Despite their overall success, the MDgs have not achieved Doubts have also been expressed about the purposes unanimous approval. 8,22, 2424 For example, it has been pointed to which the MDgs have sometimes been put. For out that despite their pro-poor focus, the MDGs have, example, the mdgs have been applied as one-size-fits-all by employing almost exclusively aggregate targets and development planning instruments with targets that every indicators, glossed over within-country inequalities, thereby country can meet, even though the MDGs were never undermining efforts required to improve conditions for the meant as targets for individual countries. Global targets poorest and hardest-to-reach populations. Figure 1.1 offers are less useful for countries with a low starting point or in an example of such disparities, showing the significant conflict situations. a greater degree of realism about each differences in mortality in children under five living in the country's ability to attain them would have helped guide poorest and richest households, children whose mothers national policy development in certain instances were the least educated compared with the most educated, and between those living in urban compared with rural areas in 49 countries SDGs inequality, 2005-2012 dle-income countries by multiple dimensions of On 25 September 2015, the UN General Assembly adopted the new development agenda"Transforming our world: the 2030 agenda for sustainable development" The agenda builds upon the outcome document of the UN Conference on Sustainable Development(Rio+ 20 conference), 26 which took place in June 2012 and led to the establishment of the Open Working Group on SDGs, a group of Member States tasked with preparing a proposal on the SDGs. The Open Working Group proposal was welcomed by the UN General Assembly in September 2014 and became the 1』直111 principal guideline for integrating SD gs into the post- 2015 development agenda. 27 Further intergovernmental negotiation processes resulted in the final document for Mother's place of the Sixty-ninth UN General Assembly in 2014, which also education residence Sex included the outcomes of major global meetings such as the Median value of 49 selected countries. enda Framework for Disaster Risk Reduction 2015-203028 and the Addis Ababa Action Agenda, 29 as well as inputs such as the synthesis report of the Secretary-General on the post-2015 agenda, The road to dignity: ending poverty, The MDG framework has also been criticized for focusing transforming all lives and protecting the planet", published attention and resources on the attainment of particular in December 2014 pro goals at the expense of others. This is, of course, in the nature of focusing, but the criticism raises important issues The 17 goals(Table 1.2)of the new development agenda nonetheless The focusing"problem" has been pa integrate all three dimensions of sustainable development apparent with regard to the health goals, where res (economic, social and environmental)around the themes of and effort have been directed at strengthening people, planet, prosperity, peace and partnership. The SDGs disease-specific or"vertical" programmes, often at the seek to continue to prioritize the fight against poverty and expense of broader, cross-cutting investments in health hunger, while also focusing on human rights for all, and the stems that can deal with all health issues in a more empowerment of women and girls as part of the push to integrated manner. This emphasis on vertical approaches achieve gender equality. They also build upon, and extend has often resulted in separate strategic plans, monitoring the MDgs in order to tackle the "unfinished business mechanisms, funding streams and implementation of the MDG era. The SDgs recognize that eradicating efforts, with only limited investment in harmonization poverty and inequality, creating inclusive economic and alignment across programmes. The MDgs focused growth and preserving the planet are inextricably linked on the ends(health outcomes), without offering major not only to each other, but also to population health; and incentives to invest in the more broad-based means-ie. that the relationships between each of these elements health systems. This has often led to major progress in are dynamic and reciprocal. For example, with regard to MDG health indicators, while leaving major deficiencies in health, a fundamental assumption of the SDGs is that health systems as a whole such as weak country capacity health is a major contributor and beneficiary of sustainable to respond to challenges, for example infectious disease development policies. 26 outbreaks(the West Africa Ebola epidemic is an obvious example)or a rapidly increasing burden of NCDs FROM MDGS TO SDGS: GENERAL INTRODUCTON
Despite their overall success, the MDGs have not achieved unanimous approval.8 ,22,23,24 For example, it has been pointed out that despite their pro-poor focus, the MDGs have, by employing almost exclusively aggregate targets and indicators, glossed over within-country inequalities, thereby undermining efforts required to improve conditions for the poorest and hardest-to-reach populations. Figure 1.1 offers an example of such disparities, showing the significant differences in mortality in children under five living in the poorest and richest households, children whose mothers were the least educated compared with the most educated, and between those living in urban compared with rural areas in 49 countries. Sex Place of residence Mother’s educationb Economic status Quintile 1 (poorest) Male Deaths per 1000 live births 0 120 100 80 60 40 20 Figure 1.1 Under-five mortality in low- and middle-income countriesa by multiple dimensions of inequality, 2005–201225Quintile 2 Quintile 3 Quintile 4 Quintile 5 (richest) No education Primary school Secondary school+ Rural Urban a Median value of 49 selected countries. b Data are not available for 10 countries. Female The MDG framework has also been criticized for focusing attention and resources on the attainment of particular goals at the expense of others. This is, of course, in the nature of focusing, but the criticism raises important issues nonetheless. The focusing “problem” has been particularly apparent with regard to the health goals, where resources and effort have been directed at strengthening certain disease-specific or “vertical” programmes, often at the expense of broader, cross-cutting investments in health systems that can deal with all health issues in a more integrated