Unlocking the Power of Healthy Longevity
Executive Summary
This report, a product of the Healthy Longevity A key reason for the sluggish pace of improve-
Initiative (HLI), presents the rationale and recom- ments in health outcomes among older adults is
mendations for focusing on the many the growing contribution of NCDs. NCDs—
opportunities presented by healthy longevity. This including cardiovascular disease, diabetes,
summary highlights particular points from each respiratory disease, cancer, and selected mental
chapter in turn. health conditions—are responsible for at least 70
percent of deaths globally each year and most
disabilities. The majority of NCD deaths already
Chapter 1: Better health throughout the occur in LMICs, where absolute NCD burdens are
life course is achievable also rising fastest.
Demographic transformations are reshaping the By 2050, based on current projections, there
world, with the global population expected to will be a rise in overall deaths to 92 million from 61
reach 9.7 billion by 2050. Notably, the number of million in 2023, concentrated among middle-aged
middle-age and older adults is rising sharply, and older adults, and most of these deaths will be
creating both opportunities and challenges. from NCDs. The world has, over the last three
Reductions in fertility and child mortality have years, largely overcome the COVID pandemic. Yet
largely driven these changes, along with age- much of the world is unprepared for the serious
structure effects. These, also known as cohort and continuing NCD pandemic of recent decades.
effects, relate to the relative size of different age
Death in very old age is inevitable, but the main
groups.
lesson from centuries of demography and ep-
There are important lessons from the last few idemiology is that death prior to very old age need
decades. The world has made remarkable not be common anywhere. This report’s analysis of
progress in saving children’s lives. From 2000 to avoidable mortality suggests that about 7 in 10 of
2019, the deaths of 65 million children under 5 all deaths in 2019, or 40 million, could have been
were averted in low- and middle-income countries avoided at the lowest observed death rates of
(LMICs). various countries. Deaths can be avoided by
Major global goals, like the Sustainable Devel- applying the abundant knowledge of cost-effective
opment Goals (SDGs), focus on reducing mortality ways to prevent, treat, and palliate NCDs, directly
rates, particularly for children and from NCDs. To- and through their major risk factors, most notably
day, urgent new global health challenges are smoking, obesity and alcohol abuse.
emerging, linked to rapid demographic This report provides a unique lens on NCDs by
transformation, with a big increase in the size of strongly emphasizing a life-course approach. Im-
older age groups and a related rise in cases of plementing this approach will increase good
NCDs. health during longer lives. This will be associated
Population aging carries economic implica- with increased human capital (knowledge, skills,
tions, potentially slowing growth unless there is in- and other individual aspects that contribute to
creased labor force participation and productivity. productivity) applied over longer working lives, as
Countries need careful analysis for policies that well as with positive impacts on gender and
balance economic demands, social services, and income equity.
long-term care costs. Migration policy becomes If all countries were to accelerate their
crucial in this context, depending on the size and progress through life-course approaches by
skill composition of demand, and leveraging the matching the rate of progress that the top 20
differential stages of demographic transition percent of countries have achieved for each age
across countries. Climate change adds an and sex group, cumulatively over 500 million lives
additional layer of complexity, particularly for could be meaningfully extended by 2050, and 25
countries facing both aging populations and rapid million lives could be saved in the year 2050. This
changes in climate.
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would halve avoidable deaths and help achieve the their employment and income while exacting high
relevant SDGs. health care and associated costs. Nor would
This report’s life-course approach to NCDs avoidable diseases kill them prematurely.
aims for not only a longer lifespan but also good Moreover, family members, usually women, would
health throughout. It introduces the Economic not have to compromise their own opportunities to
Value of Avoidable Mortality (EVAM), a new provide protracted care.
analysis to better describe the period of life spent Investments in the life course have proven fea-
in good health, in order to inform priority-setting sible and cost-effective in a variety of countries.
and decision-making. But a global scale-up in life-course health will
The EVAM quantifies the benefits of healthy require substantial resources and effort.
