Health at the centre of the post 2015 agenda

The Italian Presidency of the European Union (EU) is placed at a strategic moment in the negotiations that will determine the global agenda for development after 2015. At its 69th annual session in September 2014 the UN General Assembly initiated the process that will lead to the formulation of the post-2015 development agenda and, with it, new Sustainable Development Goals (SDGs) aimed at bringing tangible results in fighting poverty and improving the lives of all people. How can mistakes of the past be avoided in this fundamental step? And how to prevent the SDGs becoming the repetition of an intergovernmental path bashed by the difficulties of multilateralism?

The Millennium Development Goals (MDGs) propelled a wave of unprecedented commitment by the international community, but had some recognized limitations: the structural segmentation imposed by the strict criteria of measurement, without the possibility of measuring the reliability of the data in each country; the statutory but non-binding soft norms applied to all countries; and the institutionalization of the role of public/private partnerships in the agenda for development. Today, the mobilization produced by the MDGs requires a thorough reassessment, to properly address the challenges of a world burdened by seven years of global financial and economic downturn, by the climate and environmental crisis, by the rise of inequalities between and within countries, and by the intensification of wars and conflicts. These scenarios have, among others, significantly altered the rules of democracy and global governance.

The EU countries demonstrated in the past their ability to translate universal rights into an original social contract between the citizens and the State, thus they have the credentials to exercise a leadership role in defining the dimensions of a sustainable future. They have the body of knowledge and the tradition of experiences that can help indicate the proper political direction towards future horizons of human development, in a perspective of intergenerational equity.

Health first

The Italian Global Health Watch (OISG)[1] considers health as the starting point of any path towards true human development. Health intersects many different and critical factors in all stages of life: education, employment, gender balance, distribution of wealth and access to resources, social protection, self-determination and quality of a democracy. Health requires the implementation of cross-sectorial policies and the assessment of the degree of integration among sectors. Health is a nearly and highly sensitive detector of other indicators’ progress, and health equity measures the quality and extent of the entitlement to citizenship granted to individuals in a society.

Health inequalities, by contrast, tell of all the other inequalities. The epidemiological data from Greece[2],[3] point to the need to carefully reassess the impact and sustainability of policies to control public spending.[4] In particular, they warn policy makers against the temptation to measure states’ performance purely on financial criteria, and to intervene with severe sanctions against countries that violate the criteria of economic stability used as benchmarks.

For the post 2015 agenda, OISG proposes three pillars for building the SDGs.


Individual and population health is the result of a life in which all the determinants of health (biological, environmental, economic, social and healthcare-related) contribute in a positive way to preventing and managing discomfort, illness and disease. The indicator that best senses the pursuit of a healthy life is the Healthy Life Expectancy (HLE),[5] an indirect measure of all the other dimensions of development that influence health and of the real opportunities for people: education, employment, wages, housing, climate, and respect for human rights.

OISG recommends HLE from birth as the central indicator for determining the attainment of SDGs. The objective “more years of healthy life for all” includes improving health (more years of healthy life) and reducing inequity (for all, intended as a reduction of the gap between rich and poor, and between males and females).

The HLE, like any other health indicator, varies from country to country and within countries, by region, by distribution of resources, and above all by social class. Because it can be used to promote a reduction of the gradient of inequality, the HLE should always be measured, and presented, using an equity stratifier, i.e. a variable that measures social differences, such as the distribution by level of education or by income quintile. Globally, the level of income is the most widely used equity stratifier, because of its feasibility. The HLE of the poorest 20% can be compared, for example, with the one of the richest 20% in a population.

Other specific health objectives can be added to “more years of healthy life for all”, on aspects of health that contribute to increase the number of healthy life years. These additional objectives may vary from country to country and may interconnect in different ways within countries, if there are regional differences in terms of human development. For example, in low or very low income populations, the major contribution to the improvement of the HLE is the reduction of maternal, neonatal, infant and under-five mortality. In high-income populations it may be better to focus on the causes of disability in people over 50 years of age. In all countries, regardless of their level of development, there will be specific objectives on the prevention and control of non-communicable diseases and on strengthening health systems. All these choices should be made bearing in mind the different contexts, with a great concreteness, measurability and adaptability, without concealing any relevant factor in a given society.

Having “more years of healthy life for all” as a primary objective, with appropriate secondary objectives, does not exempt governments and the international community from their responsibility and commitment for ensuring a decorous life to people with a shorter healthy life or those who spend long periods of their life with discomfort, disease and illness.