manner. This emphasis on vertical approaches has often resulted in separate strategic plans, monitoring mechanisms, funding streams and implementation efforts, with only limited investment in harmonization and alignment across programmes. The MDGs focused on the ends (health outcomes), without offering major incentives to invest in the more broad-based means – i.e. health systems. This has often led to major progress in MDG health indicators, while leaving major deficiencies in health systems as a whole, such as weak country capacity to respond to challenges, for example infectious disease outbreaks (the West Africa Ebola epidemic is an obvious example) or a rapidly increasing burden of NCDs. Doubts have also been expressed about the purposes to which the MDGs have sometimes been put. For example, the MDGs have been applied as one-size-fits-all development planning instruments with targets that every country can meet, even though the MDGs were never meant as targets for individual countries. Global targets are less useful for countries with a low starting point or in conflict situations. A greater degree of realism about each country’s ability to attain them would have helped guide national policy development in certain instances. SDGs On 25 September 2015, the UN General Assembly adopted the new development agenda “Transforming our world: the 2030 agenda for sustainable development”.1 The agenda builds upon the outcome document of the UN Conference on Sustainable Development (Rio+20 conference),26 which took place in June 2012 and led to the establishment of the Open Working Group on SDGs, a group of Member States tasked with preparing a proposal on the SDGs. The Open Working Group proposal was welcomed by the UN General Assembly in September 2014 and became the principal guideline for integrating SDGs into the post- 2015 development agenda.27 Further intergovernmental negotiation processes resulted in the final document for the Sixty-ninth UN General Assembly in 2014, which also included the outcomes of major global meetings such as the Sendai Framework for Disaster Risk Reduction 2015–203028 and the Addis Ababa Action Agenda,29 as well as inputs such as the synthesis report of the Secretary-General on the post-2015 agenda, “The road to dignity: ending poverty, transforming all lives and protecting the planet”, published in December 2014.30 The 17 goals (Table 1.2) of the new development agenda integrate all three dimensions of sustainable development (economic, social and environmental) around the themes of people, planet, prosperity, peace and partnership. The SDGs seek to continue to prioritize the fight against poverty and hunger, while also focusing on human rights for all, and the empowerment of women and girls as part of the push to achieve gender equality. They also build upon, and extend, the MDGs in order to tackle the “unfinished business” of the MDG era. The SDGs recognize that eradicating poverty and inequality, creating inclusive economic growth and preserving the planet are inextricably linked, not only to each other, but also to population health; and that the relationships between each of these elements are dynamic and reciprocal. For example, with regard to health, a fundamental assumption of the SDGs is that health is a major contributor and beneficiary of sustainable development policies.26 FROM MDGs TO SDGs: GENERAL INTRODUCTION 7
The 17 SDGs for family planning, information and education /e will equally accelerate the pace of progress End poverty in all its forms everywhere made in fighting malaria, HIV/AIDS, tuberculosis, achieve food security and improved nutrition and promote sustainable hepatitis, Ebola and other communicable diseases and epidemics, including by addressing growing anti- 3 Ensure healthy lives and promote well-being for all at all ages microbial resistance and the problem of unattended 4 Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all diseases affecting developing countries. We are 5 Achieve gender equality and empower all women and girls committed to the prevention and treatment of non- 6 Ensure availability and sustainable management of water and sanitation for all communicable diseases, including behavioural 7 Ensure access to affordable, reliable, sustainable and modern energy for all developmental and neurological disorders, which 8 Promote sustained, inclusive and sustainable economic growth, full and productive constitute a major challenge for sustainable employment and decent work for all development ild resilient infrastructure, promote inclusive and sustainable industrialization and foster innovatio One of the 17 goals has been devoted specifically to health, 10 Reduce inequality within and among countries and is framed in deliberately broad terms that are relevant ments inclusive, safe, resilient and sustainable to all countries and all populations: "Ensure healthy lives 12 Ensure sustainable and promote well-being for all at all ages". The health 13 Take urgent action to combat climate change and its impacts goal is associated with 13 targets, including four means 14 Conserve and sustainably use the oceans, seas and marine resources for of implementation targets labelled 3. a to 3. d. Overall, the sustainable development SDGs have 169 targets 15 Protect, restore and promote sustainable use of terrestrial ecosystems, sustainabl age forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss Even though the 2030 agenda refers several times to 16 Promote peaceful and inclusive societies for sustainable development, provide the term "human right(s)"(rights to development, self- at all levels determination, an adequate standard of living, food, water 17 Strengthen the means of implementation and revitalize the global partnership and sanitation, good governance, and the rule of law),it for sustainable development does not specifically mention that health is a human right Acknowledging that the United Nations Framework Convention on the primary international, intergovernmental forum for negotiating the global response to dimate change Health targets in SDG 3 The SDGs aim to be universal, integrated and interrelated 3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 In order to take on such a wic of 3.2 cutting issues, it will be necessary to achieve far greater age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-five mortality to at least as low as 25 intersectoral coherence, integration and coordination of efforts than has hitherto been in evidence. a revitalized 