Transforming health through sustainable development.

At the United Nations Sustainable Development Summit, held Sept. 25–27, 2015, world leaders formally adopted 17 “sustainable development goals” (SDGs) to guide global development efforts over the next 15 years (2015–2030).1 The goals build on the “millennium development goals” adopted in 2000 by 189 member states to reduce global inequities in health, education and human development. Compared with the millennium development goals, which comprised 8 goals and 21 targets, the SDGs are supremely ambitious and unprecedented in scope, with 17 goals and 169 targets, intended to shift the world to a resilient path of human development that is sustainable and protects the environment.1,2 The SDGs are integrated, indivisible and universally applicable and focus efforts in five areas: people, planet, prosperity, peace and partnership.1 In this commentary, we focus on the health targets; however, success in achieving them will depend on gains made in the other 16 goals, including ending poverty and hunger; promoting educational, economic and gender equality; and building resilient structures that protect ecosystems, water bodies and the climate.1 Do the SDGs promise too much, and can the world deliver on them? Goal 3 explicitly focuses on health and aims to “ensure healthy lives and promote well-being for all at all ages.” It comprises 13 targets, which include quantitative targets to reduce maternal, neonatal and child [under-five] mortality, as well as premature deaths from noncommunicable diseases and road traffic crashes.1 Goal 3 also includes general targets on reducing narcotic and alcohol abuse, ensuring access to reproductive health, ending infectious disease epidemics, strengthening the Framework Convention on Tobacco Control,3 building capacity of the health workforce, and ensuring access to essential medications and vaccinations. That we must attain these targets may seem intuitive, but the mechanism by which they should be achieved remains less clear. Given the global variation in geopolitics, economics and culture, the SDGs offer little direction on how a lowor middle-income country could build a strong primary health care system to deliver basic health services, ensure financial health protection to its people, make available essential medications, treat substance and narcotic drug abuse, or identify the stakeholders to achieve the goals. Without further guidance, many countries will find it challenging to achieve these targets. Specific time-bound indicators are best decided locally or nationally. Moreover, progress is rarely linear, and as conditions and outcomes improve, it becomes more difficult to achieve similar proportional gains. Predicting SDG outcomes is a risky endeavour, but an examination of millennium development goals 4 and 5 may offer some clues. Fifteen years ago, the millennium development goals exposed global inequities in maternal and child health and strived for a two-thirds reduction in child mortality (goal 4) and a three-quarter reduction in maternal mortality (goal 5) by 2015.4 In evaluating child mortality in 75 countries accounting for more than 90% of childhood mortality, it is estimated that 17 and 9 countries achieved goals 4 and 5, respectively.5 Globally, child mortality has fallen from 91 deaths per 1000 live births in 1990 to 43 deaths per 1000 in 2015,6 and China has lifted 470 million people out of extreme poverty.7 Thus, despite impressive overall gains, progress has been patchy, and countries with high mortality have not achieved their targets. The SDGs reflect the aspirational nature of the millennium development goals. Therefore, it is unreasonable to believe that the SDGs will catalyze a seismic shift in policies of governments. Although all countries need to accelerate efforts toward achieving the goals, urgent action Transforming health through sustainable development