M. Riley, and 92 BIBLIOGR APHY U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Fiona C. Bull. 2018. “Worldwide trends in insufficient physical many), University of California, Berkeley (USA), and French In- activity from 2001 to 2016: a pooled analysis of 358 popula- stitute for Demographic Studies (France). www.mortality.org. tion-based surveys with 1.9 million participants.” Lancet Global 82. Hutchinson, Paul, Alejandra Leyton, Dominique Meekers, Health 6 (10): e1077–86. Charles Stoecker, Francine Wood, Joanna Murray, Naa Dodua 70. Haldane, Victoria, Gisela M. Garcia, Tahir Bockarie, Daphne Dodoo, and Adriana Biney. 2020. “Evaluation of a multimedia Wu, Cristian A Herrera, Maria Luisa Latorre Castro, Debapriya youth anti-smoking and girls’ empowerment campaign: SKY Chakraborty, Beverly Essue, Prabhat Jha, and Jeremy Veillard. Girls Ghana.” BMC Public Health 20 (1): 1734. 2024. “Healthy Longevity Initiative: a performance dashboard 83. International Institute for Population Sciences (IIPS), Nation- for decision-making in low- and middle-income countries.” al Programme for Health Care of Elderly (NPHCE), Ministry in Unlocking the Power of Healthy Longevity: Compendium of of Health and Family Welfare (MoHFW), Harvard T. H. Chan Research for the Healthy Longevity Initiative. Washington, DC: School of Public Health (HSPH) and the University of South- World Bank. ern California (USC). 2020. “Longitudinal Ageing Study in India 71. Hallegatte, Stephane, Mook Bangalore, Laura Bonzanigo, Mar- (LASI): Wave 1, 2017-18: An Investigation of Health, Economic, ianne Fay, Tamaro Kane, Ulf Narloch, Julie Rozenberg, David and Social Well-being of India’s Growing Elderly Population.” Treguer, and Adrien Vogt-Schilb. 2016. Shock Waves: Manag- Mumbai: IIPS. ing the Impacts of Climate Change on Poverty. Washington, DC: 84. Institute for Economics & Peace (IEP). 2023. Ecological Threat World Bank. Report 2023: Analysing Ecological Threats, Resilience & Peace. 72. Henkens, Kène, Hendrik P. van Dalen, and and Hanna van Sydney: IEP. Solinge. 2021. “The Rhetoric and Reality of Phased Retirement 85. Institute for Health Metrics and Evaluation (IHME). 2019. “The Policies.” Public Policy & Aging Report 31 (3): 78–82. Global Burden of Disease (GBD) study.” University of Washing- 73. Hernández, Abraham, Jorge López, Fernando Galindo, and ton: IHME. https://vizhub.healthdata.org/gbd-results/. Fernanda Salas. 2017. Miles for Retirement. Ottawa: Interna- 86. Inter-American Development Bank (IDB). 2023. Panorama of tional Actuarial Association. Aging and Long-term Care. Washington, DC: IDB. 74. Hinz, Richard, Robert Holzmann, David Tuesta, Noriyuki 87. Intergovernmental Panel on Climate Change. 2022. Climate Takayama. 2013. Matching Contributions for Pensions: A Review Change 2022: Impacts, Adaptation and Vulnerability. Contribu- of International Experience. Washington, DC: World Bank. tion of Working Group II to the Sixth Assessment Report of the 75. Hossain, Babul, K. S. James, Varsha P. Nagargoje, and Papai Bar- Intergovernmental Panel on Climate Change, Cambridge Uni- man. 2023. “Differentials in private and public healthcare ser- versity. Cambridge and New York: Cambridge University Press. vice utilization in later life: do gender and marital status have 88. International Diabetes Federation (IDF). 2021. IDF Diabetes At- any association?” Journal of Women & Aging 35 (2): 183–93. las, 10th edition. Brussels: IDF. 76. Hosseini Jebeli, Seyede Sedighe, Aziz Rezapour, Ahmad Ha- 89. International Institute for Population Sciences (IIPS), and ICF. jebi, Maziar Moradi-Lakeh, and Behzad Damari. 2021. “Scal- 2021. “National Family Health Survey (NFHS-5): 2019-2021: ing-up a new socio-mental health service model in Iran to India: Volume 1.” Mumbai: IIPS. reduce burden of neuropsychiatric disorders: an economic 90. International Labour Organization (ILO). 2021a. “ILOSTAT.” In- evaluation study.” International Journal of Mental Health Sys- ternational Labour Organization. https://ilostat.ilo.org/. tems 15: 47. 91. ____. 2021b. World Social Protection Report 2020–22: Social 77. Hossen, Abul, and Anne Westhues. 2010. “A socially excluded protection at the crossroads ‒ in pursuit of a better future. Ge- space: restrictions on access to health care for older women neva: ILO. in rural Bangladesh.” Quality Health Research 20 (9): 1192–201. 92. International Monetary Fund (IMF). 2022. Fossil fuel subsidies. 78. Hou, Xiaohui, Jigyasa Sharma, and Feng Zhao. 2023. Silver Op- Washington, DC: IMF. portunity: Building Integrated Services for Older Adults around 93. Irwin, Alexander; Patricio V Marquez, Prabhat K Jha, Richard Primary Health Care. Washington, DC: World Bank. Peto, Blanca Moreno-Dodson, Mark Goodchild, Anne-Ma- 79. Hum, Ryan J., Prabhat Jha, Anita M. McGahan, and Yu-Ling rie Perucic et al. 2018. Tobacco tax reform at the crossroads Cheng. 2012. “Global divergence in critical income for adult of health and development: technical report of the World Bank and childhood survival: analyses of mortality using Michaelis– Group global tobacco control program (Vol. 2): Main report (En- Menten.” eLife 1: e00051. glish). Washington, DC: World Bank. 80. Hum, Ryan J., Stephane Verguet, Yu-Ling Cheng, Anita M. 94. Jailobaeva, Kanykey, Jennifer Falconer, Giulia Loffreda, Stella McGahan, and Prabhat Jha. 2015. “Are global and regional im- Arakelyan, Sophie Witter, and Alastair Ager. 2021. “An anal- provements in life expectancy and in child, adult and senior ysis of policy and funding priorities of global actors regard- survival slowing?.” PLoS One 10 (5): e0124479. ing Non-communicable disease in low- and middle-income 81. Human Mortality Database. 