A grand convergence and a historic opportunity.

e38 www.thelancet.com Vol 382 December 7, 2013 The 1993 World Development Report (WDR) was a landmark publication: it put health squarely on the radar as a mainstream development opportunity. WDR 1993 made the important linkage between health gains and economic development, and it did so with arguments, metrics, and an audience that would have a substantial impact on how the world’s decision makers prioritised and fi nanced health. It is timely and appropriate that now, 20 years later, we take stock and revisit the trends, opportunities, and investment case. Building on the unprecedented progress in health over the past 20 years, the Lancet Commission on Investing in Health lays out the opportunity and components of a “grand convergence”: to reduce infections and child and maternal mortality to low rates universally, and to tackle non-communicable diseases (NCDs) and the impoverishing eff ects of health expenditures within a generation. In the work of the Global Fund to Fight AIDS, Tuberculosis and Malaria, we see a similar historic opportunity, as the confl uence of scientifi c advancement, epidemiological intelligence, and experience from more than a decade of implementation comes together to off er the plausible goal of ending HIV, tuber culosis, and malaria as public health threats, while expanding the human family, strengthening health systems, and promoting partnerships. And, indeed, we must capitalise on this historic opportunity now; it is imperative that we curb the costs and casualties of these still potent diseases, which—as this Commission notes—will continue to impose a heavy burden over the coming years, even as we begin to see a shift in the global disease burden towards NCDs. From our eff orts to date on infectious diseases, there are signifi cant capacities, infrastructures, and lessons that we should strategically leverage and apply as we prepare for the shift towards NCDs, such as in the linkages between HIV and cervical cancer. Our collective work in HIV has furthermore been the fi rst time we have tackled a chronic disease at national scale in developing countries, from prevention and diagnosis to eff ective treatment and care. This should serve as a useful starting point for lessons learned and, where possible, a platform for the growing needs related to the management of NCDs. The Commission rightly points out that much of the incremental costs of achieving convergence can be covered from domestic sources, given the expected continued economic growth of low-income and middleincome countries. Without doubt, the health gains of the next 20 years will need to be fi nanced increasingly through domestic funds. There is increasing recognition by countries themselves of the need to commit more domestic resources to health, for example when African heads of state recently called for the need to “look inwards for innovative mechanisms and solutions in health fi nancing” at the recent AIDS Watch Africa Meeting in Addis Ababa, Ethiopia. Coun tries will need to follow through with these pledges and step up their domestic investments in health; this will serve to improve their own health and economic wellbeing and maintain external resource commitments. But we must also be mindful that categories such as middle income capture a broad range of economic means, and we will, therefore, need to manage expectations about how much of the necessary funds will realistically come from implementing countries themselves. Similarly, although we have made excellent progress in increasing access to essential health products through discounted pricing for low-income countries, we will increasingly also need to work on calibrated pricing terms to increase access to the over 70% of the world’s poor who now live in middle-income countries. A grand convergence and a historic opportunity