<p>Attention to social, economic, environmental and political determinants of health is not new. In the 19<sup>th</sup> century, scholars such as Friedrich Engels, Rudolf Virchow and others documented the relationship between ill-health, working conditions and poverty. Historically we have seen strides in population health when there are improvements in housing and working conditions and access to food. McKeown, for example, argued that population growth and declines in mortality were due to economic growth and related improvements in socioeconomic conditions, rather than specific health interventions.[qtip:1|McKeown T. 1976. <em>The Role of Medicine: Dream, Mirage or Nemesis?</em> London: Nuffield Provincial Hospitals Trust.] This broad understanding of health is also recognized by the WHO Constitution of 1946 which defines health as a state of complete physical, mental and social well-being, not merely the absence of disease. Health is therefore strongly influenced by the broader cultural, economic, political and social environment and in turn influences the attainment of peace, security and economic, political and social development. Good population health improves productivity, sustainability and the economy, across sectors and society as a whole.</p>
These linkages between public health and social progress have been reiterated through more recent scholarship. The WHO Commission on Social Determinants of Health drew attention to the 'causes of the causes' – the social factors that determine how people grow, live, work and age – and that needed to be addressed to reduce health inequities between and within countries.2 The social gradient of health has now been demonstrated to be fairly universal across countries and health conditions and can be mitigated through improved access to primary health care, public policy focused on the social determinants of health and targeted health and social development interventions. This understanding is echoed by many national health strategies and socioeconomic development plans of countries, which have long recognized that health and sustainable development are interlinked and interdependent.
Dramatic improvements in health and the economy
Countries in the Asia Pacific Region made remarkable progress in past decades with many experiencing rapid economic growth and impressive increases in GDP.3 This economic progress has been particularly notable in East and Southeast Asia, where increases in health status and life expectancy generally went had in hand with decreases in poverty and improvements in housing and education. This perspective linking poverty, economic progress and health was also core to the Millennium Development Goals (MDGs).
The MDGs were programmatic, indicator-driven, led by UN agencies and focused on priorities for which effective interventions were available for scale-up. The idealism at the time was that poverty could be eradicated through scale up of such interventions. Global investments during the MDG era resulted in great improvements at the population level. The WHO's Western Pacific Region did particularly well,4 reaching all but two of the health-related MDG targets and making significant progress in the remaining two.5 For example, the prevalence of underweight among children under five decreased from 13.5% in 1990 to 2.6% in 2014. The estimated maternal mortality ratio decreased by 64% between 1990 and 2015. Malaria cases and TB incidence decreased, access to antiretroviral therapy increased for people living with HIV. Almost 100% of the population now uses an improved drinking water source, up from 71% in 1990. In the WHO South–East Asia Region,6 progress was more nuanced, with four targets met and progress made in another six.7 Significant achievements were for example made in the area of communicable disease control and access to safe drinking water. These achievements set countries up well for future advances in public health and social progress.
However, a range of complex factors challenged the MDG dream —including the political economy, conflict, climate change, and social unrest. In the Western Pacific Region, much of the success in regional targets can be explained by improvements in poverty reduction and life expectancy in China. Experiences from the MDGs also pointed to problems with the approach, including limitations of stand-alone health and disease programmes working in silos, weak health systems and a ‘one-size-fits-all’ approach that didn't take account of local contexts. By 2015 it became clear that the world had to grapple with these more fundamental issues to achieve economically, socially and environmentally sustainable development.
The SDGs build on lessons from the past
In 2015, UN Member States adopted a new agenda for development to 2030.8 The Sustainable Development Goals (SDGs) represent a new era for public health and social progress. They recognize that today's health and development challenges are complex and interlinked. The SDG paradigm addresses past problems with programme specific interventions in health and adopts a 'social determinants of health' framework. Reflecting this, there are 17 goals and while Goal 3 focuses on health and well-being for all, core health issues can be found in other goals. Health influences and is influenced by all SDGs. Moreover, the 2030 agenda is at its core ambitious and does not shy away from ‘wicked’ problems, but rather embraces their complexity, requiring intersectoral partnerships for action. This is timely given the realities of public health and social progress in countries of the Western Pacific Region.
Stark inequities persist in health and access to care in countries of the Region. Up to half the population in some countries are missing out on essential health services. More deaths of children under 5 occur in poorer or remote households. Populations most affected by HIV are disproportionately in need of testing and treatment. Chronic rural–urban inequities persist in, for instance, access to safe drinking water and sanitation. These inequities are often exacerbated by rapid urbanization and environmental degradation. Even where MDG targets were achieved at the population level, not all groups benefitted equally. Income inequality increased in some countries despite economic growth. Up to 60% of people living in some countries of the Western Pacific Region lack coverage with essential health services, and many households report spending more than 10% of their income on health services, leading to financial hardship.9 In South-East Asia, over 800 million people do not have full coverage with essential services, and at least 65 million people are pushed into extreme poverty by costs for health care.10 These and other shortfalls point to need for interventions at a service delivery level, at a community and public policy level and the importance of connecting the local and the global.