3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tr global partnership for sustainable development, based on diseases and combat hepatitis, waterborne diseases and other communicable a spirit of strengthened global solidarity, informed by a 3.4 By 2030, reduce by one third premature mortality from noncommumic readiness to reach across sectors and guided by clear and through prevention and treatment and promote mental health an measurable objectives will be critical for the mobilization 3.5 Strengthen the prevention and treatment of substance abuse, including narcotic of the means required to implement the SDg agenda, drug abuse and harmful use of alcohol focused particularly on the needs of the poorest and most 3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents vuInerable 3.7By2030 cluding for family planning, information and education, and the integration of eproductive health into national strategies and programmes The health goal quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all Paragraph 26 of the 2030 agenda for sustainable 3.9 By 2030, ubstantially reduce the number of deaths and illnesses from development addresses health as follows chemicals and air, water and soil pollution and contamination Convention on Tobacco Control in all countries, as appropriate To promote physical and mental health and well- being, and to extend life expectancy for all, we must 3.b Support the research and de ent of vaccines and medicines for th e diseases that primarly affect developing achieve universal health coverage and access to d publ quality health care. No one must be left behind. We Health, which affirms the right of developing countries to use to the full the commit to accelerating the progress made to date in Trade-Related Aspects of Intellectual Pr Rights regarding flexibilities to protect public health, and, in particular, provi reducing newborn, child and maternal mortality by access to medicines for all ending all such preventable deaths before 2030.We 3. c Substantially increase health financing and the recruitment, development, are committed to ensuring universal access to sexual in least-developed countries and small island developing States and reproductive health-care services, including early waming, risk reduction and management of national and oping countries, for HEALTH IN 2015: FROM MDGs TO SDGs
for family planning, information and education. We will equally accelerate the pace of progress made in fighting malaria, HIV/AIDS, tuberculosis, hepatitis, Ebola and other communicable diseases and epidemics, including by addressing growing antimicrobial resistance and the problem of unattended diseases affecting developing countries. We are committed to the prevention and treatment of noncommunicable diseases, including behavioural, developmental and neurological disorders, which constitute a major challenge for sustainable development. One of the 17 goals has been devoted specifically to health, and is framed in deliberately broad terms that are relevant to all countries and all populations: “Ensure healthy lives and promote well-being for all at all ages”. The health goal is associated with 13 targets, including four means of implementation targets labelled 3.a to 3.d. Overall, the SDGs have 169 targets. Even though the 2030 agenda refers several times to the term “human right(s)” (rights to development, selfdetermination, an adequate standard of living, food, water and sanitation, good governance, and the rule of law), it does not specifically mention that health is a human right. 1 End poverty in all its forms everywhere 2 End hunger, achieve food security and improved nutrition and promote sustainable agriculture 3 Ensure healthy lives and promote well-being for all at all ages 4 Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all 5 Achieve gender equality and empower all women and girls 6 Ensure availability and sustainable management of water and sanitation for all 7 Ensure access to affordable, reliable, sustainable and modern energy for all 8 Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all 9 Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation 10 Reduce inequality within and among countries 11 Make cities and human settlements inclusive, safe, resilient and sustainable 12 Ensure sustainable consumption and production patterns 13 Take urgent action to combat climate change and its impactsa 14 Conserve and sustainably use the oceans, seas and marine resources for sustainable development 15 Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss 16 Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels 17 Strengthen the means of implementation and revitalize the global partnership for sustainable development a Acknowledging that the United Nations Framework Convention on Climate Change is the primary international, intergovernmental forum for negotiating the global response to climate change. Table 1.2 The 17 SDGs The SDGs aim to be universal, integrated and interrelated in nature. In order to take on such a wide range of crosscutting issues, it will be necessary to achieve far greater intersectoral coherence, integration and coordination of efforts than has hitherto been in evidence. A revitalized global partnership for sustainable development, based on a spirit of strengthened global solidarity, informed by a readiness to reach across sectors and guided by clear and measurable objectives will be critical for the mobilization of the means required to implement the SDG agenda, focused particularly on the needs of the poorest and most vulnerable. The health goal Paragraph 26 of the 2030 agenda for sustainable development addresses health as follows:1 To promote physical and mental health and wellbeing, and to extend life expectancy for all, we must achieve universal health coverage and access to quality health care. No one must be left behind. We commit to accelerating the progress made to date in reducing newborn, child and maternal mortality by ending all such preventable deaths before 2030. We are committed to ensuring universal access to sexual and reproductive health-care services, including 3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births 3.2 By 2030, end preventable deaths of newborns and children under five years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-five mortality to at least as low as 25 per 1000 live births 3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, waterborne diseases and other communicable diseases 3.4 By 2030, reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being 3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol 3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents 3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes 3.8 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 3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination 3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate 3.b Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all 3.c Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least-developed countries and small island developing States 3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks Table 1.3 Health targets in SDG 3 8 HEALTH IN 2015: FROM MDGs TO SDGs
