From mdgs to sdgs

The UN Secretary General Ban Ki-Moon calls the MDGs, signed in January 2000, ‘the most successful antipoverty movement in history’,13 by lifting more than one billion people out of extreme poverty, and making specific gains on targets such as reducing hunger, increasing female education and advancing environmental protection. At the same time, it is recognised that much work remains to be done to address persistent inequalities and uneven progress.14 ,15 There are also concerns that recent conflicts, growing extremism, unprecedented levels of migration,16 continued economic and financial volatility, and large-scale environmental changes are undermining some of the MDGs achievements.12 ,14 ,17

In this context, high expectations are being placed on the SDGs to do more over the next 15 years.2 ,3 The new agenda departs from the MDGs in two important respects. First, the UN Secretary General's High-Level Panel on Sustainable Development highlights the importance of addressing the determinants of development and well-being within a ‘universal framework’ by which goals apply to every country and across all sectors of society. While the MDGs applied to developing countries, the SDGs are framed to address poverty alleviation in all countries. Second, the SDGs place sustainability at the heart of the development agenda,18 recognising the need to address the complex links between development and the environment. Based on lessons from the MDGs, the 2030 Agenda for Sustainable Development is seen as a unique opportunity to design new objectives, measures and indicators which are innovative and transformative.19 Of particular concern is the need to move away from a narrow set of quantitative goals and targets towards a broader range of more ‘integrated and indivisible’ goals and targets.

Health and well-being within the sdgs

Health is defined by the World Health Organization (WHO) as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.20 Broadly speaking, ‘health is a concern to all people, and is influenced by and as well contributing to policies across a wide range of sectors’.10 As health is extensively determined by economic, social and environmental conditions, we argue here that health is connected with topics such as poverty, gender equality, education, growth, among others,9 being thus crucial for the effective conditions for sustainable development.10

Health figured prominently in the MDGs. Three of the eight goals focused directly on health-related issues—reducing child mortality (MDG 4), improving maternal health (MDG 5) and combating HIV/AIDS, malaria and other diseases (MDG 6)—while three others were indirectly related to health—eradicating extreme poverty and hunger (MDG 1), ensuring environmental sustainability (MDG 7), and developing a global partnership for development (MDG 8). Under the SDGs, some argue that having only one health goal (SDG 3) among 17 goals is a step back from the MDGs.8 ,9 ,21 Others, however, assert that giving such prominence to a single sector is out of step with the new emphasis on universality and sustainability. Thus, the UN asserted that the role of health should be reconsidered, including its relationship alongside the concept of ‘well-being’.22 The Centers for Disease Control and Prevention (CDC) define well-being as ‘a positive outcome that is meaningful for people and for many sectors of society, because it tells us that people perceive that their lives are going well. Good living conditions (eg, housing, employment) are fundamental to well-being’.23

Implementation of the 2030 Agenda for Sustainable Development, therefore, faces a need to reconcile strong support for better health and well-being, and the more integrated approach of sustainable development. The Rio Declaration on Environment and Development, signed by 170 countries in 1992, clearly and fully addresses the links between health and development. Principle 1 states that ‘human beings are at the centre of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature’.24 This link between health and sustainable development has been part of declarations that have followed. Despite this, and more recently regarding the new 2030 Agenda for Sustainable Development, it has been argued that the relationship between health and development should be further addressed22 so that health and well-being become central to sustainable development as argued here. In doing so, the UN and its agencies,22 in their ‘Health in the post-2015 UN development agenda’ report, have explicitly looked at the linkages between health and sustainable development through three different perspectives. Such relationship includes the idea that health can be a contributor, a beneficiary and a vehicle to measure success in achieving sustainable development.22 ,25

Some authors consider that SDG 3, to ‘ensure healthy lives and promote well-being for all at all ages’, fairly represents health and well-being within the SDGs as they stand.7 ,17 For example, the WHO asserts that the health and well-being goal is one that is very broad, allowing a multitude of issues lacking under the narrower MDGs to be addressed. These include mental health, environmental health and health security.17