longevity. It considers the acquisition and protec- Innovations can make investments more
tion of health throughout life, comparing actual affordable. While it is significantly cheaper now to
and projected mortality rates against a frontier of save a child’s life than it was several decades ago,
low observed rates. This comparison enables it is more expensive to save an older adult’s life. In
quantification, albeit imperfectly, of avoidable 2019, to keep up with the top 20 percent of peer
mortality. The EVAM method estimates the countries in reducing mortality in children under
economic value of avoiding deaths, emphasizing 15, LMICs had to spend US$182 per capita,
the potential gains from improving life-course substantially less than the US$342 needed in 1990.
investments. This approach makes it possible to But to achieve similar performance for adults aged
compare the economic value of various rates of 50–69, they had to spend US$255, which is more
progress toward reducing mortality. It suggests than the US$198 required in 1990.
that substantial progress is possible, emphasizing The rising relative cost to save an adult life em-
the importance of accelerating efforts to reduce phasizes the need for more effective interventions
NCDs. through research and development (R&D) and oth-
er global public goods (GPGs) to bend the cost
curve downward, as has happened for children’s
Chapter 2. Healthy longevity, NCDs, and health.
human capital: Action across the life
course Taking a life-course approach to NCDs pro-
vides an economic case for what is already clear
By acting across the life course, the world can on moral grounds, and which shone through the
achieve a more desirable and dignified form of lon- world’s collective response to the COVID pandem -
gevity that benefits individuals, households, and ic: the lives of older adults are well worth saving.
societies alike. This report defines healthy Life-course programs, starting at a young age, to
longevity as the state of good physical, cognitive, reduce NCDs have a modest positive impact on
and social functioning for nearly the full lifespan of human capital (more education and on-the-job
an individual. Healthy longevity is a key component training) and enable deployment of that human
of people’s wellbeing, and thus important in itself capital over longer working lives. Lower NCD
as a key objective for development. It is burdens also reduce absenteeism and decrease
simultaneously a driver of greater equity and social age-related depreciation of human capital, so
inclusion—socioeconomic, gender, and increasing worker productivity. Extending working
intergenerational. The ultimate vision is for people lives will be particularly important as the labor
to live longer, healthier, more productive, and force grows more slowly (or even shrinks) in an
more satisfying lives. Some of the health and increasing number of middle-income countries.
wellbeing benefits to be had in the future will, This opens up the possibility of increased
rightly, be after retirement. economic growth, depending on the effectiveness
This vision would mean that in their formative of government policies and of their
years, adolescents and young adults would be implementation—not just in NCDs but on labor
much less likely to take up smoking, start drinking market and other directly related issues. It
to excess, or become obese—all activities that sig- depends even more on the evolution of broader
nificantly increase their likelihood of developing underlying determinants of growth, including
NCDs. In this improved scenario, chronic ill health economic management, education, institutions,
would be much less likely to mar their lives, limiting and technology.
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Even more importantly, reducing prevalence, preventable death and disease, both before
morbidity, and mortality from NCDs also brings scaling up starts and in the longer run, because it
about improvements in human wellbeing. This will inevitably take a long time for scaling up to
comes not only through higher incomes, but also reach full coverage.
as a direct consequence of being healthy. A commitment to healthy longevity through a
In discussing the wellbeing impacts of life-course approach can be realized in part by
addressing NCDs, it is important to bear in mind continuing investments in child and maternal
the equity dimension. People living in poverty and health and nutrition. To improve health from teen
other disadvantaged groups are more likely to have to older ages, Chapter 3 lists a range of 31 cost-
NCDs. This is partly because poor people are more effective, evidence-based interventions that
prone to adopt behaviors that lead to NCDs, such countries can select from and adapt in view of their
as smoking and obesity, and to have worse mental unique needs and constraints. The HLI
health. Poor people are also more likely not to be recommended menu of clinical health
able to afford, and may be far from, the diagnostic interventions can largely be delivered through
and treatment care they need. In addition, studies primary health care (PHC) systems, ideally in
show that the combination of high medical bills concert with community-based care. These
and lost income of a breadwinner creates a high interventions are not only cost-effective but also
risk of personal and family impoverishment. address equity, reducing financial risk, and feasi-
Addressing NCDs also reduces gender bility of implementation. Countries can draw on
inequality. This is partly because women have and adapt these interventions, depending on their
heavy specific NCD burdens over their lifetimes, specific needs and capacities. Scaling up all of the
which are usually longer than those of men. It is items in the prioritized list of interventions to cover
also, importantly, because of the societal even 80 percent of the population in all LMICs by
expectation that women will provide care to older 2030 would dramatically reduce NCD mortality
household members suffering from NCDs instead and would be highly cost-effective—even though in
of seeking gainful employment outside the practice it would take longer in most countries to
household. Women also frequently experience get in place all the financing and capacity needed.
