How does global health fare in the Sustainability Development Goals?

This originally appeared on Global Health TV on Sept. 28, 2015.

Last weekend in New York City, world leaders formally approved the Sustainability Development Goals (SDGs), which will guide development efforts over the next 15 years. They replace the Millennium Development Goals (MDGs) that were signed in 2000 and expire on Dec. 31, 2015.

The MDGs were terrific for global health, both in raising money, and raising its profile on the global agenda.

Eight goals made up the MDGs, and three of them were entirely focused on health. In addition, two other goals included health-related targets. Eight (38%) of the 21 total MDG targets were health-related, and seven of those targets were numerical (i.e. reduce maternal mortality by three quarters).

Between 2000 and 2014, $228 billion was allocated to address the three health-related MDGs, according to the Institute for Health Metrics and Evaluation (IHME) 

More importantly than how much was raised, serious progress was made on many of these health fronts. For example, two weeks ago, the World Health Organization announced that malaria death rates have plunged by 60% since 2000 and that the malaria target to have halted and begun to reverse the incidence of malaria by 2015 has been met “convincingly.” Most people think the Target 1A to halve the proportion of people living on less than $1.25 has been met.

But where is health in the SDGs? The answer to that question contains both good and bad news for global health advocates.

The bad news is that health is much less prominent in the SDGs. The SDGs comprise 17 goals, only one of which is health-related:

Goal 3: Ensure healthy lives and promote well-being for all at all ages

Those 17 goals have 169 targets and Dr. Christopher Murray, director of the IHME, has identified 23 of them (13.6%) as being health-related. You can view those 23 health-related targets in his article in the New England Journal of Medicine.

“If we consider health in the SDGs in light of the factors that contributed to progress toward the health-related MDGs, there are reasons for concern,” Dr. Murray writes. “Health clearly does not occupy the central role in the SDGs that it did in the MDGs. There is only one specifically health-focused goal — though a number of other factors that affect health (such as water, sanitation, poverty, and gender equality) are targets in other goals, leading to a total of 23 health-related targets. Inevitably, health's lower profile in the goals will mean less national-level political attention beyond the health sector. Within the health sector, the more diffuse agenda may mean less progress in addressing the challenges that the MDGs prioritized.”

Even more worrisome is the fact that Dr. Murray says that only 13 of the 23 health-related targets are framed quantitatively and that “targets without concrete quantification probably won’t receive consistent attention.”

Another concern is the extent to which the SDGs address — or do not address — sexual and reproductive health. There are two targets that explicitly mention sexual and reproductive health — Target 3.7 and 5.6.

“The SDGs are comprehensive, visionary and inspiring in many ways. But they fall short: they take a narrow view of sexual and reproductive health and rights, one of the most crucial, but also most controversial, parts of the SDG agenda,” writes Ann Starrs, president and CEO of the Guttmacher Institute, in The Lancet.

“The SDGs are not likely to encompass other important elements of sexual and reproductive health and rights, including safe abortion, non-discrimination based on sexual orientation or gender identity, and the importance of high-quality, confidential and timely sexual and reproductive health services.”

The good news is that the SDGs cover some critical areas of global health that were totally ignored by the MDGs. I am thinking specifically of health issues that account for much of the global burden of disease, like non-communicable diseases (such as cancer, cardiovascular disease, diabetes, mental disease and respiratory disease), substance abuse and traffic accidents. Target 3.4 of the SDGs states that:

By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment, and promote mental health.

“This victory marks the culmination of a six-year campaign led by the NCD Alliance”, said José Luis Castro, chair of the NCD Alliance and executive director of the Union Against Tuberculosis and Lung Disease last Friday. "In 2009 when the NCD Alliance was founded, one of the four initial goals was to secure NCDs — namely diabetes, cancer, cardiovascular diseases, chronic respiratory disease, and mental/neurological disorders — in the successors to the MDGs. Since then, the NCD Alliance has worked tirelessly with many partners and stakeholders to lay the foundations for this historic agreement today.”

This infographic shows how the SDGs will address the NCDs.

The process of developing the SDGs was tortuous and time-consuming but two even greater challenges lay ahead.  

First, how do we measure whether the targets are being met, so citizens can hold their governments accountable? The UN has set a deadline of March 2016 for development of the accountability framework.

Second, who will pay for the SDGs? Estimates vary but “analysts say it could cost as much as $4.5 trillion per year in state spending, investment and aid,” according to a backgrounder from the Council on Foreign Relations. That’s a huge question but one that was starting to be addressed last weekend, when UN Secretary-General Ban Ki-moon announced over $25 billion in initial commitments over five years to help end preventable deaths of women, children and adolescents.