This century began with the Millennium Development Goals but after fifteen years moved on to the Sustainable Development Goals, to build up on the gains of the Millennium Development Goals but also to pursue a much more comprehensive agenda of interlinked and inclusive development. Beginning with MDGs, and then subsequently having a strong focus on social determinants of health through the WHO commission on social determinants of health as well as a major thrust towards universal health coverage brought about by the World Health report of 2010 which focused on health financing, particularly as a foundation for universal health coverage, and then also looking at different emerging public health challenges of the 21st Century, the whole area of non-communicable diseases which in September 2011 formed the subject of a UN high level meeting resulting in a political declaration calling for concerted global action to prevent and control NCDs.
All of these in the last fifteen years have coalesced together towards the Sustainable Development Goals, but the clarion call for the SDGs came from the Rio+20 meeting in 2012 where the world pledged that they would work for sustainable development and said that collectively we will create the future we want. Basically at Rio+20 and subsequently through the actions of the United Nations for framing the Sustainable Development Goals three pillars were identified which were economic, social and environmental. Clearly, health is linked to all three of them. But along with this we also need to position another underlying element, if not as a pillar at least as the platform, and that is good governance.
The economic case for linking health to sustainability is very clear. Healthcare costs pushed 100 million people below the poverty line and this was from the World Health Report of 2010 published by the World Health Organization. Catastrophic health expenditures are commonplace not only in lower and middle income countries but also in some of the high income countries, for example in the United States we have seen a fairly large number of uninsured people suffering the problems of either inaccessible healthcare or impoverishing healthcare. Universal health coverage ensures financial protection through risk pooling and reduction of out of pocket spending. Clearly, therefore, there is a case for linking health to the economic development and ensuring that economic inequities do not affect health and also we provide greater health equity through suitable financial pathways like the universal health coverage with built in financial protection.
We also meet to ensure that households avoid spending their disposable incomes on avertable health problems so that that can be spent on other goods and services, improving the welfare of households like nutrition or even to give a fill up to the global economy by spending on other consumer goods. But if you’re spending money on avoidable angioplasties and coronary surgeries and so on, you do not have money to buy other consumer goods and that affects the pace of recovery in a sluggish global economy.
Clearly there is also a social case for linking health to sustainable development. We cannot talk of sustainable development or of health for that matter without talking about gender equality and human rights. They’re intimately linked to health. We recognize that these are important inputs into advancing health of societies and bridging gaps in health equity. So they become fundamental to any concept of sustainable development.
Other social determinants of health like education, social stability, and social networks, all of them are integral to good health. We see the co-dependency of many of these on health of societies so the social case for health is also clearly made.
When we look at the environmental case, while this was not very clear and not explicitly made in the past, we now increasingly recognize that we must place health alongside environment and the overall framework of sustainable development because there are many linked determinants and that framework will allow inter-sectoral policies that promote health as well as improved environmental sustainability simultaneously. For example agricultural sustainability. We can’t think in terms of food and agriculture systems merely as commercial activities because ultimately their purpose is to provide healthy nutrition to every citizen at every stage of life across the world. And if they’re not aligned to health, then clearly we see that agriculture and food systems are failing in their primary objective.
There are other elements as well, like resilient cities. When we talk about resilient cities, we are talking about cities that are not only resilient to climate change but also to natural disasters. We’re talking about promoting active means of transport which will reduce vehicular density, vehicular pollutions, and reduce environmental degradation at the same time protect the lungs and bodies of people and we recognize that air pollution is a major threat to health of people and we need to link that to environmental concerns. And therefore, bringing in the environment and health together into a common platform is very critical to both and that is where sustainable development provides that kind of a linkage.