The 13 targets that underpin the broad health goal are shown Table 1.4 in Table 1.3. It is noted that the mdG goals on maternal Examples of targets in other goals linked to the health soG3 mortality (3.1), child mortality(3.2)and infectious diseases 1.3 Implement nationally appropriate social protection systems and measure (3.3)have been retained in the SDG framework, augmented for all, including fioors, and by 2030 achieve substantial coverage of the poor by new and more ambitious targets for 2030, and expanded to include neonatal mortality and more infectious diseases tionally agreed targets on stunting and wasting in children under five such as hepatitis and waterborne diseases. The targets on years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons access to sexual and reproductive health-care services(3.7) 4.2 By 2030, ensure that all girls and boys have access to quality early childhood and access to vaccines and medicines (3. b) are also closely development, care and pre-primary education so that they are ready for related to the MDG targets. Sexual and reproductive rights are addressed under MDG 5 on gender equality Build and upgrade education facilities that are child, disability and gender sensitive and provide safe, non-violent, inclusive and effective learning environments for all The SDGs include new targets on NCDs and mental health 5.2 a minate all forms of violence against all women and giris in the public and (3.4), substance abuse(3.5), injuries (3.6), health impact 5.3 Eliminate all harmful practices, such as child, early and forced marriage and from hazardous chemicals, water and soil pollution and contamination (3.9)and the implementation of the WHo Ensure universal access to productive health and reproductive Framework Convention on Tobacco Control (WHO FCTC) Conference on Population and Development and the Bei ng Platform for Action (3. a). Target 3. d addresses reducing and managing national and the outcome documents of their review conferences and global health risks, and health financing and health 6.1 By 2030, achieve universal and equitable access to safe and affordable workforce issues in least-developed countries and small drinking-water to all island developing states are addressed by Target 3.c 6.2 By 2030, achieve access to adequate and equitable sanitation and hygiene fo all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations UHC is also a new target (3.8), which provides an overall 6.3 By 2030, improve water quality by reducing pollution, eliminating dumping framework for the implementation of a broad and ambitious of untreated wastewater and substantially increasing recycling agenda in all countries. UHC is the only target that cuts and safe reuse glob across all targets of the health goals, as well as addresses 10.4 Adopt policies, especially fiscal, wage and social protection policies, and progressively achieve greater equality linkages with health-related targets in the other goals. The issue of UHC in the SDGs is addressed in Chapter 3 where 11.5By2030,sig ntially decrease the direct economic losses relative to its importance for all health targets, including notably targets for NCDs, is outlined. A simple framework for 16.1 Significantly reduce all forms of violence and related death rates everywhere organizing the health targets in a logical manner is proposed 16.2 End abuse, exploitation, trafficking and all forms of violence against and in Chapter 9 torture of children 16.6 Develop effective, accountable and transparent institutions at all levels Health in other goals 16.9 By 2030, provide legal identity for all, including birth registration Health is linked to many of the non-health goals, reflecting least-developed countries and small island the fact that health affects, and is in turn affected by many economic, social and environmental determinants location and other characteristics relevant in national contexts Progress in health is dependent on economic, social and environmental progress. Well over a dozen targets in other goals can be considered health-related and should be given of environmental degradation and climate change, which special attention in strategies, policies and plans to achieve have the highest relative impact on the poorest countries the health goal and in monitoring progress(Table 1. 4). Goal and the least healthy and poorest groups within countries 17 is about means of implementation and links to the four means of implementation targets of the health goal Policies made in all sectors can have a profound effect on population health and health equity the health of people is One of the strengths of the SDgs is the breadth of their not solely a health sector responsibility; it is also impacted embrace, which seeks to encompass communicable by issues such as transport, agriculture, housing, trade diseases, NCDs and injuries as well as determinants of and foreign policy To address the multisectoral nature of health such as increasing urbanization, pollution and health determinants requires the political will to engage climate change. The SDG agenda emphasizes the close links the whole of government in health. The health sector between health and sustainable development. health policy should promote Health in All Policies", an approach to can contribute to sustainable development and poverty public policies across sectors that systematically takes reduction if people have access to the information and into account the health implications of decisions, seeks services they need to promote and protect their health and synergies and avoids harmful health impacts in order to are protected from catastrophic expenditure when they fall ill. improve population health and health equity and address Sustainable development, in turn, limits the adverse impacts the social determinants of health.32, 33 FROM MDGS TO SDGS: GENERAL NNIRODUCTN
