The Covid-19 pandemic reinforces the need for sustainable health planning.

The 2030 Agenda for Sustainable Development highlighted the growing attention to the adequacy of health planning models to sustainable development. A re-reading of the results of a round table debate on "sustainable planning", which took place at the 5th National Congress of Tropical Medicine (Portugal, 2019) under a participant observation strategy, framed by the findings of a "synthesis of better evidence" literature review and cross-referenced with the reflections of different authors and experts about the momentum created by the COVID-19 pandemic, underlined the challenges to sustainable health planning that have emerged and are projected beyond the current pandemic context. Variable perceptions of the term "sustainable health development", leading to the potential loss of their relevance in guiding the elaboration of policies and strategic plans, and the potential higher effectiveness of the participatory approaches of health planning in achieving sustainable health were highlighted in the debate and literature, in general and in public health emergency contexts. Those results gained new relevance during the current COVID-19 pandemic, bringing back to the forefront a reflection of the inadequate planning framework that has usually been used to understand and respond to global health challenges, despite the already existing experience, evidence and support instruments.

BACKGROUND

The 2030 Agenda for Sustainable Development reinforced the growing attention of countries and health systems to the adequacy of planning models to sustainable development. , , , , As a joint global action initiative, it commits countries to decide how best to integrate the 17 Sustainable Development Goals (SDGs) and their 169 targets in the planning processes, policies and strategies, continuing the importance attached to planning by successive global action plans since 1987 as a useful process for the implementation of sustainability strategies. , , ,

In general, and in the current pandemic context, recognising the central role of health in achieving sustainable development poses specific challenges to health planning, , , which have been addressed in different ways by countries and multilateral health agencies. , , , ,

The current pandemic COVID‐19 has rekindled the debates about the development of a health planning model within the framework of the SDGs, providing new opportunities to revisit previous reflections and research results on the topic. In this sense, we propose a re‐reading of the results of a round table debate on ‘sustainable planning’, which took place at the 5th National Congress of Tropical Medicine (5NCTM) (Portugal, Lisbon, April 2019) under a participant observation strategy, gathering about 80 participants from different countries, framed by the findings of a ‘synthesis of better evidence’ literature review and cross‐referenced with the reflections of different authors and experts about the momentum created by the COVID‐19 pandemic.

This approach reiterated the challenges for sustainable health planning showing not only its timeliness but also its projection beyond the current pandemic context.

MAIN ARGUMENT

The variability of concepts to define ‘planning for sustainable health’, the need for citizen participation in these processes and the imperative of intersectoral articulation, as particularly relevant components of a sustainable health planning framework, were three of the main themes that emerged during the 5NCTM round table debate. In the literature consulted they were also highlighted.

Only a minority of participants in the debate framed the term ‘planning for sustainable health’ as planning that contributes to the achievement of the SDGs, highlighting allusions such as: planning ‘based on the balance of the three pillars of sustainable development: environment, society and economy’, or ‘that responds to needs without ecological damage and without compromising future generations’. Other perceptions were suggested by expressions such as: planning ‘that guarantees the continuity of the planning cycle’ or ‘that ensures implementation’. This variability is consistent with the lack of consensus regarding the perception of the concepts of ‘sustainable’ and ‘sustainability’ described in the literature consulted, contributing, as a consequence, to the potential loss of relevance of the concept of ‘sustainable health development’ in guiding the elaboration of policies, strategic plans and in the implementation of coherent strategies. Whenever used in fields that require its rigorous operationalisation, the clear definition of those terms is recommended. ,

Participatory approaches to health planning, integrating both citizen participation and intersectoral articulation, with a particular focus on reducing health inequities and achieving universal coverage, were considered most effective in achieving health and well‐being objectives in line with the principles of sustainable health development, both at the debate and in the literature consulted. , , The participation of citizens in all stages of the planning process and the advantages of its precocity were underlined, considering, in the debate, that the involvement of people and communities is ‘the most effective way of adjusting solutions to the intersectoral needs of society and the population’. The consulted literature reinforces that the early involvement of citizens and civil society increases the potential for all sectors to adhere to the resolution of health problems, in general and in public health emergency contexts. , ,

