The year 2016 marks an end of the era of Millennium Development Goals (MDGs), which drove the global development agenda since the new millennium. The MDGs have paved the way for Sustainable Development Goals (SDGs) that the world will strive to achieve over the next fifteen years. It is an opportune moment to reflect on the successes and the lessons learnt from the MDG era and the possible way forward for achieving the ambitious and inclusive agenda of SDGs in the health sector.
First, high-level political commitment globally and nationally drove much of the progress towards MDGs. We need nothing less for the SDGs.
Second, while MDGs helped improve the overall health of nations, the focus was on the aggregate targets ignoring inequities within countries. To understand the real progress and challenges there is a need to disaggregate data by gender, economic status and geographical area.
Thirdly, neither the economic benefits of good health nor the direct financial consequences of ill-health were sufficiently captured by MDGs. We know that nations require a healthy population to prosper. When people do fall sick, high out-of-pocket expenditures on healthcare lead to financial hardship and diminish the ability of the population to contribute to the economy. In India, nearly 60 million people fall into poverty just paying for healthcare, while many more abstain or delay seeking healthcare due to financial difficulties.
Fourthly, MDGs did not capture the importance of prevention, early detection and response to disease threats. The growing noncommunicable disease (NCD) epidemic and consequent premature deaths could be prevented by reducing lifestyle risk factors, specifically tobacco use, food intake, inactivity, and alcohol consumption. In addition, diseases like SARS, Ebola, MERS and Zika pose threats to global health security and have the potential to cripple countries. MDGs missed this important issue.
Lastly, it is not only about ‘more money for health, but also more health for money’; the MDGs focused on addressing specific disease and symptoms, which led to fragmentation, duplication and inefficiencies in the health systems. WHO estimates that nearly 20-40 per cent of all health resources are wasted.
The way forward
Unlike MDGs, which had three dedicated health goals, the SDG agenda has only one health goal (SDG-3) which aims to ‘ensure healthy lives and promote well-being for all in all ages’. The 13 broad targets under health goal are in-tune with current global epidemiological reality. Besides the unfinished MDG agenda of reducing maternal and child mortality and tackling the communicable disease, the SDG-3 also aims to tackle the epidemic of NCDs, substance abuse and ill-effects of environmental hazards. Health is also interlinked to several other SDGs related to poverty, gender equality, education, food security, water sanitation etc.
The unprecedented scope of SDGs provides immense opportunity to bring health at the centre of economic growth agenda, which is PM Modi’s topmost priority. Universal Health Coverage (UHC), which is an explicit target under SDG-3, can act as the anchor to guide and inform SDG goals in health.
It is interesting that these thoughts have their roots in what was envisioned by Mahatma Gandhi. He said, “Recall the face of the poorest and weakest man you have seen, and ask yourself if this step you contemplate is going to be any use to him.” It is this thinking, which was reflected in the MDGs and is now even more central in the SDGs.
Towards sustainable development
India can progress towards sustainable development in health if it follows the following five steps.
First, health must be high on the national and state agenda, as it is the cornerstone for economic growth of the nation. This requires high political commitment and collective long-term efforts by ministries beyond the Ministry of Health to invest in health. The proposal in India’s draft National Health Policy 2015 to raise public to health expenditure to 2.5 per cent of the GDP by 2020 is commendable.
Second, India should invest in public health and finish the MDG agenda through further improvements in maternal and child health, confronting neglected tropical diseases, eliminating malaria, and increasing the fight against tuberculosis. For all these challenges, it is clear what needs to be done; programmes and interventions need to be taken to scale, with a central emphasis on equity and quality of services.
Third, accelerate the implementation of universal health coverage. UHC is important to prevent people slipping into poverty due to ill health and to ensure everyone in need has access to good quality health services. To complement tax revenue based health financing, incremental expansion of prepayment and risk pooling mechanisms such as Social Health Insurance are worth considering. UHC is at the core of SDGs and in the interest of people and governments.
Fourth, build robust health system in all aspects and strengthen both the rural and urban components, with comprehensive primary health care at its centre. Given the magnitude of the private sector in India, more effective engagement with private healthcare providers is vital. Appropriate contracting modality, which is an important feature under the Social Health Insurance or RSSY, can be worked out and private sector can be instrumental in complementing the public sector as demonstrated by different country experiences, including Thailand and Philippines.
Finally, develop a strong system for monitoring, evaluation and accountability. It is absolutely essential to regularly review and analyse the progress made for feeding into policy decisions and revising strategies based on the challenges.
In conclusion, the SDGs have the potential to create a world where no one is left behind.
The SDGS also make it possible to achieve what the WHO constitution mandates: attainment by all peoples of the highest possible level of health.