The 13 targets that underpin the broad health goal are shown in Table 1.3. It is noted that the MDG goals on maternal mortality (3.1), child mortality (3.2) and infectious diseases (3.3) have been retained in the SDG framework, augmented by new and more ambitious targets for 2030, and expanded to include neonatal mortality and more infectious diseases such as hepatitis and waterborne diseases. The targets on access to sexual and reproductive health-care services (3.7) and access to vaccines and medicines (3.b) are also closely related to the MDG targets. Sexual and reproductive rights are addressed under MDG 5 on gender equality. The SDGs include new targets on NCDs and mental health (3.4), substance abuse (3.5), injuries (3.6), health impact from hazardous chemicals, water and soil pollution and contamination (3.9) and the implementation of the WHO Framework Convention on Tobacco Control (WHO FCTC) (3.a). Target 3.d addresses reducing and managing national and global health risks, and health financing and health workforce issues in least-developed countries and small island developing states are addressed by Target 3.c. UHC is also a new target (3.8), which provides an overall framework for the implementation of a broad and ambitious agenda in all countries. UHC is the only target that cuts across all targets of the health goals, as well as addresses linkages with health-related targets in the other goals. The issue of UHC in the SDGs is addressed in Chapter 3 where its importance for all health targets, including notably targets for NCDs, is outlined. A simple framework for organizing the health targets in a logical manner is proposed in Chapter 9. Health in other goals Health is linked to many of the non-health goals, reflecting the fact that health affects, and is in turn affected by, many economic, social and environmental determinants. Progress in health is dependent on economic, social and environmental progress. Well over a dozen targets in other goals can be considered health-related and should be given special attention in strategies, policies and plans to achieve the health goal and in monitoring progress (Table 1.4). Goal 17 is about means of implementation and links to the four means of implementation targets of the health goal. One of the strengths of the SDGs is the breadth of their embrace,31 which seeks to encompass communicable diseases, NCDs and injuries as well as determinants of health such as increasing urbanization, pollution and climate change. The SDG agenda emphasizes the close links between health and sustainable development. Health policy can contribute to sustainable development and poverty reduction if people have access to the information and services they need to promote and protect their health and are protected from catastrophic expenditure when they fall ill. Sustainable development, in turn, limits the adverse impacts 1.3 Implement nationally appropriate social protection systems and measures for all, including floors, and by 2030 achieve substantial coverage of the poor and the vulnerable 2.2 By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under five years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons 4.2 By 2030, ensure that all girls and boys have access to quality early childhood development, care and pre-primary education so that they are ready for primary education 4.a Build and upgrade education facilities that are child, disability and gender sensitive and provide safe, non-violent, inclusive and effective learning environments for all 5.2 Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation 5.3 Eliminate all harmful practices, such as child, early and forced marriage and female genital mutilation 5.6 Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences 6.1 By 2030, achieve universal and equitable access to safe and affordable drinking-water to all 6.2 By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations 6.3 By 2030, improve water quality by reducing pollution, eliminating dumping and minimizing release of hazardous chemicals and materials, halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally 10.4 Adopt policies, especially fiscal, wage and social protection policies, and progressively achieve greater equality 11.5 By 2030, significantly reduce the number of deaths and the number of people affected and substantially decrease the direct economic losses relative to global gross domestic product caused by disasters, including water-related disasters, with a focus on protecting the poor and people in vulnerable situations 16.1 Significantly reduce all forms of violence and related death rates everywhere 16.2 End abuse, exploitation, trafficking and all forms of violence against and torture of children 16.6 Develop effective, accountable and transparent institutions at all levels 16.9 By 2030, provide legal identity for all, including birth registration 17.18 By 2020, enhance capacity-building support to developing countries, including for least-developed countries and small island developing States, to increase significantly the availability of high-quality, timely and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location and other characteristics relevant in national contexts Table 1.4 Examples of targets in other goals linked to the health SDG 3 of environmental degradation and climate change, which have the highest relative impact on the poorest countries and the least healthy and poorest groups within countries. Policies made in all sectors can have a profound effect on population health and health equity. The health of people is not solely a health sector responsibility; it is also impacted by issues such as transport, agriculture, housing, trade and foreign policy. To address the multisectoral nature of health determinants requires the political will to engage the whole of government in health. The health sector should promote “Health in All Policies”, an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve population health and health equity and address the social determinants of health.32,33 FROM MDGs TO SDGs: GENERAL INTRODUCTION 9
