The Sustainable Development Goals challenge us to step beyond traditional development approaches and to consider strategies that are evidence informed and innovative. The concepts are familiar; themes aligned with Harmonization, Primary Healthcare, Leadership, Public Private Partnerships, Community Engagement,  and Integrated Technologies. However, to optimize resources and overcome today’s challenge with sustainable solutions, we must capture lessons learned and apply evidence developed to inform and expand the thinking to shape and inform new paradigms. The tools, the experience, and the evidence are at our finger-tips. We must hold ourselves accountable to turn that rudder and hold the line so that the ship can advance toward universal health coverage that ensures healthy lives and promotes wellbeing for all at all ages. Health is where economic well-being, labour opportunities, educational advancement, gender equity and access to food, water, clean air come together to advance the wellbeing of all. This juncture is most significant at community level, where health systems intertwine with the social and cultural fabric and health workers stand at the interface between the health system and the people it serves. In these manuscripts, thought leaders in the health sector share evidence and experience to help us consider how we will use this intersection to push all nations to achieve all the SDGs.

$4,000,000,000US per year. That is the estimated price tag on the Sustainable Development Goals. In the area of health alone (SDG 3), the World Health Organization (WHO) has estimated that, with an ambitious scenario, achieving the SDG health targets will require new investments increasing, over time, from an initial US$134 billion annually to US$371 billion – an annual increase of US$237 billion in resources. To meet this need, country governments, institutions, commercial entities and communities will have to adapt their roles in resourcing and accountability to maximize the potential of their contributions. 

That adaptation means that traditional approaches to developing and sustaining effective health systems will not work. National and global actors will have to take greater accountability in mobilizing resources, and transparently and effectively stewarding those resources to measurable results. What moved us forward to achieve many of the health-related millennium development goals (MDGs) and to advance toward more equitable and healthy societies will not meet the health needs of growing populations, unemployed women and youth and poor communities 

Simply, what got us here will not get us there. 

The special issue of World Health & Population highlights several areas in health where paradigm shifts are happening and where they are most needed. 

This series examines familiar yet still unanswered challenges as well as new possibilities to explore this new paradigm and what it means for governments, development actors, communities and investors in health and related sectors and the health workforce. Through seven articles, the series considers global perspectives in low- and middle-income countries (LMICs) and high-income countries (HICs) as well as local realities. 

The piece on harmonization, written by the collaboration of Zambian authors from the ministry, education sector and development partner roles, challenges harmonization strategies and points out the difficult realities of on-going politics and competing agendas. Goma et al. offer an important dialogue about harmonization that is worthy of consideration by other countries to develop, strengthen and implement quality primary healthcare delivery to communities through community engagement. The 2005 Paris Declaration on Aid Effectiveness called on countries to consolidate and harmonize aid resources and activities for greater effectiveness and that countries take ownership of development agendas in their nations, and hold themselves and their partners for aligning with priority development goals and achieving measurable results. The subsequent 2008 Accra Agenda for Action highlighted progress made by signatory countries in the Paris Declaration roadmap and highlighted areas for improvement. 

There is still need for improvement. Goma et al. identify some of the areas for improvement in Zambia, and purport that through building capacity in leadership at all levels, barriers to harmonization can be overcome. That is barriers that remained impermeable during the MDGs can be overcome through being accountable to real harmonization to advance the SDGs at the country level. How do we, as a global community and individual players in that community, translate the lofty Paris Agreement ideals of harmonization and cooperation onto the ground where individual agendas still segment communities into cadres and diseases and project objectives? What mechanisms have failed us, and what approaches may better illuminate the win-win scenarios? 

