- Email: [email protected]
Quantifying targets for the SDG health goal
Comment
BB is Norwegian Minister of Foreign Affairs. BH is Norwegian Minister of Health and Care Services.
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Copyright © Brende et al. Open Access article distributed under the terms of CC BY-NC-ND. 1 2
UN. The Millennium Development Goals report 2013. New York: United Nations, 2013. Sustainable Development Platform. Outcome Document—Open Working Group on Sustainable Development Goals. 2014. http:// sustainabledevelopment.un.org/focussdgs.html (accessed Sept 11, 2014).
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Norheim OF, Jha P, Admasu K, et al. Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health. Lancet 2014; published online Sept 19. http://dx.doi.org/10.1016/S01406736(14)61591-9. Furtwangler T. Help us envision how innovation will change the world. PATH blog, Aug 27, 2014. http://www.path.org/blog/2014/08/envisioninnovation (accessed Sept 12, 2014).
Quantifying targets for the SDG health goal Published Online September 19, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61655-X See Articles page 239
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The Millennium Development Goals (MDGs) represent the best example of an international commitment to a set of normative principles underpinned by ideals of equity, solidarity, and peace.1,2 The goals achieved universal support because they were ambitious, included indicators that permitted measurement and accountability, and set 2015 for final reporting. The goals institutionalised poverty as multidimensional, and shaped development as beyond economics.3 Criticisms of the MDGs included the omission of many of the concerns of the Millennium Declaration, and the lack of adequate consultation on the process.4 Several contributions have been made from various constituencies and sectors to the successor arrangements for the post-2015 era, including a Global Thematic Consultation on Health.5 In an effort to ensure wide participation, a member-state driven process was established through an Open Working Group (OWG) which, with widespread consultation, crafted a set of 17 proposed Sustainable Development Goals (SDGs) and 169 targets.6 This approach, essentially a political process, retains a normative feature in direct lineage to the Millennium Declaration. Health is the third of the OWG-proposed SDGs with an overall goal “to ensure healthy lives and promote well-being for all at all ages”.6 In the context of a need for quantification, the paper by Ole Norheim and colleagues7 in The Lancet is an important contribution. Their proposed goal is to avoid, in each country, 40% of premature deaths (ie, deaths under age 70 years that would be seen in the 2030 population at 2010 death rates) and improve health care at all ages. Reinforcing this are four global subtargets for 2030: avoid two-thirds of child and maternal deaths; two-thirds of deaths due to tuberculosis, HIV, and malaria; a third of premature deaths from non-communicable diseases (NCDs); and a
third of those from other causes (other communicable diseases, undernutrition, and injuries). According to the authors’ detailed analyses, achieving these targets would result in a halving of deaths under age 50 years, avoiding a third of the NCD deaths in people aged 50–69 years, and, overall, result in avoidance of 40% of deaths under age 70 years by 2030. The significant advance in this paper is to introduce quantification to the target-setting process, based on rigorous analysis of mortality trends by age as well as by disease category. The proposed targets focus on premature mortality and avoid more complex metrics that are much harder to measure and track over time. The authors stress the importance of countries adapting the targets to their own circumstances. The logic of the argument is impeccable, but there are several aspects that must also be considered in deliberations on the SDG health goal and targets. Although the addition of improving health care at all ages was not the focus of this paper, it is surprising that there is no mention of universal health coverage (UHC), which includes promotion, prevention, and treatment services. UHC is one of the targets in the OWG-proposed SDG 3 and would be fundamental to achieving the reductions in mortality proposed.8 Reference is frequently made to the need to accelerate current progress toward MDG-related targets to achieve the targets Norheim and colleagues propose, but there is little indication of how this is to be done. Perhaps less emphasis might be put on the lack of political will and more on the scarcity of resources, both human and financial, and the inadequacies of many health systems. It might also be made clear that the focus on premature mortality does not, in any way, diminish the importance of several of the other targets under SDG 3 proposed by the OWG: strengthening prevention and treatment of substance misuse, increasing health www.thelancet.com Vol 385 January 17, 2015