The best strategy to ensure more years of healthy life with an equity and intergenerational lens lies in addressing the very early stages of life, from conception to the first three years. This is the critical period for health and nutrition, and for cognitive, emotional and social development, with long lasting effects throughout the life course. During this crucial period, poverty, lack of access to appropriate care starting from pregnancy and childbirth, and lack of adequate nutrition and other growth and development opportunites, such as educational and socio-relational ones, contribute to the vicious circle of poverty and disease. The early years are therefore an unparalleled window of opportunity for interventions to prevent risks and to promote health and development.[6]

The way parents invest on their children depends on their employment status and social position, on their state of health and level of education, and ultimately on their capacity for self-determination. It also depends on the type of solidarity which a national community can put in place. Social protection, full employment and income support, universal health and education policies and services that reach individuals and families from the pre-conceptional period, particularly with respect to families in difficult situations and children with special needs, are all recognized as the best way to ensure human development.

OISG recommends for every child the best possible start in life, as this is one of the most far-sighted and effective policies that governments can adopt to build equity and sustainability. “Investing in children: breaking the cycle of socio-cultural disadvantage” is a policy recommended by the European Commission in February 2013.[7] Investments in health, nutrition and cognitive, emotional and social development in the early years of life afford the highest economic returns for individuals and for society. Ultimately, it is also an ethical imperative, as well as a worldwide-recognized right and a binding duty for governments.[8]


The greatest challenge for the post-2015 targets is probably to avoid reproduce the past dissociation between the awesomeness of global proposals (the promised results and deadlines for achieving them) and the uncertainty and limitations, or even absence, of achieved quantitative objectives that can be reliably measured.

To this well-known and deep dissociation, an even more worrying additional element, hardly discussed at intergovernmental level, comes into sight in the negotiations for the post-2015 agenda: The lack of a binding system of accountability and obligations for governments and the international community. Such a system is no foreseen, neither in the planning stage, nor for the evaluation of results. Again, a logic that conceives the SDGs as non-binding recommendations is likely to prevail. A logic mistakenly taken for granted by a global community in which public actors and private interests intertwine in pretty loose ways. Health and health care coincide closely with the protection, the guarantee and the promotion of human rights for individuals and populations; they belong, therefore, to the realm of imperativeness[9],[10]. Their violation, by commission or omission, in this sense coincides with a fault of respect for the uninfringeable right to a decorous life.

OISG recommends a formulation of compulsory accountability for the SDGs, starting from the goals related to health, at individual and collective level, with an obligation to produce specific and not generic reports. In this formulation, it is essential to clearly specify:

  • who bears the responsibility to foresee, plan and implement a health care legislation that ensures universal coverage;
  • where and to what extent these responsibilities are decided at the level of countries, regions and international agencies;
  • that trade and economic rules must be flexibly interpreted and implemented if they are in conflict with universal human rights (e.g., intellectual property rights as opposed to access to life-saving medicines and vaccines), and how this will be done;
  • the safeguards that should guide governments’ conduct and decisions, especially in relation to bilateral and multilateral trade agreements, whose potential impact on sustainable development after 2015 is of great concern and should be subject to rigorous analysis;
  • the areas to be formally monitored to protect the public sector from the interests and investments (often illegitimate as well as illicit) of private actors, including regional and global financial agencies and groups involved in health and social services across borders.

The definition of the post-2015 agenda is undoubtedly a demanding challenge. It is also a unique opportunity for a conceptual and operational leap, in the name of policies that will deal with the real problems of people worldwide.

In a global society drenched in a sense of widespread insecurity, the concept of sustainable development requires audacity and vision. The international community must engage in the changes needed to overcome the current sharp contrasts and to re-establish the priority of universalistic policies and spaces of democracy, both crucial to ensure a life worth living.

Putting health at the center of this path is the first step. No one shall be left behind.

Rome, 16 October 2014.



[2] Kondilis E et al. Economic crisis, restrictive policies and the population’s health and health care: the Greek case. Am J Public Health 2013;103:973-9

[3] Karanilolos  M et al. Financial crisis, austerity and health in Europe. Lancet 2013;381:1323-31

[4] Stuckler D, Basu S. The Body Economy: Why Austerity Kills. Basic Books, New York, 2013

[5] The HLE is typically 10-20 years lower than LE (Life Expectancy).Both can be estimated from birth or after reaching a given age.

[6] Walker SP et al. Inequality in early childhood: risk and protective factors for early child development.Lancet2011;378:1325-38

[7] European Commission. Investing in children: breaking the cycle of disadvantage. Bruxelles, 2013

[8]Convention on the Rights of the Child

[9] International Covenant on Economic, Social and Cultural Rights. United Nations, New York, 1966

[10] World Health Organization. 25 questions and answers on health and human rights. WHO, Geneva, 2002



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