Importantly, at that community level, how does the voice of people most in need travel to the ears of the most powerful? The need for engaging citizens in healthcare policy making is critical, and different approaches are gaining traction internationally. However, citizen engagement seems more difficult to implement in LMICs because of political, practical and cultural reasons. Ellen et al. advance the idea that community voices must play a major role in forming policy and they are critical to reaching SDGs in health and economic growth. The piece on citizen engagement, authored by researchers from four HICs, advocates for stronger mechanisms for transferring community experience as evidence; and establishing mechanisms for monitoring how that evidence informs policies that impact the citizens of those communities. The processes for citizen engagement and social accountability are critical, and the time is now to engage communities in a meaningful way – in a way that actually places people within the sphere of decision-making. Evidence needs to move out of communities and districts through broader communication and knowledge translation avenues that not only go beyond mere technologies for information exchange but also include mechanisms that ensure that decision-makers are accountable to citizens. Those avenues must allow community voices to influence and shape national- and global-level policies and strategies. Ellen et al. make it clear that development investments have the most impact and are needed most at the community level. Yet it is at that level where the results or the value for money is most difficult to measure. Improving health and advancing education are many times overlooked when resources are allocated, especially at the level where it is most needed. 

The Global Strategy for Human Resources for Health: HRH 2030, adopted by the World Health Assembly in May 2016, addressed that resource allocation. The strategy has key objectives, which are aligned with the SDGs and emphasize the move toward UHC: to optimize the health workforce to accelerate progress toward universal health coverage (UHC) and the SDG; to understand and prepare for future needs of health systems, to harnessing the rising demand in health labor markets to maximize job creation and economic growth; to build the institutional capacity to implement this agenda and to strengthen data on HRH for monitoring and ensuring accountability of implementation of both national strategies and the Global Strategy itself (WHO 2016a). 

Further to the global health workforce strategy, a UN high-level commission was established to provide further direction on actions that could “make recommendations to stimulate and guide the creation of at least 40 million new jobs in the health and social sectors, and to reduce the projected shortfall of 18 million health workers, primarily in low- and lower-middle income countries, by 2030” (WHO 2016b: 8). The commission’s report sets the stage for much of the thinking in this journal. 

Shamian et al. reinforce the principles of the UN SDGs, UHC and global health workforce strategy, that the “… health workforce should be geared toward the social determinants of health, health promotion, disease prevention, primary care and people-centred, community-based services” (WHO 2016b: 29). The UN High Level Commission on Health Employment and Economic Growth (HEEG) addressed this challenge by laying out clear advantages of these types of investments, and how investments in the health area specifically address both the supply and demand side of the investment equation and brings long-lasting value that re-invests in continued social and economic growth. 

Likewise, the World Bank’s Human Capital Initiative, launched in October 2017, aligns with the HEEG and bases its advocacy on the growing evidence that improving health outcomes and educational outcomes may be more highly correlated to growth than anything else. 

Evans et al. examine the critical juncture between health, education and population health needs. Authors advance that health workforce shortages remain a critical bottleneck in achieving UHC and that to achieve global health goals and maximize opportunities for employment and economic growth, all in the context of limited fiscal realities, a paradigm shift is needed with respect to how education systems correspond to health workforce needs. Authors acknowledge the role of the private sector in education and training and explore the challenge to re-align market driven resources toward fair, gender-friendly employment at a rate that matches the overall growth of the health economy. They emphasize the importance and implications of such a paradigm shift. They advocate a need for a framework for health professional education that represents a more satisfactory interface between supply and demand for a varied health labour force in line with the need for UHC, which is propelled through the confluence of a fit-for-purpose health workforce, job creation and economic growth. 

Echoing the HEEG report, Dr. Jim Yong Kim announced the Human Capital Initiative. In the October 2017 announcement, Dr. Kim emphasized that the Initiative would focus on women and youth. Empowering women and youth to learn, to use technologies, to contribute to and benefit from the labor sector is essential to strengthen fragile countries and to further advance growing economies. Investments in health systems and health workers are a critical piece of this vision. This issue invites us to explore various areas of health development that must be harmonized and stewarded to maximize results for the communities that need it most. 

Michael Bzdak’s paper looks at the role of private sector in contributing to this investment. Bzdak explains how the role of the private sector has changed over time, and specifically how the corporate or commercial sector has shifted the paradigm of its development role from philanthropy and assistance to collaborator and investment partner. Bzdak gives examples of leveraged commercial investments can result in win-win scenarios that are realized and articulated for both communities in need and investors with a commitment to a public purpose. 