2022. “Human Mortality Data- countries.” Global Health 17 (1): 68. base.” Max Planck Institute for Demographic Research (Ger- 95. Jamison, Dean T., Ala Alwan, Charles N. Mock, Rachel Nugent, U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y BIBLIOGRAPHY 93 David Watkins, Olusoji Adeyi, Shuchi Anand et al. 2018. “Uni- 109. Kočiš Krůtilová, Veronika, Lewe Bahnsen, and Diana De Graeve. versal health coverage and intersectoral action for health: key 2021. “The out-of-pocket burden of chronic diseases: the cas- messages from Disease Control Priorities, 3rd edition.” Lancet es of Belgian, Czech and German older adults.” BMC Health 391 (10125): 1108–20. Services Research 21 (1): 239. 96. Jeet, Gursimer, J. S. Thakur, Shankar Prinja, and Meenu Singh. 110. Kontopantelis, Evangelos, Tim Doran, David A. Springate, Iain 2017. “Community health workers for non-communicable Buchan, and David Reeves. 2015. “Regression based quasi-ex- diseases prevention and control in developing countries: evi- perimental approach when randomisation is not an option: dence and implications.” PLoS One 12 (7): e0180640. interrupted time series analysis.” BMJ 350: h2750. 97. Jha, Prabhat, and Frank J. Chaloupka. 1999. “Curbing the epi- 111. Kruk, Margaret Elizabeth, Denis Porignon, Peter C. Rockers, demic: governments and the economics of tobacco control.” and Wim Van Lerberghe. 2010. “The contribution of primary Development in Practice. Washington, DC: World Bank. care to health and health systems in low- and middle-income 98. Jha, Prabhat, and Ramanan Laxminarayan. 2009. Choosing countries: a critical review of major primary care initiatives.” Health: An entitlement for all Indians. Toronto: Centre for Global Social Science & Medicine 70 (6): 904–11. Health Research. 112. Kudrna, George, Chung Tran, and Alan Woodland. 2022. “Sus- 99. Jha, Prabhat, and Richard Peto. 2014. “Global effects of smok- tainable and equitable pensions with means testing in aging ing, of quitting, and of taxing tobacco.” New England Journal of economies.” European Economic Review 141: 103947. Medicine 370 (1): 60–8. 113. Kudrna, George, Philip O’Keefe, and John Piggott. 2024. “Pen- 100. Jha, Prabhat, Catherine Hill, Daphne C. Wu, and Richard Peto. sion policy in emerging Asian economies with population 2020. “Cigarette prices, smuggling, and deaths in France and aging: what do we know, where should we go?” In Routledge Canada.” Lancet 395 (10217): 27–8. Handbook on the Economics of Ageing, edited by David E. 101. Jha, Prabhat, David Brown, Nico Nagelkerke, Arthur S. Slutsky, Bloom, Alfonso Sousa-Poza and Uwe Sunde, 234–61. Abing- and Dean T. Jamison. 2005. “Global IDEA.” Canadian Medical don: Routledge. Association Journal 172 (12): 1538–38. 114. Lane, Christopher. 2022. “Meeting health challenges in de- 102. Jha, Prabhat, Mary MacLennan, Frank J. Chaloupka, Ayda veloping Asia with corrective taxes on alcohol, tobacco, and Yurekli, Chintanie Ramasundarahettige, Krishna Palipudi, unhealthy foods.” Manila: ADB. Witold Zatońksi, Samira Asma, and Prakash C. Gupta. 2015. 115. Lee, Hyejin, Yuna Lee, Hyunsoo Choi, and Sung-Bom Pyun. “Global Hazards of Tobacco and the Benefits of Smoking Ces- 2015. “Community integration and quality of life in aphasia sation and Tobacco Taxes.” In Cancer: Disease Control Priorities, after stroke.” Yonsei Medical Journal 56 (6): 1694–702. Third Edition, edited by Hellen Gelband, Prabhat Jha, Rengas- 116. Lee, Ronald, and Andrew Mason. 2017. “Cost of aging.” Finance wamy Sankaranarayanan, and Susan Horton. Washington, DC: & Development 54 (1): 7–9. The International Bank for Reconstruction and Development, 117. Lee, Ronald. 2016. “Macroeconomics, aging, and growth.” In The World Bank. Handbook of the Economics of Population Aging, edited by J. 103. Jha, Prabhat, Rachel Nugent, Stephane Verguet, David E. Piggott and A. Woodland, 59–118. Amsterdam: Elsevier. Bloom, and Ryan Hum. 2013. “Chronic Disease.” In Global Prob- 118. Lena, A., K. Ashok, M. Padma, V. Kamath, and Asha Kamath. lems, Smart Solutions: Costs and Benefits, edited by Bjørn Lom- 2009. “Health and social problems of the elderly: a cross-sec- borg, 137–85. Cambridge: Cambridge University Press. tional study in Udupi Taluk, Karnataka.” Indian Journal of Com- 104. Jha, Prabhat. 2009. “Avoidable global cancer deaths and total munity Medicine 34 (2): 131–4. deaths from smoking.” Nature Reviews Cancer 9 (9): 655–64. 119. Lepeska, Molly, David Beran, and Margaret Ewen. 2021. “Ac- 105. ____. 2020. “The hazards of smoking and the benefits of ces- cess to insulin: a comparison between low- and middle-in- sation: A critical summation of the epidemiological evidence come countries and the United Kingdom.” Practical Diabetes in high-income countries.” eLife 9: e49979. 38 (4): 13-16 106. Kaselitz, Elizabeth, Gurpreet K. Rana, and Michele Heisler. 120. Lewington, Sarah, Robert Clarke, Nawab Qizilbash, Richard 2017. “Public policies and interventions for diabetes in Latin Peto, and Rory Collins. 2002. “Age-specific relevance of usual America: a scoping review.” Current Diabetes Reports 17 (8): 65. blood pressure to vascular mortality: a meta-analysis of indi- 107. Kaur, Damanpreet, Prasad Rasane, Jyoti Singh, Sawinder Kaur, vidual data for one million adults in 61 prospective studies.” Vikas Kumar, Dipendra K. Mahato, Anirban Dey, Kajal Dhawan, Lancet 360 (9349): 1903–13. and Sudhir Kumar. 2019. “Nutritional interventions for elderly 121. Linn, Johannes F. 2022. “Expand multilateral development and considerations for the development of geriatric foods.” bank financing, but do it the right way.” Future Development, Current Aging Science 12 (1): 15–27. Brookings (blog), November 29, 2022. https://www.brook- 108. Kelly, Michael P., and Mary Barker. 2016. “Why is changing ings.edu/articles/expand-multilateral-development-bank-fi- health-related behaviour so difficult?” Public Health 136: nancing-but-do-it-the-right-way/. 109–16. 122. Liu, Fange, Di Lv, Lumin Wang, Xiaoyu Feng, Rongjun Zhang, 94 BIBLIOGR APHY U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y Wendong Liu, and Wenchao Han. 2022. “Breastfeeding and 135. Melliou, Sofia. 