In the past few months, we have come across hundreds of short and long commentaries raising a tough question: “Why have countries failed to achieve Millennium Development Goals (MDGs)?” or a variation of this question, “Are there success stories and lessons from them for poorer countries?” Both, are pertinent queries.
In September 2015, the United Nations General Assembly (comprising about 200 member countries) formally adopted a set of 17 Sustainable Development Goals (SDGs), along with a set of 169 targets to be achieved over 15 years, i.e by 2030.
The MDGs, as spelt out in 2000 and agreed upon by UN member countries, reflected the world we would like to see by the end of 2015. These goals have now been reconceived and recast through a series of inter-governmental iterative processes over the past three years. These reflect enormously coordinated efforts required of several member countries to establish the ‘Future We Want’, the concomitant commitment and resources needed to follow up the implementation of the agenda and a document entitled ‘Transforming our world: the 2030 agenda for Sustainable Development’, which was adopted by the UN General Assembly during September 25-27 in New York.
In this short piece, I wish to flag three specific issues:
1. What do SDGs say on health and how different are they from MDGs?
2. How should we measure progress towards these goals (health in particular) and;
3. What guiding principles should governments keep in mind while “allocating our resources and efforts” towards these goals?
Comprehensiveness of SDG-3
SDG-3 aims to “ensure healthy lives and promote well being for all” across all age groups. It has nine sub goals, covering issues beyond MDG’s goals 4-6 put together. Let us look at these nine sub goals, more or less reproduced below for the reader:
1. Reduce the global maternal mortality ratio to less than 70 per 100,000 live births.
2. End preventable deaths of newborns and children under the age of five, with all countries aiming to reduce neonatal mortality to at least 12 per 1,000 live births and under-five mortality to at least 25 per 1,000 live births.
3. End the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.
4. Reduce by one-third, premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well being.
5. Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.
6. Halve the number of global deaths and injuries from road traffic accidents.
7. Ensure universal access to sexual and reproductive health-care services, including family planning, information and education, and the integration of reproductive health into national strategies and programmes.
8. Achieve universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
9. Substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination.
There are several new things here, not found in the earlier MDG. There is a direct reference to address mental health (point 4 above), prevention and treatment of abuse of narcotic drugs (point 5), reduce road traffic accidents (point 6). Most importantly, there is a direct reference to reduce deaths due to exposure to hazardous chemicals and various sources of pollutants (point 9). And point 8 on achieving Universal Health Coverage (UHC) sums up our global concerns on reducing the iniquitous and catastrophic financial burden, on the poor in particular, arising from inadequate access to essential health care.
The report appeals to less developed countries to substantially increase health financing and develop policies to recruit, train and retain a health workforce.
It should be noted that concerns for health are reflected in almost all of the remaining 16 goals as well, highlighting the fact that all of these goals are “indivisible and integrated” and global in nature, as the report states repeatedly.
Evidently, SDG-3 is more holistic than MDGs goals 4-6 put together, and clearly recognises public finance, both domestic and international, to play a vital role “in providing essential services”.
How are we to measure the progress towards SDGs?
The report discusses at length accountability mechanisms to be put in place and developing yard sticks to monitor and evaluate progress made over the next 15 years. There are two related issues here: One relates to what is to be measured (health outcomes over the years vs additional resources mobilised and deployed after 2015) and possessing “statistical capability” to track the progress, reliably, accurately and at an appropriate time.
While it is a fact that our statistical data base on health is improving, we are far from having a statistical system that is robust enough to measure our progress. Our official figures even on maternal mortality rates (MMR) and IMR (infant mortality rates) could be contested at various levels. Massive information on morbidity levels, health-seeking behaviour and out of pocket expenses, most assiduously collected through the National Sample Survey Organisation (NSSO), particularly through the state-level offices, lie unused by planning commissions of various states, for a variety of reasons. “Data is key to decision making”, as the document says, but our efforts to strengthen statistical capacity is woefully inadequate, and our tradition of using data in planning processes seems to have eroded over the decades.
We seem to be obsessed with measuring the final health outcomes and the “gap” between the target and where we are at the end of journey, and then declare ourselves as having “failed” in achieving the goals. This is a meaningless exercise, unless we also measure how well are we progressing towards the end goals over a decade after the SDGs declaration compared to the decade before SDGs declaration, and simultaneously also develop indicators of our commitment to these goals. Look at our state governments’ expenditure on health, for example. Are they increasing at least in nominal terms? Very few states can proudly claim so. How much of the health budget is towards primary healthcare (PHC)? Are we recruiting periodically to deliver the promised healthcare? What is being done to improve the physical infrastructure of the delivery system? Have we revisited the various norms being used for building health delivery system (population to PHC ratio, for example)? How much of rational planning takes place with regard to production and absorption of health workforce: Have we invested adequately on training field functionaries, paramedics, physicians, public health specialists? What have we done to strengthen the role of private sector in meeting public health goals? How well are we integrating the role of civil societies in the overall management of public healthcare system? How do we measure these efforts? Statistical capability must include ability to comprehensively measure multi-dimensional nature of progress towards SDGs. We lack the most rudimentary database on the functioning of private health sector in the country. The importance of building our statistical capability can never be over-emphasised. Clearly, we have a long way to go.
Some over-arching principles
(a) Let us insist on having indicators that reflect “policy efforts and additional resources” put into achieving SDGs, rather than only health outcomes indicators; (b) We must accord highest priority on reducing inequities (in outcomes and access) across states and within states—even in better off states such as Tamil Nadu, there are sections of society and regions suffering systematically from lack of access to basic primary care; we need specific targets and renewed efforts and resources to achieve their health care needs; (c) All government policies (be it in transportation, housing, energy, agriculture or the industrial sector) should be assessed in terms of their potential effects on public health, as evidence of our commitment towards “health in all”, as part of our holistic (systemic) approach towards SDG-3; (d) The government must earmark a definite amount of its annual budget for health, in absolute terms or on per-capita basis and this must be adequate to cover essential care across the state and finally (e) We must truly embrace in principle “health as a fundamental right”—most actions will spring out of this principle and will fall in the right place and in the right order, over time.
- By V R Muraleedharan, Dept of Humanities and Social Sciences; Coordinator, Centre for Technology and Policy, IIT Madras. The writer served as a Member, Mission Steering Group, National Rural Health Mission.
[This article has been reproduced with permission from Indian Institute of Technology, Madras]