Evolution from the Millennium Development Goals to the Sustainable Development Goals
The adoption of the Sustainable Development Goals (SDGs) in 2016 by the global community marked a radical shift in direction from the previous Millennium Development Goals (MDGs) . While the MDGs reflected an economical list of relatively narrow targets that addressed low and middle income countries (LMICs) alone, the SDGs are more numerous and reflect a more holistic understanding of the nature of sustainable development and its interactions with human health, environmental protection and social justice . While in many respects the MDGs were highly successful in driving international and national investments, and the world’s focus upon the identified goals, they had also been criticized for being insufficiently inclusive in their process of development (in particular in terms of including representatives from the most affected contexts), providing insufficient justification for why they focused on the issues that they did, and for neglecting environmental issues . The SDGs sought to address these criticisms. They were negotiated in a far more consultative fashion using 13 rounds of discussion within the Open Working Group, they clearly address environmental issues, and they are much broader in terms of the targets identified.
For the MDGs, the World Health Organization (WHO) established an international task force to identify health systems research priorities . The Task Force employed an interpretive approach, relying largely on the views of its members to identify a number of broad priority topics including for example: human resources for health at the district level and below; drugs and diagnostic policies; governance and accountability. Since the work of the Task Force, there have been several further efforts, supported by the Alliance for Health Policy and Systems Research, based at the WHO, to engage policy and decision-makers so as to define global priorities for specific domains of health policy and systems research (HPSR) including health financing , human resources for health , access to medicines  and the private health sector . These exercises have drawn upon policy-maker consultations and overviews of research reviews to identify relevant research questions across the various sources. These research questions have then undergone a priority ranking process by researchers, thus providing considerably greater specificity than the broad domains identified by the Task Force.
Health policy and systems research and the link to the SDGs
HPSR is an applied field, oriented around solving real-world problems, where the value of research findings is inextricably linked to their relevance to policy and decision-making. Accordingly, research priority setting processes which engage policy- and decision-makers in identifying the key challenges that they face in order to frame and prioritize research questions are helpful in ensuring that scarce research funding is used most efficiently .
The wide-ranging and interconnected nature of the SDGs may make it challenging to identify how best to act from any one sectoral (education, agriculture, health, environmental sustainability, etc.) perspective. However, this same quality of the SDGs also presents an opportunity for creative and innovative approaches, including for those working in or with the health sector. Goal 3 on health encompasses a large number of disease or condition-specific areas (maternal and child health, infectious diseases, non-communicable diseases, injuries, substance-abuse, road traffic accidents) as well as cross-cutting or systems-related issues including universal health coverage, health financing, human resources for health and disease surveillance. The combination of targets under Goal 3 mean that a narrow focus upon a handful of specific health conditions and the systems needs related to them is no longer a viable health systems strengthening strategy, instead we need to consider how different approaches to health systems strengthening may intersect with multiple different health conditions. Moreover, the non-health goals have many points of connection with health, for example Goal 1 on Ending Poverty includes targets that concern the development of social protection systems and access to basic services; Goal 10 on inequalities addresses empowerment, including for disabled people; Goals 6 and 11 both address aspects of providing clean water, effective sanitation and waste management. The last two, cross-cutting goals on Peace, Justice and Strong Institutions (Goal 16) and Partnerships for the Goals (Goal 17) have implications for health systems given their focus on, among other things, developing effective, accountable and transparent institutions; ensuring responsive, inclusive, participatory and representative decision-making; ensuring public access to information; and capacity building.
Given the paradigmatic shift represented by the SDGs, a new set of HPSR priorities were needed to inform the unique thinking required to address these interconnected goals.
