INTRODUCTION:

India considers sustainable development goals as part and parcel of its long standing tradition and heritage by adopting Vasudhaiva Kutumbakamas the slogan for implementation which means “world is one family” (United Nations, 2017). As one of the fasted growing economy of the world, it is responsibility of India to work on inclusive development and sustainable development goals for betterment of economy and society globally and domestically both. Not with standing its scarce financial resources due to relatively lowper-capita income, large population and vast geographical expanse, India is committed to achieving within a short period such ambitious goals as universal rural electrification, road and digital connectivity for all, massive expansions of clean and renewable energy, sanitation and housing for all and universal elementary school education and also improved health care services for healthy population.

The Sustainable Development Goals are a new set of development goals as collectively decided by the United Nations in 2015, which succeeded the Millennium Development Goals and are official called “2030 Agenda for Sustainable Development”. This agenda is a result of many years of negotiations between 193 general assembly nations of the UN and it aims in promoting welfare of mankind in a sustainable and equitable manner. The SDGs came into action in January 2016 and aimed at offering a broad and inclusive framework for ending poverty and worldwide in the next 15 years. These are set of 17 integrated and wider scoped targets set to achieve global prosperity by removing hunger and poverty from root. Still, this does not mean that every target applies to every country. Rather targets are defined as aspirational and global, with each government setting its own national targets guided by the global level of ambition but taking into account national circumstances. Each government will also decide how these aspirational and global targets should be incorporated into national planning processes, policies and strategies. Globally, the challenges are diverse for achieving desired results, ranging from financing to equity. Almost all major institutions of world as the UN and its institutions, the World Bank, the WHO, the respective state governments etc are contributing to the aim by promoting and financing major projects. It should not be forget that SDG goal 16 and 17 are itself for institutional and international participations and partnerships towards achieving this agenda targets.

Reinforcing India’s commitment to the National Development Agenda and SDGs, the country’s Parliament has organized several forums to develop policy and action perspectives on elimination of poverty, promoting gender equality and addressing climate change. The NITI Aayog, with the Prime Minister as its chairperson, is to provide the overall coordination and leadership. The institution has carried out a detailed mapping of the 17 Goals and 169 targets to Nodal Central Ministries, Centrally Sponsored Schemes and major government initiatives. Most state governments have carried out a similar mapping of the SDGs and targets to the departments and programmes in their respective states.

Sustainable Development Goal 3: Ensure healthy lives and promote well-being for all at all ages.

Moving ahead and talking about the specific aim of this paper on addressing the issue of healthy population. The Sustainable Development Goal: 3 deals in ensuring good and equitable health care to all. The goal 3 is stated as “Ensure healthy lives and promote well-being for all at all ages”. The goal puts light on importance of health as poor health not only deprives right to life of an individual but also deprives him of financial resources and other opportunities that a healthy man have. This goal can be easily integrated to all other 16 goals and it can be easily infer that good health plays an important role in social, political and economic development of a nation.Within the health promotion literature, sustainable development refers to the use of resources, direction of investments, the orientation of technological development, and institutional development in ways which ensure that the current development and use of resources do not compromise the health and well-being of present as well as future generations.(Nunes, Lee and O’riordan, 2016). Broadly speaking, health is a concern to all people, and is influenced by and as well contributing to policies across a wide range of sectors.

Health figured prominently in the MDGs. Three of the eight goals focused directly on health-related issues-reducing child mortality (MDG 4), improving maternal health (MDG 5) and combating HIV/AIDS, malaria and other diseases (MDG 6)-while three others were indirectly related to health-eradicating extreme poverty and hunger (MDG 1), ensuring environmental sustain- ability (MDG 7), and developing a global partnership for development (MDG 8). So, the UN asserted that the role of health should be reconsidered, including its relationship alongside the concept of ‘well-being’.

There are as much as nine targets under SDG goal 3, which are shown in table below:

Number	Target
3.1	By 2030, reduce the global Maternal Mortality Ratio to less than 70 per 100,000 live births
3.2	By 2030, end preventable deaths of Newborns and Children Under 5 Years of Age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births
3.3	By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other Communicable Diseases.
3.4	By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being
3.5	Strengthen the prevention and treatment of Substance Abuse, including narcotic drug abuse and harmful use of alcohol
3.6	By 2020, halve the number of global deaths and injuries from Road Traffic Accidents
3.7	By 2030, ensure universal access to Sexual and Reproductive Health-Care Services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.
3.8	Achieve Universal Health Coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all
3.9	By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil Pollution and contamination.

