More is less? Health in the Sustainable Development Goals

On September 25, world leaders will meet in New York to formalise the new Sustainable Development Goals. These 17 goals will guide efforts to reduce poverty and increase well-being, without destroying the Earth. The Conversation is looking at how we got here, and how far we have to go.

Health has secured its place as one of the 17 Sustainable Development Goals, expanding its scope from the Millennium Development Goals. But without clear mechanisms to report, finance or engage other sectors, could more end up as less?

Most of the people I know who work in global health were not confident that health would do well out of the Sustainable Development Goals (SDG). My colleagues in the Go4Health research project, an international consortium of researchers advising the European Union on the development of the post-2015 development agenda, were cautious about what to expect. As were many of the senior technocrats in the United Nations agencies, development banks and related organisations whom we interviewed.

The call for the Sustainable Development Goals put to the Rio 20+ Conference on Sustainable Development hadn’t, after all, mentioned health. And in early proposals by advocates such as Jeffrey Sachs, it seemed marginal, just one aspect of sustainable social development.

But in its precursor, the Millennium Development Goals (MDG), health had dominated the eight goals. Three were directly focused on reducing child mortality, maternal mortality and deaths from AIDS, tuberculosis and malaria. And health was also integral to other goals addressing poverty, water and sanitation, and gender.

Securing a place for health

In 2013, we were being warned that “health has had its turn”. The focus was most likely to shift to climate change and a sustainable environment, with sustainable economic development the key to global change.

But three factors got health over the line in the final formatting of the SDG. First, the qualified success of the MDG; there was enough progress to argue the goals had mobilised global solidarity, but with substantial shortfall in most health targets. Sub-Saharan Africa, in particular, had not achieved most of its goals.

The second factor was the substantial growth in development assistance that specifically targeted health. Three sources dominated: the United States and United Kingdom governments and the Bill & Melinda Gates Foundation. Their priority in development assistance was health, and together they dominated international aid financing for development.

Health has dominated international aid financing for development from major donors such as the Bill & Melinda Gates Foundation.Steven Depolo/Flickr, CC BY

The third factor was the World Health Organisation’s (WHO) persistent advocacy for universal health coverage. They saw this as the health goal that could extend health service coverage to the whole population, ensure the quality and scope of those services, and protect those seeking health care from significant financial risk.

In protracted SDG negotiations, universal health coverage acted as a proxy for health systems more broadly. Having it as a preferred goal focused the energies of WHO and its allies, and threats to the idea of universal health coverage mobilised health systems advocacy from UN member states, as well as key donors and civil society.

The world we want

The major criticism the MDG faced was that they weren’t consultative. They were a technical exercise, put together by a room full of UN bureaucrats and included in Kofi Annan’s 2001 report following the Millennium Summit, without clear member state endorsement.

The SDG process would not be the same. In all, 12 months of UN-driven talks from 2012 to mid-2013 saw 11 thematic consultations (including one on health), close to a hundred country consultations, and a “world we want” website that allowed hundreds of thousands to express their opinions.

Despite this extensive consultation, the politics of the SDG have been unpredictable. Universal health coverage, for instance, didn’t make it as the SDG health goal. But with the process shifting to the member states’ open working group in 2013, advocacy for health was championed by states who valued its transformative potential. And they have been successful in securing its place in the final draft of the SDG.

Goal 3 (Ensure healthy lives and promote well-being for all at all ages) includes nine targets and four “means of implementation”. It may be only one goal, but it covers territory that’s much more expansive than the three health-specific MDG.

One goal, but more health targets

In the SDG, the continuing agenda of the MDG has been ramped up several notches: reducing the global maternal mortality ratio to less than 70 per 100,000 live births; ending preventable deaths in newborns and under-fives; and ending the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases.

Ambitious indeed, but at least it’s territory we’re familiar with.

But beyond these, new targets seek to reduce the premature death from non-communicable or lifestyle diseases that dominate the global burden of disease in both developed and developing countries: heart disease, stroke and diabetes. And promote mental health and well-being, however that might be defined.

Among the SDG health targets is the aim to strengthen prevention and treatment of substance abuse — including alcohol — and the effects of hazardous chemicals and pollution.NeilsPhotography/Flickr, CC BY

Further targets strengthen prevention and treatment of substance abuse — including alcohol — and the effects of hazardous chemicals and pollution. And aim to halve deaths and disability from road traffic accidents.

Over the past 15 years, we’ve set up reporting mechanisms that allow us to track progress on the MDG. For this additional raft of targets, reporting mechanisms don’t yet exist in many countries. Many of the targets don’t yet have clear indicators or baseline data and, for several of them, there’s limited evidence on how to address this expanded agenda globally.

In many ways, these first seven targets follow the MDG model, focused on single disease entities. For many of these targets, however, we’ve embraced issues that are well beyond the scope of the health sector to manage alone. But the SDG document doesn’t offer any proposal for the multi-sectoral mechanisms that will be needed to address well-being, dietary and lifestyle change, environmental health and trauma from road accidents.

But is more less?

There are two health service targets — universal health coverage and access to sexual and reproductive health services — but there’s no structural connection that links them to the seven disease targets. This failure to integrate bodes poorly for imagining health into what is a very complex, inter-related development agenda.

The four “means of implementation” targets reflect the need to enshrine hard-won global political concessions for health. They include strengthening the Framework Convention on Tobacco Control, which is crucial to reducing the burden of non-communicable disease; supporting development of vaccines and medicines while preserving the protections negotiated through the World Trade Organisation; financing, resourcing and retaining the health workforce needed for developing country health systems; and extending risk surveillance and response capacity to all nations.

Health has secured its place in the SDG, but my anxiety remains. I have argued that one of the disadvantages of the MDG was the way they targeted specific issues. By achieving progress for those issues, they narrowed aid priorities and distorted health systems development. But now I’m faced with a massively expanded — but still not exhaustive — set of targets in health, with no comprehensive strategy for addressing them.

The overall sustainable development agenda of 17 goals and 269 targets is extremely unwieldy. And the financial climate for development is less optimistic than it was in 2000. The funding estimates for achieving them fall well short of the currently available resource envelope.

Sustainable development depends on social, environmental and economic transformation. But in terms of meeting this challenge for health by 2030, I can’t help wondering if more isn’t less.

Peter Hill receives funding from the European Union’s Seventh Programme for research, technological development and demonstration (grant ref: HEALTH-F1-2012-305240) and the Australian Government’s National Health and Medical Research Council–European Union Collaborative Research Grants (grant ref: 1055138).