Adam Lewis

‘Sustainability’ Remains the Holy Grail: But the road to achieving it is paved with divergent visions

There are few, if any, keywords that receive as much airtime in global health and development as “sustainability”* (save for perhaps the dreaded I’s of “innovation” and “impact”). Fourteen letters long, it has at least as many connotations, as elusive to articulate as it is to achieve. Yet it remains the holy grail of all global development programs. It is the lighthouse that guides social entrepreneurships, the posts adjoining global health field goals, the fountain of youth empowerment. In (slightly) less figurative terms, it is the heart of the post-2015 development agenda, pumping blood into redefined interventions and targets that seek to end poverty and disease.

Two weeks ago, global health leaders gathered in Johannesburg, South Africa, for the Partners’ Forum to shape the post-2015 agenda for maternal and child health. And, naturally, sustainability reared its mystical head. On the surface, it would appear that the roughly 1,200 participants from NGOs, UN agencies, governments, companies and universities reached an important consensus: Sustainability is and will remain a chief element of all efforts to end preventable maternal and child mortality. But just below the surface lay a truth even more profound: Sustainability manifests differently for just about everyone.

To many, sustainability meant country ownership. As Dr. Margaret Chan, director-general of WHO, championed in the opening plenary, “We must rally behind country (i.e., government) plans to sustain development.” This sentiment echoed through the walls of the convention center, reverberating most commonly among representatives of governments and the UN. Distinguished speakers like Graca Machel, board chair of the Partnership for Maternal, Newborn & Child Health; Erna Solberg, prime minister of Norway and Babatunde Osotimehin (executive director of the United Nations Population Fund) – all former or current government leaders – emphasized the need for the international community to relinquish their preconceived agendas and notions of success – a top-down approach that is ineffective, unsustainable and increasingly obsolete. Instead, for efforts to be sustainable, national governments must be at the helm, pursuing targets that are country-specific, interventions that are responsive to their country’s unique needs and financing that is planned, implemented and eventually owned by the public sector.

Other conference attendees saw things slightly differently. To them, while government ownership is paramount, it is the unwavering commitment of local actors that is the key to sustainability. Keiko Osaki (senior health adviser, Japan International Cooperation Agency) argued that sustaining long-term progress hinges on the dedication of local NGOs, faith-based organizations, private-sector groups and the communities themselves. Likewise, Julian Schweitzer (principal at Results for Development) maintained that sustainable development in maternal and child health demands the interconnectedness of all sectors – from energy to agriculture to water to roads to health. In fact, if sustainability was the conference’s gold standard, “multi-sector collaboration” was certainly its silver.

Traditional NGOs seemed to deviate furthest from how most of the world understands sustainability. To many donor-dependent groups, as long as a steady stream of funding is flowing from foundations and bilateral agencies, their efforts are sustainable. Other interpretations of this ever-elusive concept varied still. As Iulian Circo, founder of Movercado, explained, “Sustainability is creating an environment in which something can evolve into something else” – the idea of “platforms, not projects.” Dr. Makhduma Nargis, project director, Revitalization of Community Health Care Initiatives in Bangladesh, claimed that training is the trick. If we can impart lifesaving skills and knowledge on health workers, this one-time intervention will pay dividends for years to come.

The most platitudinal definition of sustainability was “partnership” – the nondescript, amorphous buzzword that seems to get more lip service at conferences than it does implementation on the ground.

(Image, left, courtesy of Partners’ Forum 2014)

But there was one meaning that failed to make its way into the conference agenda, speeches or presentations, and it’s perhaps the most intuitive of all: market-based models through which revenues cover costs. In other words, programs that are selfsustaining.

It was clear that there was a distinct level of discomfort with the idea of commercial solutions to maternal and child mortality, and understandably so: The lives of the world’s most vulnerable women and children should not be exploited for profit. But with the launch of new, wildly ambitious targets for reducing maternal and newborn deaths in the post-2015 world, business (or lack thereof) as usual will not be enough to meet those goals and do so sustainably.

The fact is, the private health care market in the developing world is too expansive, too active and too conducive to sustainability to overlook in the post-2015 agenda.

Take Sub-Saharan Africa and South Asia, for example. These two regions combine for 86 percent of maternal deaths and 68 percent of child deaths worldwide. But approximately half the population in Africa and up to 80 percent in South Asia seeks health services from their local private sector. Most of these doctors, midwives, clinics, hospitals, pharmacies and drug shops rely on community-tailored models of care that are well-suited to deliver locally appropriate services, and are often preferred to their public sector counterparts.

Of course, the private sector is not without its setbacks: Care is often exorbitantly expensive and services are never assured to be high quality. But these providers and businesses remain crucial components of health systems across the developing world and must be part of the solution to improve maternal and child health.

It would be difficult, and probably foolish, to imagine a world where global health and development leaders agree on a single meaning of sustainability. The Partners’ Forum certainly reinforced this reality. But, taken together, the various definitions appeared to inch closer to the idea of sustainability as country ownership, just not necessarily government ownership. Rather, sustainability in maternal and child health centers on the systemic coordination of a country’s institutions – be they public, private or otherwise – such that it has the ability to sustain progress for the long run. Ergo, sustain-ability.

* For the purposes of this article, “sustainability” is referred to outside the context of environmental sustainability.

Adam Lewis is a senior associate at Rabin Martin, a global health strategy firm in New York.

Environment, Health Care
governance, reproductive health