greater barriers to health care for their own NCDs, For the great majority of countries, adopting all of
especially because of their often-limited financial the measures at once would involve unrealistic in-
means and decision-making power within the creases in health expenditure and institutional ca-
household, particularly in LMICs. It is for these pacity. Realistically, most LMICs will need to focus
reasons the HLI includes a strong, explicit initially on a subset of interventions and sequence
emphasis on gender in its recommendations. the order and expansion of their coverage. Most
countries will likely want to apply “progressive uni-
In sum, reducing the prevalence of NCDs
versalism”: limiting costs by concentrating public
would also reduce socioeconomic and gender
financing initially on the poor and disadvantaged,
inequalities. The healthy longevity approach to
then moving toward universal coverage of a set of
NCDs consistently emphasizes taking account of
basic services, and then adding to that set as
these inequalities in strategies and interventions—
financing and institutional capacity permit.
whether in prevention and care of NCDs or in
policies related to labor markets, pensions, or The chapter also provides a framework for pri-
long-term care (LTC). oritizing NCD interventions based on three other
criteria beyond cost-effectiveness: equity, finan-
cial risk protection, and implementation
Chapter 3. Advancing healthy longevity feasibility. The list of high-priority intervention
now: What countries can do includes six population-level prevention
Countries can make major advances toward measures, all of which are highly cost-effective
healthy longevity with well-chosen policies and and relatively inexpensive to implement. The
life-course interventions if implemented quickly. A biggest and most cost-effective gains would
key general message is the need to substantially generally come from “health taxes”— particularly
accelerate NCD interventions, which have been taxes on tobacco. These policies are feasible to
underused, and to do so early. Delays in adopting implement even in countries with weak in-
interventions will result in massive and stitutional and financial capacity, including in
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those recently emerging from war or conflict. There LMICs who have worked in the informal sector.
is vast evidence that health taxes reduce This can help the many older adults and families
consumption of these substances that sicken and facing both low incomes and high out-of-pocket
kill; in the case of tobacco, prolonged smokers medical expenses, especially in those countries
lose an average of one decade of life compared to far from achieving universal health care.
non-smokers. Yet this fiscal tool is greatly Additionally, to ensure the healthy and dignified
underused worldwide. The high priority package aging of people who require LTC, countries should
also recommends other clinical interventions— consider how best to bolster, oversee, and -as
including pulmonary rehabilitation and treatment needed- partly subsidize community and home-
for chronic heart failure—and prioritizes them based care, with less emphasis on sparse and
based on country income level. expensive residential LTC. For both non-
Overall, fully implementing the high-priority contributory pensions and LTC systems, countries
package of interventions starting from 2023 to will have quite different needs and capacities, and
2050 could avert up to 150 million deaths by 2050, so different approaches. Well-evaluated pilots of
at an incremental cost of US$1.3 trillion (US$9,300 both, supported as appropriate by external
per death averted). The budgetary implications of funding, can help countries assess what makes
the package would be more manageable. Total the most sense for them before large-scale
cost (at 80 percent coverage) would in the longer expansion.
run range from a relatively affordable 7 percent of Adults who continue working longer contribute
projected public spending on health in 2050 in to household income. They can also support
upper-middle income countries, to a much more children and other, needier elders by providing
challenging 20 percent in low-income countries. family or community care. As they age, they can re-
This cost is based on the assumption that tain some independence—with many aging in their
countries invest in the package constantly every own homes, with family, community, and public
year from 2023 to 2050. Given that programs take support. For older adults, especially women, there
some years to reach full operational capacity and is a need for adequate access to health care.
the cost to save a life increases over time, it is Ideally, ill health would be confined to a short
urgent that countries act now in prioritizing, period just before the end of their lives.
