Health In The Sustainable Development Goals

The United Nations Millennium Development Goals (MDGs) completed their life cycle of 2000-2015 and ushered in their successor, the Sustainable Development Goals (SDGs) which will act as the compass for global development efforts during 2016-2030. At first glance, it appears the importance accorded to health has diminished, featuring in only one of the seventeen SDGs, in contrast to three of the eight MDGs. A closer look reveals that health has indeed been given a broader and better remit within the single goal and, even more important, has a clear intersect with many of the other SDGs which vitally influence the many determinants of health.

The MDGs focused on maternal and child health and major infections, assuming that these were the main public health challenges of the low and middle income countries (LMIC). They served a useful purpose by mobilising global and national resources for galvanising action to achieve preset targets in these areas by 2015. However, they ignored the huge and rising burden of non- communicable diseases (NCDs), mental illness and traffic injuries that were also afflicting these countries, straining their health systems and threatening their economies. The MDGs fragmented the health system by disease and segmented the response by age, ignoring the health needs of adolescents, adult males, non- pregnant women and the elderly. They focused exclusively on mortality related targets, ignoring the high burden of illness and disability that occurs even when diseases don't kill immediately. Further, the goals and targets were intended only for the LMIC, with no obligation for the high income countries (HIC).

The SDGs, on the other hand, are applicable to all countries. The lone but lofty health goal calls on all nations to "ensure healthy lives for all and promote wellbeing for all at all ages". This encompassing life course perspective ensures that health needs of every person are addressed at each stage of life. Moving on from an exclusive focus on averting deaths, the mission now also addresses the protection of health and promotion of wellbeing as important priorities. Major causes of death and disability like cardiovascular diseases, cancers, diabetes, chronic respiratory diseases (grouped under NCDs), mental illness, traffic injuries, substance abuse and pollution. The unfinished agenda of the MDGs- improvement of maternal and child health and control of infectious diseases- continues with renewed commitment, in the health SDG.

The health goal sets nine specific targets which embrace this integrated agenda. The most important target introduced in the health SDG is 'universal health coverage for all, with financial protection, and access to medicines and vaccines'. This brings a health system approach, without which other health targets will be difficult to achieve. Indeed, even the SDG on poverty reduction will be defeated if health care related impoverishment drives millions of people in to poverty each year.

All of the health targets, and the SDGs overall, are highly relevant to India. Despite creditable recent acceleration of decline in infant and maternal mortality, we fell short of the MDG targets. More important, many of our South Asian neighbours are better placed than us and are accelerating faster in their gains. Undernourished children and anaemic women still abound in large numbers. Multi- drug resistant tuberculosis is a growing menace. Heart diseases, strokes and diabetes are imposing huge health and economic burdens in the productive prime of life. Tobacco claims more than a million lives a year, while alcohol causes havoc through a range of ill effects ranging from liver disease and cancers to traffic accidents and domestic violence. Air, water, soil and food pollution are eroding health and wellbeing across the country. Over 60% of health care expenditure is out of pocket, threatening to push around 60 million Indians into poverty each year. Advanced medical care is mainly urbanised, while primary care services are inaccessible or of uncertain quality in most parts of the country.

The SDG targets are specific and stiff, but must be attained if we are to provide good health to all of our people - both as a lever for economic development and as right that must be respected as the hallmark of a civilised society. The targets for 2030 are set for a maternal mortality ratio of less than 70 per 100,000 live births, under-5 child mortality rate of 25 and neonatal mortality rate of 12 per 1000 live births. Premature deaths from NCDs, in the age group of 30-70 years, are intended to be reduced by a third during this 15 year period. These and other targets will soon have specific indicators for monitoring. Our health information systems are not fully geared up for measuring these indicators. We need to leverage our strengths in information technology to set up robust data acquisition and analysis systems for target surveillance and monitoring of progress on the recommended indicators. Country-specific adaptation of some of the indicators would also be needed. Disaggregated data analyses will also provide information on how health equity gaps are being bridged across different population groups in the country, across geography, gender and social class.

However nobly intended and however well designed, such health initiatives cannot be force fitted into dysfunctional health systems. We need to speedily strengthen our health systems to meet the targets set by the SDGs. This calls for more financial and human resources, as well improved implementation processes and better governance. A higher level of public financing is essential if we are to succeed, as experience from other LMIC shows. Universal health coverage (UHC) has to have a common national framework for portability, while accommodating state level specificities. Primary health services and district hospitals have to be strengthened to provide a continuum of care. Public, private and voluntary sectors have to be unified in a well-defined design of service provision. Since the success of UHC depends on risk pooling across a large population, tax funding and a fusion of all government funded health insurance schemes must flow into a single payer system. Pooled public procurement and efficient distribution will reduce drug prices and improve access. Human resources for health need to be rapidly scaled up, with priority accorded to technology enabled front line health workers and allied health professionals.

The other SDGs too need to be vigorously pursued, if we are to achieve the health goal. Poverty reduction, agriculture and food systems that provide nutrition security, education, gender equity, livelihoods, clean energy, environmental protection, biodiversity, urban design and peaceful societies- all matter to health. The strength, and the challenge, of SDGs lies in this interconnected agenda of interdependent goals. It requires great policymaker vision and strong political commitment- across the Centre and the States- for India to undertake this collective journey successfully to reach the SDGs by 2030. It is time now to 'Make Health In India'.

This article is part of a series on the SDGs for BW Sustainability