Follow-up and review Member States in the World Health Assembly(WHA) Dozens of targets already exist that correspond to the SDg Tracking progress has been vital in maintaining momentum health targets, and while some SdG health targets do not of the MDGs, as well as in identifying areas requiring greater yet have corresponding, specific WHA health targets, the efforts. It will be no less important in the context of the general adoption of the SDg framework makes these targets SDGs. The SDG declaration pays considerable attention relevant for the WHA. to the systematic follow-up and review of implementation at national, regional and global levels. Globally, the High Monitoring the overarching health goal Level Political Forum on Sustainable Development will play a critical role in overseeing a network of review processes. There is a need to monitor the SDgs at the goal level. The The reviews will be informed by an annual report prepared overall health SDG is to, "Ensure healthy lives and promote by the Un Secretary-General in cooperation with the Un well-being for all at all ages". WHo has considered several system overarching indicators that might serve to monitor that goal, including life expectancy, number of deaths before age Follow-up and review processes will be voluntary and 70, and healthy life expectancy 37,38 If it could be measured country-led. The SDG resolution states that national reliably, healthy life expectancy would be a suitable single governments should"set their own national targets guided indicator that captures both mortality and years of life by the global level of ambition but taking into account lived in less than good health (i.e. with a disability ). There is national circumstances" How this will actually be done increasing interest in the accurate measurement of health and what, for instance, the role of regional and global disability and well-being, especially given the context of mechanisms will have to be worked out as part of the ageing populations and the growing prominence of chronic indicator framework. diseases as causes of disability and premature mortality There is some evidence that life expectancy in high-income The UN Statistical Commission will provide a proposal countries is increasing faster than healthy life expectancy for a global indicator framework(and associated global The monitoring efforts being undertaken in the European and universal indicators) by march 2016 for subsequent Union are interesting in this regard, setting a target for adoption by the economic and Social Council of the Un Members States of achieving an additional two healthy General Assembly. 4 Monitoring the progress of the 17 life years by 2020. 9.40 However, while many attempts SDGs and their 169 targets will be a challenge, given the have been made to measure population health status in sheer number of targets and indicators. Furthermore, some addition to the underlying causes of declines in health, of the new goals and targets have little track record in terms challenges remain with regard to the availability of data of data and monitoring on population level functional status that are comparable over time and across populations and collected through Among the health agencies and countries, there is regular surveys. 142 considerable agreement around the key indicators which should be selected from the existing, well-tested Despite the large gaps in coverage of global mortality indicators, included in the Global Reference List of 100 Core information systems, mortality is more amenable to Indicators. However, less-established indicators may be accurate measurement than disease or disability. Several required in some targets. One of the biggest challenges cause-specific mortality targets are proposed for the faced in developing meaningful indicators is the lack of data post-2015 agenda, many focusing on reducing or ending in many countries, even for well-established indicators such "preventable"deaths. 43 Life expectancy is an attractive as those used to monitor cause-specific mortality Domestic summary measure of mortality rates at all ages, and all and international investments in robust health information health and health-related programmes contribute to it and statistical systems, including civil registration and vital Box 1.1 shows the dramatic improvements observed in life statistics systems, are thus urgently required. 36 expectancy during the mDg era. WHO has estimated that achievement of the major SDG health targets for child, As the lead agency for the health SDGs, WHO should maternal, infectious diseases and NCDs would result in an provide Member States with detailed annual updates of increase of global average life expectancy of around four progress and inform the overall SDG monitoring process, years by 2030. The gap between high-and low-income coordinated by the United Nations Statistics Division, with countries would narrow from around 17. 5 years in 2015 to regular updates on a small set of core indicators. Optimal around 13-14 years. 41 fulfilment of this task will depend on close collaboration with other agencies such as UNICEF, the United Nations Also worthy of consideration is a proposal for a measure Office on Drugs and Crime(UNODC), the United Nations of premature mortality with a target of reducing the Population Fund(UNFPA) and the World Bank. The SDg number of deaths before age 70 by 40% by 2030 globally health and health-related targets are closely related to and in every country. 44 Countries at different stages of many of the targets that have been adopted by the who development could achieve such gains by bringing down HEALTH IN 2015: FROM MDGs TO SDGs
Follow-up and review Tracking progress has been vital in maintaining momentum of the MDGs, as well as in identifying areas requiring greater efforts. It will be no less important in the context of the SDGs. The SDG declaration pays considerable attention to the systematic follow-up and review of implementation at national, regional and global levels. Globally, the High Level Political Forum on Sustainable Development will play a critical role in overseeing a network of review processes. The reviews will be informed by an annual report prepared by the UN Secretary-General in cooperation with the UN system. Follow-up and review processes will be voluntary and country-led. The SDG resolution states that national governments should “set their own national targets guided by the global level of ambition but taking into account national circumstances”.1 How this will actually be done and what, for instance, the role of regional and global mechanisms will have to be worked out as part of the indicator framework. The UN Statistical Commission will provide a proposal for a global indicator framework (and associated global and universal indicators) by March 2016 for subsequent adoption by the Economic and Social Council of the UN General Assembly.34 Monitoring the progress of the 17 SDGs and their 169 targets will be a