Bzdak, like Evans et al., point out the long-standing hierarchical resource flow, where HICs donate development funds to low-income countries and commercial or corporate entities either follow high-income investments or establish social responsibility giving to meet middle- and low-income needs as a both a marketing investment and a tax strategy. Lower and/or middle income countries, aiming to make it to the next rung on the ladder, hone business administration skills to manage the dollars that come in and the stakeholder agendas that come with them.

With yesterday’s blueprint, countries and external partners have weathered many a crisis, reached most of the MDGs and improved national economies across the globe. But today is a brave new world. This world may not be flat, but understanding the potential for mutual benefit changes the resource mapping so that it is no longer a vertical financing framework. The definition of private sector has expanded to include NGOs, foundations, local businesses and international conglomerates; and across those entities, the delineations have blurred with countries as a much stronger partner, bringing market potential to the table. 

Bzdak illustrates the growing commercial interest in the triple bottom line approach with examples of Starbucks and Dow and their collaborations respectively with socially conscious NGOs. Venture capital monies are also finding long-term investment value in global health, and specifically in the community health space. Low interest loans to nursing students have multiplied front-line health and benefitted financial institutions, and investments in social franchising bring micro-enterprise opportunities to the poor and financial returns to impact investments. Even research and development investments have brought market growth returns whole saving lives through advancements in medicines, vaccines and treatments. 

Pointing to THETs “Principal’s of Partnership” as an example, Bzdak alludes to the importance of good stewardship of both private and public investments to maintain incentives that ensure reasonable economic returns. Shared values and clear roles and accountability mechanisms for countries and external partners are part of a framework that will enable on-going partnerships that advance the interest of all actors. 

This framework toward ethical advancement and these same principles guide digital development. Moore et al. look at the growing importance that information and communication technologies (ICT) play in supporting front-line health workers and communities in improving primary care access and delivery. Authors reinforce the critical notion that current efforts must shift to from single-purpose applications of digital health to integrated systems and solutions that align with national strategies. The pertinent examples from health information systems, data and health worker training demonstrate how governments and stakeholders are working in important ways to integrate digital health services. 

The ICT space in health is a crowded one, and the enthusiasm for the exploding possibilities that technology brings to health has yet to be harnessed in a systematic way. The challenge is complex because technology and innovation go hand and hand and in some ways, fly against the face of systemization and institutionalization. However, to benefit from technologies and the innovations that come with them, country leaders and health system developers must create and maintain an environment where the system leverages the ICT and not the other way around. Meaningful collaboration between all actors – particularly health workers themselves – is essential to ensure that digital tools meet their potential to transform primary healthcare. Moore et al. propose a new paradigm that will focus on consolidation and collaboration guided by national holistic digital health strategies. 

Authors purport digital health’s high potential to strengthen health systems, to support health workers and to improve primary care has been hampered by short-term approaches that are not harmonized with other approaches or guided by national strategies. Three factors crucial to harmonization and collaboration: development and implementation of national digital health strategies; technical interoperability and collaborative approaches to ensure that digital health has an impact on the primary care level are fully explored. To do that, countries must continually improve their capacity to support integrated systems, manage information and analyze data for understanding and decision-making. They must move away from single-purpose applications of digital health toward integrated systems and solutions that align with national strategies. 

That harmonization and integration must also be reflected in the support of the front-line teams that both use these technologies and benefit from their advancements. With the fascination that comes with shiny and new technologies, countries and partners have often invested in gadgets and applications and then aimed to fit them into a health facility or a community activity. The investments at community level must be harmonized and human-centered. Understanding how primary service delivery is best delivered and most positively experienced enables effective decisions that leverage resource investments to maximize system performance, service quality and health outcomes. 

