Only a bottom-up approach will deliver global health development targets

Frontline workers need to be engaged in the process of building responsive, interconnected health systems. Reuters

There is an urgent need to put together a coherent goal-readiness plan to drive the sustainable development goals related to health. To succeed it needs to address three critical elements: how the goals will be financed, what health systems need to be established and how new skills, new thinking, and new ways of working together across systems can be developed.

Nine months after the United Nations’ sustainable development goals came into force implementation is still at the starting blocks. Most of the world still needs to learn about the goals and understand exactly why they matter.

The goals have been on the agenda of world leaders. At the recent Global Fund for Development meeting in Canada governments of both poor and wealthy countries committed to funding the fight against HIV, tuberculosis and malaria. These are epidemics that the sustainable development goal for health seeks to eliminate.

But a much more comprehensive approach needs to be developed to achieve the sustainable development goals in totality and to meet the 2030 deadline.

aHe millennium development goals were laudable. But the top-down approach that was often taken to reach programmes did not result in the intended success it aimed for. For the sustainable development goals to be successful, they need to be owned by everyone. A hierarchical approach will not serve these ends. Global leaders need to take a different approach to the one taken with the millennium development goals.

Learning from previous mistakes

There were some notable successes in meeting the millennium development goals. These included increased gender parity in primary education enrolment. There were also some notable failures, such as winning the fight against HIV.

Overall the goals were criticised for being too focused on achieving specific measurable targets, without considering the context in which these needed to be achieved. Take for example the target to reduce the number of deaths of children younger than five. This target gave no consideration to the contexts and systems in countries that affect child mortality – such as conflict and insecurity. These conditions render children vulnerable despite frontline workers’ best efforts.

Focusing on disease specific measurable targets is considered a vertical approach. All resources are directed or funnelled towards fixing only one specific problem.

But this is problematic. It takes resources away from other needs. It does not strengthen the overall health system and does not address the context in which the problem occurs.

This approach may fix problems in the short term. But in the long term the broader contextual factors that remain in place are likely to result in the problem reoccurring.

Unlike the millennium development goals the sustainable development goals place greater emphasis on the relationship between individual health and its social determinants.

For example, the success of goal three – which looks broadly at good health and well being – is dependent on the other 16 goals being achieved. And collectively the goals and their targets address the key social determinants underlying poor health. The goals realise that good health is dependent on food security, which in turn is affected if all the sustainable development goals are not achieved.

Put another way, the sustainable development goals are more integrated. This is an improvement on the limitations of the millennium development goals’ vertical approach. The clear shift from a disease or condition-specific focus to overall well-being is very important.

Better health systems

The World Health Organisation defines a health system as all organisations, people and actions whose primary interest is to promote, restore or maintain health. There are many components to this system and all need to work together. This includes:

  • financing,

  • information systems,

  • supply mechanisms,

  • human resources,

  • physical infrastructure,

  • appropriate training, and governance.

If one of these components is weak, all of the rest of the components are at risk. Establishing better health systems is therefore critical to ensure that all the components operate effectively.

The only way to enable better health systems is through policy and implementation. But policy needs to be more than a well-articulated wish list. Written policies mean nothing if they do not substantially and positively change everyday people’s lived reality. For this to happen, careful consideration is needed to translate decisions made at a macro-level to fit the reality at the coalface of implementation.

This means focusing on those at the frontline. Health workers, educators, engineers and an array of other development workers – and not only government leaders – will ultimately be responsible for delivering the sustainable development goals.

But how well are these workers being prepared to meet these goals? Do they know about the agenda? Have they heard of the goals, and do they understand their role in fulfilling them?

Frontline workers need to be engaged during this foundational phase to use the sustainable development goals to build resilient and responsive health systems that are interconnected with other service delivery systems.

And it means that policymakers and managers will need to have a more creative and innovative approach: less top-down, allowing greater discretion at local level.

It is important to invest in these workers’ buy-in. Their opinions on how to make the goals possible in their own contexts must be heard and considered. The diversity of their perspective and approach also needs to be embraced rather than controlled or dismissed.

Changing the approach

From our perspective the individual goals work together as part of a complex whole. The old system of control through vertical programme targets needs to be relinquished. A system of integration where the global goals are owned as part of the every day workings of communities and in government’s service delivery.

Unlike in the past governments, frontline workers and communities should not be expected to deliver on targets that are unrealistic because of constraints outside their control. This includes financial, material, human resource and time constraints as well as a constrained way of thinking.

Instead, the success of the sustainable development goals requires a vision for integration that includes a clear plan, and contingencies for the plan. This will ensure ownership and accountability to the people – not only within health systems but within all global systems.

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