Leave no-one behind
Attention to equity in health is central to the principle of leaving no-one behind at the heart of universal health coverage (UHC). Translating this commitment into policy and programme priorities requires working in different ways, including collaboratively across government, with stakeholders beyond government and with affected communities, to both address the social determinants of health equity and to establish systems and service delivery models that are integrated, people centred and equitable. It also means stronger leadership to improve governance at different levels of the system to deliver UHC policies and strategies. The WHO regional framework on “Universal Health Coverage: Moving Towards Better Health”, provides a broad foundation for a comprehensive, whole-of-system approach to health and development.11 UHC is a specific target of the SDG agenda as well as a platform bringing together disparate health and development efforts and for achieving equitable and sustainable health outcomes.
More broadly, the SDGs recognize that in this increasingly complex world new approaches are required to work across sectors, stakeholders and borders to leave no-one behind. Partnerships between health and other sectors can result in multiple benefits. For example, tackling air pollution, a growing challenge in the Region, is a shared interest for both the health and environment sectors. Similarly, promoting healthy diet for children, a public health priority in the Republic of Korea, relies on collaboration between three Ministries and local government and this multi-sectoral approach has led to co-benefits across sectors and for children’s health and well-being.
Applying lessons from health in all policies for improved impact
The interplay between multiple social, economic, environmental and political factors, coupled with the rapid pace of change in the Western Pacific Region, highlights the importance of identifying critical junctures where action can be most effective. The opportunity to promote action on the social determinants of health through implementing health in all policies (HiAP) – working across sectors for mutual gain, including in improving population health – has never been better. HiAP is not a new concept, and there is a long history globally as well as many useful lessons that policy-makers can draw on.12 For example, Thailand is a well-known and comparatively mature example of HiAP, with its National Health Assembly providing a platform for participatory governance, citizen engagement and intersectoral collaboration. In China, Healthy China 2030 frames health as a whole of government priority, with the involvement of over 20 ministries as well as local governments, private institutions and social groups. It is informed by continuous monitoring, experimentation and development to reach "a prosperous society, fulfil the SDGs and modernize society".
Not only do we have significant evidence that such approaches work for health and provide co-benefits for other sectors, we know that the most pressing health challenges can only be addressed if we develop a different kind of approach involving a wide range of partners. For example, the Asia Pacific Parliamentarians Forum on Global Health provides a mechanism to engage directly with parliamentarians to exchange ideas, build political support, strengthen capacities, and foster collaboration in driving sustainable action for health. It is a key component of WHO’s long-term strategy to support Member States in the Western Pacific Region to strengthen legal frameworks in the SDGs through whole-of-government approaches.
The SDGs not only aim for mobilizing a wide range of different players, they also stress the importance of taking action at multiple levels of governance. For example, urban health offers opportunities for bringing different government sectors together under a shared vision at the local level.13 The Western Pacific Region has a long history of promoting healthy cities to create co-benefits between health and other city policies. The important role of cities and communities was reiterated in 2016 by the Shanghai Consensus on Healthy Cities.
Other major priorities for the Region – such as addressing antimicrobial resistance (AMR) and climate change – require action across borders. For example, the Biregional Technical Consultation on Antimicrobial Resistance in Asia and the resulting Tokyo Communique (2016) stressed the importance of tackling AMR as a development issue through systems strengthening and effective national, regional and global governance mechanisms for multi-sectoral collaboration.14 Similarly, the SDGs and agreements, such as the Paris Agreement on climate change and the Manila Declaration on Health and the Environment (2016), provide leverage points to prioritize actions that produce co-benefits for health and the environment and ensure health as a resource for future generations. This means stronger leadership to improve governance at different levels of the system to deliver policies and strategies across sectors and borders.
Monitoring progress – early lessons from the global level
One of the successes of the MDGs was the consensus on clearly defined targets and goals that could be monitored at local, provincial, national, regional and global levels, with clear divisions of responsibility. The SDGs similarly underline the importance of timely, high-quality data, translating information into policy and action and using it to assess progress and guide planning. At the global level, the High-level Political Forum (HLPF) under the auspices of the UN Economic and Social Council, is a central platform for annual follow-up and review of the 2030 Agenda.