adapting, and implementing the package, so that Another urgent area for country action is the
consequently with economies of scale, scaling up strengthening of country data systems that can
coverage for these interventions remains feasible. help set and measure progress on life-course
The HLI intervention package should be con- health. Expanding open data sources for
sidered a starter or catalytic package that needs to widespread use is needed to help countries
be customized to local contexts. For political consider how to improve their performance,
economy and institutional reasons, some including by providing data with which to measure
countries will continue NCD interventions not in their progress and problems against those of peer
the HLI list, even if they are relatively less cost- countries. Essential investments include supports
effective. In addition, over time there will be new for national vital events, registration systems, and
cost-effective interventions (new or newly cost- improved statistical capacity. There is also a need
effective) because of declining prices, including for healthy longevity dashboards: an innovative
from GPGs. data visualization tool tailored to countries that
Moving beyond health-specific interventions, aims to help turn data into action. It synthesizes
policies on jobs, social protection, and LTC will key indicators to improve management and
also be needed to progress on the NCD and evaluation and enables and encourages countries
healthy longevity agendas. In terms of to draw on available data to assess their
employment, countries could call on a range of performance in relation to others.
policies to support older workers who wish to
continue working, with resultant benefits for their,
and potentially, national incomes. For those no
longer able to work, a critical area of social
protection is non-contributory pensions, where
fiscally feasible, for the large poor populations in
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Chapter 4. Financing for healthy longevity: investments. Development partners (external
Country leadership and key supporting donors and partners of development—bilateral
roles for development partners and multilateral organizations, foundations, and
The NCD and other aspects of the healthy longevity NGOs) can also help in analysis and technical
agenda are ambitious, and the necessary financing assistance.
will be considerable. But these investments will Development partners have enormous scope
deliver strong returns on investment, contributing for increasing their financial assistance. Currently
to human capital while reducing poverty. just 2 percent of all official development
The time for action is now, as delaying NCD-re- assistance for health (ODA) goes to NCDs.
lated interventions will result in increased NCD Development partners as well as countries should
death, disease, suffering, and worsening poverty. work closely with foundations, academia, and
While some interventions can affect change NGOs. The private sector also has a major role to
quickly, most NCD programs take some years to play in research, production, financing, and
establish the financial and institutional capacity— technical capacity. Stewardship of the private
and needed political support—for adequate sector should be encouraging while still taking
national coverage. Strong country ownership is account of diverging incentives.
essential. And it is at the country level where the The HLI comes at a time when there is mo-
bulk of the financing will need to be mobilized. mentum for a strengthening the role of multilateral
To extend the high-priority package of recom- development banks (MDBs). MDBs are well placed
mendations to all LMICs would cost up to US$220 to use their financial, technical, and institutional
billion in 2050. The cost would be reasonably resources, their cross-country experience, and
affordable, at 8 percent of projected public their close relations with both finance ministries
expenditures on health in 2050 for lower-middle and health ministries to encourage and support
income countries, 6 percent for upper-middle country-owned NCD and broader healthy living
income countries, and 20 percent for LICs. The initiatives and programs. The World Bank Group
corresponding benefits of life-course investments stands ready to apply its full set of relevant
are large—corresponding to over US$3.2 trillion in instruments to implementation of the HLI, tailored
economic value of avoidable mortality in 2050. to specific country circumstances as a part of its
Thus, the benefit-cost ratio is very favorable, at growing support for health and social protection.
about 16 to 1 overall for all LMICs. Countries need Experience from NCDs suggests three priori-
to customize interventions to various contexts and ties for planning responses to future pandemics: (i)
over time. The overall cost-benefit ratio of the HLI reducing NCDs, given that much of COVID’s very
is sufficiently high to suggest that various large death tolls occurred among those with pre-
combinations that include most of the HLI existing chronic disease and that NCD sufferers
interventions should be attractive investments. are also likely targets for future viruses; (ii)
The political economy of investments over the improving data systems for both emergencies and
life course suggests that each country would have routine diseases, including nationwide systems to
to consider the benefits and demands from its monitor deaths and detect outbreaks; and (iii) the
citizens. Most interventions will require long-term close link between NCDs and the impact of
efforts to attain full coverage. Reassuringly, longer- pandemics adds a strong argument in favor of a
term costs would fall somewhat through cost-effective global adult vaccination program to
economies of scale plus benefits from expand routine antigen coverage and to provide
investments in GPGs (health technologies, good surge capacity for future pandemics.