The requirement of integration globally:

Despite being set out as a separate goal SDG 3 is recognized as critical for the achievement of other SDGs. Measures of health and well-being can be used to assess progress in the implementation of the SDGs. Conversely, most of the new generations of SDGs have a range of direct positive impacts on human health and well-being (e.g., reductions in cardiovascular disease, lung cancer and stroke). There are also a range of health and well-being co-benefits of sustainable development (i.e., poverty reduction, sustainable energy sources, safe drinking water, adequate sanitation, sustainable food production and distribution, urban planning). This is why the WHO argues that health and well- being is central measures of progress in achieving the SDGs as an overall strategy of the post-2015 agenda.

Working on all these targets and achieving them is not possible in isolation. There is a need to integrated policy framework especially in developing countries as India which take cares of inter-dependence of these goals. For example: reducing mortality from water pollution is not possible without focusing on Goal 11: Sustainable Urbanization. Today, the world needs such integrating frameworks among the SDGs for fuller implementation and results. Health, well-being and sustainable development are considered to be intrinsically connected, with health regarded as a precondition indicator, as well as an outcome of successful sustainable development

Recently a framework has been provided by Nunes, Lee, & O’riordan (2016) for integrating the targets of health with others and vice versa. The authors mentioned that the integration of health and well-being across the SDGs as both preconditions and outcomes of sustainable development. The authors gives a table describing linkages of Goal 3 with all other 16 goals and the sectors involved. Such frameworks will help policy makers in clearly deciding which sectors are to be taken along for achieving goal of healthy population. As health is extensively determined by economic, social and environmental conditions, poverty, gender equality, education, growth, etc. we need to integrate the efforts towards these goals also.

In this way, health and well-being remain central to the sustainable development framework, with SDG 3 as more integrated under this new agenda than the MDGs. For example, the impacts of better health and well-being on poverty reduction and increased equality and, as a result, on achieving overall sustainable development, can be realized through more collaborative efforts between health and non-health sectors.The improvement of social protection, health systems and services, the reduction of poverty and malnutrition, the access to sanitation, water and hygiene facilities, and the use of clean energy sources are further examples. Simultaneously, actions in the health sector can directly address health problems caused by broader determinants of health, such as the natural (e.g., air, water and land pollution), working and built environments (housing quality, urban planning, sanitation and drinking water facilities, ventilation, toxic exposure).

Nunes et al.,(2016)also gives potential new indicators, which specifically encourage connections between health and non-health sectors within the sustainable development agenda. In this way, an integrated approach will be created which provides opportunities for more coherent and coordinated action across all sectors. For example, a focus on human rights, equity and basic cultural freedoms is included as affecting health-related sustainable development outcomes. The integrated framework to the SDGs put forth by Nunes et al.(2016), WHO and other agencies requires closer cooperation across the multiplicity of actors that now populate the global health governance landscape. Indeed, such an approach to the SDGs may provide an opportunity to build networks among these diverse actors, bringing together their efforts to work across health issues and sectors. For example, within the health sector, tackling diarrheal diseases might bring together the technical expertise of theWHO on disease prevention, control and treatment, financing of infrastructure by the World Bank, local capacity building efforts, research funding for innovative solutions by the NGO’s, and community level initiatives by the Global Public-Private Partnership for Hand washing etc. and in the non-health sector, the development of innovative solutions to water, sanitation and hygiene needs for children of the UN Children’s Fund (UNICEF), advocacy by the UN Development Programme (UNDP) for access to clean water and sanitation as a basic right. This network ofGlobal Health Governance (GHG) actors could be brought together with community, national and regional organizations to form a focused network around a specific set of SDGs or targets.

SDG 3 in context to India:

Earlier India had National Health Policy, 1983 and National Health Policy, 2002 which served the purpose of Five Year Plansand the targets. In the light new liberal and privatized health care market, GOI introduced, in alignment to the SDG and targets made a new health policy namely, National Health Policy, 2017. In the official policy document of this policy, the achievement of SDG 3 is given an important role and focus has been given to these targets. The targets of NHP 2017 arealigned to the targets of SGD3 by taking into account local circumstances and issues. Even inVoluntary National Review document, as prepared by NITI AAYOG, on implementation of SDGs, NHP 2017 is mentioned as a step further to achieve the targets under SDG 3.