Despite being set out as a separate goal, moreover, SDG 3 is recognised as critical for the achievement of other SDGs. Measures of health and well-being can be used to assess progress in the implementation of the SDGs. Conversely, most of the new generation of SDGs have a range of direct positive impacts on human health and well-being (eg, reductions in cardiovascular disease, lung cancer and stroke). There are also a range of health and well-being co-benefits of sustainable development (ie, poverty reduction, sustainable energy sources, safe drinking water, adequate sanitation, sustainable food production and distribution, urban planning). Consequently, the WHO argues that health and well-being are central measures of progress in achieving the SDGs as an overall strategy of the post-2015 agenda.26 For example, health and well-being are influenced by an array of factors (ie, determinants of health) such as social, environmental and economic factors that are intrinsically related to other SDGs.21 A series of indicators for sustainable cities, energy, water, sanitation and hygiene, and food production have been presented linking health and the SDGs.19 Overall, the WHO is confident that health and well-being remain central to the sustainable development framework, with SDG 3 as more integrated under this new agenda than the MDGs.17

An integrating health and well-being framework

Given recognition of the links between health and well-being, the SDGs, and sustainable development as a whole, there is need for a framework to guide more integrated action. This framework would focus on the interdependencies between goals, and encourage connections among different sectors.6 For example, the impacts of better health and well-being on poverty reduction and increased equality and, as a result, on achieving overall sustainable development, can be realised through more collaborative efforts between health and non-health sectors.

As a first step towards such a framework, we compile and compare lists of health-related SDG targets (see table 1). Murray27 identifies 23 health-related SDGs targets and Le Blanc6 includes seven targets related to health within the SDGs and asserts that health is linked with another eight goals. The WHO28 provides a more comprehensive list of health-related SDGs, which includes 27 targets plus all the health goal targets (17). In a recent report, the WHO29 considers a slightly different set of 17 targets as being health-related and linked to SDG 3. Table 1 shows that health is more embedded within the SDGs than previous approaches have identified.6 ,27 ,28 ,30

As a next step, and drawing on Wilkinson and Hulme,12 we can identify integrating links between goals. Table 2 sets out the synergies between health and well-being (SDG 3), and other SDGs, and the various sectors relevant to each. In this table, we acknowledge the cross-cutting role that health and well-being play, as preconditions, as well as outcomes,17 ,22 ,25 ,31 ,32 and vehicles to measure sustainable development.17 Additionally, we incorporate the ‘'Health in All Policies (HiAP)' strategy25 ,33 to make links, between the SDGs, and health and well-being. Given that health, and health-related issues, fall within sectors other than health,25 incorporating health in all policies to support the SDGs has been suggested as a way to bring better integration and coherence to the new sustainable development agenda.34 In short, achieving SDG 3 is crucial to other SDGs, and achieving other SDGs is crucial to SDG 3. The integrating framework of table 2 provides a shared language and encourages more dialogue across sectors (table 2).

Implementing and monitoring the health and well-being framework

Once synergies across the SDGs and sectors are identified (table 2), highlighting the interdependencies between health and well-being and other SDGs, there is a need to operationalise this approach through the identification of specific objectives, and measures or indicators, to monitor their achievement.

Table 3 sets out six examples of major health issues and how they relate to particular SDGs targets (eg, 1.1; 7.2) and current indicators for each target (eg, 1.1.1; 7.2.1). The six examples focused on the synergies between health and well-being, and other SDGs are advanced through specific objectives we propose to support intersectoral action. We argue that these actions seek to improve health and well-being as part of sustainable development. Actions in non-health sectors, aimed at reducing the disease burden arising from unsustainable practices, include infrastructure provision, economy, agriculture and food, in collaboration with the health sector. The improvement of social protection, health systems and services, the reduction of poverty and malnutrition, the access to sanitation, water and hygiene facilities, and the use of clean energy sources are further examples. Simultaneously, actions in the health sector can directly address health problems caused by broader determinants of health, such as the natural (eg, air, water and land pollution), working and built environments (housing quality, urban planning, sanitation and drinking water facilities, ventilation, toxic exposure).

