The era of the Millennium Development Goals (MDGs) came to an end on 8 September 2015, and a new era in global milestones have been launched with the Sustainable Development Goals (SDGs). In India, most of the MDG targets were not achieved; and this raises the question: what role do such goals play in achieving better health for all?
The Alma Ata Declaration (1978) recommended an approach to healthcare provision that would promote equality of access, responsive to the actual health needs experienced by the community: comprehensive primary health care (PHC). This was later modified in response to critiques that deemed this approach too idealistic and expensive: selective PHC was born. The World Development Report (1993) shifted the paradigm further, by operationalizing selective PHC through the use of burden of disease estimation to identify those diseases that caused the greatest morbidity and mortality, and the use of the Disability Adjusted Life Year (DALY) to arrive at the most cost-effective approach to combat those diseases. The Millennium Development Goals (MDGs) extended this type of thinking into the next century by explicitly targeting specific diseases with a well-defined set of cost-effective interventions.
Given the limited resources available for health in most developing countries, such prioritization is perhaps inevitable. The issue is with the methods used to address the selected diseases. One of the targets under the MDGs was to halt and reverse the spread of Tuberculosis, for example. The strategy was to provide 100% coverage of the TB treatment protocol, called Directly Observed Therapy Short-course (DOTS), involving six months of intensive chemotherapy. Despite globally recognized success with the DOTS strategy, India did not achieve the MDG target and has the additional problem of being home to the largest number of people globally with MDR TB.
Are the SDGs any different from the MDGs? They extend the MDGs but go further by including targets for non-communicable diseases, and substance abuse. If we are to learn anything from the experience of the TB programme, it is that focusing on disease-specific targets alone will not suffice. The findings of the WHO’s Commission on the Social Determinants of Health have amply demonstrated the critical need to address issues such as class, caste, and gender to improve health outcomes. In India’s case, the National Rural Health Mission has made an honest attempt to reprise Alma Ata by creating institutional space for community voice to be heard. It has tried to strengthen and extend the primary care network, with the hope that this will make the system more responsive to community needs.
We have traveled a considerable distance away from Alma Ata and its vision of a health system responsive to community needs, holding out the hope of just and equitable access to healthcare. Recent developments have shown that a narrow target-oriented approach can go only so far; a broader and more inclusive approach is necessary if we are to achieve true equity and “health for all.”
Competing interests: None declared.
Shreelata Rao Seshadri, professor of health and nutrition at the Azim Premji University, Bangalore, India. Her research focuses on the social determinants of malnutrition among primary school children; and exploring innovative approaches to addressing this problem.