2023. “Unleashing the power of AI in drug overweight/obesity among children and adolescents: a design: paving the path to open chemistry data”. Structural cross-sectional study.” BMC Pediatrics 22 (1): 347. Genomics Consortium (SGC). July 27, 2023. www.thesgc.org/ 123. Liu, Lan, Xiao-yuan Dong, and Xiaoying Zhen. 2010. “Parental node/1649631. care and married women’s labor supply in urban China.” Femi- 136. Menon, Geetha R., Lucky Singh, Palak Sharma, Priyanka Yadav, nist Economics 16 (3): 169–92. Shweta Sharma, Shrikant Kalaskar, Harpreet Singh et al. 2019. 124. Luy, Marc. 2016. “The impact of biological factors on sex differ- “National Burden Estimates of healthy life lost in India, 2017: ences in life expectancy: insights from a natural experiment.” an analysis using direct mortality data and indirect disability In Gender-specific life expectancy in Europe 1850-2010, edited data.” Lancet Global Health 7 (12): e1675–84. by Martin Dinges and Andreas Weigl, pg 17-46. Stuttgart: 137. Million Death Study Collaborators. 2017. “Changes in Franz Steiner Verlag. cause-specific neonatal and 1-59-month child mortality in 125. Macinko, James, Barbara Starfield, and Temitope Erinosho. India from 2000 to 2015: a nationally representative survey.” 2009. “The impact of primary healthcare on population health Lancet 390 (10106): 1972–80. in low- and middle-income countries.” Journal of Ambulatory 138. Millwood, Iona Y., Robin G. Walters, Xue W. Mei, Yu Guo, Ling Care Management 32 (2): 150–71. Yang, Zheng Bian, Derrick A. Bennett et al. 2019. “Conventional 126. Macinko, James, Frederico C. Guanais, Pricila Mullachery, and and genetic evidence on alcohol and vascular disease aetiolo- Geronimo Jimenez. 2016. “Gaps in primary care and health gy: a prospective study of 500 000 men and women in China.” system performance in six Latin American and Caribbean Lancet 393 (10183): 1831–42. countries.” Health Affairs 35 (8): 1513–21. 139. Moscona, Jacob, and Awa Ambra Seck. 2021. “Social structure 127. Madhav, Nita, Ben Oppenheim, Nicole Stephenson, Rinette and redistribution: evidence from age set organization.” Cam- Badker, Dean T. Jamison, Cathine Lam, and Amanda Meadow. bridge: Massachusetts Institute of Technology and Harvard 2023. Estimated Future Mortality from Pathogens of Epidemic University. and Pandemic Potential. Washington, DC: Center for Global 140. Munnell, Alicia H., and Abigail N. Walters. 2019. “Proposals to Development. keep older people in the labor force.” Economic Studies at 128. Mahmoud, Abeer M. 2022. “An overview of epigenetics in Brookings. Washington, DC: The Brookings Institute. obesity: the role of lifestyle and therapeutic interventions.” In- 141. Munnell, Alicia H., and April Wu. 2013. “Do older workers ternational Journal of Molecular Sciences 23 (3): 1341. squeeze out younger workers?” Stanford Institute for Econom- 129. Mahumud, Rashidul Alam, Jeff Gow, Md Parvez Mosharaf, ic Policy Research SIEPR Discussion Paper No. 13-011. Stan- Satyajit Kundu, Md Ashfikur Rahman, Natisha Dukhi, Md Sha- ford, CA: Stanford University. hajalal, Sabuj Kanti Mistry, and Khorshed Alam. 2023. “The 142. Murphy, Kevin M., and Robert H. Topel. 2003. Measuring the burden of chronic diseases, disease-stratified exploration and Gains from Medical Research: An Economic Approach. Chicago: gender-differentiated healthcare utilisation among patients in University of Chicago Press. Bangladesh.” PLoS One 18 (5): e0284117. 143. ____. 2005. “The value of health and longevity.” National Bu- 130. Manthey, Jakob, Kevin D. Shield, Margaret Rylett, Omer SM reau of Economic Research Working Paper Series No. 11405. Hasan, Charlotte Probst, and Jürgen Rehm. 2019. “Global al- Cambridge, MA: National Bureau of Economic Research cohol exposure between 1990 and 2017 and forecasts until (NBER). 2030: a modelling study.” Lancet 393 (10190): 2493–502. 144. NCD Alliance, and the George Institute for Global Health. 131. Manthey, Jakob, Syed Ahmed Hassan, Sinclair Carr, Carolin Kil- 2023. Paying the Price: A deep dive into the household economic ian, Sören Kuitunen-Paul, and Jürgen Rehm. 2021. “What are burden of care experienced by people living with Non-communi- the economic costs to society attributable to alcohol use? A cable diseases. Geneva: NCD Alliance. systematic review and modelling study.” Pharmacoeconomics 145. NCD Alliance. 2011. Non-communicable Diseases: A Priority for 39 (7): 809–22. Women’s Health and Development. Geneva: NCD Alliance. 132. Marquez, Patricio V., Konstantin Krasovsky, Tatiana Andreeva, 146. NCD Countdown collaborators. 2022. “NCD Countdown 2030: and Paul Isenman. 2019. Uruguay - Overview of Tobacco Use, efficient pathways and strategic investments to accelerate Tobacco Control Legislation and Taxation. Washington, DC: progress towards the Sustainable Development Goal target World Bank. 3.4 in low-income and middle-income countries.” Lancet 399 133. McArthur, John W., and Krista Rasmussen. 2018. “Change of (10331): 1266–78. pace: Accelerations and advances during the Millennium De- 147. NCD Risk Factor Collaboration (NCD-RisC). 2021. “Worldwide velopment Goal era.” World Development 105: 132–43. trends in hypertension prevalence and progress in treatment 134. McCurdy, Madison. 2022. “Health Benefits of Eating Locally.” and control from 1990 to 2019: a pooled analysis of 1201 pop- University of New Hampshire. (blog). May 17, 2022. https://ex- ulation-representative studies with 104 million participants.” tension.unh.edu/blog/2022/05/health-benefits-eating-locally. Lancet 398 (10304): 957–80. U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y BIBLIOGRAPHY 95 148. Nikolov, Plamen, and Alan Adelman. 2018. “Short-Run Health Statistics. www.ons.gov.uk/peoplepopulationandcommuni- Consequences of Retirement and Pension Benefits: Evidence ty/healthandsocialcare/disability/datasets/disabilityinenglan- from China.” Forum for Health Economics and Policy 21 (2): dandwales2021. 