practices, and other “tools” at the global or While climate investments are essential for
regional level with benefits beyond borders). planetary health, they are also complementary to
External assistance could play an important life-course investments. Synergistic investments,
role in accelerating expenditures and policy such as expanding green transportation in urban
actions in the early years of scaling up NCD settings, can reduce carbon footprints and
programs. The external financing would be increase incentives for physical activity. Ending
available to support countries’ efforts at harmful subsidies for fossil fuels, which represent
determining priorities, institutional reforms, and to about 7 percent of global gross domestic product
kick-start the scaling up of life-course (GDP), can free up major amounts in government
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budgets that can be used for health as well as Chapter 5. From knowledge to action
climate change mitigation and adaptation and Prevention and control of NCDs amidst demo-
other priorities. graphic transformation is a grand challenge for the
GPG investments are a powerful lever for im- first half of the twenty-first century, commensurate
proving health throughout the life course and for in scale to climate change and global pandemics.
amplifying the equity impact of such efforts. They The overall recommendation is for countries to
are much needed to bend downwards the cost invest in life-course investments for NCDs, with
curve (reduce costs) and improve results for related reforms of labor markets, pensions, and
developing countries. GPGs relevant to NCD long-term care. The former covers three areas: (i)
prevention and management include knowledge- scaling up high-impact interventions; (ii) address-
sharing networks, sharing of intellectual property, ing specific social protection and long-term care
and global procurement mechanisms for health needs; and (iii) supporting data and global public
commodities, as well as relevant scientific goods for healthy longevity. More detailed recom-
breakthroughs for NCD treatment. Our broad mendations are provided in the various chapters
definition of GPGs also includes technical and are summarized above.
assistance to countries on uptake of GPGs. This
Acting on these recommendations would con-
includes possible expansion of the role of artificial
tribute to three linked key outcomes: (i) reduced
intelligence (AI) in global health. AI tools could help
death and disease from NCDs and improved
identify new treatments and spur efficiencies in
wellbeing; (ii) reduced poverty and gender
delivery and quality assurance of life-course
inequality; and (iii) improved productivity, choice,
investments. Careful cross-country regulation and
and equity in work.
transparent governance will be required to curb
disinformation and other harmful AI practices and If all countries improve their performance to
share benefits equitably. match their best-performing peers, this could avert
up 25 million deaths in the year 2050, halve avoid-
Development partners should give high priority
able deaths, and achieve many of the SDGs.
to investing in and fostering the uptake of GPGs for
healthy longevity as an important complement to At both country and global levels, building
their financing at country level. Financing to date strong support at top political and other leadership
for GPGs for elders and other adults has been levels for adopting and advancing the agenda is
grossly inadequate. While most financing for NCDs required. That will take a strong and coordinated
at country level will come from the countries them- whole-of-society effort that includes, within
selves, this is not the case for GPGs. Rather, GPG governments, ministries of finance, planning,
support is a critical area where multilateral and bi- social protection, labor, and gender among others,
lateral development partners, foundations, NGOs, as well as championing by health ministries. That
academia, and public health groups can spur effort should go far beyond governments and
transformation. MDBs are considering how they external partners to include academia, NGOs,
can best give higher priority to participating in the foundations, the media, civil society, the private
development and application of such GPGs. sector, and the broader global and national
development and health communities including
GPGs have helped to foster incredible im-
people living with NCDs. The challenge facing all
provements in child survival and have driven the
who recognize the feasibility and importance of
significant decrease in the cost of saving a child’s
healthy longevity is moving from knowledge to
life. They could help to do the same for adults.
large-scale, sustainable action and impact.
Drawing on the lessons from those improvements
and applying the same energy to a life-course ap-
proach to address NCDs has the potential to con-
tribute to putting the world on a path to a more
equitable and healthy future.
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