Ideas to Action:

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Views from the Center


Among the many disparities and inequities that COVID-19 has shone a light upon, the chasm in health outcomes between rich and poor countries is being particularly sharply highlighted. While Israel, the US, the UK, and a handful of high- and upper-middle income countries are charging forward with their vaccination programmes, many of the poorest are left behind—sometimes to rapidly soaring infection rates, as in India. Universal health—that is, a basic level of health and nutrition achieved globally—seems a distant prospect.

The second CGD/Gui2de Future of Development seminar featured Pascaline Dupas and Jishnu Das discussing if and how higher levels of health and nutrition status can be achieved universally in a wide ranging conversation taking in income growth,  public health investments and infrastructure,  the role of innovation and technology, and how the sequencing of advances in these areas differed in high-income and developing countries. The conversation focused on the obstacles and strategies to achieving better health and nutrition outcomes overall, rather than the strategy of universal health coverage per se, although the two issues are closely inter-related.

Pascaline’s argument was that progress towards better health in high-income countries came from three sources in a particular order: first, incomes, standards of living, and nutrition improved; then investments in public health were made by the state; and then dramatic advances in technologies and innovation facilitated further improvements. This has not been the case in developing countries. The adoption of innovation and new technologies primarily designed for the problems of high-income countries have sometimes come before either public health investments or income growth. Although healthcare itself is top-of-mind for policymakers, much of the progress towards better health and nutrition will therefore depend on progress outside the healthcare system, though still within the domain of public action.

She highlighted three specific challenges: (i) malnutrition remains too high (though declining), requiring economic progress to increase incomes and productivity; (ii) the environment that the poor live in remains unhealthy, and is in some dimensions worsening, requiring substantial public effort and investment; (iii) those left behind are increasingly difficult to reach—whether due to conflict, or intra-household inequalities. Making further progress, she said, means going beyond the low-hanging fruit and promoting investments outside the health sector to achieve universal access to a healthy environment, an approach that requires national as well as local investment, and the political will to go with it.

Jishnu’s discussion picked up on the last point: the need for big ‘G’ government public health in the pursuit of broad, sustained, and deep progress in health outcomes in poor countries. He argued that a consensus that ‘big government does not work in developing countries’ has emerged, favouring the provision of public goods using private or non-government delivery, and led to substantial weaknesses in the ability of developing countries to delivery truly widespread health improvements. He gave the examples of investments being made in chlorine dispensers (‘small g’) rather than clean water (‘big G’), and pit toilets (‘small g’) rather than sanitation systems (‘big G’). This needs to change for universal health to be achieved, he argued.

The discussion, orchestrated by Shanta, considered how such a large and ambitious agenda can be prioritized, and indeed how realistic all parts of it are. As the sheer breadth and depth of CGD’s Global Health programme shows, meeting these aspirations requires a huge amount of change at the national level and in the international system.

The next edition of our “Future of Development” seminar series will feature Atif Mian and Jing Cai discussing the perils and promise of financial markets for developing countries on April 30—join us for what promises to be another fascinating discussion!


CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.