The costs of reaching the health-related SDGs
Authors: Arian Hatefi
Journal: The Lancet Global Health (2017)

The estimated additional US$274–$371 billion needed annually until 2030 to achieve the targets of Sustainable Development Goal 3 (SDG3) in low-income and middle-income countries (September issue, p e875)1Stenberg K Hanssen O Edejer TT-T et al.Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries.Lancet Glob Health. 2017; 5: e875-e887Summary Full Text Full Text PDF PubMed Scopus (213) Google Scholar may seem like a high price tag—it is. But these costs account almost exclusively for downstream health-system investments. The donor community can perhaps help relieve this cost burden through concurrent investments in comparatively smaller, upstream, and targeted global functions. In 2013, the Lancet Commission on Investing in Health (CIH)2Jamison DT Summers LH Alleyne G et al.Global health 2035: a world converging within a generation.Lancet. 2013; 382: 1898-1955Summary Full Text Full Text PDF PubMed Scopus (786) Google Scholar set out to understand the resources required to close the gap between rich and poor countries in key health domains; our updated analysis3Boyle CF Levin C Hatefi A Madriz S Santos N Achieving a “grand convergence” in global health: modeling the technical inputs, costs, and impacts from 2016 to 2030.PLoS ONE. 2015; 10: e0140092Crossref PubMed Scopus (18) Google Scholar estimated that the resources required to close the gap to 2030 amounted to an additional $70 billion annually. But the CIH was right to flag the increasing importance of global functions expected as countries undergo economic transition in their march toward 2030. Global functions are the “core functions” of health that “transcend the sovereignty of any one nation state” to advance health worldwide.4Jamison DT Frenk J Knaul F International collective action in health: objectives, functions, and rationale.Lancet. 1998; 351: 514-517Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 5Schäferhoff M Fewer S Kraus J et al.How much donor financing for health is channelled to global versus country-specific aid functions?.The Lancet. 2015; 386: 2436-2441Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar They include the provision of global public goods, management of cross-border externalities, and global health leadership and stewardship.5Schäferhoff M Fewer S Kraus J et al.How much donor financing for health is channelled to global versus country-specific aid functions?.The Lancet. 2015; 386: 2436-2441Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar Yet because all nations benefit from the provision of global functions, free riding means they are notoriously underprovided.6Kaul I Conceicao P Le Goulven K Mendoza R Providing global public goods: managing globalization. Oxford University Press, New York2003Crossref Scopus (398) Google Scholar In 2015, Schäferhoff and colleagues5Schäferhoff M Fewer S Kraus J et al.How much donor financing for health is channelled to global versus country-specific aid functions?.The Lancet. 2015; 386: 2436-2441Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar estimated that only a fifth of donor assistance is allocated to the provision of global functions, probably well short of what is truly needed. It is tempting to continue funnelling resources directly into national or subnational programmes (so-called “country-specific functions”) that operate under the usual health aid metrics such as lives saved or disability-adjusted life-years (DALYs) averted. But the problem of non-communicable diseases (NCDs) illustrates well how this breaks down. NCDs are widely recognised as a global problem that is crippling to national economies, but has such high resource requirements that the donor community (which often intentionally or unintentionally influences country priorities) has avoided any substantive response. The most recent estimates are that less than 1·7% of 2016 global health financing has been dedicated to NCDs. The same story can be told of efforts to strengthen health systems. Country-specific programmes should continue to operate with a results-based orientation, but they cannot be the whole solution. Facing such a large price tag, global functions become more attractive. If provided in a goal-driven way with clear objectives, comparatively small investments in global functions can benefit all countries simultaneously. Tried and true examples, such as the Global Fund to fight AIDS, Tuberculosis, and Malaria, can provide models for future investment. Further, global functions acknowledge that human health exists today in the global commons. This is widely appreciated for infectious diseases, but even NCDs—once relegated to the individual sphere—are increasingly appreciated as socially transmitted through global channels.7Allen LN Feigl AB Reframing non-communicable diseases as socially transmitted conditions.Lancet Glob Health. 2017; 5: e644-e646Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar Global collective action has thus become increasingly important for all human disease. There should be no mistake: both global functions and country-specific functions are needed. Whereas national governments will continue to have to increase the share of gross domestic product allocated to health, donors should recognise that the old ways of providing health assistance must adapt with the times. Leading donors can do much to chart the way forward. As examples, they can provide global leadership mechanisms where vacuums exist (for instance, on NCDs or health system strengthening), transform private goods (like country data) into public goods accessible to all, explicitly make programme results generalisable to the global community at large, support countries to enable use of currently provided global functions, or change metrics of success to better reflect the challenges of capturing downstream benefits of global functions. These examples are only a few of the many possibilities. Although today's geopolitics have created a populist recession from globalism, the syndrome of globalisation persists. To support countries in their quest to deliver on SDG3, the global community would perhaps be prudent to pay greater attention to the provision of global functions. And following closely behind, it should measure their effect to ensure that the return on investment is truly worthwhile. I declare no competing interests. Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countriesAll countries will need to strengthen investments in health systems to expand service provision in order to reach SDG 3 health targets, but even the poorest can reach some level of universality. In view of anticipated resource constraints, each country will need to prioritise equitably, plan strategically, and cost realistically its own path towards SDG 3 and universal health coverage. Full-Text PDF Open AccessThe costs of reaching the health-related SDGsKarin Stenberg and colleagues1 estimate the resources needed at both country and global levels to progress towards the health-related Sustainable Development Goals (SDGs). Their analysis included 67 low-income and middle-income countries, selected on the basis of income and population, which account for 95% of the population in all low-income and middle-income countries. Full-Text PDF Open Access