How the global health community will need to shift to tackle the Sustainable Development Goals

The global health goals for the 2030 Agenda for Sustainable Development is bold and ambitious. Achieving the health targets requires complete departure from the healthcare delivery standards set to meet Millennium Development Goals (MDGs). The existing health systems, particularly in low-income countries and some middle-income countries are frail and a nationally-led overhaul is needed. Nations should operate in partnership with key actors including the community. Further, innovation and high-quality evidence should drive policy decisions, clinical or public health practice and further investment in health. Only through bolstered health systems, robust partnerships and innovative healthcare delivery, lofty targets in the health sustainable development goals can be met.


INTRODUCTION
In 2015, the United Nations (UN) officially transitioned its global development goals from Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs). In several ways the health targets in the SDGs have shown significant expansion compared with that of their predecessor, the MDGs. As a result, public health targets have evolved from a few areas to become more comprehensive, and they now comprise neglected tropical diseases, non-communicable diseases, injuries and substance abuse. Further, the focus has shifted from reduction of major infectious diseases (tuberculosis (TB), malaria, and HIV) to ending these public health threats for good. Maternal and child health targets have been elevated from reduction in mortalities to ending all preventable deaths. 1,2 Despite the advances in expanding and stretching the targets, more work remains to be done in redefining the processes, the priorities and metrics (including health care equity stratifiers) to track the progress in a comprehensive way. [3][4][5] As we have begun charting the new era of SDGs, we require a new combination of areas of global focus. We argue that stronger health systems, more robust partnerships in health and across SDGs, and greater investment in health innovation are needed to meet these ambitious targets.

BOLSTER NATIONAL HEALTH SYSTEMS
Health systems in most low-income and some middle-income countries are frail, and in many cases, nationally-led overhauls are needed. The existing systems are not on par with ending major communicable diseases or preventable maternal and child deaths. Even more important, the systems are inelastic. The health systems cannot effectively respond to outbreaks; cannot concurrently deal with regular healthcare delivery. A major outbreak could lead to systemic calamity even beyond the health sector. The 2014-2016 Ebola outbreak in West Africa (Sierra Leone, Liberia and Guinea) showed that there were very weak health systems in these countries. 6 Due to the dearth of the medical facilities, staffing, and medical supplies, these systems were not prepared to respond to a new threat to the sub-region. The outbreak in a handful of nations exposed the inadequacies of preparedness of broader global health to tackle this previously unknown threat. Ultimately, it uncovered that the global health community did not have a high impact action to contain the outbreak occurred in a relatively tiny part of the world. 7,8 In fact, external contributing factors like prior war and conflict, for instance, in Guinea and Liberia had major toll on the health systems in these countries. As a consequence, expansive spread of the disease claimed thousands of lives way too long before further transmission was effectively interrupted.
Current health systems cannot continue to accommodate the growing change in the landscape of public health threats. For instance, the rising challenges of non-communicable diseases in low-income and middle-income countries warrant integration of such services to primary health care. Evolving health challenges like antimicrobial resistance also require coordination of healthcare delivery at the spectrum of care from primary to highly specialized tertiary care and meaningful collaboration with other sectors, particularly with livestock sector. Thus, we argue that the current trajectory towards health SDGs could be improved only with major national overhaul and surge capacity with regards to human resource, equipment and infrastructure.

BUILD ON CURRENT PARTNERSHIP ECOSYSTEM
In silo national implementations, particularly in low-income and middle-income countries cannot lead us anywhere. Rather, nations have to lead a pack of partnerships and collaboration of like-visioned actors to achieve their targets. In the era of MDGs, multinational partnerships including Global Alliance for Vaccines and Immunization (GAVI), the Global Fund (GF), the Joint United National Programme on HIV/AIDS (UNAIDS) and other agencies coalesced around catalyzing nations' efforts to reduce TB, malaria and HIV and vaccine preventable infections. While we believe that partnerships of broader range and scale are required to accelerate the downward trend of both burden of and mortalities due to these diseases, low-income nations should also boost political commitment to health including domestic financing to meet health SDGs.
Further, healthcare delivery in low-income countries and middle-income countries could significantly benefit from partnership with high-income countries. This could narrow the clear gaps in healthcare practice and health outcomes, and eventually help mainly low-income countries and middle-income countries achieve their health SDGs. Equally important are partnerships between countries in the Global South. Context-based, cross-fertilization of proven best practices among low-resource nations could potentially transform healthcare delivery and health outcomes in these countries. 9 Non-state actors and private sector have essential roles to play to achieving health SDGs. In the era of MDGs, philanthropies mainly Bill and Melinda Gates Foundation (BMGF) substantially contributed to saving millions of lives in low-resource countries. Gratefully, the number and the scale of support of philanthropies is growing in the era of SDGs. National policies should encourage partnerships with philanthropies, private sector and others, that could lead to result-driven healthcare delivery and improved population-level impact. 10 At national level, coherent operations across all SDGs could accelerate the progress towards health SDGs. At subnational level, the community could be the most crucial partner in healthcare delivery. As a consequence, consistent and sustained engagement of the community in health could be vital to achieve both aggregate and equitygrounded targets. If systematically engaged, communities could serve as key decision makers and producers of their own health. For instance, Ethiopia has successful experience in partnering with communities in healthcare delivery through Health Extension Programme and Health Development Army. 11 As proven effective, this can be contextually replicated to other parts of Africa and the rest of the Global South. Universal health coverage could be achieved only if all geographies and populations are empowered to make key decisions in their own health.

INTENSIFY INNOVATION
We believe that innovation is a linchpin to meeting the health SDGs. The current healthcare delivery standards were largely designed to meet the MDGs. To ultimately achieve the health SDGs, there is a need of complete departure from the current paradigm of healthcare delivery. A new and transformative healthcare delivery standard should be set through internally-led, high quality research and widely-sourced innovations. In this regard, we have seen several examples of breakthrough innovations which saved millions of lives worldwide. Insecticide-treated nets, for instance, have had principal role in the promising path towards malaria-free world. Relatedly, the ambitious target of ending TB by 2035 cannot be achieved without additional investment in research and innovation. Unmet need of TB research and innovation includes enhancing diagnosis accuracy and provision of family-centred effective treatment. The lofty target of ending AIDS could also be achieved through intensified research and innovation.
Similarly, ending preventable maternal and child deaths require new tools and innovations. In this area, innovation in healthcare delivery should dismantle intractable maternal health challenges during pregnancy, child birth and postpartum. Also, major causes of child mortality, particularly newborn deaths should be the central focus of innovation in child healthcare delivery.
The United States Agency for International Development, the UK Department for International Development, BMGF, Grand Challenges Canada and few others are major contributors to stimulating innovation, supporting transition-to-scale and investment at scale at national or supranational scale. The current challenges in healthcare and the bold global goal warrant more investment in innovation by more nations and agencies. Also, population-level impact could be maximized if innovation and high-quality evidence drive healthcare delivery policy and practice and further investment in health sector. Equally important, programmatic uptake of new evidence and innovation should be improved.

CONCLUSION
The ambitious health SDGs can be met by transforming national health systems, building results-driven partnerships and supporting and enhancing the uptake of healthcare delivery innovations. Investment and health outcomes should be regularly tracked in the spirit of leaving "no one behind" and universal health coverage. Heightened political commitment and community leadership could contribute to bending the current curve on mortality at national level and improving health of each individual. These could propel the global community to a monumental milestone in the history of humankind, meeting the health SDGs.