11–10 160. Onder, Harun, and Pierre Pestieau. 2014. “Is aging bad for the 149. Nolen, Stephanie. 2022. “A Door-to-Door Effort to Find economy? maybe.” Economic Premise 144: 1–7. Out Who Died Helps Low-Income Countries Aid the Liv- 161. Organisation for Economic Co-operation and Development ing.” New York Times. April 19, 2022. https://www.nytimes. (OECD). 2017. Pensions at a glance. Paris: OECD. com/2022/04/19/health/death-records-africa-electronic-au- 162. ____. 2019a. The Heavy Burden of Obesity. Paris: OECD. topsy.html. 163. ____. 2019b. Individual Learning Accounts: Design is key for 150. Nolte, Ellen, and Martin McKee. 2003. “Measuring the health success. Paris: OECD. of nations: analysis of mortality amenable to health care.” BMJ 164. ____. 2019c. Working Better with Age. Paris: OECD. 327 (7424): 1129. 165. ____. 2020. Health: Tackling the Obesity Epidemic in Mexico. 151. Nordhaus, William D. 2003. “The Health of Nations: The contri- Paris: OECD. bution of improved health to living standards.” In Measuring 166. ____. 2021. “OECD Stat.” OECD Statistics. OECD. https://stats. the Gains from Medical Research: An Economic Approach, ed- oecd.org/. ited by Kevin H. Murphy and Robert H. Topel, 9–40. Chicago: 167. ____. 2022a. Avoidable mortality: OECD/Eurostat lists of pre- University of Chicago Press. ventable and treatable causes of death. Paris: OECD. 152. Norheim, Ole F., Prabhat Jha, Kesetebirhan Admasu, Tore 168. ____. 2022b. Multilateral Development Finance 2022. Paris: Godal, Ryan J. Hum, Margaret E. Kruk, Octavio Gómez-Dantés OECD Publishing. et al. 2015. “Avoiding 40% of the premature deaths in each 169. Packard, Truman, Ugo Gentilini, Margaret Grosh, Philip O’keefe, country, 2010-30: review of national mortality trends to help David Robalino, and Indhira Santos. 2019. Protecting All: Risk quantify the UN sustainable development goal for health.” Sharing for a Diverse and Diversifying World of Work. Washing- Lancet 385 (9964): 239–52. ton, DC: World Bank. 153. Notre Dame Global Adaptation Initiative (ND-GAIN). 2021. 170. Palacios, Robert. Forthcoming. “Rethinking public pension “ND-GAIN Country Index.” University of Notre Dame, Research provision in Asia.” Washington, DC: World Bank. Environmental Change Initiative. https://gain.nd.edu/our- 171. Pan American Health Organization (PAHO). 2015. “Breast- work/country-index/rankings/. feeding and Non-Communicable Diseases (NCDs).” https:// 154. Nugent, Rachel, Melanie Y. Bertram, Stephen Jan, Louis W. www.paho.org/en/topics/breastfeeding-and-complementa- Niessen, Franco Sassi, Dean T. Jamison, Eduardo González Pier, ry-feeding. and Robert Beaglehole. 2018. “Investing in non-communica- 172. Pan American Health Organization (PAHO). 2022. “Tobacco ble disease prevention and management to advance the Sus- control.” https://www.paho.org/en/topics/tobacco-control. tainable Development Goals.” Lancet 391 (10134): 2029–35. 173. Paraje, Guillermo, and Fabio S. Gomes. 2022. “Expenditures on 155. Nussbaum, Martha C. 2011. Creating capabilities: the human sugar-sweetened beverages in Jamaica and its association with development approach. Cambridge: Belknap Press of Harvard household budget allocation.” BMC Public Health 22 (1): 580. University Press. 174. Paraje, Guillermo, Prabhat Jha, William Savedoff, and Alan 156. Nzinnou Mbiaketcha, Imelda Sonia, Collins Buh Nkum, Ket- Fuchs. 2024. “Taxation of harmful products, including tobacco, ina Hirma Tchio-Nighie, Iliasou Njoudap Mfopou, Francois alcohol and sugar-sweetened beverages, and related topics.” Nguegoue Tchokouaha, and Jérôme Ateudjieu. 2023. “Chronic in Unlocking the Power of Healthy Longevity: Compendium of diseases and mortality among hospitalised COVID-19 patients Research for the Healthy Longevity Initiative. Washington, DC: at Bafoussam Regional Hospital in the West region of Camer- World Bank. oon.” PLOS Global Public Health 3 (2): e0001572. 175. Pednekar, Mangesh S., Rajeev Gupta, and Prakash C. Gupta. 157. O’Keefe, Philip, and Victoria Haldane. 2024. “Towards a frame- 2011. “Illiteracy, low educational status, and cardiovascular work for impact pathways between non-communicable mortality in India.” BMC Public Health 11: 567. diseases, human capital and healthy longevity, economic 176. Pedron, Sara, Karl Emmert-Fees, Michael Laxy, and Lars and wellbeing outcomes.” in Unlocking the Power of Healthy Schwettmann. 2019. “The impact of diabetes on labour mar- Longevity: Compendium of Research for the Healthy Longevity ket participation: a systematic review of results and methods.” Washington DC: World Bank. Initiative.  BMC Public Health 19 (1): 25. 158. Obita, George, and Ahmad Alkhatib. 2022. “Disparities in the 177. Pérez-Escamilla, Rafael, Cecília Tomori, Sonia Hernán- prevalence of childhood obesity-related comorbidities: a sys- dez-Cordero, Phillip Baker, Aluisio JD Barros, France Bégin, tematic review.” Frontiers in Public Health 10: 923744. Donna J. Chapman et al. 2023. “Breastfeeding: crucially im- 159. Office for National Statistics. 2023. “Dataset: Disability in En- portant, but increasingly challenged in a market-driven gland and Wales, 2021.” Census 2021. UK Office for National world.” Lancet 401 (10375): 472–85. 96 BIBLIOGR APHY U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y 178. Piatti, Moritz, Helene Barroy, Fedja Pivodic, and Federica Mar- World Bank. gini. 2022. “Don’t let the budget fool you.” Investing in Health, 190. Rojas, Ana Maria, Ana Maria Munoz Boudet, Ellen Moscoe, World Bank (blog). March 1, 2022. https://blogs.worldbank. Julian Jamison, and Carlos Rumiallo Herl. 2024. “Behavioral org/health/dont-let-budget-fool-you. aspects of healthy longevity.” in Unlocking the Power of Healthy 179. Preston, Samuel H. 1975. “The changing relation between Longevity: Compendium of Research for the Healthy Longevity mortality and level of economic development.” Population Initiative. Washington, DC: World Bank. Studies 29 (2): 231–48. 