Health in the 2030 Agenda for Sustainable Development – Report by the Secretariat

Following the 138^th Session of the Executive Board and adoption of resolution EB138.R5, the WHO Secretariat has issued an updated version of the paper on Health in the 2030 Agenda for Sustainable Development (A69/15). (See: WHO Paper Recommends ‘Governance for Health’ to Achieve SDGs and WHO Executive Board consideration of Health in the 2030 Agenda for Sustainable Development)

The birth of the Sustainable Development Goals

The paper highlights the differences between the Millennium Development Goals (MDGs) and the Sustainable Developments Goals (SDGs), outlining some areas that it considers to be of strategic importance to global health. It also includes possible changes “regarding WHO’s priorities and methods of work, to ensure that the Organization plays a leading role in implementation and review of the health-related Sustainable Development Goals.”

The 2030 Agenda on Sustainable Development (2030 Agenda) included a declaration, 17 goals and 169 targets and means of implementation, and follow-up and review. Two processes still had to be completed when the SDGs came into effect on 1 January 2016. The first is the development through the Inter-Agency and Expert Group (IAEG-SDGs) of the global indicator framework, which contains 230 indicators, including 26 indicators under the health goal. Second, according to the Declaration each Government will set “its own national targets guided by the global level of ambition but taking into account national circumstances.” As pointed out in this paper “How this will work in practice and what will be the role of global and regional institutions in supporting countries in setting such targets remain to be seen.”

The paper continues, “Once an indicator framework has been agreed, a complex and intensive reporting, follow-up and review process will begin.” It refers to the annual Secretary-General’s reports and global sustainable development reports (at a frequency to be decided) that will inform the high-level political forum on sustainable development (HLPF) under ECOSOC, with meetings every fourth year under the auspices of the General Assembly to “provide high-level political guidance on the Agenda and its implementation.”

The paper notes the differences between the SDGs and the MDGs such as the “political context in which they have been developed and in which they are implemented,” with the SDGs being “integrated and indivisible, global in nature and universally applicable.” In addition is the “breath of the agenda,” with the SDGs covering the three pillars of social development “with a strong focus on equity,” articulated in the concept of “no one will be left behind.”  It can also be argued that the scope of the SDGs “more closely reflects the range of issues with which a government in reality has to contend.” While the MDGs, moreover, were “silent” on the impact of political factors in countries, most of those where they were not achieved, “have gone through a period of sustained political turbulence requiring humanitarian and developmental support.” Meanwhile, SDG 16 recognizes the importance of peace and security.

The responsibility of countries for their own economic and social development is a focus together with the recognition of the importance of development assistance for a decreasing number of “poor and often fragile states.” Interlinkages and the integrated nature of the goals are also important to the realization of the 2030 Agenda. Meanwhile the political context is different from that of the MDGs through economic insecurity, cuts in public service and growing inequality in many developed countries that will have to be addressed to allow countries to “have the political space to pursue the idea of global solidarity that underpins the new Agenda.”

The place of health in the Sustainable Development Goals

Several of the health targets follow on from the unfinished MDG agenda and many of the others come from WHA resolutions and related action plans. While health is a goal in itself, health and its determinants influence and are influenced by other goals and targets. It argues against those who say that health has been demoted from the MDGs, where three out of the eight goals were on health, pointing to the cross-cutting nature and interlinkages of the SDGs and the importance of reducing inequalities as included in Goal 10. One health goal “is both logical and in no way underplays the importance of health” It is “positioned as a major contributor” to the other SDGs which cannot be achieved without health. The health goal also benefits from progress towards the other SDGs.

The following diagram shows how targets that have been “carried forward and enhanced” from the MDGs and those that are “means of implementation,” in addition to Goal 17.

The paper highlights gaps in the health SDGs including immunization coverage as a target in itself. While access to sexual and reproductive health care is included, “sexual and reproductive rights, violence and discrimination against women and girls are dealt with elsewhere (Goal 5). Older people are found under Goals 2 (nutrition) and 11 (safe environments), while population ageing is absent, except indirectly through noncommunicable diseases (NCDs) and mental health, which “needs to be seen as an integral part of progress towards universal health coverage” (UHC). Antimicrobial resistance, a WHO leadership priority, is also missing as a target.

Health systems are central to the new Agenda

Paragraph 26 of the Declaration places UHC “as the target that underpins and is key to the achievement of all the others…” in stating:

“To promote physical and mental health and well-being and to extend life expectancy for all, we must achieve universal health coverage and access to quality health care. No one must be left behind…”

UHC is defined “as all people and all communities receiving the services they need, while ensuring that they are protected from financial hardship” and includes “health protection, promotion, prevention, treatment, rehabilitation and palliation.”

One of problems associated with MDGs was the “fragmentation of country health systems” resulting in problems in establishing “health systems capable of providing integrated, people-centred care and achieving multiple targets, with realistic estimates of overall cost.” Insofar as the 13 health targets cover most national health concerns and “majority of WHO’s work programme areas,” focusing on individual programmes in isolation would be counterproductive, risking greater fragmentation and failing to address some cross-cutting issues.

The Sustainable Development Goals can put governance for health centre stage

The SDGs are “integrated and indivisible” but translating this into action will be a key challenge. While many synergies are well known, others are less familiar eg sustainable consumption and NCDs or climate change and the spread of vector-born diseases. A number of other sectors can impact on health negatively or positively. “Governance for health” is needed to influence other policy areas to promote and protect health and it allows WHO to can pursue a more integrated role. Governance, as highlighted in the Declaration is also important at the national and regional levels.