financing, and strengthening country capacity to manage global health risks.6 Good evidence of how the reduction in NCD mortality might be achieved already exists. Kontis and colleagues9 have shown that, by attention to just six modifiable risk factors—tobacco use, harmful use of alcohol, salt intake, raised blood pressure, raised blood glucose, and obesity— as recommended by WHO, premature mortality could be substantially reduced.9 If the reduction in tobacco use were increased to 50% instead of the currently recommended 30%, the target of a 25% reduction in premature mortality from NCDs by 2025 could readily be achieved. Since the OWG SDG 3 already calls for a strengthening of the implementation of the Framework Convention on Tobacco Control as one of its targets, and proposes health-system targets, the target for reduction in premature mortality from NCDs proposed by Norheim and colleagues7 is eminently feasible. In the case of maternal, neonatal, and child health, a partnership has been established to bring together a wide cross-section of stakeholders to accelerate the achievement of MDGs 4 and 5.10 Whereas no new strategies or attempts to address new risk factors have been put in place, increased access to knowledge, focused advocacy, and encouraging accountability at the country level has already led to substantial improvement, and the subtargets for maternal health and child health proposed by Norheim and colleagues7 are likely to be achieved. What approaches should be taken in the other areas, in particular injuries, is less clear. We welcome this contribution to the ongoing deliberations with respect to health in the post-2015 era. Our view is that the OWG health goal, which has emerged from a member-state process, should remain as it is, but serious consideration should be given to the proposals by Norheim and colleagues7 as a substantial contribution to the quantification of some of the targets in SDG 3. The proposals are concise, science-based, action-orientated, measurable, and attainable. Moreover, they are universal, flexible, they allow for country adaptation, and would be reasonably easy to communicate to the general public. The data in their paper for the combined effects of the existing rates of decrease of under-70 mortality plus some improvement in those existing rates on the number of deaths avoided just in the year 2030 are staggering: of the 41 million deaths before age 70 years that would be seen if 2010 death rates persisted, 17 million could www.thelancet.com Vol 385 January 17, 2015
Niu Xiaolei/Xinhua Press/Corbis
Comment
be avoided—and, this excludes the cumulative deaths avoided between 2015 and 2030. We hope that this paper will influence the ongoing discussions on the health SDG. *George Alleyne, Robert Beaglehole, Ruth Bonita Pan American Health Organization, Washington, DC 20037, USA (GA); and University of Auckland, Auckland, New Zealand (RBe, RBo) [email protected] We declare no competing interests. Copyright © Alleyne et al. Open Access article distributed under the terms of CC BY-NC-ND. 1
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Fukada-Parr S. Should global goal setting continue, and how, in the post-2015 era? DESA Working Paper no. 217 ST/ESA/2012/DWP/117. July, 2012. http://www.un.org/esa/desa/papers/2012/wp117_2012.pdf (accessed Sept 12, 2014). Hulme D. The making of the Millennium Development Goals: human development meets results-based management in an imperfect world. Manchester: Brooks World Poverty Institute, 2007. Jahan S. Does it make sense to have set of global development goals? New York: United Nations Development Program, 2012. Hulme D, Scott J. The political economy of the MDGs: retrospect and prospect for the world’s biggest promise. January, 2010. Brooks World Poverty Institute Working Paper 110. Manchester: Brooks World Poverty Institute, 2010. http://www.bwpi.manchester.ac.uk/medialibrary/ publications/working_papers/bwpi-wp-11010.pdf (accessed Sept 9, 2014). Global Thematic Consultation on Health. The world we want: health in the post-2015 agenda. April, 2013. http://www.worldwewant2015.org/ file/337378/download/366802 (accessed Sept 12, 2014). Sustainable Development Platform. Outcome document—Open Working Group on Sustainable Development Goals. 2014. http:// sustainabledevelopment.un.org/focussdgs.html (accessed Sept 9, 2014). Norheim OF, Jha P, Admasu K, et al. Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health. Lancet 2014; published online Sept 19. http://dx.doi.org/10.1016/S0140-6736(14)61591-9. WHO. World Health Report 2010. Health system financing: the path to universal health coverage. Geneva: World Health Organization, 2010. Kontis V. Mathers CD, Rehm J, et al. Contribution of six risk factors to achieving the 25×25 non-communicable disease mortality reduction targets: a modelling study. Lancet 2014; 384: 427–37. The Partnership for Maternal, Newborn & Child health. About the Partnership (PMNCH). 2014. http://www.who.int/pmnch/about/en/ (accessed Sept 9, 2014).
