With the promise of “leaving no one behind", the UN General Assembly adopted the universal, integrated and transformative 2030 Agenda for Sustainable Development, along with a set of 17 Sustainable Development Goals (SDGs) almost two years ago.
It is interesting that these thoughts have their roots in what was envisioned by Mahatma Gandhi. He said, “Recall the face of the poorest and weakest man you have seen, and ask yourself if this step you contemplate is going to be any use to him." It is this thinking, which found reflection in the Millennium Development Goals (MDGs) and is now even more central in the SDGs.
Positioned as a key feature of human development, the health goal aims at “ensuring healthy lives and promote well-being for all in all ages". It is interlinked to several other SDGs related to poverty, gender equality, education, food security, urbanization, water sanitation, etc.
The unprecedented scope of SDGs provides immense opportunity to bring health at the centre of economic growth.
Universal Health Coverage (UHC), which is an explicit target under SDG3, can anchor, guide and inform SDG goals in health. This is the only target that cuts across all of the health goals, addressing linkages with health-related targets in the other goals. It also reflects SDG’s strong focus on equity and the importance of addressing the needs of poor or disadvantaged groups.
For India to progress towards sustainable development in health, five recommendations are proposed.
First, to “promote health and well-being of all Indians", health must be high on the national and state agenda; it is the cornerstone for economic growth of the nation.
This requires high political commitment and collective long-term efforts by ministries beyond the ministry of health to invest in health. India’s National Health Policy 2017 provides for raising public health expenditure to 2.5 % of the GDP by 2025; this is a welcome step.
Equally important is driving the convergent action of other sectors that have impact on health e.g. nutrition, water sanitation and hygiene, environment education and housing, etc.
Second, invest in public health and finish MDG agenda through further improvements in maternal and child health, confronting neglected tropical diseases, eliminating malaria, strengthening the country’s surveillance system to detect and respond to diseases and accelerating the fight against tuberculosis.
All these challenges, programmes and interventions need to be taken to scale, with an underlying emphasis on equity and quality of services.
Third, accelerate the implementation of universal health coverage. It is at the core of SDGs and in the interest of people and governments. UHC is important to prevent people slipping into poverty due to ill-health and to ensure everyone in need has access to good quality health services. To complement tax revenue based health financing, incremental expansion of prepayment and risk pooling mechanisms such as social health insurance are worth considering. The National Health Protection Scheme (NHPS), which is under consideration, would be a welcome first step to enlarge the population coverage for financial protection and access to services.
The journey toward UHC calls for defining and agreeing on vision and goals for 2030. This will serve as a national framework and roadmap that defines the roles of the centre and the states, and that of the public and private sector. The goal needs to be operationalized into well-defined 3-to-5-year plans with clear milestones, allowing for a step-by-step approach.
Health being a state subject, states should be encouraged to choose a model of their choice, develop their own path and determine the pace. The national framework will ensure convergence in the long term.
It is well recognized that while “more money for health" is necessary, obtaining “more health for money" requires that national and state plans are evidence-informed and managed in an integrated manner.
Fourth, develop a heath investment plan for each state to strengthen and build robust health systems in infrastructure and staffing with a focus on rural areas with comprehensive primary health care at its centre. The national health mission has laid an excellent foundation to further build on. The system is needed for all services—preventive, promotive, clinical, rehabilitation and palliation, and to detect and respond to health security challenges.
Given the magnitude of the private sector in India, a more effective engagement with private health care providers is vital. An appropriate contracting modality, which is an important feature under the social health insurance and NHPS, can be worked out and the private sector can be instrumental in complementing the public sector as demonstrated by different country experiences.
Finally, develop a strong and robust system for monitoring, evaluation and accountability. It is essential to regularly review and analyse the progress made for feeding into policy decisions and revising strategies based on the challenges.
In conclusion, SDGs have the potential to ensure healthy lives and promote well-being for all at all ages, to realize the right to health and leave no one behind to create the world we want. SDGs also make it possible to achieve what WHO constitution mandates: attainment by all peoples of the highest possible level of health.
Dr Henk Bekedam is the WHO representative to India