The adoption of the SDGs provides an opportunity for a fresh look at the required institutional arrangements to improve and maintain people’s health, which would widen the scope of discussion on “global health architecture” beyond financing and institutional positioning. This could include, for example, improving cross-border health security; relevance and coherence of UN bodies in the field of health; addressing the causes of NCDs; and enhancing standardized measurement and accountability.

Financing the Sustainable Development Goals

The aim of the SDGs is progressive realization. The emphasis is on national target-setting. Goal 3 can be costed more accurately than some of the more aspirational targets. The 2030 Agenda will not be financed primarily from aid budgets, bearing in mind that 75 percent of the total health budget of average low-income countries is financed from domestic resources. While development assistance will remain important in some countries, the numbers are likely to decrease, being concentrated in a few, fragile, least developed countries. A growing concern is the integration of humanitarian and development assistance.

Low and lower-middle income countries are expected to grow their economies relatively rapidly. It is hoped given the statements of intent at the Conference on Financing for Development, that countries’ capacity will increase to raise and spend funds domestically; to make national tax systems more efficient; combat tax evasion and illicit tax flows; and provided “partnerships with private sector entities align investments with the principles of better health and sustainable development.”

The key question is whether the SDGs will change the patterns of spending within the health sector. While NCDs do not threaten global security, increases in such diseases in low and middle-income countries threatens to overwhelm fragile health systems, without rapid investments in disease prevention and health promotion. NCDs are still considered to be competing for health funds by development assistance agencies and the growing interest in health systems is related more to health security than to UHC and people-centred care.

Follow-up and review

The annual review will take place through the HLPF, under ECOSOC, with the four-yearly reviews by the General Assembly, as set out in the Declaration. The process will be complex and there could be too many demands for data, with the process failing to gain support…” There are many existing reporting systems that can be used for the health goal, and the 2030 Agenda provides an opportunity to rationalize the reporting requirements found in many WHA resolutions. On the other hand, current efforts to develop indicators, assess progress and hold Governments and others accountable to individual targets may ignore the “big picture” and equity, in particular.

There are several overarching indicators that can be used for the health goal, including life expectancy, the number of deaths before the age of 70 years and healthy life expectancy, which, if measured reliably, could “capture both mortality and years of life loved in less than good health (ie with a disability).” There is more emphasis than for the MDGs on country and regional follow-up and review, and it can be assumed that civil society bodies and others will use the SDGs to hold governments to account, with social media playing an important role.

Implications for the work of WHO

The UN system to deliver on the 2030 Agenda should be “innovative, inclusive, results-oriented and responsive to the differentiated needs of countries.” For WHO the implications of the SDGs should be considered “in the context of an overall shift towards integrated approaches to their implications,” including support of national plans, strategies and development cooperation considerations for targeted actions. WHO will also be called on to provide assistance, including redoubling technical support; facilitating new approaches for training and capacity building; strengthening of institutions and facilitating discussions for identifying needed health reforms; facilitating knowledge transfer; and developing modalities for enabling cross-sector partnerships.

The SDGs will “require WHO to revisit what the Organization needs to do, how the relevant objectives are achieved and with whom WHO needs to partner in order to ensure timely and effective delivery.”

Programmatic implications

Integration of priorities:  The SDGs, which are aligned with the priorities in the WHO Twelfth General Programme of Work 2014-2019, will “require WHO to maintain and strengthen its core functions ” including supporting countries in generating funding, advising on cost-effective interventions and defining indicators and research priorities. While WHO will work closely with partners, “it is the only global organization with a mandate to cover the whole field of health.”

Planning, budgeting, financing and resource allocation: Responding to the 2030 Agenda will mean that WHO must gear its support to a “broader set of national priorities in health and related sectors” and that “individual programme areas contribute to, and work within, the framework of a country’s overall health plan or strategy.” It will be necessary to consider questions such as “how planning, budgeting and resource allocation can provide the incentives needed to drive more collaborative work across the Organization.”

Progress reporting and reviews: National and subnational systems for integrated monitoring of health programmes and their performance should be strengthened. WHO will be asked to assist countries in collection, analysis, monitoring and use of timely and accurate data. The breadth of the health targets, moreover, poses an important governance challenge as to “how to provide a reliable indication of whether health is improving.”

Research: It is likely that responding to the need for health policy and systems research will be a major factor in achieving the SDGs.

Managerial implications

Universality of the 2030 Agenda presents challenges for support to countries and will increase demand for staff with appropriate competencies, although many such changes have been foreseen in the existing WHO reform programme. 

Governance for health

While achieving individual targets will remain at the heart of WHO’s core business, realizing this “higher ambition” will necessitate thinking about the SDGs as an “integrated and indivisible” agenda. “The successful achievement of the Goals will depend on WHO’s ability to deepen existing relationships in the health sector while expanding work beyond health and across other sectors.”

Conclusion

The 2030 Agenda provides WHO with an opportunity “to demonstrate that the goal of healthy life and well-being for all at all ages is more than the sum of individual targets that contribute to it attainment.” The SDGs integrated nature also “provides new legitimacy for addressing the wider determinants of health.”