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By setting ambitious targets, the global health community has played a pivotal role in motivating the world to achieve remarkable improvements in health. Over 21 million additional lives were estimated to have been saved due to the accelerated progress promoted by the Millennium Development Goals.1 Most countries have translated global goals into their own targets, with many even incorporating them into their national health plans. Financing instruments (such as development-linked indicators, performance-based financing and development impact bonds) that offer financial rewards in exchange for strong health results have pushed countries to further accelerate progress. Taken together, the collective ambition to improve health has translated into enormous pressure for health systems to achieve targets.
However, we have also seen the ugly side of this—the high stakes, the ambition and the expectation can instil a fear of failure, stifle risk-taking and innovation, and lead to the fabrication of achievement. On the long and difficult road to sustained health improvements, we cannot ignore the political, financial and reputational blowback that countries face when they fail to deliver on ambitious targets. Political promises, national pride, financial reward and job security weigh heavily on politicians and health systems managers. This can create perverse incentives for countries to embellish their reporting.
The problem is further exacerbated in countries that lack transparency of information, freedom of press and democratic rules of engagement. Should we believe Rwanda’s claims on poverty reduction, even as experts2 have cast doubt on the validity of their data? Should we believe China’s self-reported success stories on achieving universal health coverage3 and dramatic improvements in key health indicators,4 when there are widespread concerns5 about the independence of their national …
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