Health and sustainable development- I

The word development means many things to many people. Mostly people think of it as economic development. Others think of it also as social development. Some would like to think of development only when it is truly inclusive development, when the fruits of development are available to everybody in society. But now we’re also moving on to the concept of sustainable development where development not only happens, but it happens in a manner that is sustainable across generations taking into account the need for planetary health as well as human health and a very balanced economic and social development across the global community.

At the beginning of this century the focus was much more on bridging the huge gaps that existed between the levels of development across the world both in terms of high income and abject poverty and also huge gaps in health equity. So the whole idea was- can we begin the century to try and promote greater equity in terms of development including some of the critical areas of health? But now we are moving on to a period where we are actually beginning to discuss sustainable development as the goal for this century and beyond. Therefore, the Brundtland Commission looked at sustainable development from the point of view of the development not only of the current generations but also the future generations. It titled its report in 1987 as Our Common Future. And sustainable development was defined as one that meets the needs of the present without compromising the ability of future generations to meet their own needs. Therefore it was very important that the inter-generational equity concept was also integrated into the idea of spreading greater equity along with progress in the present day world.

The Millennium Development Goals which were annunciated and adopted by the global community in the year 2000 under the auspices of the United Nations reflected the urge of that time to try and bridge the inequities that were very manifest in the different developmental profiles of the countries. Poverty, ill health, lack of educational opportunities, all of these were clearly reflective of those inequities. So eight goals were designed to end extreme poverty and multiple deprivations with specific targets to be achieved by the year 2015. And these eight goals reflected various areas of developmental concern.

The first one was to eradicate extreme poverty and hunger, the second was to achieve universal primary education, the third to promote gender equality and to empower women, fourth to reduce child mortality especially under the age of five years, the fifth was to improve maternal health, the sixth was to combat major infectious diseases like HIV/AIDS, malaria and other major killers, the seventh was to ensure environmental sustainability, and the eighth was to build global partnerships for development. All of these were considered absolutely essential for altering the developmental gaps that existed across the world.

Three of these Millennium Development Goals directly related to health. Goal four was to reduced child mortality and a specific target was identified for action up to 2015. The target was to reduce by two-thirds between 1990 and 2015 the under five mortality rate, taking 1990 as the base year. Goal five was to improve maternal health with two targets, one was to reduce by three-quarters between 1990 and 2015 the maternal mortality ratio. Target two was to achieve by 2015 universal access to reproductive health recognizing that there was huge gap in the access to reproductive health services in many countries and virtually all across the world. But the whole area of maternal health can not only be reduced to maternal mortality. We also have to look at maternal morbidity issues. That was implicit but not directly measured as a target. Goal six was to combat HIV/AIDS, malaria and other diseases with three specific targets. Target one was to have halted by 2015 and begun to reverse by then the spread of HIV/AIDS across the world. HIV/AIDS was the big specter that was haunting the world at 2000, as the big killer. Target two was to achieve by 2010 universal access to treatment of HIV/AIDS for all those who need it. The whole are of access to essential drugs was becoming a major concern, especially because HIV/AIDS was killing people who could potentially have life saved with access to anti-retro-viral drugs. Target three is to have halted by 2015 and begin to reverse by then the incidence of malaria and other major diseases. These other major diseases were left unspecified but it is very clear that HIV/AIDS, malaria, and tuberculosis are the main areas of focus among infectious diseases at that time.

The other goals also indirectly affected health, even though they did not specify health as their primary objective. Goal one was to eradicate extreme poverty and hunger and we know that ill health is related both to poverty as well as malnutrition. Goal two was to achieve universal primary education and we know that education actually promotes health by improving knowledge and the ability of individuals and communities to take better care of themselves. Goal three was to promote gender equality and empower women. Women have suffered health inequities more than other groups in the society and in every society we have seen unless we promote gender equality and empower women we can not achieve better health indicators not only for them but for their children and for the families of the whole.

Goal seven was to ensure environmental sustainability. For the first time we were bringing in health and environment close together along with other areas of development because we now recognize that unless the environment is also protected, health will suffer.

Goal eight was to develop a global partnership for development, obviously this included partnerships for health as well. So all of the goals in some way or the other related to health, though three of the goals were specifically directed at health related targets.

We have achieved a fair amount of progress on the MDGs by 2014 when the review was conducted it was found that as far as tuberculosis and malaria were concerned, three million malaria deaths were avoided between the year 2000 and 2012. Twenty-two million lives were saved from tuberculosis between 1995 and 2010. About 17,000 fewer children are dying per day. And between 1990 and 2010 there was a 47% reduction in maternal mortality though that has not been uniform across the world. Over 2.3 billion people have gained access to improved water between 1990 and 2012. There’s been a greater enrollment of girls in schools and greater political participation of women. Extreme poverty has been reduced by half between 1990 and 2010. About 50% of the population on less than $1.25 which was the state of affairs in 1990, to 22% of the global population at that level of extreme poverty.

So we have had much to celebrate as a result of the success of the efforts to advance the MDG goals to their targets.  However, the agenda is very much unfinished. In several cases we have fallen short of the targets. For example one in four children are still undernourished. Child mortality from preventable diseases is still a problem. About 800 women die daily from pregnancy related causes. Hunger has declined but still over 800 million people still go hungry all over the world. Nearly one billion people still resort to open defecation. So the ambitious agenda of the MDGs while having achieved several benefits still remains to be pursued in order to attain the targets if not by 2015, soon thereafter.

