The Sustainable Development Goals and the 2030 Agenda

It has been almost 3 years since the United Nations announced the new Sustainable Development Goals (SDGs) and 2030 Agenda.1 The third of the 17 goals (SDG3) is specifically focused on health and is composed of 13 targets addressing a comprehensive set of global health priorities (https://sustainabledevelopment.un.org/sdg3). Successful pursuit of SDG3 will require strong leadership from national governments and the United Nations system but also from other partners including multilateral organisations, civil society, business and the private sector.2 Among the partners, academic institutions working in global health have a pivotal role to play.3 We argue that, although the SDGs are imperfect, there remain strategic reasons, value-generating opportunities and a moral responsibility for academic institutions both in high-income and low-income to middle-income countries to fully incorporate the pursuit of SDG3 and other SDGs into their strategies, plans or operations to help advance the SDGs globally (box 1).

Seven good reasons to pursue the SDGs

First, the SDGs’ target date of 2030 can incentivise academic institutions to think long term and strategically, avoid pursuing funding and planning operations on a year-by-year basis, and answer critical and difficult questions: “Where do we want to be in 2030?”; “Are the 13 targets within SDG3 the best we can achieve or can we do better?”; “Will we still need to work on a particular global health priority or in a particular country after 2030?”; “How will our work in 2030 differ from what it is now?”. Academic institutions can also play an important role in addressing challenges associated with the SDGs themselves, which have been criticised for being a product of the same imperfect and unequal world, countries and societies that they are trying to change.4 For example, the presence of governance and accountability gaps between and within nation states, the excessive vulnerability of health policies and practices to broader political determinants of health, and an insufficient emphasis on a rights-based approach to health are among the major criticisms specifically raised against SDG3.5 Through research and scholarship, academic institutions can raise awareness and develop solutions to some of these challenges.

Second, by shifting from short-term plans to strategies that are aligned to the SDGs and are on a timeline longer than the funding cycle for most grants, academic institutions will be incentivised to be guided by strategy in the pursuit of funding rather than the other way around. The priorities of the host country—rather than the likelihood that donors will fund a particular set of activities—should in fact be the primary determinant of the types of goals that academic institutions opt to pursue. Unfortunately, funding for global health has plateaued over the past 3 years despite the fact that there is currently an estimated gap of US$20–50 billion per year needed to achieve SDG3 in 67 low-income and middle-income countries.6 A series of additional trends are contributing to an evolving funding environment, which academic institutions must now confront. These trends include (1) transition from core or longer-term funding towards more discretionary funding, (2) transition from country-led decision-making towards multistakeholder governance and (c) transition from broader systemic goals towards problem-focused vertical initiatives.7

To overcome these challenges, academic institutions will need to seek additional funding sources.8 Among these sources, private philanthropy has the potential to play a critical role as long as academic institutions are able to address concerns related to its accountability, transparency, coordination with other donors and focus on short-term improvements rather than deep structural changes.9 Academic institutions will also need to spend more strategically the funding available through traditional donors so that the short-term projects funded by these donors are building blocks laid in the pursuit of longer-term strategies, with new projects systematically building on the achievements of their predecessors. By embracing the SDGs, which have been officially endorsed by the majority of national governments and multilateral organisations, academic institutions would be able to create a compelling message to scale up their independent fundraising efforts through their development departments and private philanthropy networks. Lastly, the SDGs would also provide a platform for academic institutions to advocate more effectively with traditional donors for increased spending flexibility and a much-needed increase in the amount of funding devoted to global health.

Third, the SDGs provide an agreed-on minimum standard for health and supporting metrics. Holding themselves accountable to these metrics will allow different academic institutions to harmonise their individual strategies and operations and create synergy towards the achievement of common goals. Concerns have been raised about the fact that global imbalances in both availability of financial resources and capacity for data collection and analysis can skew the selection of health metrics towards those prioritised by resource-rich countries rather than those valued by countries with the greatest burden of disease.10 While these concerns are valid, having a minimum standard for health and supporting metrics (even if imperfect) would still promote accountability and harmonisation. At the same time, academic institutions would retain ample room for innovation and for setting goals that are longer term, more comprehensive, more equitable and more ambitious than the SDGs.