We also recognize that all of this is not going to happen unless health challenges are seen as something that all of society must respond to, because they cannot be tackled in isolation. We required the engagement of multiple stakeholders, the government, the civil society, academia, the media, the private industry. It has to be an all of society effort for inter-sectoral action to take place because all of these are interlinked goals which can only be advanced by collective action. And at the same time in order to make sure that policies are not misaligned, we need health in all policies. For example, when we look at the non-communicable disease prevention and control plan of the World Health Organization, we recognize that the multi-sectorality implied in that action plan is something that warrants the active engagement of multiple ministries and multiple agencies and unless we link them together we will fail in preventing or controlling NCDs. Similarly even for a number of other areas of health, we need multiple stakeholders to come together. So health in all policies becomes absolutely critical as an important area of advancing health, but in the same time that provides a very smooth passage to sustainable development as the common agenda.
Margaret Chan, the director general of the World Health Organization has said that universal health coverage is the single most powerful concept that public health has to offer. However, there are some questions that have been raised about UHC when we talk about it as a SDG goal. Is it measurable in a comparable way across the world? What are the targets and indicators? Is it related only to financial protection or does it include other health system components? Does it balance vertical equity which is gap filling with horizontal equity which is equality of access? Does it ignore the social determinants of health by focusing only on health sector actions? These are legitimate concerns. But fortunately the global discourse on SDGs over the period when they were actually being debated actively by the global public health and development communities has brought us now closer to a consensus, that UHC needs to have a core component of financial protection but UHC cannot be delivered unless the other elements of health system are strengthened but at the same time health cannot be assured by UHC alone acting through the health sector.
But it has to now bring in actions into other sectors especially on social determinants of health to the fore by ensuring that there is synergy between the health sector actions as well as the actions in other sectors to advance the social determinants of health as well. So we now recognize as we move towards implementation of SDGs that action is required in each of these areas.
Finally there is a big question that had been asked of the SDGs while they were being developed. UHC is of course relevant and must be part of the goal but in the health goal something that we can develop which is applicable to all countries, the MDGs were not applicable to all countries, they were only applicable to the low and middle income countries, so how can we ensure that the new goal in the SDGs is something that all countries subscribe to and become accountable for? So UHC is one where it matters to everybody high or low income. We have seen that. Even countries like the United States still need to address the UHC as an important part of their agenda. Progress on MDGs is also needed but it’s still relevant to low and middle income countries. But non-communicable disease targets are relevant to all countries. They’re a bit more challenging for low and middle income countries where the epidemic is on the upswing rather than for the high income countries where the epidemic has stabilized or is on the downswing. But nevertheless, the whole world faces the challenge of NCDs so we need an income percent goal which combines all of these three elements. So we are really looking at the goal of a healthy planet with healthy people as our ultimate objective and for this it’s been proposed that firstly we must accelerate progress on the health MDGs, we must also reduce the burden of major NCDs and for these we need core enablers which are universal health coverage and access as well as action on social determinants of health. They provide the platform. So if you can combine all of these we have set the goal for health within the SDG context. So we do require what will be the ultimate way the Sustainable Development Goal is worded or interpreted, there are several actions which are needed for implementation. First is to build on addressing the gaps in achievements of the MDGs four, five and six which were the health MDGs or the health Millennium Development Goals. We also need to adopt a life course approach to health promotion, disease prevention and healthcare. We know that human beings live one single life. And therefore their health cannot be segmented and health of one stage of life impacts upon the health at other stages of life. So we need the life course approach.
We also need to increase public spending for health. Allocate at least 5% of the GDP as public financing for health. Without adequate financing health systems will remain feeble, they’ll not be able to deliver on UHC, they’ll not be able to deliver on health as an important part of the sustainable development agenda. And high income countries must do at least .1% of their gross national income as overseas development assistance for health. Of late, we have seen the declining trend in this kind of financial assistance that’s being provided except possibly to the least developed countries. Many of the low and middle income countries need that kind of a continued assistance without which their health systems cannot really be strengthened. So the high income countries must fulfill their social obligation to support other countries through an increased overseas development assistance.
All countries must provide high quality healthcare based on comprehensive primary health services. That is the foundation for good health and therefore a health system must prioritize primary health services.