191. Romieu, Isabelle, Laure Dossus, Simón Barquera, Hervé M. 180. Prizzon, Annalisa, and Bianca Getzel. 2023. “Prospects for aid Blottière, Paul W. Franks, Marc Gunter, Nahla Hwalla et al. 2017. in 2023: a watershed moment or business as usual?”, ODI. May “Energy balance and obesity: what are the main drivers?” Can- 18, 2023. https://odi.org/en/insights/prospects-for-aid-in- cer Causes & Control 28 (3): 247–58. 2023-watershed-moment-or-business-as-usual/. 192. Roser, Max. 2014. “Fertility Rate.” Our World in Data, Glob- 181. Purun, Shi, Zhengxiu Sun, Jiaying Cao, and Zhile Li. 2023. “Has al Change Data Lab and Oxford Martin Program on Global new rural pension system reduced the intake of junk food Development. Oxford, UK: University of Oxford. https://our- among rural older adults? Evidence from China.” Frontiers in worldindata.org/fertility-rate. Public Health 11: 1131337. 193. Rtveladze, Ketevan, Tim Marsh, Laura Webber, Fanny Kilpi, Da- 182. Raghuveer, Geetha. 2010. “Lifetime cardiovascular risk of vid Levy, Wolney Conde, Klim McPherson, and Martin Brown. childhood obesity.” American Journal of Clinical Nutrition 91 2013. “Health and economic burden of obesity in Brazil.” PLoS (5): 1514S–19S. One 8 (7): e68785. 183. Ramachandran, Raja, and Vivekanand Jha. 2013. “Kidney trans- 194. Rumgay, Harriet, Kevin Shield, Hadrien Charvat, Pietro Ferra- plantation is associated with catastrophic out of pocket ex- ri, Bundit Sornpaisarn, Isidore Obot, Farhad Islami, Valery EPP penditure in India.” PLoS One 8 (7): e67812. Lemmens, Jürgen Rehm, and Isabelle Soerjomataram. 2021. 184. Reyes-Sánchez, Francisco, Ana Basto-Abreu, Rossana Tor- “Global burden of cancer in 2020 attributable to alcohol con- res-Alvarez, Francisco Canto-Osorio, Romina González-Mo- sumption: a population-based study.” Lancet Oncology 22 (8): rales, Dwight D. Dyer-Leal, Ruy López-Ridaura, Christian A. 1071–80. Zaragoza-Jiménez, Juan A. Rivera, and Tonatiuh Barrien- 195. Rutstein, David D., William Berenberg, Thomas C. Chalmers, tos-Gutiérrez. 2022. “Fraction of COVID-19 hospitalizations and Charles G. Child 3rd, Alfred P. Fishman, Edward B. Perrin, Jacob deaths attributable to chronic diseases.” Preventive Medicine J. Feldman et al. 1976. “Measuring the quality of medical care.” 155: 106917. New England Journal of Medicine 294 (11): 582–88. 185. Riphahn, Regina T., and Rebecca Schrader. 2021. “Reforms of 196. Saadat, Seemeen, Meriem Boudjadja, and Sameera Altuwaijri. an Early Retirement Pathway in Germany and Their Labor Mar- 2024. “Gender gaps in health and well-being of older adults: ket Effects.” IZA Discussion Paper No. 14908. Bonn, Germany: A review of the burden of non-communicable diseases and IZA - Institute of Labor Economics. barriers to healthcare for women and men,” in Unlocking the 186. Robinson, Lisa A., James K. Hammitt, Michele Cecchini, Kalipso Power of Healthy Longevity: Compendium of Research for the Chalkidou, Karl Claxton, Maureen Cropper, Patrick Hoang-Vu Healthy Longevity Initiative. Washington, DC: World Bank. Eozenou et al. 2019. “Reference Case Guidelines for Bene- 197. Schäferhoff, Marco, Parth Chodavadia, Sebastian Martinez, fit-Cost Analysis in Global Health and Development.” https:// Kaci Kennedy McDade, Sara Fewer, Sachin Silva, Dean Jami- ssrn.com/abstract=4015886 son, and Gavin Yamey. 2019. “International funding for glob- 187. Roder-DeWan, Sanam, Ojaswi Pandey, and Aakash Mohpal. al common goods for health: an analysis using the Creditor 2019. NCDs, education, and human capital: how do NCDs in- Reporting System and G-FINDER databases.” Health Systems & teract with education to affect human capital accumulation? Reform 5 (4): 350–65. Draft paper and PowerPoint presentation. Non-Communicable 198. Scheil-Adlung, Xenia. 2015. Long-term care protection for older Diseases and Human Capital Analytic Work and Key Messaging persons: A review of coverage deficits in 46 countries. Geneva: ILO. Workshop, July 9-10, 2019. Toronto, Canada: University of To- 199. Schwarz, Anita, and Montserrat Pallares-Miralles. Forthcom- ronto Dalla Lana School of Public Health. ing. “Understanding old age income security.” Washington, 188. Rodgers, Jennifer L., Jarrod Jones, Samuel I. Bolleddu, Sahit DC: World Bank. Vanthenapalli, Lydia E. Rodgers, Kinjal Shah, Krishna Karia, and 200. Schwingshackl, L., and G. Hoffmann. 2013. “Long-term effects Siva K. Panguluri. 2019. “Cardiovascular risks associated with of low glycemic index/load vs. high glycemic index/load diets gender and aging.” Journal of Cardiovascular Development and on parameters of obesity and obesity-associated risks: A sys- Disease 6 (2): 19. tematic review and meta-analysis.” Nutrition, Metabolism and 189. Rofman, Rafael, and Ignacio Apella. 2020. When We’re Six- Cardiovascular Diseases 23 (8): 699–706. ty-Four: Opportunities and Challenges for Public Policies in a 201. Scott, Susana, Lindsay Kendall, Pierre Gomez, Stephen RC Population-Aging Context in Latin America. Washington, DC: Howie, Syed MA Zaman, Samba Ceesay, Umberto D’Alessan- U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y BIBLIOGRAPHY 97 dro, and Momodou Jasseh. 2017. “Effect of maternal death “Relationship of race and poverty to lower extremity function on child survival in rural West Africa: 25 years of prospective and decline: findings from the women’s health and aging surveillance data in The Gambia.” PLoS One 12 (2): e0172286. study.” Social Science & Medicine 66 (4): 811–21. 202. Sen, Amartya Kumar. 1997. “Human capital and human capa- 215. Tiwari, Sadhika. 2020. “Aam Aadmi Mohalla Clinics: what has bility.” World Development 25 (12): 1959. worked, what hasn’t.” IndiaSpend. February 6, 2020. https:// 203. Shekar, Meera, and Barry Popkin. 