Between 2016 and 2019, 14 Western Pacific Region Member States completed or committed to participate in voluntary national reviews feeding into the UN HLPF.15 Despite the diverse approaches adopted by different countries some common lessons have emerged, including the importance of building on existing policies and structures and fostering strong partnerships across sectors and with stakeholders. Common challenges pertain to achieving policy coherence and implementing whole-of-government approaches. Improving capacities for coordination across sectors and monitoring complex and dynamic trends are shared priorities across countries. Several reviews also emphasise the need to build institutional capacity of local governments who are at the forefront of implementation of many goals.
Monitoring for improved impact on the ground
While the SDGs have provided countries with a new shared global goal, one of the defining characteristics of the 2030 agenda is its emphasis on country ownership and country impact. Early experiences in countries underline the alignment of laws, policies and plans with the SDGs, supported by localised monitoring and financing mechanisms. At least 15 Member States have incorporated the SDGs into their national development plans. The processes of SDG localisation are as much characterised by commonalities across countries and country specificities. For example, in Cambodia, SDG localisation was led by the Ministry of Planning using existing national technical working group mechanisms. Targets and indicators were selected through a multi-partner process and financing and monitoring strategies for advancing these goals and targets were identified. Multiple Cambodian policies and strategies incorporate a focus on the SDGs. In the Philippines, a focus was placed on translating the SDGs into actionable goals and targets under the Philippines Development Plan (2017-2022). SDG 3 falls under the second pillar of the plan on “inequality reducing transformation”, and more specifically in relation to accelerating human capital development in recognition that better human development outcomes are attained by reducing inequalities in the Filipinos’ ability to stay healthy and continue learning throughout their lives.
More fundamentally, there is a need for more granular monitoring to identify where to focus attention, in what order to tackle public health and social progress questions, where to invest resources, and how to determine what will make a difference. This provides an opportunity for academics and civil society to engage in analysis of what is happening and to draw out the lessons learned for improved country impact. While there has long been evidence of the importance of the social determinants of health, many questions remain about the effectiveness of interventions and their adaptation to different contexts and advancing the SDGs requires understanding what interventions will be effective under what conditions. In addition to intervention and implementation research, better linkages across disciplines and between information systems across sectors will be required. Recent reports on monitoring and evaluation of UHC and the SDGs in the Western Pacific and South-East Asia regions acknowledge the need to expand our understanding of monitoring public health and social progress, including by improving collection, analysis and use of equity indicators, applying a more sophisticated understanding of social determinants and their interactions and building system capacity for equity analysis.16
Way forward for health and other sectors
If the 2030 Agenda is to be realised, synergies enabled through whole of government, whole of society action will need to be maximised. To this end and in response to requests by Member States, the WHO Regional Office for the Western Pacific developed the Regional Action Agenda on Achieving the Sustainable Development Goals in the Western Pacific in 2016.17 This agenda identifies 12 action domains across four guiding questions – on monitoring and evaluation, policy and programme priorities for leaving no one behind, implementation options and health sector capabilities. While this agenda focuses on the health sector, each sector will need to reflect on and develop capabilities to address similar questions. For example, how will monitoring frameworks be revised so to enable collection of data useful for informing action and tracking progress across the SDGs, and in particular for equity focused monitoring and evaluation? How will equity issues be addressed and how can public financing be most effectively utilised for health and social equity? How can enabling conditions and institutional arrangements be structured to maximise conditions for realisation of win-wins through intersectoral action and how can communities and civil society organisations be better engaged to inform development priorities and actions? How can we develop the institutional, workforce and research capacities for these new ways of working?
Conclusions
The SDGs place renewed demands on Member States, on WHO and partners in the Asia Pacific Region. Finding entry points for change is not always easy. Lessons from the social determinants of health and HiAP fields can be adapted and expanded to address the SDGs, and vice versa. This challenges us to look beyond the narrow target that we may be focused on to the broader development challenges that we can only move forward collectively. Reorienting our health systems to better respond to the changing economic, political, demographic and environmental realities in the Region, through timely policies and better coordination and collaboration across sectors without leaving anyone behind, is at the core of progressing the development agenda. The strength of the SDG framework – and arguably its greatest challenge – lies in its emphasis on a different way of thinking and working on public health and social progress.
Vivian Lin, Professor of Public Health, La Trobe University; and Director, Health Systems Division, WHO Regional Office for the Western Pacific.
Britta Baer, Technical officer, WHO Regional Office for the Western Pacific.
Kate Silburn, Senior Project Manager, La Trobe University; and Coordinator, Equity and Social Determinants, WHO Regional Office for the Western Pacific.
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