challenge, given the sheer number of targets and indicators. Furthermore, some of the new goals and targets have little track record in terms of data and monitoring. Among the health agencies and countries, there is considerable agreement around the key indicators which should be selected from the existing, well-tested indicators, included in the Global Reference List of 100 Core Indicators.35 However, less-established indicators may be required in some targets. One of the biggest challenges faced in developing meaningful indicators is the lack of data in many countries, even for well-established indicators such as those used to monitor cause-specific mortality. Domestic and international investments in robust health information and statistical systems, including civil registration and vital statistics systems, are thus urgently required.36 As the lead agency for the health SDGs, WHO should provide Member States with detailed annual updates of progress and inform the overall SDG monitoring process, coordinated by the United Nations Statistics Division, with regular updates on a small set of core indicators. Optimal fulfilment of this task will depend on close collaboration with other agencies such as UNICEF, the United Nations Office on Drugs and Crime (UNODC), the United Nations Population Fund (UNFPA) and the World Bank. The SDG health and health-related targets are closely related to many of the targets that have been adopted by the WHO Member States in the World Health Assembly (WHA). Dozens of targets already exist that correspond to the SDG health targets, and while some SDG health targets do not yet have corresponding, specific WHA health targets, the general adoption of the SDG framework makes these targets relevant for the WHA. Monitoring the overarching health goal There is a need to monitor the SDGs at the goal level. The overall health SDG is to, “Ensure healthy lives and promote well-being for all at all ages”. WHO has considered several overarching indicators that might serve to monitor that goal, including life expectancy, number of deaths before age 70, and healthy life expectancy.37,38 If it could be measured reliably, healthy life expectancy would be a suitable single indicator that captures both mortality and years of life lived in less than good health (i.e. with a disability). There is increasing interest in the accurate measurement of health, disability and well-being, especially given the context of ageing populations and the growing prominence of chronic diseases as causes of disability and premature mortality. There is some evidence that life expectancy in high-income countries is increasing faster than healthy life expectancy. The monitoring efforts being undertaken in the European Union are interesting in this regard, setting a target for Members States of achieving an additional two healthy life years by 2020.39,40 However, while many attempts have been made to measure population health status in addition to the underlying causes of declines in health, challenges remain with regard to the availability of data on population level functional status that are comparable over time and across populations and collected through regular surveys.41,42 Despite the large gaps in coverage of global mortality information systems, mortality is more amenable to accurate measurement than disease or disability. Several cause-specific mortality targets are proposed for the post-2015 agenda, many focusing on reducing or ending “preventable” deaths.43 Life expectancy is an attractive summary measure of mortality rates at all ages, and all health and health-related programmes contribute to it. Box 1.1 shows the dramatic improvements observed in life expectancy during the MDG era. WHO has estimated that achievement of the major SDG health targets for child, maternal, infectious diseases and NCDs would result in an increase of global average life expectancy of around four years by 2030. The gap between high- and low-income countries would narrow from around 17.5 years in 2015 to around 13–14 years.41 Also worthy of consideration is a proposal for a measure of premature mortality with a target of reducing the number of deaths before age 70 by 40% by 2030 globally and in every country.44 Countries at different stages of development could achieve such gains by bringing down 10 HEALTH IN 2015: FROM MDGs TO SDGs
satisfaction: a reflective assessment on a persons life or ife expectancy improvements during the MDG era some specific aspect of it; i)affective or hedonic: a persons of the health improvements since 1990 Figure 1.2). Life expectancy incresummary feelings or emotional states, typically measured with aster rate in most regions from 2000 onwards and, overall, there was a global increase reference to a particular point in time and (ii)eudemonic =m亚加门2m出 self-realization 5 It may, however, be too early to adopt an a sense of meaning and purpose in life autonomy and The gap between African life expectancy and European life expectancy has narrowed indicator as part of the SDg monitoring by four years in the MDG period. Monitoring equity Figure 1 rends in average life expectancy at birth, by WHO region and globally. 1990-2015 Equity is at the heart of the SDgs, which are founded on AFR■AMR■SEAR■EUR■EMR■WPR■ Global the concept of "leaving no one behind". The overall health SDG calls for healthy lives for all at all ages, positioning equity as a core, cross-cutting theme, while SDg 10 calls for the reduction of inequality within and among countries, and Target 3.8 calls for the establishment of UHC, founded on the principle of equal access to health without risk of financial hardship. a movement towards equity in health in part, on strong health and financing information systems that collect disaggregated data about all health areas and health expenditures. This fact is recognized in Target 17.8, which calls for efforts to 2005 2010 2015 build capacity to enable data disaggregation by a number cluding income, gender, age, ethnicity, etc. Disaggregated data enable policy-makers s ea 15 e ad appied there were 42 fewer ma fewer to identify vulnerable populations and direct resources due to other causes, including the main NCOs and injuries. accordingly MDGs were focused on national progress and on specific mortality due to HIV, malaria, TB or child mortality or NCD populations, notably mothers and children and people deaths between ages 30 and 70- depending on their affected by Hiv, TB and malaria. In contrast, the health relevant priorities. A 40% reduction in