2020. Obesity: Health and www.indiaspend.com/aam-aadmi-mohalla-clinics-what-has- Economic Consequences of an Impending Global Challenge. worked-what-hasnt/. Washington, DC: World Bank. 216. Tobacconomics. 2022. Evidence Matrix: Mexico. Chicago: Insti- 204. Shiri, Rahman, Aapo Hiilamo, Ossi Rahkonen, Suzan JW Ro- tute for Health Research and Policy, University of Illinois. broek, Olli Pietiläinen, and Tea Lallukka. 2021. “Predictors of 217. Tumas, Natalia, Santiago Rodríguez López, Usama Bilal, Ana F. working days lost due to sickness absence and disability pen- Ortigoza, and Ana V. Diez Roux. 2022. “Urban social determi- sion.” International Archives of Occupational and Environmental nants of non-communicable diseases risk factors in Argenti- Health 94 (5): 843–54. na.” Health & Place 77: 102611. 205. Simmonds, Mark, Alexis Llewellyn, Christopher G. Owen, and 218. U.S. National Cancer Institute, and WHO. 2016. The Econom- N. Woolacott. 2016. “Predicting adult obesity from childhood ics of Tobacco and Tobacco Control. National Cancer Institute obesity: a systematic review and meta-analysis.” Obesity Re- Tobacco Control Monograph 21. NIH Publication No. 16-CA- views 17 (2): 95–107. 8029A. Bethesda, MD: U.S. Department of Health and Human 206. Spence, Michael, and Maureen Lewis. 2009. Health and Services, National Institutes of Health, National Cancer Insti- Growth: Commission on Growth and Development. Washing- tute; and Geneva: World Health Organization. ton, DC: World Bank. 219. UNESCO Institute of Statistics. 2021. “Data for the Sustainable 207. Stankuniene, Aurima, Mindaugas Stankunas, Mark Avery, Jutta Development Goals.” UNESCO. https://uis.unesco.org/. Lindert, Rita Mikalauskiene, Maria Gabriella Melchiorre, Fran- 220. United Nations Children’s Fund (UNICEF). 2007. “How to cisco Torres-Gonzalez et al. 2015. “The prevalence of self-re- calculate average annual rate of reduction (AARR) of under- ported underuse of medications due to cost for the elderly: weight prevalence.” Technical Note. Statistics and Monitoring Results from seven European urban communities.” BMC Health Section/Division of Policy and Practice/UNICEF Data. New Services Research 15 (1): 1–8. York: UNICEF. 208. Staubli, Stefan, and Josef Zweimüller. 2013. “Does raising the 221. ____. 2019. The State of the World’s Children 2019. Children, early retirement age increase employment of older workers?” Food and Nutrition: Growing well in a changing world. New Journal of Public Economics 108: 17–32. York: UNICEF. 209. Stenberg, Karin, Odd Hanssen, Tessa Tan-Torres Edejer, Melanie 222. United Nations Environmental Programme. 2018. Inclusive Bertram, Callum Brindley, Andreia Meshreky, James E. Rosen Wealth Report 2018. Nairobi: UN Environment. et al. 2017. “Financing transformative health systems towards 223. United Nations Population Fund (UNFPA), Sri Lanka Ministry achievement of the health Sustainable Development Goals: of Health. 2019. National Strategic Plan (2019 - 2023): Well a model for projected resource needs in 67 low-income and Woman Programme. Colombo: United Nations Population middle-income countries.” Lancet Global Health 5 (9): e875–87. Fund Sri Lanka. 210. Steptoe, Andrew, Angus Deaton, and Arthur A. Stone. 2015. 224. United Nations, Department of Economic and Social Affairs, “Subjective wellbeing, health, and ageing.” Lancet 385 (9968): Population Division (UNPD). 2022. “World Population Pros- 640–648. pects 2022, Online edition.” UNDP. 211. Steptoe, Andrew. 2019. “Happiness and health.” Annual Review 225. United Nations. 2021. Multidimensional Vulnerability Index for of Public Health 40: 339–59. SIDS. New York: United Nations Department of Economic and 212. Sulser, Timothy, Keith D. Wiebe, Shahnila Dunston, Nicola Ce- Social Affairs, United Nations. nacchi, Alejandro Nin-Pratt, Daniel Mason-D’Croz, Richard D. 226. United Nations. 2023. “Causes and Effects of Climate Change.” Robertson, Dirk Willenbockel, and Mark W. Rosegrant. 2021. New York: United Nations. Climate Change and hunger: Estimating costs of adaptation in 227. Vassall, Anna, Sedona Sweeney, Jim Kahn, Gabriela Gomez the agrifood system. Washington, DC: International Food Policy Guillen, Lori Bollinger, Elliot Marseille, Ben Herzel et al. 2017. Research Institute. Reference Case for Estimating the Costs of Global Health Services 213. Sweeny, Kim, Bruce Rasmussen, and Peter Sheehan. 2015. and Interventions. Bill and Melinda Gates Foundation, Univer- “The impact of health on worker attendance and productivity sity of Washington. Seattle: Global Health Cost Consortium. in twelve countries.” Project Report. Melbourne: Victoria Insti- 228. Vega, Angela, Gisela Garcia, and Jeremy Veillard. Forthcoming. tute of Strategic Economic Studies, Victoria University. “Trends, Estimates and the Economic Cost of Avoidable Mor- 214. Thorpe Jr, Roland James, Judith D. Kasper, Sarah L. Szanton, tality in Colombia.” Bogota: World Bank. Kevin D. Frick, Linda P. Fried, and Eleanor M. Simonsick. 2008. 229. Verguet, Stéphane, Cindy L. Gauvreau, Sujata Mishra, Mary 98 BIBLIOGR APHY U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y MacLennan, Shane M. Murphy, Elizabeth D. Brouwer, Rachel 240. Wilmoth, John R., Kirill Andreev, Dmitri Jdanov, Dana A. Glei, C. A. Nugent, Kun Zhao, Prabhat Jha, and Dean T. Jamison. 2015. Boe, M. Bubenheim, D. Philipov, V. Shkolnikov, and P. Vachon. “The consequences of tobacco tax on household health and fi- 2021. “Methods protocol for the Human Mortality Database.” nances in rich and poor smokers in China: an extended cost-ef- HMD Methods Protocol v6: 78. fectiveness analysis.” Lancet Global Health 3 (4): e206–16. 241. Wood, Angela M., Stephen Kaptoge, Adam S. Butterworth, 230. Verguet, Stéphane, Sarah Bolongaita, Angela Y. Chang, Diego Peter Willeit, Samantha Warnakula, Thomas Bolton, Ellie Paige S. Cardoso, and Gretchen A. Stevens. 