The MDGs were conceived as a partnership between richer and poorer countries to end extreme poverty. Interventions targeted low-income countries with high burdens of disease. Despite early aspirations to achieving broad-based development, these interventions were generally top-down (vertical) rather than systemic (horizontal); focused more on technologies and less on the means of using them; were driven by foreign aid rather than domestic finance; measured progress in terms of national averages concealing inequalities among individuals; and set short-term deadlines rather than promoting long-term development. Even so, substantial health gains were made in the MDG era: The number of people living in extreme poverty; the malaria, tuberculosis (TB), and under-five mortality rates; and the maternal mortality ratio all fell by about one-half or more between 1990 and 2015.
Analyses of progress toward the MDGs [such as (1, 2)] have exposed strengths and weaknesses of such targeted health programs, making at least two often-forgotten points. First, although medical technologies such as vaccines and drugs can be linked to better health, these interventions rely on functioning health services, run by skilled health workers with health information systems, supply chains, and financing and governance mechanisms. In some settings, vertical programs targeting selected diseases may have damaged the health systems that they needed to succeed, by attracting resources disproportionately, or simply through neglect (3). Reintegrating disease-control programs into general health services now poses operational challenges (4).
Second, these studies reaffirm the indirect health risks (and potential benefits) of social, economic, and environmental factors that lie outside the control of the health sector, such as female education and fertility, family income, and access to safe water and sanitation. The idea of modifying these factors by working across disciplines and sectors has a long history, but multidisciplinary research and intersectoral action are still exceptional rather than routine. For example, cross-disciplinary initiatives from the human (“Health in All Policies,” HiAP) and veterinary health (“One Health”) communities have common aims but remain largely separate enterprises. One challenge of working across sectors is to balance the control of selected diseases of high importance (such as HIV/AIDS, TB, malaria) with the management of systemic risks to health (e.g., provision of safe water, sanitation, and housing, or mechanisms for finance, governance, monitoring, and planning). Both are important, but the MDGs emphasized the former, whereas the SDGs stress the latter.
The choice between the two should encourage, in the SDG era, a more open-minded approach to investigating causes and risks of ill health, unconstrained by specific methods or disciplines. The ideal response to any risk would consider interventions across the whole chain of events from primary (upstream) causes to ultimate (downstream) effects on health. But assessment of risk is typically partial, rarely comprehensive. Thus, if a study focuses, for example, on selected social determinants of TB (e.g., income, employment, housing), then the proposed solutions will likely address only these determinants, missing other possible behavioral (tobacco smoking), environmental (air pollution), medical (HIV coinfection), metabolic (diabetes), and occupational (mining) risks and, critically, the interactions between them. Furthermore, the failure to implement proven interventions (e.g., early diagnosis and treatment for TB) is rarely considered to be a “risk factor,” but could be the largest modifiable cause of illness or death in any given setting (5). There is not yet a standard, comprehensive approach to evaluating preventable risks to health.
The MDGs became the world's principal framework for international cooperation in development. Now that the SDGs have inherited that role, advertising the interlinkages between health and all other goals, the debate about how to improve health is taking place not just among health ministers but also among heads of state, private businesses, nongovernmental organizations, and civil society. That national and international debate should be informed by a research agenda that is equally broad and actively promoted among all players.
Source : http://science.sciencemag.org/content/359/6382/1337.full658