The benefits of those investments culminate in the interface between the health system and the communities served – at the front-line health team. Enormous resources will be required to meet epidemiological and demographic needs; effectively educate, allocate, and retain performing front-line teams and mentor professional development toward policy-supported career paths. Public and private investments in primary healthcare are critical to achieving safe, quality care and advancing toward UHC. The best stewardship of those investments requires leadership of fit-for-purpose teams to optimize performance and insure the safety and quality of services delivered. Looking at the role of nurses, in the piece by Foster et al., the communities themselves, along with ministry of health managers, define the role of the nurse as critical in the effectiveness of the health system to deliver quality care. Beneficiaries, providers and managers all pointed to the leadership competencies of the nurses and midwives as being the differential factor in those facilities that delivered the highest quality primary healthcare. This piece underscores the importance not only of investment but of the stewardship of that investment. The authors highlight that investments need to go not only into developing health workers but also in building teams that work together and support systems that sustain them. 

Community health systems drive the effectiveness of the national health system toward UHC and SDG3. The formative assessment in Zambia demonstrates the critical role that nurses play in steering primary healthcare at the community level. Throughout all levels of the community health system, actors identified the nurses’ capacity to lead front-line teams as the key factor in delivering quality, safe, accessible care. The article defines community front-line teams as a complex collaboration among community members and leadership, volunteer health agents, community health workers and clinical or professional staff. Enormous investments have gone into developing and strengthening the community systems in Zambia and throughout both the developing and developed world. The promotion and institutionalizing of community health workers has been coupled with community engagement initiatives, volunteer registration and training, digital tools and health worker retention schemes – all to fill the gaps that plague low-resourced areas and overcome obstacles to quality and access. These initiatives have made strong inroads toward improved population health, contributing to improved maternal and child health and overcoming preventable diseases. Despite progress, national resources and community systems are seldom able to sustain these advances because of the vertical nature of external interventions that focus on individual provider groups or singular diseases. Nurses are at the helm of primary care, responsible for the services delivered in community facilities. This paper recommends that it is the nurses that must be enabled to leverage the community investments so that the primary healthcare is integrated and task shifting is coordinated through teams. It recommends that in that important role, nurses as facility heads require investments that will best move countries forward. 

Recently, the All -Party Parliamentary Group (APPG) on Global Health has called for more attention to nurses, saying that “achieving universal health coverage globally will depend on them being able to use their knowledge and skills to the full. Yet they are too often undervalued and their contribution underestimated” (APPG on Global Health, 2016, p. 3). Launching a “Nursing Now” initiative, the AAPG on Global Health advocate nurses, because of their knowledge, values and close intimacy with the communities they serve, are positioned to have a triple impact on the future – contributing to better health, gender equality and stronger economies. Foster et al. recommend that to sustain and maintain quality care, to provide the guidance and mentoring that lesser trained providers need and to engage communities to contribute to responsive services, nurses must be capacitated with the leadership and management skills, empowered with access to information and technologies and rewarded with professional and academic opportunities. 

As we stand at the 30th anniversary of Alma Ata and in the early years of the SDG era, we are reminded of the complexity of global health. The multi-sector complexity of the health arena and the human factors that intersect communities, providers and decision-makers among the actors across primary healthcare throw challenges and obstacles across the path of progress. Even so, the last thirty years have seen an evolution in global health development and national health system improvements. These system improvements have borne population health improvements that have reached and surpassed many SDGs and have emboldened us with ambitious yet achievable goals: including the 90/90/90 HIV/AIDS goals, new vaccines for HPV, malaria and meningitis; ending preventable maternal and child deaths, and the elimination of preventable diseases. Most notable of the progress made is the understanding of the broad universe of health and the exponential economic and social gains that can be made from investing in the health sector, and specifically with investments in health workers and the communities they serve. This journal recognizes that we have come a long way despite grappling with many of the same challenges. It explores the new paradigms we are building in education, information, collaboration and harmonization and challenges us to guide investments and steward them well so that the seeds we plant will grow healthy families with educated children, employed youth, empowered health workers and equity of access to quality care for all women and for poor and disenfranchised people, across global communities and national populations.  

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