The need for HPSR priority setting in the SDG era
While other authors had written about the need for research linked to the SDGs [10,11,12,13], there had been no other systematic effort to identify health research priorities linked to the goals. A preliminary literature review through searches in PubMed and Google Scholar that combined terms related to (i) the Sustainable Development Goals (ii) health or health systems and (iii) research, yielded 28 papers. Most (n = 14) of the papers were commentaries and editorials expressing the views of the authors and frequently seeking to raise the profile of a particular issue (cardiovascular health, eye health, violence against women, health research in Africa) within the context of the SDGs. A further set of more analytical papers (n = 11) either reviewed the literature around particular topics related to the SDGs (such as strategies for scaling up early childhood development, or universal health coverage and the SDGs) or analyzed the SDGs themselves. There were just a handful of empirical papers, often quite loosely linked to the SDGs, even if their titles suggested otherwise. Of the 28 papers identified, Universal Health Coverage (UHC) was a central theme of many [14,15,16,17,18,19,20]. Additional papers addressed non-communicable diseases (NCDs) which had been entirely absent in the MDGs [12, 21,22,23,24], achieving political priority as a precursor for domestic funding [10, 15, 24, 25] and engagement with private sector actors to address inappropriate marketing of harmful products and/or access to life saving drugs and technologies [24, 26, 27]. Overall, we concluded, that there had been little rigorous research or analysis exploring HPSR needs associated with the SDGs, and further, there was not a coherent approach or shared understanding of the likely implications of the SDGs for HPSR.
Given the breadth and complexity of the SDGs already described, establishing an appropriate starting point for a research priority setting exercise was not straightforward. While many have suggested that UHC is the preeminent target within the health goal , prior research priority setting efforts, such as those on health financing , have already substantively addressed this topic. The SDGs have also cast a spotlight on previously neglected health priorities including NCDs , road traffic injuries  and mental health , but focusing an HPSR priority setting effort around such health topics felt counterintuitive and likely unable to capture the potential paradigm shift that the SDGs represent for HPSR. That said, the research team seriously considered a focus upon understanding and addressing the health system challenges associated with NCDs, including strategies for improving continuity of care, supporting self-care within the household, and strengthening community care systems. However, we decided instead to try to identify as starting points for the research-priority setting exercise, themes that captured the spirit of the SDGs - in particular their focus upon inclusion and social justice, as well as their integrated and connected nature. Drawing upon existing literature and consultations with key stakeholders, including the Alliance HPSR, we identified three themes that distilled some of the unique and innovative attributes of the SDGs, did not overlap with previous priority setting efforts, and offered new potential directions for HPSR. These three themes are:
Theme 1 - protecting and promoting access to health services through systems of social protection
SDG 1 on poverty explicitly identifies the importance of systems of social protection, that is, systems that help prevent and mitigate risks related to unemployment, social exclusion, sickness, disability and old age. SDG 1 also acknowledges the critical role that systems of social protection can play in enhancing access to services. The health systems community has placed a high priority on achieving UHC. While this objective is often viewed within the relatively narrow context of the health sector, in practice, UHC can probably only be achieved in conjunction with broader systems of protection that help protect against the risk of impoverishment and facilitate access to complementary social services. Within this domain, we were interested in exploring what kind of research on systems of social protection could help inform the target of achieving UHC.
Theme 2 - strengthening multisectoral collaborations for health
Many of the non-health goals acknowledge health aspects within their targets, reflecting growing appreciation of the importance of factors such as urban environment, early childhood education, patterns of food consumption, and changes in the environment and climate on human health. Multisectoral collaboration involves purposeful engagement with actors beyond the health sector to address complex challenges that may undermine health and well-being. While there is growing recognition of the importance of multisectoral collaboration [28, 29], to date it has not been a substantive area for research within HPSR. We were interested in what kind of research could inform the development and implementation of effective multisectoral collaborations for health.
Theme 3 - developing more participatory and accountable institutions for health
This theme builds directly upon SDG 16 (Promote just, peaceful and inclusive societies), but also reflects a growing interest within health systems [30, 31]. The theme encompasses alternative strategies for strengthening civic engagement and local accountability within health systems to promote transparency, inclusiveness and participation. This theme is also linked to efforts to create more people-centered health systems, meaning health systems that respond holistically to people’s and communities’ needs .
Alternative themes that were considered included (i) how to establish greater political priority for health-related SDGs including domestic financing for health, as well as relatively newer services such as early childhood development, that has received considerable attention in the literature [10, 15, 33], and (ii) issues around engaging private sector actors to address some of the commercial drivers of ill health [24, 26, 27]. Ultimately, however, the research team concluded that the three themes presented above better captured the breadth of HPSR concerns. The theme-specific findings of this research have already been published elsewhere [34,35,36] with considerably more detail than this paper provides. This paper seeks to synthesize the findings across all three themes, so as to reflect more broadly on new directions for HPSR in light of the SDGs.