ever before in human history has such a comprehensive development agenda been agreed on at the global level through heads of states. Seventeen sustainable development goals (SDGs) with 169 targets cover almost all conceivable dimensions of social, economic and environmental development. Progress is measured through 230 indicators set against the targets. Transforming Our World: 2030 Agenda for Sustainable Development, the outcome document of the United Nations summit in 2015 is one of the most important documents of our times. It has a grand vision encompassing the planet, people and prosperity.

The third SDG relates to human health, which was defined in 1948 in the constitution of the World Health Organisation as “… a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The SDG 3 aims at “good health and well-being: [to] ensure healthy lives and promote well-being for all at all ages”. Health is central to human life as without health nothing is achievable. Health contributes to all other SDGs and benefits from the progress made in others. In fact, all SDGs are closely interlinked and interdependent.

Pakistan is among the 193 UN member countries that originally signed and adopted the sustainable development agenda. Despite its low ranking in human development, environmental sustainability and poverty, Pakistan has taken SDGs relatively seriously. The process of “localisation” of SDGs was started and institutional arrangement made in the Ministry of Planning and Development in order to plan and monitor in accordance with the SDGs; even a parliamentary caucus came into being to discuss and provide parliamentary oversight. The relevant ministries took up the mantle as a priority. The Ministry of National Health Service, Regulation and Coordination initiated the work on SDG 3.

The third SDG has nine targets, four enabling actions and 28 indicators.

One of the most important targets under SDG-3 is 3.8: “[to] achieve universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. This target is fundamental and requires health system development across the board in order to support all other health-related goals and targets.

The WHO and the World Bank have developed an index to measure the UHC. The UHC index is a measure on a scale of 0 to 100 based on the average coverage of selected essential health services in four groups: maternal, newborn and child health; infectious diseases; non-communicable; and health service capacity and access. The target to be achieved by 2030 is 80 percent. The UHC index in Pakistan has improved from 39.70 percent in 2015 to 49.90 in 2020 – this needs to go up 30 points by 2030. What will this vital figure be in December 2022, now that calamitous floods have ravaged the country seriously impacting the health infrastructure? The disaster will inevitably negatively affect all important health indicators.

The first target under SDG 3 (3.1) is related to maternal mortality. The target is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births. Pakistan has come a long way from 306 mothers per 100,000 live births dying in 2000 to 186, according to the latest Pakistan Maternal Mortality Survey findings released in 2020 – still unacceptably high. Just to bring perspective, in Iran, the maternal mortality ratio is 16 per 100,000 live births. One of the key indicators of saving mothers during birth is the proportion of births attended by skilled health personnel. According to the Pakistan Demographic and Health Survey (DHS) 2017-18 published in 2019, 69 percent of deliveries are now conducted by skilled birth attendants, and 66 percent of deliveries take place in a health facility. There is a lot of progress in this regard but still a long way to go.

The second target is to end preventable deaths of newborns and children under five 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 no more than 25 per 1,000 live births. Under-5 mortality rate for Pakistan was 71.34 deaths per 1,000 live births in 2020 and neonatal mortality rate was 40.4 in the same year. In Iran, these rates that year were 12.9 and 8.3, respectively.

The third target, by 2030, is to end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases, and to combat hepatitis, water-borne diseases and other communicable diseases. Pakistan’s scorecard on all these diseases is abysmal and there is no likelihood at present that Pakistan will be able to even halt, let alone end the epidemic of these diseases. We have the highest rate of increase in new HIV cases in Asia and Pacific after the Philippines, i.e., 75 percent increase between 2010 and 2019. We have around 25,000 new cases every year added to the pool. Pakistan is ranked 5th in the world in carrying the burden of TB and has 4th highest prevalence of multidrug resistant TB, globally. We also have the dubious distinction of a country with the second highest global burden of hepatitis C virus infection i.e., over eight million people living with hepatitis C.

The fourth target is to reduce premature mortality by one third from non-communicable diseases (NCDs) through prevention and treatment, and to promote mental health and well-being. Even to stop the growing burden of NCDs is a very big challenge. According to the official National Action Plan 2021-30 on NCDs and Mental Health, 2019 marked a year when more than half the total burden of disease tilted towards NCDs and mental health. Cardiovascular diseases with underlying high prevalence of risk factors like blood pressure and hyperlipidemia, cancers, diabetes and chronic kidney diseases, chronic respiratory diseases and mental disorders are the major groups of NCDs that are only growing unabated in Pakistan. Going by current trends, there is no likelihood that by 2030 we will be able to achieve this target.

The fifth target is to strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol. Pakistan is one of the most drug-affected countries in the world. According to a UN report, we have 7.6 million drug addicts in Pakistan and only around 30,000 of these get treatment. Pakistan still does not provide proper replacement therapy to addicts. Cannabis and heroine are the most abused substances in the country.

The sixth target is (or was) to halve the number of global deaths and injuries from road traffic accidents by 2020. Long past the deadline, Pakistan continues to see more deaths and injuries due to road accidents. Between 2000 and 2019, the share of burden of injuries increased from 4.73 percent to 6.35 percent. In 2019, injuries constituted 5.7 percent of deaths in Pakistan i.e., 85,000 deaths.

The seventh target is to ensure by 2030 the universal access to sexual and reproductive healthcare services, including for family planning, and the integration of reproductive health into national strategies and programmes. One of the biggest development challenges faced by Pakistan today is unhindered population growth. We have become the 5^th largest country in the world by population and at 2.4 percent we have one of the world’s highest population growth rates. Contraceptive Prevalence Rate (CPR) is defined as a proportion of women of reproductive age who are using or whose partner is using a contraceptive method at a given point in time. Pakistan’s CPR is extremely low at 34.5 percent. To bring this into perspective, Iran has a CPR of 77.4 percent and Turkey 73.5 percent. Bangladesh’s CPR has climbed to 62.4 percent. Pakistan’s CPR of 34.5 percent means that 65.5 percent of women of reproductive age and their partners are not using any contraceptive method.

The ninth target is to substantially reduce by 2030 the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination. Pakistan is among the five most polluted countries in the world. Lahore, due to smog, is the most polluted city. Air pollution is a major public health problem across Pakistan, where an estimated 128,000 people die annually from air pollution-related illnesses. Pollution in big cities is approximately four times beyond the WHO permissible limit and the situation is only deteriorating. Only, 20 to 30 percent of the population of Pakistan has access to safe drinking water. The primary source of contamination is sewage, which pollutes drinking water systems. A secondary source of pollution is the disposal of toxic chemicals from industrial effluents, pesticides and fertilisers from agriculture sources into water bodies.

The combined effect of an already weak health infrastructure and very low spending on health; the current devastating climate change induced floods; and the earlier impacts of the Covid-19 waves risk sliding Pakistan back, from bad to worse. The people, especially the poor and the vulnerable, will take the biggest hit. While there are more than seven years to achieve the goals, Pakistan’s chances of achieving the SDG 3 by 2030 are bleak.

The writer is a former special assistant to the prime minister on health, a professor of health systems at Shifa Tameer-i-Millat University and a WHO adviser on UHC. He can be reached at  zedefar@gmail.com