Fourth, SDGs can contribute to eliminating the dichotomy between the Global North and the Global South. There are numerous innovations in health service delivery piloted and scaled up by low-income and middle-income countries that can be adopted by high-income countries.11 Given the fact that many high-income countries are facing severe health disparities themselves, witnessing increases in health-associated costs and struggling to provide universal health coverage to its populations, the SDGs provide tremendous opportunities for transnational learning in health service delivery, an effort which academic institutions would be best positioned to lead. Critically though, imbalances in the political economy of knowledge generation can lead to research endeavours that are conducted in low-income countries but produce results consumed by or benefiting primarily high-income countries.12 To avoid this unequitable dynamic, it will be critical for academic institutions to level the playing field by further strengthening research capacity in the Global South through training of local investigators and the support or establishment of local research institutions and organisations.

Fifth, the SDGs are multidisciplinary and multisectoral. SDG3 and its 13 targets alone address a comprehensive global health priorities including maternal and child health, HIV/AIDS, tuberculosis, non-communicable diseases and health workforce development. Additionally, other SDGs such as SDG8 (‘Decent Work and Economic Growth’), SDG10 (‘Reduced Inequalities’) and SDG13 (‘Climate Action’) do not stand in isolation and can be linked to health. At the same time, a growing body of evidence underscores how better health in return promotes economic growth, national security and social cohesion.13 Addressing SDG3’s 13 targets will require expertise from a vast set of disciplines within the health sector but also from sectors outside of health including education, human rights, agriculture, water and sanitation, housing, environment and finance. While multidisciplinary collaborations must be rooted in a common set of values and norms to have the desired impact, a commitment to achieving the SDGs would serve as a critical catalyst for academic institutions to promote collaborations across disciplines and sectors both internally (among different departments and schools) and externally (among different institutions) and further develop and expand global health as a field.

Sixth, SDG16 (‘Building Effective, Accountable and Inclusive Institutions at All Levels’) and SDG17 (‘Revitalizing the Global Partnership for Sustainable Development’) emphasise the pivotal role played by partnerships and institutional capacity strengthening in the achievement of all the SDGs, including SDG3. Together, these goals encourage academic institutions working in global health to partner and network with other academic institutions and with national governments, non-governmental organisations and donors. To be effective, this diverse coalition of stakeholders will need to reach consensus on the most pressing global health challenges, their remedies, ways to mobilise the necessary resources and a governance structure that facilitates collective action.14 All of this requires time and long-term commitment. However, while time and long-term commitment are necessary, they alone are not sufficient. Partnerships must have legitimacy (with all partners democratically agreeing to a common set of principles, rules and goals such as the SDGs), be rooted in a sincere commitment to working together and being invested in each other’s betterment, and address potentially damaging dynamics such as unequal distribution of resources and expertise, overreach, complacency or codependency among partners. Therefore, SDG16 and SDG17 also imply that partnerships will have to evolve over time and that academic institutions will have to strengthen their own capacity and that of their partners for achievements to be sustained. While institutional capacity strengthening and sustainability are considered a necessary outcome primarily for partners from low-income and middle-income countries, the established practices and lack of accountability of non-state actors from high-income countries (including academic institutions) can prevent global health partnerships from being as effective as they could be in strengthening local capacity and achieve sustainability.15 16 A commitment to achieving SDG16 and SDG17 would provide a pathway for academic institutions to move beyond this double standard and think of institutional capacity strengthening and sustainability as a necessary outcome for all partners, regardless of their country of origin.

Seventh, the SDGs can help academic institutions define metrics to determine whether critical, yet hard to measure, ‘soft’ goals are being achieved. For example, despite the growing consensus among development experts on the importance of partnerships in global health, the evidence on the effectiveness of these partnerships remains thin.17 Embracing SDG17 would further incentivise academic institutions to define evidence-based metrics on what makes a partnership successful and how partnerships compare with other models of engagement in global health. At the same time, embracing SDG16 would incentivise academic institutions to define evidence-based metrics to determine whether and to what extent each partner improved its practices and strengthened its capacity over time and whether such capacity leads to long-term sustainability.

Sustainability metrics should address ‘technical domains’ such as clinical care, training and research. For example, many academic institutions in low-income and middle-income countries are still burdened by a severe shortage of faculty. Faculty from high-income countries deployed overseas can help teach local students until these institutions are able to retain some of the new graduates as faculty and can help mentor and supervise local faculty in the early and most critical stages of their career.18 19 However, sustainability metrics should also address ‘enabling domains’ such as administration, infrastructure, equipment, information technology and finance. There are in fact myriads of administrative, legal, technological, financial and even ethical challenges that one encounters when working internationally.8 For example, the lack of well-defined academic career paths in global health, limited grants-management expertise within academic institutions in low-income and middle-income countries, or the persistence of legal and immigration hurdles which prevent academic institutions from hosting foreign faculty and students or from deploying their own overseas can all hinder the success of global health partnerships and the achievement of sustainability.