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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Looking Beyond the Millennium Development Goals Toward a Sustainable Development Agenda

At the turn of the millennium, recognizing the failure of the international community to meet the needs of the world’s poor, the United Nations (UN) General Assembly unanimously adopted the Millennium Declaration. The Millennium Development Goals (MDGs), which followed the declaration, are the world’s most broadly supported and comprehensive development targets, creating numerical benchmarks for tackling poverty and hunger, ill health, gender inequality, lack of education, lack of access to clean water and adequate sanitation, and environmental degradation to achieve by 2015.

Lawrence Gostin, JD

The MDG health goals include reducing child mortality (including the benchmark of a two-thirds reduction of the mortality rate of children younger than 5 years); improving maternal health (including a three-quarters reduction in the number of maternal deaths per 100 000 live births, between 1990 and 2015, from causes related to pregnancy or its management); making a three-quarters reduction in the maternal mortality ratio; and combating HIV/AIDS, malaria, and other diseases such as tuberculosis.

Despite major advances, most MDG targets have not been met, partly as a result of 4 global crises in finance, food, energy, and climate change. In 2008, World Health Organization (WHO) Director-General Margaret Chan observed that even though “the health sector had no say when the policies responsible for these crises were made… health bears the brunt.”

The MDGs end in 2015 and the UN is debating a set of post-2015 sustainable development goals (SDGs). The UN met on September 25 to foster global agreement on the SDGs, but the result was inconclusive. The Outcome Document from that meeting merely “resolved that the post-2015 development agenda should reinforce the international community’s commitment to poverty eradication and sustainable development.” Intergovernmental negotiations will begin at the 69th General Assembly next September, with the adoption of the SDGs set for a UN high-level meeting in September 2015.

The SDGs are likely to focus on poverty and the environment, but a debate is swirling within the international health community concerning what the health goals should be. The WHO favors universal health coverage, while others, such as the Gates Foundation, advocate for more easily measurable goals such as for child and maternal health. UN Secretary-General Ban Ki-moon stressed that the SDGs must be “rights-based,” with the first pillar being “a far-reaching vision of the future firmly anchored in human rights and universally accepted values and principles.” Go4Health, a European Commission–financed coalition of academics and civil society, recently threw its weight behind the right to health as the central building block of the health SDGs.

I believe that the health-related post-MDG vision should address the full scope of the primary conditions in which people can be healthy and safe, focusing on 3 mutually reinforcing conditions needed for better lives: public health, health care, and socioeconomic determinants.

  • Public health services address the task of building a habitable, safe environment for the population as a whole. Governments should provide all the goods and services needed for a safe and healthy life in a well-regulated society—hygiene and sanitation, potable water, clean air, nutritious food, vector abatement, injury prevention, and tobacco and alcohol control—as well as build environments conducive to good health, such as green spaces for recreation, walking and bike paths, safe vehicle and road design, and environmental controls.

  • Universal health coverage requires all vital health care services to be available, affordable, and accessible to the entire population, whether poor or rich, physically and mentally able or disabled, urban or rural. Effective health systems require health care facilities (such as clinics, hospitals, and nursing homes), human resources (physicians, nurses, community workers, and others), and essential medicines to serve the full range of population needs.

  • Socioeconomic determinants of health that undergird healthy and productive lives are the third essential condition. Key underlying determinants include education; income support; housing; employment; social inclusion; and racial, ethnic, and gender equality. Effective interventions require action beyond the governmental health sector and indeed beyond government—requiring an “all-of-government” and “all-of-society” strategy.

Global governance is essential for achieving a robust vision of health for all with justice. A coalition of organizations and individuals from civil society, governments, and academia, the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI), is proposing a Framework Convention on Global Health (FCGH) and initiating an inclusive campaign for an FCGH. UN Secretary Ban Ki-moon and UNAIDS Executive Director Michel Sidibé have endorsed the FCGH. A global health treaty grounded in human rights could provide necessary accountability behind the SDGs, such as fighting corruption; demanding transparency; facilitating civil society and community engagement and empowerment; setting targets, standards, and priorities; establishing obligations on financing and regulating private sector health actors; and monitoring results.

This approach would be a bottom-up strategy, demanding fulfillment of the human right to health. Building on the work of civil society from global networks like the People’s Health Movement to national organizations like SECTION27 in South Africa, the Lawyers Collective in India, and the Center for Health, Human Rights, and Development in Uganda, it would establish a platform for people to more effectively claim their rights in the future.

The future health and development agenda requires audacious thinking and action. Adopting narrow health goals (relating to AIDS or maternal health, for example)—while important—would not be transformative. Even universal health coverage is too medically oriented.

Instead, the international community could boldly pronounce a goal of “health throughout the life span for all” based on the human right to health, with a rich array of public health and health care services, and assurance of the key social determinants of health. That promise would be backed by a global health treaty such as an FCGH that would hold states and stakeholders accountable for ensuring the human right to health.

That is the only way to genuinely achieve the universal aim of global health with justice, reversing decades—even centuries—of vast differentials in health and longevity between the world’s rich and poor.

About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights.