How the new global goals can help drive systems to address health challenges better
The fact that the sustainable development goals have only one solitary goal for health has been criticised by many. There are concerns that it signals a more diluted and less ambitious era in global health.
We disagree. We believe that the sustainable development goals promise a significant improvement for global health over what went before.
Of the eight anti-poverty millennium development goals, three focused on global health. They committed the global community to reduce child mortality, improve maternal health and combat HIV/AIDS, malaria and other diseases. The benefit of the eight was that they helped propel global health into the public’s consciousness and into aid agencies’ budgets. But they also led to unintended consequences.
By contrast, of the 17 proposed sustainable development goals, only one focuses on health. And this is framed in a very broad fashion:
To ensure healthy lives and promote well being for all at all ages.
Under this goal there are nine targets. These encompass diverse health objectives, from averting road traffic accidents to reducing substance abuse and improving environmental health along with the more traditional fields captured in the millennium development goals.
More is not always better
One of the major challenges with the millennium development goals was the way in which they compartmentalised specific health goals.
By casting a spotlight on specific diseases and conditions they drove resources to particular types of programmes. In practice, an individual’s health is indivisible. They may be saved from dying during childbirth only to face a chronically debilitating illness later in life. Or the treatment someone receives for HIV/AIDS may be undermined by inadequate nutrition.
To deliver any of these essential health services, countries need a functioning health system. It should be responsive to people’s multiple needs and enable them to access affordable qualified health practitioners. These practitioners must be equipped with necessary drugs and technologies and operate in a regulated and supported environment.
In the early days of the millennium development goals, the laser-like focus on specific goals at times created distortions in health systems – for example, sucking in scarce health workers to work on well-funded programmes that supported the goals, or creating parallel systems for the procurement and distribution of drugs and commodities that bypassed (and undermined) regular government systems.
Over time, global health funders grew savvy to these concerns and sought to address them through complementary funding for systems strengthening. But the sustainable development goals should further help steer clear of this problem. The target on universal health coverage clearly adopts a much more holistic perception of health.
Second, one of the significant challenges with the health millennium development goals was the standard prescription that they offered for health sector priorities.
Regardless of epidemiological or demographic profile, countries were pointed to the same priorities. While these priorities are important in most developing countries, it has been argued that outsized spending on HIV/AIDS, for example, did not match countries’ own priorities.
Tailored approaches make more sense
Unlike their predecessors, the sustainable development goals are meant to be equally relevant to countries at all different income levels. This, together with the participatory process used to develop the sustainable development goals, has brought about a much broader health agenda that may be tailored to the needs of different countries.
The fact that low-, middle- and high-income countries all have shared health goals creates new and promising opportunities for cross-country learning and exchange.
There is certainly much that low-income countries can learn from their high-income counterparts about how to organise health services to address a multiplicity of health problems. But there is also much that high-income countries can learn from developing ones. This includes shifting simple tasks to less qualified but adequately skilled health workers, building community support for health services or employing information and communication technologies within the health system.
Finally, while only one of the sustainable development goals speaks directly to health, concerns relevant to health are threaded through many of the other goals. There are obvious linkages between ending poverty and hunger, improving education, ensuring water and sanitation and promoting gender equality and health.
But health priorities may also be sustained through several of the other goals. These include:
- Goal 8: decent work for all;
- Goal 11: making cities and human settlements safer and more sustainable;
- Goal 13: combating climate change;
- Goal 16: promoting peaceful and inclusive societies; and
- Goal 10: reducing inequality.
Too frequently those working within the health sector place artificial boundaries around the scope and mandate of the sector. This is despite the fact that one of the earliest and most significant global health policies, the Alma Ata Declaration, defined health in a very broad and encompassing fashion as “a state of complete physical, mental and social well-being”.
A new approach
In the next 15 years many of the major challenges to human health will originate outside of the health sector. These range from emerging zoonotic diseases to pollution, climate change and the growing epidemic of obesity.
Tackling these challenges effectively will require health experts to better understand and intervene in the health system. But they will also have to consider and effect change in broader social systems that encompass health – such as housing, transport, animal health, urban land use and agriculture.
The sustainable development goals are a timely reminder of the complexity of human health and the systems that support it.
Achieving the goals presents a truly challenging new agenda for global health. Attainment of these goals will require us to learn collaboratively about how to strengthen health systems and break down artificial boundaries across systems. As we do this we should sustain the inclusive spirit in which the goals were developed, and the collective quest to build healthier societies.
Associate Professor and Associate Director, Health Systems Program, Johns Hopkins University
Senior Scientist and Director, Health Governance Hub, Public Health Foundation of India