April 2015, No. 4 Vol. LI, Beyond 2015
Health is fundamental to human development. All people, regardless of social status, consistently rank good health as a top priority,1 and healthy people are critical to sustaining societies. It is therefore not surprising that four of the eight Millennium Development Goals (MDGs) directly relate to health.2
The MDGs were successful at focusing global attention and resources on specific, pressing world challenges, including hunger, maternal and child health, HIV/AIDS and malaria. These issues were placed at the top of the global agenda, inviting international agencies, Governments, non-governmental organizations and civil society, private firms, and other stakeholders to come together in order to achieve the goals. As a result, extreme poverty fell by half, there has been significant progress in the fight against malaria and tuberculosis, and over 2 billion people gained access to safer drinking water.
Nonetheless, as with many other global targets, alongside strengths and successes there are also challenges and weaknesses. Progress has been uneven, both within and across countries. Although chronic undernutrition, child and maternal mortality have fallen significantly, there is still much to be done. Public education and rapid diagnostic testing for HIV/ AIDS has reduced the number of new cases, and more effective treatments allow HIV-positive people to live longer. Yet access to treatment needs to become more widespread, new cases need to be prevented, and stigma and discrimination reduced.
The MDGs encouraged specific interventions benefitting subpopulations, namely pregnant women and children under 5 years of age, rather than all people. Some countries, however, sought to improve indicators through investments in their health systems to support the entire population, which resulted in dramatic progress in the health of all people at all ages. Other countries focused interventions on delivering health services largely to pregnant women and young children, and saw fewer improvements in the overall health of the general population. A new agenda is needed to prioritize equity in outcomes, and address health systems in addition to targeting specific diseases.
Further, the global burden of disease has shifted greatly in the past 30 years, increasing the need for a focus on health systems. Non-communicable diseases such as stroke, cancer and diabetes are responsible for a growing share of both mortality and morbidity in both developed and developing countries.3 In fact, rapid economic growth in many developing countries has left them facing a challenging dichotomy; in poorer, more remote areas there is much to be done on the MDGs agenda, while diabetes and heart disease are rising in more affluent cities. Even within households, family dynamics may result in some family members suffering from caloric or micronutrient deficiency, while others are obese. Looking forward, we need a post-2015 agenda that can support countries in addressing all of these issues.
Medical research has shown that health issues once relegated to the back burner play a much larger role in our overall health and well-being. Mental health is one such issue. There is a growing consensus that we need to work more to reduce the stigma of mental illness and offer mental health services to people. Addressing indoor and outdoor air quality, water quality, and other environmental determinants of health is another example. Tackling these issues is critical to safeguarding global health, and needs to play a larger role in the post-2015 agenda.
We therefore recommend a post-2015 development agenda that both reaffirms commitment to the MDGs and expands beyond them to cover new issues that merit urgent global attention. The formulation of SDG 3—ensure healthy lives and promote well-being for all at all ages—can easily accommodate such a broad agenda. The current text, which includes numerical targets for child and maternal mortality, can revitalize action to complete the MDGs agenda. Targets addressing non-communicable diseases, substance abuse, and environmental health will raise global awareness about the importance of these issues and spur progress.
Perhaps the most revolutionary aspect of the current goal is the target on universal health coverage (UHC). This is vulnerable to the critique of being too broad and therefore difficult to attain or to measure. However, ambitious targets are often needed to inspire progress. While the MDGs prioritized specific interventions for pregnant women and children under 5 years of age, UHC promotes healthier lives for all through investment in health systems. There is a growing body of evidence that investments in health systems are key to better health outcomes.4
In brief, UHC strives to ensure that all people have access to needed, quality health services without suffering financial hardship. It supports increased equity in health outcomes, as it allows even the poorest people to afford needed care. It supports taking a life course approach by addressing health issues at all ages. When properly implemented, it meets demands for primary care for all people, and supports promotive, preventive, curative, palliative and rehabilitative services. Finally, UHC can be implemented in such a way as to capitalize on social and environmental determinants of health, including behavioural choices (diets, exercise, air quality, tobacco use, etc.).
A focus on UHC for the next 15 years could be truly transformative for both rich and poor countries. It is vitally important that health improvement accrue to everyone, not just certain groups. Causal analyses from 153 nations show that “broader health coverage generally leads to better access to necessary care and improved population health, with the largest gains accruing to poorer people.”5 The World Health Report 2010 demonstrated the catastrophic effects of health care costs, with nearly 150 million people worldwide suffering financial hardship and 100 million being pushed below the poverty line as a result of out-of-pocket spending.6 UHC focuses attention and efforts on removing financial barriers to care, working towards universal access, and ensuring that no one forgoes needed treatment due to cost.
Of course, setting global goals and priorities can only go so far. The real test will be how the goals are implemented, and how progress is monitored and evaluated. Given the broad goal of ensuring healthy lives and promoting well-being for all at all ages, Governments, international organizations, and other actors need to be pragmatic about how to implement policy and monitor progress. Agreement on global goals and targets, as with all policy decisions, will inevitably be a political as well as technical process, even with buy-in by participating stakeholders. The tension between the political and technical has to be managed for goals and targets to become implementable, so that it is possible to track and monitor implementation.
Discussion over what indicators to use and how to finance the SDGs is ongoing. The Sustainable Development Solutions Network (SDSN, www.unsdsn.org) has proposed a framework of post-2015 indicators. They need to be clear and straightforward, selected with consensus from a diverse group of stakeholders, and based upon existing data sources. These indicators should measure outcomes as much as possible, and be disaggregated by a wide range of socioeconomic variables (age, gender, urban/rural, etc.) to ensure equal progress. In addition, Governments should support calls for a “data revolution” and move as much as possible towards annual reporting of publicly available data. New technologies such as mobile phones and remote sensing make it increasingly easy to rapidly collect and analyze high-quality data; the post-2015 agenda should take advantage of this.
We have been given an opportunity to establish an ambitious, equitable development agenda for the next 15 years. Global political processes are on track to deliver a meaningful outcome, which could be transformative for global health. As we move towards September 2015, stakeholders must hold Governments accountable to fulfil their promises for a substantial agreement, and begin working together to implement the SDGs.
1 John Helliwell, Richard Layard and Jeffrey Sachs, eds., World Happiness Report (New York, Sustainable Development Solutions Network, 2012).
2 Here we count MDGs 1 (poverty and hunger), 4 (child mortality), 5 (maternal health), and 6 (HIV/AIDS, Malaria, and TB).
3 Institute for Health Metrics and Evaluation (IHME), GBD Compare, Seattle, Washington, University of Washington, 2013. Available from http://vizhub.healthdata.org/gbd-compare/.
4 World Health Organization, Everybody’s Business: Strengthening Health Systems to Improve Outcomes (Geneva, 2007). Available from http://www.who.int/healthsystems/strategy/everybodys_business.pdf.
5 Rodrigo Moreno-Serra and Peter C. Smith, “Does progress towards universal health coverage improve population health?” The Lancet, vol. 380, no. 9845, (September 2012), pp. 917–923. Available from http://www.thelancet.com/journals/lancet/issue/vol380no9845/pIIS0140-6736(12)X6037-9.
6 World Health Organization, Health Systems Financing: the path to universal coverage. World Health Report 2010 (Geneva, 2010). Available from http://www.who.int/whr/2010/en.
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