Importance of health in India:

The importance of health in India can be viewed from the fact that every year many individuals in India are driven to poverty purely due to the huge medical expenses that are borne out of one’s own pocket (Duggal, 2007). The burden of disease or health care has a direct impact on household’s income levels and hence in consumption. The main reason behind this is the out-of-pocket spending by the households for treatment and prevention of diseases due to lack of Universal Health Coverage facilities as insurance etc. The facts provided by World health statistics by WHO also shows that public spending share in total health spending in India is mere around 30%, whereas such share in developed countries as Germany is more than 80%. In such scenario, where poverty ridden country is facing high out-of-pocket expenditure, the high private health service utilization further exaggerate the problem as the public sector is inefficient for mass coverage and quality assurance. Moreover, health can be easily linked to educational levels, agrarian distress, including farmer suicide and childhood malnutrition, displacement, migration, and social conflict relating to communicable and non-communicable diseases.(Narayan, 2011)

In such circumstances, healthcare in India should be considered at center of policy making as it will further help in poverty eradication, educational attainments, high savings rate, gender parity and economic growth as well. In this era when we are giving our full efforts on attaining high rates of economic growth, how can we ignore important component as healthcare which will enhance our human resource and leads us to high level of growth. This relationship between health and development is well established by various authors as Weil (2005), Rivera & Currais (1999) etc.

From above discussion, it is made clear that health is utmost important for economic as well as sociological growth of nation. Now, the Sustainable Development Goals under 2030 Agenda on eradicating poverty and hunger have came to Indian policy as an impetus only. By following and approaching these principles, India not only can achieve high economic growth but with sustainability and overall prosperity. The importance of nine targets under SDG3 is clear from the fact that the labour force can become more productive, eradication of communicable disease can lead to higher capital investments in the country, the prevention of substance abuse disorder can help building and maintain better labour force, universal health coverage can help increasing income levels of the poor strata, equity in health care access will help gender equality as well as income parity in the country. The problems as climate change and health issues arising out of it can be easily tackled by approaching the core of SDG 3 and its principles. Such integrated policies should be promoted in India also as mentioned earlier by Nunes et al.(2016) and others also.

The Government of India has also shown commitment in its efforts by releasingNational Health Policy, 2017 and aligning its targets with targets of SDG3. Some of the highlights of national health policy are:

1. Progressively achieve Universal Health Coverage: accessible and affordable health care facilities with public as well as private partnerships and controlling financial health shocks by increasing public spending on health care.

2. Reinforcing trust in Public Health Care System: by making it predictable, efficient, patient centric, affordable and effective.

3. Align the growth of private health care sector with public health goals:Strategic purchasing by the Government to fill critical gaps in public health facilities (as purchase of health technology ) would create a demand for private health care sector in alignment with the public health goals.

4. Specific Quantitative Goals and Objectives: specific goals have been set for health programme assessment and health system performances to make this system sustainable.

Some of the specific goals set under NHP, 2017 are :

1. Reduce Infant Mortality Rate to 28 by 2019 under “India New Born Action Plan.”

2. Reduce Maternal Mortality Ratio to 100 by 2020.

3. Reduce Neonatal Mortality to 16 by 2025.

4. Reduce Under-Five Mortality to 23 by 2025.

5. Completely immunize 90% of newborn children by 2025.

6. Immunize all unimmunized and partially immunized children against vaccine-preventable diseases by 2020.

7. Enhance skilled birth attendance to more than 90% by 2025.

8. Increase antenatal care coverage to 90%.

9. Achieve the global target of 90:90:90 for HIV/AIDS by 2020.

10. Eliminate Kala Azar by 2017, Lymphatic Filariasis in endemic pockets by 2017 & Leprosy by 2018

11. Achieve & maintain a cure rate of more than 85% in new sputum positive TB patients; and reduce incidence of new cases to reach elimination status by 2025

12. Reduce premature mortality from cardiovascular diseases, cancer, diabetes & chronic respiratory diseases by 25% by 2025

Many government schemes as NRHM, ICDS, ANMOL, RBSK, National Vector Borne Disease ontrol Programme, Integrated Disease Surveillance Programme, National Programme for the prevention of non-communicable, ASHA etc have been rolled out by GOI to achieve the targets.