premature mortality SDGs address health and well-being at all ages, including by 2030 would be achievable by: averting two thirds of in newborns and children, adolescents, adult women and maternal and child deaths; two thirds of Hiv, tB and malaria men, and older persons. Not only is the goal to be monitored deaths; one third of premature deaths from NCDs; and one much broader, but it is also extended over time, and will thus third of deaths from other causes(other communicable require a comprehensive life course approach. Needless to diseases, undernutrition and injuries). These challenging say, such an approach will also be relevant in monitoring subtargets would halve under-50 deaths, avert one third progress towards UHC of the(mainly NCD) deaths at ages 50-69, and so prevent 40% of under -70 deaths. Such a reduction would result in a global increase in life expectancy of five years, assuming mortality rates at age 70 and over also decline, as projected by WHo. Concerted action to reduce ncd deaths before ge 70 is likely to also reduce ncd death rates for people age 70 and over. The"promote well-being"component of the overall health SDG also presents an interesting monitoring challenge, as does health Target 3.5, which refers to "promote mental health and well-being. While health and self-reported well-being are intricately related(health status is a critical determinant of subjective well-being, for example)they are not synonymous. 7484950 Measurement of self-reported well-being shares many of problems encountered in the measurement of non-fatal health outcomes the field of measuring subjective well-being is rapidly expanding and distinguishes different aspects including: (i evaluative life FROM MDGS TO SDGS: GENERAL NNIRODUCTN
mortality due to HIV, malaria, TB or child mortality or NCD deaths between ages 30 and 70 – depending on their relevant priorities. A 40% reduction in premature mortality by 2030 would be achievable by: averting two thirds of maternal and child deaths; two thirds of HIV, TB and malaria deaths; one third of premature deaths from NCDs; and one third of deaths from other causes (other communicable diseases, undernutrition and injuries). These challenging subtargets would halve under-50 deaths, avert one third of the (mainly NCD) deaths at ages 50–69, and so prevent 40% of under-70 deaths. Such a reduction would result in a global increase in life expectancy of five years, assuming mortality rates at age 70 and over also decline, as projected by WHO. Concerted action to reduce NCD deaths before age 70 is likely to also reduce NCD death rates for people age 70 and over. The “promote well-being” component of the overall health SDG also presents an interesting monitoring challenge, as does health Target 3.5, which refers to “promote mental health and well-being”. While health and self-reported well-being are intricately related (health status is a critical determinant of subjective well-being, for example) they are not synonymous.47,48,49,50 Measurement of self-reported well-being shares many of problems encountered in the measurement of non-fatal health outcomes. The field of measuring subjective well-being is rapidly expanding and distinguishes different aspects including: (i) evaluative life Box 1.1 Life expectancy improvements during the MDG era Overall trends in life expectancy at birth provide one partial, but important, summary of the health improvements since 1990 (Figure 1.2). Life expectancy increased at a faster rate in most regions from 2000 onwards and, overall, there was a global increase of 6.8 years in life expectancy from 1990 to 2015, with even larger increases of 9.3 years in the African Region and the South-East Asia Region. This corresponds to an average increase in global life expectancy at birth of 2.7 years per decade, which is faster than the increases in today’s high-income countries over the past century.45 The gap between African life expectancy and European life expectancy has narrowed by four years in the MDG period. AFR AMR SEAR EUR EMR WPR Global 1990 2015 45 80 70 65 60 55 50 2010 75 1995 2000 2005 Figure 1.2 Trends in average life expectancy at birth, by WHO region and globally, 1990–201546 Life expectancy at birth (years) All major causes of deaths contributed to these huge gains. For instance, WHO calculations indicate that compared to the numbers of deaths in 2012 that would have been expected if death rates in 2000 had applied, there were 42% fewer maternal and child deaths, 36% fewer deaths due to HIV, TB and malaria and around 7% fewer due to other causes, including the main NCDs and injuries. satisfaction: a reflective assessment on a person’s life or some specific aspect of it; (ii) affective or hedonic: a person’s feelings or emotional states, typically measured with reference to a particular point in time; and (iii) eudemonic: a sense of meaning and purpose in life, autonomy and self-realization.51 It may, however, be too early to adopt an indicator as part of the SDG monitoring. Monitoring equity Equity is at the heart of the SDGs, which are founded on the concept of “leaving no one behind”. The overall health SDG calls for healthy lives for all at all ages, positioning equity as a core, cross-cutting theme, while SDG 10 calls for the reduction of inequality within and among countries, and Target 3.8 calls for the establishment of UHC, founded on the principle of equal access to health without risk of financial hardship. A movement towards equity in health depends, at least in part, on strong health and health financing information systems that collect disaggregated data about all health areas and health expenditures. This fact is recognized in Target 17.8, which calls for efforts to build capacity to enable data disaggregation by a number of stratifying factors, including income, gender, age, race, ethnicity, etc. Disaggregated data enable policy-makers to identify vulnerable populations and direct resources accordingly. MDGs were focused on national progress and on specific populations, notably mothers and children and people affected by HIV, TB and malaria. In contrast, the health SDGs address health and well-being at all ages, including in newborns and children, adolescents, adult women and men, and older persons. Not only is the goal to be monitored much broader, but it is also extended over time, and will thus require a comprehensive, life course approach. Needless to say, such an approach will also be relevant in monitoring progress towards UHC. FROM MDGs TO SDGs: GENERAL INTRODUCTION 11