Chasing goals rather than solving problems?

Linda P. Fried & Lynn P. Freedman | 11 May 2010
Global Health Magazine
We stand at an unprecedented moment in global health: advances in public health science enable us to project health trends into the future as never before and to understand how to prevent or effectively treat many of the significant global health concerns - or position us to figure out more effective approaches. We also have global experience in setting goals, deploying resources, and observing outcomes. This is a critical time to be cognizant of the broad changes that are in process and take stock of whether current approaches will serve us well in this changing world. This article seeks to reflect on both of these issues and suggest on how each can inform the other for future success in improving global health.

The new world of global health will be characterized by persistence of our longstanding concerns to mitigate infectious disease and improve maternal and child health, food and water availability and safety. In these areas, there is little doubt that global goals and targets have been critical for redirecting policy attention and mobilizing advocacy. Witness the rise of attention to maternal mortality once it was chosen as an MDG - and the equally striking decline in the fortunes of reproductive health when it was omitted from the original Goals. Yet, even when there is such welcome attention, successive goals and targets have come and gone, largely unmet.

Our poor track record may stem from the reliance on plans that are formulated with an eye trained exclusively on the bar set globally by the goal, while ignoring what science teaches us is needed locally for lasting solutions. In fact, recent analyses by Peters et al, in the 2009 The World Bank's Improving Health Service Delivery in Developing Countries: From Evidence to Action, clearly demonstrate how global goals and targets have been set without reference to crucial aspects of the country context that influence change, and without acknowledging the varying pace of change that is possible across different settings with different starting points.

Too often, global goals and targets that were meant primarily to refocus political attention are mistakenly assumed to dictate appropriate first steps in a plan of action for effective implementation. For example, there is clear consensus that a goal such as MDG 5 on maternal mortality cannot be met without an approach that strengthens district-level health systems. Yet many of the Roadmaps for Reduction of Maternal and Newborn Mortality developed by countries in Sub-Saharan Africa, while aspiring to meet global MDG targets for births attended by skilled health professionals, are devoid of adequately resourced implementation plans to tackle the systemic problems that have repeatedly sabotaged such aspirations.

Insights from the fields of systems science and implementation science would guide us toward a rather different approach to implementation - one that builds from the local level up, starting with a strategically developed understanding of the power dynamics and institutional constraints that currently hamper progress. Such plans for meeting goals and targets might use results-based financing and management approaches, but they would be deployed using a conceptual framework and monitoring design that can accommodate unintended consequences, policy resistance and emergent, changing properties of the system itself. Implementation would proceed with focused attention to these dynamics of the system and with a flexible plan to strengthen the capacity for local problem solving. Ultimately, according to Potter and Brough's 2004 Health Policy and Planning paper "Systemic Capacity Building: A Hierarchy of Needs," the pace of progress would depend substantially on the success at strengthening the institutional arrangements - rules, accountability, incentives, organizational structures - on which the health system is built.

Clearly, this evidence-based approach to implementation would argue for a different relationship between aspirational global goals and the metrics that govern action on the ground. When global targets are nonetheless used to grade countries as "success" or "failure," and intense pressure for fast results is allowed to eclipse attention to institution building, or even to justify violation of rights, the damage can go beyond simple failure to meet the goal. Painful experiences with contraceptive targets and coercion in the family planning field teach us that numbers are not neutral: their operation within a health system is filtered through the wider power dynamics operating in a society.

Now let's consider the dramatically different epidemiologic and demographic picture of the coming decades that these longstanding health concerns will nest within. The world, over the next 20-30 years, will manifest a number of significant changes. Mortality and morbidity from chronic, noncommunicable diseases will be the dominant causes of ill-health - fueled by world-wide changes in health behaviors and environment. Already, according to WHO in 2004 and then again in their fact sheet number 310 of October 2008, of the top 10 causes of death in low-income countries, three were noncommunicable disease: coronary heart disease, stroke and cerebrovascular disease, and chronic obstructive pulmonary disease; in middle income countries, seven of the top ten were noncommunicable. (See GLOBAL HEALTH magazine, Issue 4, Fall 2009) Associated with this rise in noncommunicable disease is the aging of all populations, globally. A great success of public health, our increasing life expectancy, this brings a need for a new set of goals for healthy aging and whole new range of methods to accomplish this.

Global and national goals for prevention of these noncommunicable diseases and health in an aging world are much needed to align global action with these new realities. But at the operational level, new types of solutions that will be effective in prevention on a population level are also needed. The approach and ability to manage the complexity of the problem will matter: for example, consider the picture of a world-wide obesity epidemic coexisting with persisting malnutrition in many developing countries; this will make goal setting and problem solving necessarily complicated, because we must be able to design solutions that don't take people from starvation to obesity. Further, the most effective methods for accomplishing these goals could bring co-benefits in terms of more effectively addressing many other co-existing health concerns.

Given the massive changes in population health status and needs, and the complexity of real-life challenges, in comparison to the necessary simplicity of goals, we ask if we have all the necessary goals, and whether global health goals serve us well as a guide in shaping our strategies to solve these future scenarios.