2024. “The economic val- et al. 2018. “Risk thresholds for alcohol consumption: com- ue associated with avoidable mortality: a systematic assess- bined analysis of individual-participant data for 599 912 cur- ment by cause of death across world regions.” in Unlocking the rent drinkers in 83 prospective studies.” Lancet 391 (10129): Power of Healthy Longevity: Compendium of Research for the 1513–23. Healthy Longevity Initiative. Washington, D.C. World Bank. 242. World Bank. 1993. World Development Report 1993: Investing in 231. Walters, Dylan D., Linh TH Phan, and Roger Mathisen. 2019. Health. Washington, DC: Oxford University Press. “The cost of not breastfeeding: global results from a new tool.” 243. ____. 2018. “The Human Capital Project.” Washington, DC: Health Policy & Planning 34 (6): 407–17. World Bank. https://www.worldbank.org/en/publication/hu- 232. Watkins, David A., Dean T. Jamison, T. Mills, T. Atun, Kristen man-capital. Danforth, Amanda Glassman, Susan Horton et al. 2017. “Uni- 244. ____. 2019. “SWEDD in Action.” World Bank Interactive Data, versal health coverage and essential packages of care.” In Dis- September 17, 2019. https://www.worldbank.org/en/data/ ease Control Priorities: Improving Health and Reducing Poverty, interactive/2019/09/17/swedd-in-action edited by Gelband H Jamison DT, Horton S, Jha P, Laxmina- 245. ____. 2020. “Epidemic Preparedness and Response.” World rayan R, Mock CN, Nugent R. Washington, DC: International Bank Results Brief, October 12, 2020. https://www.worldbank. Bank for Reconstruction and Development/World Bank. org/en/results/2020/10/12/epidemic-preparedness-and-re- 233. Watkins, David A., Gavin Yamey, Marco Schäferhoff, Olusoji sponse Adeyi, George Alleyne, Ala Alwan, Seth Berkley et al. 2018. “Al- 246. ____. 2021. World Bank Support to Aging Countries: An Inde- ma-Ata at 40 years: reflections from the Lancet Commission pendent Evaluation. Independent Evaluation Group. Washing- on Investing in Health.” Lancet 392 (10156): 1434–60. ton, DC: World Bank. 234. Watkins, David A., Jinyuan Qi, Yoshito Kawakatsu, Sarah J. Pick- 247. ____. 2021a. The Changing Wealth of Nations 2021: Managing ersgill, Susan E. Horton, and Dean T. Jamison. 2020. “Resource Assets for the Future. Washington, DC: World Bank. requirements for essential universal health coverage: a mod- 248. ____. 2021b. “Survival to age 65, female (% of cohort) - Sierra elling study based on findings from Disease Control Priorities, Leone.” World Development Indicators. World Bank. https:// 3rd edition.” Lancet Global Health 8 (6): e829-39. genderdata.worldbank.org/indicators/sp-dyn-to-65-zs/. 235. Watkins, David, Sali Ahmed, and Sarah Pickersgill. 2024. “Pri- 249. ____. 2021c. “World Bank Country and Lending Groups.” Data ority setting for NCD control and health system investments.” Help Desk. World Bank. https://datahelpdesk.worldbank.org/ in Unlocking the Power of Healthy Longevity: Compendium of knowledgebase/articles/906519-world-bank-country-and- Research for the Healthy Longevity Initiative. Washington DC: lending-groups. World Bank. 250. ____. 2022. Poverty and Shared Prosperity 2022: Correcting 236. Watts, Nick, W. Neil Adger, Paolo Agnolucci, Jason Blackstock, Course. Washington, DC: World Bank. Peter Byass, Wenjia Cai, Sarah Chaytor et al. 2015. “Health and 251. ____. 2023a. “Advancing Girls and Women Empowerment climate change: policy responses to protect public health.” to Build Resilient Communities in the Face of Rising Threats.” Lancet 386 (10006): 1861–914. World Bank Press Release  2023/017/AFW. September 29, 237. Wen, Richard, Rajeev Kamadod, Cheryl Chin, Asha Behdinan, 2023. https://www.worldbank.org/en/news/press-re- Leslie Newcombe, Areeba Zubair, Thomas Kai Sze Ng et al. lease/2023/09/29/afw-advancing-girls-and-women-empow- “Comparison of ChatGPT to physician-assigned causes of erment-to-build-resilient-communities-in-the-face-of-rising- death in Sierra Leone.” Unpublished manuscript, January 2, threats. 2024, typescript. 252. ____. 2023b. Ending Poverty on a Livable Planet: Report to Gov- 238. Wilding, John PH, Rachel L. Batterham, Melanie Davies, Luc F. ernors on World Bank Evolution. Washington, DC: World Bank. Van Gaal, Kristian Kandler, Katerina Konakli, Ildiko Lingvay et al. 253. ____. 2023c. World Development Indicators Database. World 2022. “Weight regain and cardiometabolic effects after with- Bank. https://databank.worldbank.org/source/world-devel- drawal of semaglutide: The STEP 1 trial extension.” Diabetes, opment-indicators. Obesity and Metabolism 24 (8): 1553–64. 254. ____. 2023d. “Sahel Women’s Empowerment and Demo- 239. Williamson, Camilla. 2015. Policy mapping on ageing in Asia graphics Project.” Projects & Documents. Washington, DC: and the Pacific: Analytical report. UNFPA, HelpAge Internation- World Bank. https://projects.worldbank.org/en/projects-op- al. Chiang Mai: HelpAge International. erations/project-detail/P150080 U N LO CK I N G T H E P OW ER O F H E ALT H Y LO N G E V I T Y BIBLIOGRAPHY 99 255. ____. 2023e. World Development Report 2023: Migrants, Refu- 275. ____. 2022c. The UN Decade of Healthy Ageing 2021-2030 in a gees, and Societies. Washington, DC: World Bank. Climate-changing World. Geneva: WHO. 256. World Health Organization (WHO). 1997. The world health 276. ____. 2023a. “Adolescent sexual and reproductive health and report, 1997: conquering suffering, enriching humanity : ex- rights.” Geneva: WHO. ecutive summary. WHO Office of World Health Reporting. 277. ____. 2023b. “Climate change.” Factsheet. October 12, 2023. Geneva: WHO. Geneva: WHO. 257. World Health Organization (WHO). 2014. Global status report 278. ____. 2023c. “Health system governance.” Geneva: WHO. on Non-communicable diseases. Geneva: WHO. 279. ____. 2023d. “More ways, to save more lives, for less mon- 258. ____. 2017a. Report of the Commission on Ending Childhood ey: World Health Assembly adopts more Best Buys to tackle Obesity. Implementation plan: executive summary. Geneva: Non-communicable diseases.” Departmental Update. May 26, WHO. 2023. Geneva: WHO. 259. ____. 