Introduction

During the 21st century notable progress has been achieved in improving the health of mothers and children worldwide, with substantial reductions in maternal and child mortality over the past 25 years – about 40% for the former, and 60% for the latter. Also, stunting among children declined by 27%. Improvements in access to health care, antibiotics, and vaccines, together with major investments in targeted programs, have also led to reduced deaths from many infectious diseases, including AIDS, tuberculosis, and malaria. Consequently, chronic non-communicable diseases increased as an overall cause of death from 61% in 2000 to 74% in 2019.1,2 Although these figures reflect global trends, infectious diseases still account for nearly half of all deaths in countries with low levels of economic development. In such countries, the COVID-19 pandemic has further slowed progress in public health, while the burden placed on health systems by the new infectious disease has increased deaths from tuberculosis and malaria.1,2

Before the COVID-19 pandemic, the world had been experiencing positive trends in child growth and development, control of alcohol consumption and smoking, wider access to safely managed drinking water and sanitation, improved basic hygiene, and a transition to cleaner fuels and more advanced cooking technologies.1,2 However, obesity was rising across all age groups, high blood pressure among adults was on the increase, anaemia was widespread among women, air pollution troubled urban settlements, and violence against women and other vulnerable groups was also on the increase.1 Average alcohol consumption has been slightly declining, and men consume three times more alcohol than women. Tobacco control measures have worked in many places, leading to the prevalence of active smokers aged 15 years or more globally of only 22% of the global population aged 15 years or older actively smoked in 2020: a reduction of almost one third compared with 2000.1,2

The Main Risk Factors

Among the major health risk factors affecting the global population today, high blood pressure has steadily risen in prominence. The number of adults between their third and eighth decades of life with elevated blood pressure doubled between 1990 and 2019 to a total of 1.28 billion people.1,2 It is particularly concerning that the rates are becoming non-negligible in children, too, due to remarkable changes in their lifestyles brought about by digital age.3 The overall increase can be explained in part by the growing number of people in older age groups, and partly also by lifestyle habits associated with modern ways of living.

Another major problem of continuing interest to our Journal of Global Health Economics and Policy is the lack of access to safe drinking water. It is estimated that only about three quarters of the world’s population use safely managed drinking water,1,2 which means that two billion people still lack water that would be free from disease-causing pathogens. Although the situation with water is gradually improving, sanitation seems more resistant to progress, with about 3.5 billion people worldwide still lacking adequate sanitation services and suffering from infections.1,2 Progress in ensuring access to safe drinking water and sanitation had already been relatively slow even before the COVID-19 pandemic. Now, it would need to accelerate at least fourfold for universal access to water and sanitation to be achieved by 2030. At present, about 45% of household wastewater is discharged without any treatment, which is far from that goal and any innovations that could accelerate progress in this area would be welcome.1,2

Indoor and outdoor air pollution have also been facing more scrutiny by the global health research community. Indoor air quality can deteriorate due to cooking with dirty or solid fuels, while outdoor air pollution in increasingly a challenge in crowded cities. More than two thirds of the world’s population now use clean fuels and technologies for cooking, an increase from about 50% at the beginning of the 21st century. Still, more than 95% of people globally breathe unhealthy levels of fine particulate matter and nitrogen dioxide. Another environmental health issue that is gaining prominence is microplastics and its effects on health, and we welcome innovative research in this area to improve our understanding of this challenge.4

Access to health services steadily improved throughout the 21st century, increasing from around half of the world’s population having access to health systems to about two thirds. This is a welcome progress, but the proportion of people whose out-of-pocket health expenditures exceeded 10% of their household income rose in this century from more than 9% to more than 13%, while global health expenditure more than doubled in real terms, approaching as much as 10% of global gross domestic product. Approximately 80% of this spending occurred in high-income countries, with about 70% of the funds being drawn from government budgets. Contrary to these settings, health care in low-income countries is most often financed through out-of-pocket payments or humanitarian assistance.1,2

The Main Causes of Death

Before the COVID-19 pandemic, about 55 million people were dying worldwide each year. The leading cause of death were heart attacks, with 9 million annual deaths, followed by further 6 million deaths from strokes.1,2 Cancer followed combined cardiovascular diseases as the cause of death with about 10 million, although respiratory diseases are also a less appreciated major cause of death - especially when viewed as a group. Chronic obstructive pulmonary disease (COPD) kills some 3 million people each year, while pneumonias across all age groups add further 2 million. A particularly concerning trend is the increase in Alzheimer’s disease and other dementias, which are now approaching 2 million deaths annually and are expected to continue rising.1,2

