The past few years have not been easy on the world’s health-care systems. When the United Nations set its Sustainable Development Goals (SDGs) in 2015, the threat of a pandemic sweeping the world would not have registered with most people.
In a series of weekly editorials marking the halfway point to the SDGs’ 2030 deadline, Nature is looking at each of the 17 goals in turn. It is no surprise that progress towards number 3 — “Ensure healthy lives and promote well-being for all at all ages” — has been stuttering, at best. But that does not mean that the targets embedded in this goal should be lowered when world leaders gather in New York City in September to assess progress towards achieving the SDGs. Instead, the health goal should be strengthened by increasing focus on the economic, social and power inequities that drive disease and disability worldwide — and researchers must play their part in making that happen.
The UN’s health and well-being targets cover a wide territory that includes reducing maternal mortality to one-third of current rates, halving road-traffic accidents and ending epidemics of diseases such as tuberculosis and malaria. Before the COVID-19 pandemic, there were a few encouraging signs of progress.
From 2015 to 2021, 146 countries out of 200 evaluated were on course to meet the SDG target of fewer than 25 deaths per 1,000 live births. One study using data from 2020 projected that the world’s shortage of health-care workers would fall from 15 million to 10 million by 2030 (M. Boniol et al. BMJ Glob. Health 7, e009316; 2022). This would have gone some way towards meeting the SDG target to substantially increase the health-care workforce in low-income countries.
Even before the pandemic, there was growing concern that progress was beginning to level off in some areas that previously looked promising. The rate of maternal mortality, which declined from 2000 to 2016, was fairly constant in the five years after the SDGs were established. At the last count, in February 2020, it was still around three times the SDG target of 70 maternal deaths per 100,000 live births by 2030.
But then the pandemic hit, taking millions of lives, leaving millions of people living with disability and disrupting health-care systems worldwide. There were indirect, as well as direct, effects. With world leaders focusing on the pandemic, global spending on tuberculosis services dropped by 10%, from US$6 billion in 2019 to $5.4 billion in 2021; over the same period, deaths from tuberculosis rose from 1.4 million to about 1.6 million. Malaria-associated deaths rose by 12%, from 558,000 in 2019 to 627,000 in 2020. Childhood vaccination rates against diphtheria, tetanus and pertussis fell between 2019 and 2021.
Education was also affected by the pandemic: children from disadvantaged socio-economic backgrounds experienced more setbacks in their learning than did those from higher-income ones (B. A. Betthäuser et al. Nature Hum. Behav. 7, 375–385; 2023). Prolonged school closures in several countries meant that some children left the education system early. The full ramifications of that exodus on health and well-being might not come into focus for years. For girls and young women, for example, pregnancy and HIV rates tend to decrease the longer they stay in education.
The ambition of the SDG health targets was always lofty, but they can provide a foundation for formulating national strategies and allocating resources to improve health and well-being outcomes and counter disparities. Good health is not just down to biology; it is affected by the environment, opportunity, economics and discrimination. The COVID-19 pandemic laid such influences bare, with widespread disparities between rich and poor people in terms of outcomes, treatment availability and vaccine distribution. But public discussion of the social determinants of health fizzled out as the pandemic eased, says public-health researcher Sarah Hawkes at University College London. “We seem to have moved on,” she says. “There has been a collective memory loss of just how bad it was.”
That discussion must be revived in the context of the SDGs. More researchers need to be studying the economic and social determinants of health, to, for example, help fill the data gaps that hinder effective action. Many countries still do not separate health-care statistics by sex, ethnicity or whether someone is a refugee. Without this information, it is too easy to gloss over inequities and their causes.
But to truly address global health and well-being, governments must work to reduce economic inequality, not just between nations but also within them. This means both shoring up the funding needed to provide health care and reducing the poverty, discrimination and violence that contribute to ill health.
In May, the World Health Organization released a report that laid out the economic reforms needed to improve global health. The report, entitled ‘Health for All’, set out a range of economic measures, such as the reformation of taxes on wealthy individuals and multinational corporations, and called for allowing debt relief for low-income countries during pandemics and natural disasters.
It also called for a fundamental reformulation of how we perceive health and well-being: not as an expenditure to be chopped during times of austerity, but as an investment in a country’s future economy and well-being. That is a call that must be heard and understood. Ultimately, we will not stand a chance of meeting the SDG health targets unless world leaders are willing to embrace the economic reforms necessary to reduce inequality.