2017b. Tackling NCDs: ‘best buys’ and other recommend- 280. ____. 2023e. “World No Tobacco Day 2023: grow food, not ed interventions for the prevention and control of Non-commu- tobacco.” Geneva: WHO. Licence: CC BY-NC-SA 3.0 IGO nicable diseases. Geneva: WHO. 281. Wu, Daphne C, and Prabhat Jha. 2023. “Assessing human capi- 260. ____. 2017c. WHO report on the global tobacco epidemic, 2017: tal, non-communicable diseases, and healthy longevity in low- monitoring tobacco use and prevention policies. Geneva: WHO. and middle-income countries: healthy longevity dashboard 261. ____. 2018. Global status report on alcohol and health 2018. and the case for India.” Background paper for the World Bank Geneva: WHO. Healthy Longevity Initiative. Washington, DC: World Bank. 262. ____. 2019. WHO global report on trends in prevalence of tobac- 282. Wu, Daphne C., Debapriya Chakraborty, Ryan Hum, Prabhat co use 2000-2025, third edition. Geneva: WHO. Jha, and Dean T. Jamison. 2024. “Rates of progress in mortality 263. ____. 2020a. Decade of Healthy Ageing: Plan of Action. Geneva: decline, 2000-2019.” in Unlocking the Power of Healthy Longev- WHO. ity: Compendium of Research for the Healthy Longevity Initia- 264. ____. 2020b. “Global Health Estimates 2020: Deaths by Cause, tive.  Washington DC: World Bank. Age, Sex, by Country and by Region, 2000-2019.” Geneva: 283. Wu, Daphne C., Geordan Shannon, Luz Myriam Reynales-Shi- WHO. gematsu, Belen Saenz de Miera, Blanca Llorente, and Prabhat 265. ____. 2020c. Global Health Observatory. Data Repository. Jha. 2021. “Implications of household tobacco and alcohol use Geneva: WHO. on child health and women’s welfare in six low and middle-in- 266. ____. 2020d. The Impact of the COVID-19 pandemic on come countries: An analysis from a gender perspective.” Social Non-Communicable Disease Resources and Services. Results of a Science & Medicine 281: 114102. rapid assessment. Geneva: WHO. 284. Wu, Daphne CN, Eduardo P. Banzon, Hellen Gelband, Brian 267. ____. 2021. “Raise taxes on tobacco.” Geneva: WHO. Chin, Varsha Malhotra, Sonalini Khetrapal, David Watkins, 268. ____. 2021a. Decade of healthy ageing: baseline report. Gene- Sungsup Ra, Dean T. Jamison, and Prabhat Jha. 2020. “Health- va: WHO. care investments for the urban populations, Bangladesh and 269. ____. 2021b. “Obesity and overweight.” Geneva: WHO. India.” Bulletin of the World Health Organization 98 (1): 19–29. 270. ____. 2021c. “Climate Change and Health.” Policy Brief. SIDS 285. Xavier, Denis, Prem Pais, P.J. Devereaux, Changchun Xie, Do- Summit for Health: For a healthy and resilient future in Small Is- rairaj Prabhakaran, K. Srinath Reddy, Rajeev Gupta et al. 2008. land Developing States. Geneva: WHO. “Treatment and outcomes of acute coronary syndromes in 271. ____. 2021d. “Non-communicable Diseases and Mental India (CREATE): a prospective analysis of registry data.” Lancet Health Conditions in SIDS”. Policy Brief. SIDS Summit for Health: 371 (9622): 1435–42. For a healthy and resilient future in Small Island Developing 286. Yusuf, Salim, Sumathy Rangarajan, Koon Teo, Shofiqul Islam, States. Geneva: WHO. Wei Li, Lisheng Liu, Jian Bo et al. 2014. “Cardiovascular risk and 272. ____. 2021e. WHO civil registration and vital statistics strategic events in 17 low-, middle-, and high-income countries.” New implementation plan 2021-2025. Geneva: WHO. England Journal of Medicine 371 (9): 818–27. 273. ____. 2022a. “Non-communicable diseases.” Geneva: WHO. 287. Zhang, Chuanchuan. 2012. “The relationship between elderly 274. ____. 2022b. “Non-communicable diseases: Risk factors.” Ge- employment and youth employment: evidence from China.” neva: WHO. MPRA Paper No. 37221. Germany: University Library of Munich. The Healthy Longevity Initiative Demographic change, aging populations, and the rising burden of non-communicable diseases (NCDs) pose formidable challenges worldwide. The drastic shifts in global demographics underway include an increased population of adults, higher mortality and hospitalizations, and heightened caregiving burdens, particularly impacting women. The World Bank’s Healthy Longevity Initiative (HLI) has undertaken comprehensive analyses to offer solutions, turning demographic challenges into opportunities. Key HLI recommendations focus on life course investments to improve health, reduce poverty, address gender inequity, enhance productivity, and increase overall wellbeing. A holistic, country-led approach is crucial, emphasizing the interdependence of responses to demographic shifts, pandemic threats, and climate change. Governments worldwide can prioritize life course HLI investments to control NCDs, delivering tangible benefits that grow dramatically and swiftly over time. Cost-effective measures, such as expanding low-cost treatments for common vascular diseases and cancers, can have a profound impact on households and societies. Fiscal interventions such as higher excise taxes on tobacco yield remarkably quick benefits. The HLI proposals involve increasing healthcare personnel, including essential nurses and doctors, along with upgrading primary care facilities, which yield substantial returns on investment. The HLI builds upon the remarkable achievements in reducing childhood, maternal and infectious disease mortality. The HLI emphasis on research and development, coupled with global public goods, provides a means to “bend the cost curve” for NCDs. At its core, the report underscores the imperative for country-driven initiatives to invest in Healthy Longevity. This presents a viable route to alleviate poverty and elevate well-being, utilizing the strength of the entire life course. The life-course approach can increase the impact of human capital, enabling progress and prosperity for all societies.