COVID-19 emerged as an entirely new global public health threat. Although between 2020 and 2022 the officially recorded number of deaths directly attributable to infection with the SARS-CoV-2 virus was estimated to 6-7 million deaths, it was striking that nearly 75% of the occurred in North and South America and Europe.1,2 Therefore, the reported global death toll is unlikely to be complete. Experts in global health statistics are aware that many less developed and poorer countries, often with very large populations, have limited testing capacity and lack functional registration systems capable of providing accurate and complete mortality data related to COVID-19. Consequently, estimates based on sophisticated additional calculations suggest that the true number of deaths directly or indirectly associated with the COVID-19 pandemic during its first two years alone, i.e., between January 1, 2020 and December 31, 2021, was around 15 million worldwide. This is about 7-8 million annually during each of the first two pandemic years. When these figures are compared with the leading causes of death globally in the pre-pandemic period, it is not surprising that in countries with the weakest epidemiological responses to the pandemic, COVID-19 became the leading cause of death during 2020 and 2021.1,2

The Effects of the COVID-19 Pandemic

The COVID-19 pandemic disproportionately affected particularly vulnerable populations, including older people and those with pre-existing health conditions. During the second half of 2021 and the beginning of 2022, the global supply of vaccines that provide very high protection against death from COVID-19 increased to the point that supply itself was no longer the main limitation. By early 2022, enough vaccine doses had been produced to provide all adults and adolescents with a total of three doses. By mid-2022, more than 75% of the population in high-income and upper-middle-income countries had received at least one vaccine dose.1,2 In lower-middle-income countries about 50% of people had received their first dose, while in low-income countries only about 12% of the population had been vaccinated with at least one dose. In African countries, only about one quarter of adults older than 60 years had been fully vaccinated.1,2,5

The unexpected pandemic with many severely ill patients led to shortages of staff and essential medicines, difficulties in organizing diagnostic services, and broader limitations in infrastructure and space within health facilities.1,2 The capacity to provide essential health services was already very limited in many countries, due to shortages of health workers, and the COVID-19 pandemic made the situation worse.1,2 It is projected that by 2030 the world will face a shortage of as many as 18 million health workers who would be required to provide adequate health care to the entire global population. This problem is particularly pronounced in Africa, which accounts for about one quarter of the global burden of disease.1,2 At the same time, it employs only 3% of the world’s health workforce, representing an enormous imbalance.1,2

Overall and Healthy Life Expectancy

Before the pandemic, global life expectancy had been steadily increasing, rising from 67 years in 2000 to 73 years in 2019. In parallel, healthy life expectancy, i.e., years lived without disabling chronic disease, has also increased from 58 to 64 years.1,2 Still, very large differences between the richer and the poorer remain, with disparities between countries reaching up to 20 years. Moreover, the COVID-19 pandemic halted and reversed these positive trends in many countries, leading to declines in life expectancy between 2020 and 2022.1,2

Leading international organizations concerned with global health are calling for stronger progress in three priority areas to accelerate advancement toward universal health coverage for the entire world population. These include continued strengthening of primary health care, developing sustainable financing mechanisms for health systems, and permanently reinforcing system capacity, particularly through investment in the health workforce.1 Strong primary health care remains the foundation of equitable health systems, which demonstrate considerable resilience in crises such as the COVID-19 pandemic. Insufficient attention to the development of primary health care in many countries weakened their responses to the pandemic and disrupted routine health services. Strengthening public health services and primary health care therefore represents the most effective way to preserve the positive public health trends that had been achieved in the years and decades preceding the pandemic.1,2

Areas of Interest to the Journal of Global Health Economics and Policy

Taken together, the trends outlined in this review highlight both remarkable progress in global health and persistent structural challenges that require new economic and policy thinking. The shifting burden toward chronic non-communicable diseases, persistent inequalities in access to safe water, sanitation, and health services, and the vulnerabilities revealed by the COVID-19 pandemic all underscore the need for stronger evidence linking health outcomes with financing models, governance structures, and policy design.

As a journal dedicated to global health economics and policy, the Journal of Global Health Economics and Policy is therefore looking forward to promoting research that moves beyond description toward actionable economic and policy solutions. In particular, the journal would welcome submissions examining sustainable financing models for universal health coverage, economic evaluations of strengthening primary health care systems, and policy innovations that reduce catastrophic out-of-pocket health spending in low- and middle-income countries. We also encourage analyses of cost-effective interventions addressing the rising burden of cardiovascular disease, cancer, and other non-communicable conditions, as well as research on economic strategies to accelerate progress in water, sanitation, and environmental health, including air pollution and emerging threats such as microplastics.

Further priorities include studies on health workforce economics, resilience of health systems to pandemics and climate shocks, and equitable access to vaccines and essential medicines. By inviting rigorous interdisciplinary work in these areas, the journal aims to support policies that translate global health progress into sustainable, equitable gains for all populations.