Sustainable Health Care: Challenges for India:

Till now, we have came across a large amount of literature supporting importance of hearth in economic, social and political areas, on importance of health in sustainable development, on importance of SDG3 , on inter linkages of SDGs with each other and many evidences depicting need for integrated policies to achieve targets. This literature review has totally depicted the importance of healthy population and generations for overall sustainable prosperity. But the argument is now on the practicality and of these targets. Some authors argue the compositions of SDGs and its viability in context of developing world. They question the amount of effort required in achieving them(Pogge & Sengupta, 2015). Similar questions also arises for India on following issues:

1. Health Care Financing: Stenberg et al. (2017) prepared a framework for 67 countries from 2016to 2030 on additional financial resources required to achieve SDH3 targets by 2030. India lies in low-middle income countries category and under two scenarios- progressive scenario and ambitious scenario. As per this research, around 7.5% on average of GDP is required to invest in health care for each lower middle income country and a per capita expenditure ranging from $40-$206 and $182 for countries like India is required(Stenberg et al., 2017). These estimates are far more than that provided by Indian government in NHP,2017 document (Ministry of Health and Family Welfare, 2017)

2. Need for Health Insurance Schemes:According to a survey by NSSO (National Sample Survey Organization), 40% of the people hospitalized have either had to borrow money or sell assets to cover their medical expenses. A significant proportion of population may have had to forego treatment all together.In such scenarios, many authors have mentioned private as well as public insurance policies as a remedy of financial burden of households (Nagaraju, 2014).

3. Lack of Public Health Infrastructure In India: To tackle vast population of 1.3 billion (to be extensive by 2030) the existing infrastructure is minimal and the GCF in this sector is also neglible. Public sector is lacking in super specialty hospitals, technology import, research and development in medicine sector, etc. The existing medical colleges and universities are far less than the required numbers. The bigger problem can be seen in rural health infrastructure in India. Baring few exceptions of PHCs and SHCs there is no significant presence of public as well as private health care facilities in remote part of the country. Ambitious goals as curbing tropical and communicable disease as well as combating MMR,Neo-natal mortality, IMR, improving reproductive health and universal health coverage are not achievable without inclusion of remote India

4. Lack of Regulations In Private Sector: country’s 78% of total health expenditure comes from private sector only with households having share of 71 %(Nagaraju, 2014). Still, there is no comprehensive policy for excise, custom duty and service tax exemptions or quality assurance mechanisms etc. Government need to focus on regulatory mechanisms of all 5 sector of healthcare: hospitals, pharmaceuticals, diagnostics, medical equipments and supplies and medical insurance. The government must promote private sector as well as NGOs in rural areas of the country to bring about equity in healthcare with accessible facilities. Along with it, cost control and regulations must be set up by the government in a holistic health sector policy. Another area of policy action would be setting up standard norms for medical practice and hospital care. The Bureau of Indian Standards has begun this process but more concerted efforts are needed to finalize norms and assure their implementation (Duggal, 2001)

5. Weak Past Performances of Programmes of Health Sector: there are ample evidences showing apathy of health sector schemes and policies. One of the example is Chaurasia(2013) . According to this study, performance of health schemes in terms of composite coverage index attributed to the health system is found to be zero.The WHO health system performance assessment framework argues that delivery of health services is influenced by three core functions of the health system - stewardship function, resources creation function and financing function. This means that determinants of the district health system performance should be analyzed in terms of analyzing the stewardship function, resources creation function and financing function at the district level (Chaurasia, 2013) and for that matter the performance of Indian system is quite weak. In such circumstances it is necessary that new schemes and policies should be implemented with proper timely assessment clause and support schemes.

6. Lack of Health Statistics in India is a Major Hindrance in Evidence Based Health Policy: studies as Saikia, Kularni, & Ushottam (2017) put a light on lack of ready to use data on health sector in India . Lack of research on important issue as health is a major hindrance in Evidence Based Policy in health sector.

7. Lack of linkages of health policy with others: it has been noted by majority of studies like Chaurasia (2013) and others that health policy in India lacks in integration with other sectors and their targets. For example: reproductive health and family planning target is achievable through girl education.