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BB is Norwegian Minister of Foreign Affairs. BH is Norwegian Minister of Health and Care Services.
3
Copyright © Brende et al. Open Access article distributed under the terms of CC BY-NC-ND. 1 2
UN. The Millennium Development Goals report 2013. New York: United Nations, 2013. Sustainable Development Platform. Outcome Document—Open Working Group on Sustainable Development Goals. 2014. http:// sustainabledevelopment.un.org/focussdgs.html (accessed Sept 11, 2014).
4
Norheim OF, Jha P, Admasu K, et al. Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health. Lancet 2014; published online Sept 19. http://dx.doi.org/10.1016/S01406736(14)61591-9. Furtwangler T. Help us envision how innovation will change the world. PATH blog, Aug 27, 2014. http://www.path.org/blog/2014/08/envisioninnovation (accessed Sept 12, 2014).
Quantifying targets for the SDG health goal Published Online September 19, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61655-X See Articles page 239
208
The Millennium Development Goals (MDGs) represent the best example of an international commitment to a set of normative principles underpinned by ideals of equity, solidarity, and peace.1,2 The goals achieved universal support because they were ambitious, included indicators that permitted measurement and accountability, and set 2015 for final reporting. The goals institutionalised poverty as multidimensional, and shaped development as beyond economics.3 Criticisms of the MDGs included the omission of many of the concerns of the Millennium Declaration, and the lack of adequate consultation on the process.4 Several contributions have been made from various constituencies and sectors to the successor arrangements for the post-2015 era, including a Global Thematic Consultation on Health.5 In an effort to ensure wide participation, a member-state driven process was established through an Open Working Group (OWG) which, with widespread consultation, crafted a set of 17 proposed Sustainable Development Goals (SDGs) and 169 targets.6 This approach, essentially a political process, retains a normative feature in direct lineage to the Millennium Declaration. Health is the third of the OWG-proposed SDGs with an overall goal “to ensure healthy lives and promote well-being for all at all ages”.6 In the context of a need for quantification, the paper by Ole Norheim and colleagues7 in The Lancet is an important contribution. Their proposed goal is to avoid, in each country, 40% of premature deaths (ie, deaths under age 70 years that would be seen in the 2030 population at 2010 death rates) and improve health care at all ages. Reinforcing this are four global subtargets for 2030: avoid two-thirds of child and maternal deaths; two-thirds of deaths due to tuberculosis, HIV, and malaria; a third of premature deaths from non-communicable diseases (NCDs); and a
third of those from other causes (other communicable diseases, undernutrition, and injuries). According to the authors’ detailed analyses, achieving these targets would result in a halving of deaths under age 50 years, avoiding a third of the NCD deaths in people aged 50–69 years, and, overall, result in avoidance of 40% of deaths under age 70 years by 2030. The significant advance in this paper is to introduce quantification to the target-setting process, based on rigorous analysis of mortality trends by age as well as by disease category. The proposed targets focus on premature mortality and avoid more complex metrics that are much harder to measure and track over time. The authors stress the importance of countries adapting the targets to their own circumstances. The logic of the argument is impeccable, but there are several aspects that must also be considered in deliberations on the SDG health goal and targets. Although the addition of improving health care at all ages was not the focus of this paper, it is surprising that there is no mention of universal health coverage (UHC), which includes promotion, prevention, and treatment services. UHC is one of the targets in the OWG-proposed SDG 3 and would be fundamental to achieving the reductions in mortality proposed.8 Reference is frequently made to the need to accelerate current progress toward MDG-related targets to achieve the targets Norheim and colleagues propose, but there is little indication of how this is to be done. Perhaps less emphasis might be put on the lack of political will and more on the scarcity of resources, both human and financial, and the inadequacies of many health systems. It might also be made clear that the focus on premature mortality does not, in any way, diminish the importance of several of the other targets under SDG 3 proposed by the OWG: strengthening prevention and treatment of substance misuse, increasing health www.thelancet.com Vol 385 January 17, 2015
