The adoption of the 2030 Agenda for Sustainable Development marked a defining moment in the history of the United Nations and the creation of an unprecedented development paradigm bringing together the social, environmental, and economic development strands into one comprehensive, ambitious, and balanced framework. With seventeen interdependent Sustainable Development Goals (SDGs) and 169 targets, the Agenda replaces the narrower and more limited Millennium Development Goals, and has two important features: universality (applicable to all countries and populations); and a commitment to “leaving no one behind”—irrespective of population characteristics or place on the development-humanitarian continuum. SDG 3 (the “health goal”) is supported by nine substantive targets across a broad spectrum of health issues, and four means of implementation targets covering issues such as financing, human resources, and research and development. Given that the social determinants of health (e.g., education, employment, gender-equality) are the focus of other SDGs and the Agenda’s architects conceptualize the goals and targets as interdependent with cross-cutting approaches as well as intersectoral collaboration, in practice at least eleven goals and many more targets are health-related (see World Health Organization 2017, cited under Health-Related Goals, Targets, and Indicators in Agenda 2030). Accountability is key, and many countries have reoriented their national development strategies around the SDGs and have been enthusiastic in presenting Voluntary National Reviews to the annual UN High-Level Political Forum on Sustainable Development. Nonetheless, the SDGs have been critiqued for their omissions (from social mobilization to global health security) as well as their perceived failure to disrupt deep economic and structural injustices which are harmful to people and planet. In our review of the English language literature, we identified over fifty papers addressing some aspect of the SDGs and health. We are reluctant to conceptualize these as a single literature on the broad, diverse, and complex nature of sustainable development as it relates to human health, particularly since a significant proportion are commentaries rather than primary studies or new theoretical/conceptual ideas. We have grouped the papers into six areas: the genesis and significance of Agenda 2030 and its relationship to health; goals, targets, and indicators; projections of progress and financing implications; goal interdependence and intersectoral collaboration; human rights, participation, and the principle of leaving no one behind; critiques and criticisms. If any topic dominates, it is on universal health coverage, one of the thirteen targets in SDG3; conversely the literature tends to lack a detailed prescriptive guidance on how to move from analysis to action. Given the Agenda was only agreed upon in the past few years we are hopeful that policy- and practice-relevant literature on how to implement action and activities to reach the Goals will be forthcoming in the near future. The views contained herein do not necessarily reflect those of UNAIDS.
The Genesis, Negotiations, Significance, and Implications of Agenda 2030 and Its Approach to Health
Agenda 2030 arose as a follow-up to the United Nations Conference on Sustainable Development (Rio+20), and in particular to the desire for the adoption of a successor framework to the Millennium Development Goals (MDGs). A range of consultative processes were established. Among the more prominent was a high-level UN panel co-chaired by UK prime minister Cameron, Sierra Leone president Sirleaf, and Indonesian president Yudhoyon in 2012. The governments of Botswana and Sweden co-chaired a thematic consultation on health with support of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). In light of the expansive and competitive agenda, covering planet, people, and prosperity, there were concerns that health might not enjoy the same profile in the Sustainable Development Goals (SDGs) as it had in the MDGs—where Hill, et al. 2014 notes health occupied three of the eight MDGs. Kamau, et al. 2018 outlines the political negotiations which took place in the United Nations co-facilitated by Hungary and Kenya, and which ended with adoption of the Agenda in September 2015. As noted by Brolan and Hill 2015 there was considerable contestation over the content of the health goal—particularly whether or not good health outcomes or good health services should be at the center. A coalition of countries, notably France, Germany, Japan, Thailand, and Indonesia with support from the Rockefeller Foundation, WHO, and the World Bank aimed to see universal health coverage (UHC) as the overarching health goal. Others proposed focusing on health outcomes (healthy lives) as the goal with targets for different diseases and different inputs for creating good health. Ultimately, healthy lives were adopted with UHC one among thirteen targets. Morton, et al. 2017 and other authors have analyzed the implications of the comprehensive and interlinked nature of the SDG targets and have concluded that there is a need to “do health differently.” Buse and Hawkes 2015 call for a paradigm shift in global health to focus on prevention as well as access to treatment and care services and propose a five-point agenda for change. Jha, et al. 2016 acknowledges the fundamental shifts needed, and argues that greater emphasis be placed on capacity strengthening, knowledge sharing, and innovation. The need for adequate governance structures is addressed in Waage, et al. 2015. Magnusson 2017 also calls for enhanced governance structures to manage the cross-sectoral relationships inherent in Agenda 2030 for health, and proposes framework legislation as a mechanism for managing interests. Pradhan, et al. 2017 urges a note of caution on intersectoral interaction, and by identifying synergies and trade-offs between the different indicators they find that SDG3 is linked with progress on most other goals—particularly SDG 1 (poverty reduction), 4 (quality education), 5 (gender equality), 6 (clean water and sanitation) and 10 (inequalities reduction).