Building on the current context of the SDGs, and framework of proposed indicators29 for the implementation of the 2030 Agenda for Sustainable Development, table 3 sets out examples of additional potential new indicators for guiding action, and assesses the extent to which progress is achieved towards the identified SDG targets and indicators. We acknowledge that the discussion about measurement of health and well-being has already started taking place,29 but argue that this is still at an early stage. The proposed global indicators, updated as of 4 March 2016,29 are very pragmatic but, in some ways limited. Table 3 seeks to overcome the specificity of the SDGs by illustrating how it is possible to identify synergies among them, their targets and indicators with current health and well-being concerns (eg, malnutrition, respiratory diseases, obesity). By doing this, we argue that, despite the considerations above, it is possible to reconcile the tensions between a more focused health and well-being framework to the SDGs, and a wider integrated approach that considers the interdependences among goals, targets and indicators across the sweep of sustainable development.

These potential new indicators (table 3), specifically encourage connections between health and non-health sectors within the sustainable development agenda. In this way, an integrated approach is created which provides opportunities for more coherent and coordinated action across all sectors. For example, a focus on human rights, equity and basic cultural freedoms is included as affecting health-related sustainable development outcomes. We further comment on the extent to which current global indicators29 to be measured to assess the progress of the sustainable development agenda are too broad and unfocused. We contend that they need to be more specific and tailored so as to address all connected development topics. One of many of these examples is indicator 11.2.1 which can be linked with four of the six examples presented in table 3 (ie, respiratory diseases, lung cancer, overweight and obesity, road traffic accidents). Indicator 11.2.1 comprises the ‘proportion of population that has convenient access to public transport, by sex, age and persons with disabilities’,29 where it is not clear what convenient access means in practice for it to be consistently measured across countries. Indicator 11.2.1 exemplifies one of the ways in which other indicators need expanding, need to be more comprehensive and need to be more efficient in order to support and galvanise the success of the SDGs through the implementation, monitoring and review of a high-quality, more complete and exhaustive set of potential new indicators for achieving sustainable development, such as the ones suggested in table 3.

As the UN specialised agency for health, and ‘directing and coordinating authority on international health work’, the WHO has a lead role to play in helping to identify and implement an integrating framework for health and well-being for the SDGs. The WHO can serve as the link agency, between SDG 3 and other SDGs, by ensuring all member states fulfil their commitment to the 2030 Sustainable Development Agenda. The WHO can locate this role by locating it within the implementation and monitoring of a health in all policies Agenda for Sustainable Development, providing strong technical support to developing clear objectives, measures or indicators, for national, regional and global action.

However, given the intersectoral nature of the sustainable development agenda, and the many other actors now contributing to global health cooperation, the WHO alone cannot take forward the health and sustainable development agenda. The integrated framework to the SDGs put forth here requires closer cooperation across the multiplicity of actors that now populate the global health governance landscape. Indeed, such an approach to the SDGs may provide an opportunity to build networks among these diverse actors, bringing together their efforts to work across health issues and sectors. For example, within the health sector, tackling diarrhoeal diseases might bring together the technical expertise of the WHO on disease prevention, control and treatment, financing of infrastructure by the World Bank, local capacity building efforts of the US CDC, research funding for innovative solutions by the Gates Foundation, and community level initiatives by the Global Public-Private Partnership for Handwashing; and in the non-health sector, the development of innovative solutions to water, sanitation and hygiene needs for children of the UN Children's Fund (UNICEF), advocacy by the UN Development Programme (UNDP) for access to clean water and sanitation as a basic right. This network of Global Health Governance (GHG) actors could be brought together with community, national and regional organisations to form a focused network around a specific set of SDGs or targets.

Finally, we argue that tables 1⇑–3 together offer an integrating framework that should be applied to ensure other sectors serve as cross-cutting themes to underpin the 2030 Sustainable Development Agenda. While the expansion from 8 MDGs and 18 targets, to 17 SDGs and 169 targets, is seen as a daunting and potentially unmanageable agenda, the framework identifies common and mutually reinforcing actions across the new agenda. In this way, efforts move away from the discrete objectives and institutional mechanisms of sector-specific actions, towards ‘integrated and indivisible’ actions which are innovative and transformative.