We must create and support a skilled, adequately resourced workforce for health. We have a global health workforce crisis, particularly reflecting poorly on the health systems of low and middle income countries. We need to create a multi-skilled, multi-level workforce which is competent and motivated to deliver on the UHC and SDG agendas. We must ensure access to essential medicines, vaccines, commodities and technologies using pooled procurement and distribution of quality assured drugs. Whether it is HIV/AIDS or whether it is cardiovascular disease and diabetes, we need essential drugs to be available to all and pool procurement and distribution of quality generics is the way to go. Effectively implement comprehensive tobacco control programs. The Framework Convention on Tobacco Control, this is absolutely critical because tobacco is the major killer even in the 21st Century, it’s expected to kill about a billion people so we have to ensure that people do not die because of tobacco consumption whether it’s active or passive consumption and the various provisions of the FCTC or the Framework Convention on Tobacco Control is implemented in earnest can actually bring down tobacco related mortality and morbidity.
We must align agriculture and food systems to ensure nutritional security. We must align them with health, with a nutritional goal so the population at each stage of life, so our goal must be to deliver caloric adequate but also nutritionally appropriate diets to every citizen on this earth at each stage of his or her life. And that is where agriculture and food systems must deliver.
We must ensure availability of good quality water, sanitation and hygiene reduction and exposure to air, water, light and sound pollution and we must start up pro health policies in all sectors which are conventionally not regarded as part of the health sector but which nevertheless have a profound impact on the health sector.
So when we look at all of these we recognize that when we talk about economic growth, social equity and environmental protection there are a number of factors like urbanization, transportation, air pollution, food and nutrition security, labor productivity, healthcare expenditure, all of these are so interlinked and education, gender, all of these are so intertwined with health that we cannot really tease them apart and that’s why bringing them into the framework of sustainable development is very critical, even for advancing global health.
And we must learn to recognize that some of these connections are not apparent. For example when we think in terms of tobacco, we only think of the one billion deaths that may happen in the 21st Century, bad enough, but we must also recognize that tobacco is also a major cause of deforestation. Therefore it is an environmental threat because in order to cure tobacco leaf, one has to burn wood. For three hundred cigarettes smoked anywhere, someone somewhere has killed a tree. It’s also a cause of air pollution. It exacerbates poverty. It’s a cause of food insecurity. It’s absolutely unacceptable that four million hectares of arable land are now devoted world over for this killer crop than for nutrient crops. It is also a very water intensive crop and therefore, it again is an environmental threat from that point of view by exacerbating the water usage.
So when we think in terms of connection of health with other Sustainable Development Goals, especially environment, the connections really extend beyond the conventional. Similarly when we talk in terms of emerging infectious disease threats, we cannot talk in terms of zoonotic pathogens from wildlife which are now increasing threats whether it’s H1N1 or SARS or H5N1 or avian influenza without recognizing that we are actually creating conditions for this spread by extensive deforestation and by creating a conveyor belt between viruses and vectors from the forestry and the captive veterinary habitat and into the human habitat. Similarly when we are talking about drug resistant pathogens, anti-microbial resistance coming up, whether it’s anti-tubercular drugs or other forms of super bugs, we have to recognize it’s the weakness of the health systems that are really giving rise to this and also the nature of our rapid transportation and modern communication which is also resulting in their spread. So there are multiple areas in which we ought to be able to look at all of health as linked to different areas of human activity and all of those domains are built into the Sustainable Development Goals. In the 20th Century, medicine and nutrition evolved to come under the broad umbrella of public health. In the 21st Century public health must evolve, whether it’s considered as public health within countries or global health across the world must evolve under the umbrella of sustainable development if it has to survive and thrive as an important objective of human development.
Ultimately the thread of human life extends from pulse to the planet, through persons or individuals, through people or communities or populations or nations, health has to be linked ultimately to the overall goal of sustainable development