Rise to the Challenges:

1. More Financial Assistance to Health Sector: The prime cause of weak health care sector is the minimal resource diversion to this important sector of economy. As Per Voluntary National Report, 2017, health care expenditure is mere 1.25% of GDP of the country. The need of the hour is a turn towards innovative health care financing strategies as one described by Bennet (2014) as Community based health insurance schemes. The author gives example of SEWA scheme of Ahmedabad, which is women driven micro credit agency proving limited health coverage (Bennet, 2014). Another study by Kumar et al (2011) gives way outs as changed and new patterns of centre state funding, appropriate incentive systems will be needed to ensure that states are rewarded financially for improved use of public funds and also for recording improved health outcomes. Similarly, a more effective method of equalization of public health expenditures will be needed to ensure that states with low per person public spending do not have to wait a long time to generate additional resources to achieve a nationally accepted threshold. The author gives taxation as possible method to increase health care funds. He also mentioned that simultaneous policies are required along with increased health care financing as enhance the absorption capacity of the public health system and ensure improved monitoring and assessment.

2. Focus on Strengthening Public Health Infrastructure: more infrastructure is needed in rural and remote sectors. Private sector must be encouraged in backward areas along with increased public spending. Micro institutions and NGO’s should also be welcomed.

3. Support and Regulations Private Sector: proper infrastructural and policy support must be given to private sector. Also quality assurance, cost caps and equal access must be ensured in private facilities by establishing regulatory mechanisms.

4. Timely Assessment of Government Programs and Policies :the value for the money spent on health that an individual gets will depend on the organization, management, and productivity of health-care services in different states

5. Policy and legislative changes will be needed to contain the rising costs of medical care and to ensure quality of care. The government would need to fill gaps and deficiencies in drug policies, registration of health practitioners, and guidelines for health-care interventions including use of pharmaceutical drugs and biotechnologies. The coverage of price regulation of commonly used drugs would need to be strengthened and increased.

6. StandardizedPromotion of research in field of health care, health assessment, health economics and health financing.

7. Risk pooling would need to be greatly increased as a prerequisite for the introduction of any viable system of financial protection. The country’s demographics and rising per person income make it feasible to do so.

8. Universal financial protection is necessary to guarantee health as a right of all citizens. Financial protection should be offered to all citizens, not just those who are poor, against inpatient and outpatient care. Studies as (Kumar et al., 2011)recommend a single-payer system for India that is known to have several advantages. In such a system, the governmentwould collect and pool revenues to purchase health-care services for the entire population from the public and private sectors. The state would enlist public and private providers of allopathic and non-allopathic systems of medicine, establish uniform national standards for payment, and regulate quality and cost by use of appropriate information technologies. If well managed, countries with single-payer systems have been able to deal with delays and shortages that are often encountered. They have been better able to manage competition, contain and decrease costs, negotiate reduced prices with private providers, ensure adequate funding for preventive and primary care that reduces costs of curative care, build incentives for physicians to improve quality and performance, and introduce management systems to improve efficiency of service delivery

9. Integration of health policy with other policies: an integrated policy framework as one suggested by Nunes et al.(2016) must also be brought in India for better implementation and results.

10. Integration of Right to Health and Sustainable Development: Right to Health has been mentioned as an important DPSP in Constitution of India. It includes right of healthy and safe life and the duty to ensure this lies on the state. The right to health requires States to protect vulnerable populations in terms of health resources, law and policy, participation and empowerment, and in disaggregated data. It is a high time to view SDG targets as a Right to Healthcare for general population in India as well as globally.

CONCLUSION:

The ambitious targets of reducing MMR to 70 per 10,000 births, Neonatal mortality to 12 per 1,000 live births along with combating IMR and under 5 mortality to give a right to life to new lives in world seems challengeable to India with present bleak picture in terms of access and availability. Also, facilities for prevention and treatment of dangerous diseases as AIDS, TB, malaria etc have to be made at large scale. Other challenges including substance abuse problem, road safety measures and morbidity and mortality due to pollution and contamination need a holistic policy for containment. In such circumstances, health care should be given a central and pivotal role in policy making and financing in the country. Otherwise the heart and core of sustainable development principles will be lost. For a sustainable health sector, we need support of public, private and other foundations along with International institutions.

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Received on 25.02.2019 Modified on 12.03.2019

Res. J. Humanities and Social Sciences. 2019; 10(2):298-304.

DOI: 10.5958/2321-5828.2019.00053.6