We have had several learnings from the Millennium Development Goals. They helped to position health very firmly in the development agenda of the world. They helped to focus attention and action on the major health problems of poverty, infectious diseases, under nutrition, as well as maternal and infant mortality because the failing health systems which particularly afflict poor people. They help to mobilize resources to achieve targets. The global community responded by committing more resources, if not in totality for all the MDGs, for selected MDGs of their choice. They helped to create platforms for multiple stakeholder partnerships and they strengthened global monitoring systems by affixing targets and by monitoring progress towards those targets. But having said all that the MDGs also fell short in very many ways.

They covered only the low and middle income countries and excluded the high income countries. So they were not universal in any way. They only focused on a set of countries, the targets, and the implied obligations were only applicable to some of the countries, not all of the countries in the world. They fragmented the health system through vertical programs by directing the programs only at maternal health or child health or TB or malaria or HIV/AIDS, they fragmented the health system and made it weaker in some respects and also created an opportunity cost by which the other programs suffered. Further, even the programs themselves which were the primary focus of the MDGs did not achieve their targets because you can not force fit a vertical program into a weak health system however well-designed the program may be. So we even fell short for example of tuberculosis control and we are seeing the specter of multi-drug resistant tuberculosis coming up.

At the same time the MDGs also segmented by age group. They looked at child mortality, then at maternal mortality, forgetting that adolescent girl in between. They did not look at the elderly, they did not look at the adults who were suffering from non-communicable diseases. They monitored only national aggregate indicators. Now that was helpful to say India or China or Zimbabwe for that matter reduced child mortality or maternal mortality but did it happen across all social groups? Were only certain social groups benefiting from this kind of mortality reduction? And the poorer sections still remained behind? Did the gaps in health equity actually widen even as the aggregate health indicators fell across the country? So that was something that was not really measured at all or not even intended to be measured.

They also measured mortality but not morbidity. It is not just enough to be alive. You are to be alive and healthy so that element of healthy life expectancy was ignored by the MDGs. While these are justifiable critiques of the MDGs, we must recognize that the MDGs have given us a platform to build upon further and that’s the knowledge that we need to transfer as we move across to the sustainable development goals after 2015. Therefore, we need to redefine some of the global health priorities for the period 2015 to 2030 which is the next period the SDG era, and there we need to accelerate the progress on MDGs because they’re not a done deal. Maternal and child health still require our attention, infectious diseases still need concerted action and under nutrition still remains a shameful challenge and we need to act upon them and provide momentum for their progress. At the same time we need to act upon the previously excluded priorities, non-communicable diseases, the number one killer in the world today.

Mental health, the number one contributor to disability in the world today. Injuries and disabilities, adolescent health, health of the elderly, all of these were out of the radar screen of the MDGs. We need to now bring them back into a composite picture of the global health agenda. In terms of the other priorities for 2015 to 2030 we need to create a strong health system platform. The health system needs to become the vehicle for all concerted actions directed at health MDGs or SDGs, because otherwise we will continue to fragment it and fail in our objectives. So we need an integrated delivery of a wide range of health services, we need an emphasis on equity, efficiency, effectiveness and economic viability because when we talk about sustainability we have to talk about also fiscal prudence of how the health system can manage to do all of this without really overrunning the budgets in a very imprudent manner. So we now have to build in all of these elements as well.

We need to implement the universal health coverage as the framework for achieving these goals through actions at national and global levels. We need to enable coordinated multi-sectoral action to influence the social determinants of health. Clearly we know that much of health depends upon actions in other sectors. And the sustainable development goals are addressing some of those other sectors as well, not as separate entities but as synergistic and complementary components of a single unified agenda of SDGs. We need to link health to other elements of sustainable development, not only achieve benefits for each of those elements but to maximize the co-benefits. Health for example benefits education. Sick children can’t gain learning. At the same time, education benefits health, so there are clear co-benefits working together across different SDG and developmental goals. So all of these domains will have to be really brought together and that is wherein the strength of SDGs will come in, including for global health between 2015 and 2030 and beyond that as well. But we do have some optimism when we look at the future.

While we regret that we’ve not been able to achieve some of the MDGs related to maternal mortality or child mortality or infectious diseases by 2015, in terms of their entirety we now know we can substantially bridge the gaps between high income countries and low income countries on those MDGs by year 2035 if we invest wisely and adequately in our health system and specific programs. And here, the Lancet Commission on Investing in Health in 2013 proposed goals that for the under five death rate per thousand live births which is the under five mortality, it can come down to 16 in the low and middle income countries as well as being very close to that in the high income countries now. Similarly, annual AIDS deaths per 100,000 population can come down to eight. Annual tuberculosis deaths per 100,000 population can be brought down to four. Which means the huge gaps that now exist between high income countries and low and middle income countries can be substantially bridged and we can have a grand convergence by year 2035 if we invest properly in the health of these countries and where the global health becomes a priority and a concern and a commitment that everyone shares under the overall umbrella of SDGs.

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