The discussion about the procedural and methodological characteristics of sustainable health planning that emerged during the round table gained new relevance throughout the COVID‐19 pandemic. The current SARS‐CoV‐2 pandemic context brought back to the forefront of the health planning debate significant issues related to sustainable health already identified in non‐pandemic contexts and in past pandemics. Past pledges of sustaining the lessons from previous outbreaks and be better prepared for future ones did not materialise. We are once again discussing and trying to cope with predictable challenges, previously identified – such as health systems fragility and lack of resilience, inadequate surge capacities, and poor communication. This is as much a moral failure as well as a reflection of the inadequate planning framework used to understand and respond to global health challenges, demonstrating the lack of preparedness for globally catastrophic risks. It also identifies that the lack of capacity for impactful governance and consequent planning for sustainable health development is not limited to low and middle‐income countries but widespread at all levels of development. This highlights the inability of ministries of health (MoH) to extend their leadership beyond narrow sectoral boundaries, to the pluralistic and multisectoral milieus where health determinants are embedded, to correspond to the expectations created by the SDG. It also reflects the incapacity of MoH to predict and be prepared for emergent and future challenges while continuing to manage public services and institutions.

The pandemic is affecting communities, populations, and countries throughout the world, interacting synergistically with already existing endemic infectious and non‐communicable diseases, hence deeply influencing health outcomes. Additionally, it has a synergistic effect also with socio‐economic, cultural, and contextual determinants of health which seem to contribute to poorer health and accumulating social disadvantages. Hence, we argue that the SARS‐CoV‐2 disease is of a syndemic nature and that the failure to acknowledge this contributes to weakened policy‐making processes and public health responses and ineffective health policies, plans and programs.

What is observed currently is an inappropriate framework for health policy development and planning, reflecting a biomedical bias, the ‘curse of piecemeal perspectives’ and ‘siloed frameworks’ adopted, , , which preclude planning for sustainable health. Acknowledging the syndemic nature of the pandemic implies the recognition of the need for a more holistic approach, integrating other conceptual frameworks such as ‘one health’ or ‘health in all policies’, and assuming the SDGs agenda in the solutions adopted. , , , , , ,

On the other hand, there are instruments for translating the SDG into relevant issues of sustainable health planning, namely the Gap Frame Model by Katrin Muff and collaborators. , , , A second instrument – materiality analysis – is a specific analytical technique that allows prioritising ‘material’ topics and themes and supports the mobilisation of different actors from diverse sectors to gather perceptions about the relative importance of environmental, social, economic and governance issues. , , , , , The OECD Policy Coherence for Sustainable Development (CSDP) analytical framework and its integrated checklist, with contributions from the models by Nunes et al. and Costanza et al. represent a third instrument. Finally, the Roadmap to implement the 2030 Agenda for Sustainable Development, building on Health 2020, the European policy for health and well‐being and the E4A approach – engage, assess, align, accelerate and account have also the potential to support the sustainable health planning process in the World Health Organization European Member States.

These instruments enhance the implementation of health strategies aligned with sustainable development. Others are needed to broaden the frameworks to include one health concerns in the planning process.

The good news is that several studies describe the evolution of the planning process according to the values and principles of sustainable development, albeit highlighting important differences between countries. , , , , England, Wales, Norway and New Zealand are examples of countries with health planning processes and products that are more consistent with the sustainable development paradigm, namely through the systematic integration of equity in health and intersectoral action in the respective planning cycles. ,

The current pandemic highlights the timeliness of the issues discussed in the 5NCTM in 2019 but also represents an opportunity to challenge existing health planning models and adopt more relevant ones along the lines proposed in this text, to correct the lack of critical reflection addressing short‐ and long‐term sustainable health challenges. ,

CONCLUSION

Planning for sustainable health is needed and feasible. The COVID‐19 pandemic once again exposed the fragilities of the strategic planning frameworks. A more holistic planning approach, that privileges the intersectoriality, early social and community mobilisation, and the systematic integration of equity in health, along with the clear definition of essential concepts related to sustainable development, seem to be the most adequate for governance and action towards the achievement of sustainable health, both in non‐pandemic and pandemic contexts.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ETHICS STATEMENT

This material is the authors’ own original work, which has not been previously published and not currently being considered for publication elsewhere. The paper reflects the authors’ own research and analysis in a truthful and complete manner. The paper properly credits the meaningful contributions of co‐authors and co‐researchers. The results are appropriately placed in the context of prior and existing research. All sources used are properly disclosed (correct citation). All authors have been personally and actively involved in substantial work leading to the paper, and will take public responsibility for its content.