Brolan, C. E., and P. S. Hill. 2015. Universal health coverage’s evolving location in the post-2015 development agenda: Key informant perspectives within multilateral and related agencies during the first phase of post-2015 negotiations. Health Policy and Planning 31.4: 514–526.
The paper uses an agenda-setting framework from political science to describe negotiations on the health goal in the post-2015 Agenda (SDG agenda)—in particular, the place of universal health coverage therein.
Buse, K., and S. Hawkes. 2015. Health in the sustainable development goals: Ready for a paradigm shift? Globalization and Health 11:13
Buse and Hawkes argue that success in achieving the health goal in the SDG Agenda will be dependent on five shifts in how we address global health: (1) ensuring leadership for intersectoral coherence and coordination; (2) shifting focus from treatment to prevention; (3) identifying means to tackle the commercial determinants of health; (4) integrating rights-based approaches; (5) engaging with civil society and ensuring accountability.
Hill, P. S., K. Buse, C. E. Brolan, and G. Ooms. 2014. How can health remain central post-2015 in a sustainable development paradigm? Globalization and Health 10.1: 18.
So as to ensure adequate and appropriate attention on health in Agenda 2030, the authors put forward an advocacy agenda for reframing health in the negotiations with a focus on sustainability, universality, and making health relevant to other sectors, while also calling for more attention to governance structures to implement the health goal and targets.
Jha, A., I. Kickbusch, P. Taylor, and K. Abbasi. 2016. Accelerating achievement of the sustainable development goals. BMJ 352:i409.
The paper is an output from a meeting of sixty global health policy think tanks, which agreed that beyond generation of the requisite political will, three key challenges need to be addressed to succeed on SDG3: (1) knowledge sharing on the determinants of health, response to disease and mitigation of environmental problems; (2) enhancing technical capacity to implement programs; and (3) innovation to overcome long-standing and inherent challenges in coverage and accountability.
Kamau, M., P. Chasek, and D. O’Connor. 2018. Transforming multilateral diplomacy: The inside story of the Sustainable Development Goals. London and New York: Routledge.
This book provides an insider account of the negotiations that led to the 2030 Agenda for Sustainable Development. The authors, one of the co-facilitators of the negotiations, an academic observer, as well as a senior UN official relay the events as they unfolded as well as outline how these negotiations and the resulting agreement were different than any that had come before.
Magnusson, R. S. 2017. Framework legislation for non-communicable diseases: And for the Sustainable Development Goals? BMJ Global Health 2.3.
Magnusson argues that “framework legislation” for non-communicable diseases (NCDs), and for the broader health-related SDGs, would provide the opportunity for countries to set national targets and create cross-sectoral governance structures—which could manage commercial relationships and conflicts of interest.
Morton, S., D. Pencheon, N. Squires. 2017 Sustainable Development Goals (SDGs), and their implementation. British Medical Bulletin 124.1: 81–90.
The paper reviews existing literature on the SDGs, focusing on health, and identifies areas of agreement (e.g., the need for system-wide planning) and areas of controversy (e.g., countries may not recognize the potential for positive interactions between Goals). They call for a proportional emphasis on finding solutions rather than simply focusing on causes of disease.
Pradhan, P., L. Costa, D. Rybski, W. Lucht, and J. P. Kropp. 2017. A systematic study of Sustainable Development Goal (SDG) interactions. Earths Future 5.11: 1169–1179.
The authors have quantified synergies and trade-offs of interaction between all targets across the SDG agenda, for 227 countries. SDG3 has positive synergies with a large number of Goals in most countries.
Waage, J., C. Yap, S. Bell, et al. 2015. Governing the UN Sustainable Development Goals: Interactions, infrastructures, and institutions. The Lancet Global Health 3.5.
The paper provides a framework across the Goals that reveals potential conflicts and synergies. They call for new governance structures across goals and sectors.
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