SDGs Require both systems and disease-specific funding
April 7, 2015
The years-old deliberation over the value of investment in health systems versus support for programs aimed at individual diseases took center stage at the Consortium of Universities for Global Health March 27 in Boston. Sandro Galea, dean of the school of public health, Boston University, and Olusoji Adeyi, Director of Health, Nutrition, and Population Global Practice, the World Bank, ably and convivially debated the statement, “investment in the [Sustainable Development Goal] framework should be in strengthening health systems, not specific diseases.” Galea argued for and Adeyi against.
Galea said the evolution of global health demanded a systems based approach. The Millennium Development Goals (MDGs), with their focus on HIV, malaria, and tuberculosis along with reducing maternal and child mortality, were forged in a different time. AIDS was ravaging Africa, threatening entire societies with collapse. Health disparities were more pronounced between rich and poor countries, while inequities within countries now dominate. The MDGs were organized around the notion that resources should be funneled from those who had them (developed countries) to those who didn’t (developing countries), largely based on the premise that priorities would be set by the those providing the funds.
The difference between the MDGs and the proposed Sustainable Development Goals (SDGs) is reflected in the processes for producing each document. MDG targets were developed by a small group of technical experts. The SDGs, by contrast, have involved an inclusive worldwide conversation that indicates how thoroughly the dynamic has changed from a world of “donors” and “recipients” to one of development partnerships between countries. Consequently, the SDGs are organized around country ownership and set out universally applicable targets that result in sustainable health improvements for entire populations. Galea argued that disease-specific programs, operating outside of country health systems and aimed only at certain populations, don’t fit the bill.
Further, disease trends have changed. While the world still is grappling with old foes including HIV, TB and malaria, non-communicable diseases are now the prevailing killer worldwide. They are more complex and require more complex approaches, Galea argued, nested in sustainable health systems.
To show how progress toward many goals requires a systems approach, Galea noted that the MDGs were most successful in areas amenable to relatively simple solutions: MDG 4, for example, reducing child mortality, has been advanced by scaling up discrete interventions such as childhood vaccines. MDG 5, reducing maternal mortality, is more complex, requiring health systems that can respond to the variety of potential complications arising during labor. Less progress has been made toward that goal because success requires health systems that in too many places do not yet exist. While many in global health argue that health systems have benefited indirectly from funding devoted to disease-specific programs, Galea said the slow growth of systems in many places indicates they warrant their own attention and focus, rather than being treated as a by-product of other priorities.
On the other hand, Adeyi argued that concentrating on health systems creates a diffusion of focus and a lack of accountability. Disease-specific programs have the measurable goals and proven outcomes funders embrace. Donors only invest in projects because they expect a return on investment—an outcome that is much more likely with focused action with definite goals. “Developing a system is not an end to itself,” he said. Adeyi argued that disease-specific programs have a proven track record and can then be integrated into and enhance health systems while at the same time showing measurable results. He cited the global polio eradication program, which has reduced the number of cases by more than 99 percent since its inception.
While Galea had a strong majority in his camp at the start, according to a pre-debate audience show of hands, Adeyi was successful in swaying some toward his view. Fortunately, the SDGs have enough goals and targets (17 and 169, respectively) that no one has to choose. Among the targets under SDG 3, “ensure healthy lives and promote well-being at all at all ages,” are ending preventable deaths of newborns and children under five and continuing a focus on AIDS, TB, malaria and other diseases. But target 3.8, related to universal health coverage, calls for “financial risk protection, access to quality essential health care services, and access to safe, effective, quality and affordable essential medicines and vaccines for all,” a systems goal if there ever was one.
Having both disease-specific and systems aspirations included in the SDGs is the right approach. Targeted programs draw attention and resources in a way that broader priorities don’t and progress is easier to measure. But scale up of those projects often is stymied by a lack of basic health infrastructure: health workers, facilities, and commodities. Both intellectual and financial resources should be devoted specifically to broader systems development, not as a trickle-down effect of disease-specific spending, but as a priority of its own. Only by employing both approaches can countries and global health professionals hope to tackle the myriad complex challenges they face as the SDG era unfolds.