financing, and strengthening country capacity to manage global health risks.6 Good evidence of how the reduction in NCD mortality might be achieved already exists. Kontis and colleagues9 have shown that, by attention to just six modifiable risk factors—tobacco use, harmful use of alcohol, salt intake, raised blood pressure, raised blood glucose, and obesity— as recommended by WHO, premature mortality could be substantially reduced.9 If the reduction in tobacco use were increased to 50% instead of the currently recommended 30%, the target of a 25% reduction in premature mortality from NCDs by 2025 could readily be achieved. Since the OWG SDG 3 already calls for a strengthening of the implementation of the Framework Convention on Tobacco Control as one of its targets, and proposes health-system targets, the target for reduction in premature mortality from NCDs proposed by Norheim and colleagues7 is eminently feasible. In the case of maternal, neonatal, and child health, a partnership has been established to bring together a wide cross-section of stakeholders to accelerate the achievement of MDGs 4 and 5.10 Whereas no new strategies or attempts to address new risk factors have been put in place, increased access to knowledge, focused advocacy, and encouraging accountability at the country level has already led to substantial improvement, and the subtargets for maternal health and child health proposed by Norheim and colleagues7 are likely to be achieved. What approaches should be taken in the other areas, in particular injuries, is less clear. We welcome this contribution to the ongoing deliberations with respect to health in the post-2015 era. Our view is that the OWG health goal, which has emerged from a member-state process, should remain as it is, but serious consideration should be given to the proposals by Norheim and colleagues7 as a substantial contribution to the quantification of some of the targets in SDG 3. The proposals are concise, science-based, action-orientated, measurable, and attainable. Moreover, they are universal, flexible, they allow for country adaptation, and would be reasonably easy to communicate to the general public. The data in their paper for the combined effects of the existing rates of decrease of under-70 mortality plus some improvement in those existing rates on the number of deaths avoided just in the year 2030 are staggering: of the 41 million deaths before age 70 years that would be seen if 2010 death rates persisted, 17 million could www.thelancet.com Vol 385 January 17, 2015
Niu Xiaolei/Xinhua Press/Corbis
Comment
be avoided—and, this excludes the cumulative deaths avoided between 2015 and 2030. We hope that this paper will influence the ongoing discussions on the health SDG. *George Alleyne, Robert Beaglehole, Ruth Bonita Pan American Health Organization, Washington, DC 20037, USA (GA); and University of Auckland, Auckland, New Zealand (RBe, RBo) [email protected] We declare no competing interests. Copyright © Alleyne et al. Open Access article distributed under the terms of CC BY-NC-ND. 1
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3 4
5
6
7
8 9
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Fukada-Parr S. Should global goal setting continue, and how, in the post-2015 era? DESA Working Paper no. 217 ST/ESA/2012/DWP/117. July, 2012. http://www.un.org/esa/desa/papers/2012/wp117_2012.pdf (accessed Sept 12, 2014). Hulme D. The making of the Millennium Development Goals: human development meets results-based management in an imperfect world. Manchester: Brooks World Poverty Institute, 2007. Jahan S. Does it make sense to have set of global development goals? New York: United Nations Development Program, 2012. Hulme D, Scott J. The political economy of the MDGs: retrospect and prospect for the world’s biggest promise. January, 2010. Brooks World Poverty Institute Working Paper 110. Manchester: Brooks World Poverty Institute, 2010. http://www.bwpi.manchester.ac.uk/medialibrary/ publications/working_papers/bwpi-wp-11010.pdf (accessed Sept 9, 2014). Global Thematic Consultation on Health. The world we want: health in the post-2015 agenda. April, 2013. http://www.worldwewant2015.org/ file/337378/download/366802 (accessed Sept 12, 2014). Sustainable Development Platform. Outcome document—Open Working Group on Sustainable Development Goals. 2014. http:// sustainabledevelopment.un.org/focussdgs.html (accessed Sept 9, 2014). Norheim OF, Jha P, Admasu K, et al. Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health. Lancet 2014; published online Sept 19. http://dx.doi.org/10.1016/S0140-6736(14)61591-9. WHO. World Health Report 2010. Health system financing: the path to universal health coverage. Geneva: World Health Organization, 2010. Kontis V. Mathers CD, Rehm J, et al. Contribution of six risk factors to achieving the 25×25 non-communicable disease mortality reduction targets: a modelling study. Lancet 2014; 384: 427–37. The Partnership for Maternal, Newborn & Child health. About the Partnership (PMNCH). 2014. http://www.who.int/pmnch/about/en/ (accessed Sept 9, 2014).
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