Does SDG 3 have an adequate theory of change for improving health systems performance

Sustainable Development Goal (SDG) 3 aims to “ensure healthy lives and promote well–being for all at all ages” [1]. Unlike the Millennium Development Goals (MDGs), SDG 3 takes a comprehensive view of health and well–being by expanding its focus beyond a core set of diseases. Given the global prominence of the SDGs for driving the development agenda, it is important to consider whether SDG 3 and the indicators it tracks are well–designed to achieve this intended goal. In order to examine whether SDG 3 can actually help achieve this goal, this article considers whether it has an adequate theory of change (ToC) for improving health systems performance. Such an analysis rests on two core assumptions: 1) in order to achieve the SDG 3 goal, one must improve health systems performance, and 2) in order to achieve this goal, the approach must have a strong underlying ToC. Each assumption is considered below. Since the launch of the MDGs, experience has shown that without improvements in health systems performance, progress on the MDGS was both limited and potentially unsustainable [2]. Bottlenecks in the health system limited nations’ ability to achieve progress on combatting specific diseases. In addition, theoretical and empirical work has argued that providing services which are not only clinically effective but also affordable and acceptable has intrinsic and instrumental value. Recognizing the importance of overall health systems performance, numerous organizations including WHO, the World Bank, Global Fund, and GAVI have focused on health systems strengthening (HSS) as an important component of public health programming. Therefore, since SDG 3 aims to improve both health and well–being for all populations in a sustainable way, achieving this goal will likely require broad improvements in health systems performance. With regards to the second assumption, theories of change (ToC) are standard practice in public health and development [3,4]. They help guide priority–setting, decision–making, monitoring and evaluation, budgeting, and resource allocation, among other activities. A strong ToC can ensure that all stakeholders work toward the same goal(s). The SDGs aim to improve both the coherence of development policies and their implementation at the national level, and the United Nations has offered formal guidance on ways that nations can integrate and tailor the SDGs into their national policies [5]. This guidance explicitly advocates for horizontal policy coherence (ie, coherence across different programs and sectors), vertical policy coherence (ie, coherence between different stakeholders), and linking national policies based on the SDGs to budgets [6]. Given that the SDGs aim to improve policy coherence and drive implementation at the national level, it is instructive to consider whether they have internal coherence and a strong underlying logic themselves. The ToC approach provides a useful approach to explore this question. If the inputs and outputs tracked under SDG 3 have clear linkages to improving its impact indicators, then working toward SDG 3 will allow countries to pursue a comprehensive program for improving health systems performance. On the other hand, if the inputs and outputs tracked do not link to each other or do not have logical connections to impact indicators, then aiming to improve all indicators under SDG 3 could lead to a haphazard and uncoordinated set of public health programs.