Countdown for health to the post-2015 UN Sustainable Development Goals

The UN member states face difficult decisions for health in crafting the proposed, expansive post-2015 sustainable development agenda

In December 2015, the achievements of the United Nations Millennium Development Goals (MDGs) on development in low- and middle-income countries will be assessed. Already we are aware of the progress since they were proposed as part of the UN Millennium Declaration in 2001. The world has reduced extreme poverty by half; over 3.3 million deaths from malaria and tuberculosis have been averted; over 2.3 billion people have gained access to safe drinking water; child mortality has more than halved; and access to HIV antiretroviral drugs has substantially increased.1 Beyond 2015, the residual tasks of the MDGs will be integrated into a new agenda that has arisen from the recommendations of Rio+20, the United Nations Conference on Sustainable Development in June 2012, asking all nations to commit to Sustainable Development Goals (SDGs).

As part of Go4Health, an international consortium advising the European Commission on health-related objectives in the evolving negotiations on post-2015 SDGs,2 we have tracked the debate with increasing concern. In June 2013, after a year's global consultation and the release of the report by the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda,3 we interviewed key personnel from UN multilateral organisations and related global health agencies. Their reactions to the consultation and report were complex: relief that so much of the health agenda had been maintained, but concern over potential challenges.

One such concern was that the use of health rights language, particularly regarding sexual and reproductive health, would reactivate political conflicts about contraception and abortion and extend to highly charged debate on sexual orientation and gender identity.4 In recent intergovernmental negotiations, language that called for protection of human rights “without discrimination” was opposed because of perceived covert links to sexual orientation and gender identity. Our interviewees shared the apprehension that in the debates about economic and environmental matters implicit in the post-2015 negotiations, sexual and reproductive health and rights may become vulnerable in critical trade-offs.5

In our more recent interviews in May 2014, there was also considerable anxiety among health agency personnel about the risk of fragmentation as the intergovernmental Open Working Group assumed post-consultation responsibility for developing the document on which the final SDG negotiations will be based. This document was submitted to the September 2014 UN General Assembly.6

The Open Working Group's vision has strengths in its ambitious scope, the centrality of women and its recognition of the potential of technology, but the 17 goals and 169 associated targets are unwieldy and inconsistently framed. At this stage, they lack a cohesive focus that will engage global commitment to transform health and development.7

The health SDG, “Goal 3: Ensure healthy lives and promote well-being for all at all ages”, now comprises 13 associated targets. The goal builds on the MDGs to further reduce maternal mortality and end preventable child deaths and the epidemics of AIDS, tuberculosis and malaria, but now also tackles additional infectious diseases — hepatitis, water-borne diseases and neglected tropical diseases. It includes non-communicable diseases, road traffic trauma, alcohol and substance misuse, tobacco control, and the health effects of pollution. These targets are framed by key health systems targets: achieving universal health coverage, building capacity for risk management, strengthening the workforce, and ensuring access to sexual and reproductive health services.4 All these are worthy concerns that need to be addressed.

However, the task of the SDGs is to galvanise and focus global attention on sustainable development and to ensure the consensus necessary to resource its implementation. Despite UN insistence that the SDGs have been set, in their current formulation, these goals cannot do that. If the weakness of the MDGs was the lack of consultation, under the Open Working Group, the health SDG, in particular, is problematic, reflecting the complex politics of the process and including priorities for every advocate, but diluting the cumulative impact.

Difficult decisions must be faced. If health is to remain central, it must be integral to the whole sustainable development agenda. Renewed focus should again be placed on why the global community is seeking a new set of development goals, and the values and vision for sustainable development that underline them. The UN Secretary-General's response to the SDGs in his synthesis report on the post-2015 sustainable development agenda has clustered the 17 goals into six “essential elements” — a much more manageable configuration.8 But the duplications and inconsistencies still need remedying, with the aspirational targets being redefined for achievement by 2030.

The health goal and targets need to be reworked into a compelling narrative of how health is integral to sustainable development.9 Let us work with the health goal as it is — healthy lives and wellbeing are reasonable aspirations, and recognising age differences allows both focus and a whole-of-life trajectory. However, the 13 health targets need to be reduced and restructured so that they make sense at both global and local levels and are clustered on the basis of their commonalities. We suggest the following three targets:

• “Ensure a policy environment that enables health and wellbeing.” This target could reasonably embrace the initiatives in research and development of medicines and technologies, the negative effects of pollution and trauma, global health risk surveillance and response, alcohol and substance misuse, and tobacco control.
• “Achieve universal health coverage.” This target would ensure universal access to services including sexual and reproductive health care, while guaranteeing protection against health-related financial risk, with services underwritten by the necessary finance and human-resource strategies.
• “Protect every age group from the major threats to healthy lives and wellbeing.” This target includes both the residual MDG agenda, and the expanded recognition of non-communicable diseases, but allows for other emerging priorities.

Within these three targets, the original 13 targets and other nationally significant problems could be redesignated as health indicators, aggregated to track progress across health as a whole. This restructuring would reframe health within sustainable development, establish coherent links between the systems and policy frameworks that enable interventions, and cluster disease target silos into integrated, comprehensive health services delivery.

The remaining critical matter will be the means of implementation; UN member states must commit to funding change in a global partnership for sustainable development. Forging consensus on the SDGs will be crucial, but even more so will be driving agreement on how to mobilise the domestic and global resources needed to achieve them.