SDGs and Health: A Vision for Public Policy

Challenge

Despite decades of accelerated health innovation, there are still devastating gaps in health outcomes between and within countries. Life expectancy varies drastically between rich and poor, healthcare is not universally accessible, and too many lives are cut short by preventable infectious and chronic diseases. Ensuring ‘health for all’ remains a persistent and entrenched global challenge.

The G20, in its 2016 “G20 Action Plan on the 2030 Agenda for Sustainable Development”, recognized health as a “necessary component for socio-economic stability”, and “a key aspect of sustainable development” ¹. It also noted the “need for an improved and coordinated approach to strengthening health systems, thereby contributing to universal health coverage”. The challenge now is for all G20 governments to align with these statements by elevating the priority accorded to health, and to acknowledge the centrality of health to achieving the SDGs.

The G20 Action Plan lists Global Health as the last of fifteen Sustainable Development Sectors (SDS). Understanding that the G20 will prioritize sectors of Agenda 2030 where it has comparative advantage and adds value as a global economic forum, we argue that investment in health reduces poverty, contributes to economic growth, strengthens labor productivity, builds more equitable societies, and addresses the need for gender equality. As the G20 Action Plan is updated and adapted to reflect successive G20 priorities until 2030, the Global Health SDS should achieve ever-increasing prominence on the G20 agenda.

We believe a collective G20 vision for Global Health is a priority, because:

• “Health and its determinants influence – and are influenced by – other goals and targets”².  Health is both a precondition and an outcome of socioeconomic and sustainable development policies, and analysis of health impacts is a necessary part of all public policy processes.
• Health is a fundamental human right, as embodied in Agenda 2030 and the SDGs. This incentivizes universal health coverage (UHC) and other proactive measures to reach the furthest behind first, regardless of economic benefit or cross-border impacts³. UHC is a unifying platform for the health-related SDGs and targets, but bold political commitment and strong governance are essential to make UHC a reality for all countries.
• The collection and use of high quality health data remains weak in many countries. Credible mechanisms to collect and share data with the wider public are crucial, as are robust systems and credible institutions for tracking progress towards health-related SDGs and assuring public accountability.

The SDGs now provide the framing, the moment, and the imperative for Global Health. We invite G20 leaders to share in the vision outlined in this document, to fulfill the promise of the G20 Action Plan on the 2030 Agenda, and to “make progress on realising the goals” – a main objective of the German G20 presidency.

Proposal

In September 2015, 194 countries signed on to the Sustainable Development Goals (SDGs), providing an ambitious, universal and transformational vision. For all stakeholders in global health, the “first 1000 days” of SDG implementation present an opportunity to capitalize on growing momentum, particularly as many countries are now organizing themselves in response. “Healthy lives and well-being for all” is without doubt a global goal (SDG3), made all the more relevant by the continued emergence of new global health challenges and pandemics.

This Policy Brief presents to G20 members a vision for political leadership in which concerted attention is given to catalyzing progress towards the SDGs by recognizing the centrality of health. It calls for  health-related policy-making that is grounded in robust evidence and analysis; that connects citizens with decision makers; that bridges local with global; and that generates creative yet grounded solutions to persistent health problems. It also calls on political leaders and policy makers to clearly recognize the role that health-for-all can play in building nations that are more inclusive, less divided, and less polarized.

We call on the G20 to embrace this challenge by joining in a shared vision, whereby:

• Health is integrated in all policies;
• The most vulnerable are prioritized;
• Citizens and communities are engaged in a whole-of-society approach; and
• Health data gaps are filled and evidence is used to inform policy and practice.

2.1) Adopt a Health in All Policies approach

Given their universal and multi-sectoral nature, each SDG has a relationship to health and wellbeing, and so there is an urgent need to elevate health to a higher level of priority and importance in many national contexts. The Shanghai Declaration on Promoting Health in the 2030 Agenda reinforces that good governance at all levels is crucial for better health^4,. This requires investment and action at national, local and global level. Concrete action is needed to address the damaging effects of unsustainable production and consumption (SDG 12), to give consideration to offset economic policies that create unemployment and unsafe working conditions (SDG 8), and to address marketing, investment and trade when it compromises health (SDGs 16 and 17).

• G20 countries should acknowledge and recognise the economic case for investing in health, in order to avoid the ongoing challenge of premature mortality and to make significant progress towards achieving sound health for all citizens. Health is a crucial entry-point to achieving the SDGs because it is:
  • a powerful strategy for lifting people out of poverty;
  • central for individual / household / national growth and development;
  • a critical component of human capital, and as such contributes to employability and productivity.
• We urge G20 countries to  acknowledge health as a fundamental human right and to ensure that all citizens have access to good health and wellbeing, since the economic case is insufficient alone if real progress is to be made towards achieving the health-related SDGs. The overall goal to leave no one behind is particularly important for health and related not only to SDG 1 on poverty, but to broader inequalities as indicated through SDG 11, and is closely linked to gender inequalities as indicated in SDG 5. Even as extreme poverty has been reduced globally, the inequalities within and between countries have grown and need to be addressed. Development aid is an important but a small factor in addressing this challenge.
• G20 countries should introduce measures to address upstream determinants of health such as education and early child development, as seen already in a number of countries. There is practically no health issue that does not need joint action with other sectors. For example, the agriculture and animal sector must work jointly to address anti-microbial resistance (AMR); the role of the security sectors is critical in avoiding major disease outbreaks and onward transmission; and non-communicable diseases (NCDs) can only be addressed through action on food systems, city planning, and health literacy.
• G20 countries should explore ways to make health a whole-of-government priority and ensure the cooperation between different sectors of government through a range of mechanisms and institutions⁵. They may find inspiration from those governments that have already adopted new bills and legislation which include health-impact-assessment as part of the adoption of new policies, and which give the health minister special rights when population health is at stake. We encourage them to review the 2017 Adelaide Statement on Health in All Policies which has set out key components of a successful health in all policies approach⁶.
• We urge all G20 countries to adopt a whole-of-society approach to health. This is best realised at the local and community level; the Shanghai Declaration, for example, put a special emphasis on cities (SDG 11) ⁴.
• G20 countries should put in place transformative strategies to address rapid urbanization, since these will be critical for improved health outcomes; the co-benefits of investing in environmental and health measures have been shown to be significant. Mayors around the world are becoming some of the most important instigators of health in all policies to address health, well-being and quality of life in their cities; increasingly they are also becoming an important global voice for SDG action.

2.2) Reach the furthest behind, first

Universal health coverage (UHC), based as it is on principles of justice and equity, addresses both the social determinants and the social implications of health by acting on the broader socioeconomic inequities that leave people behind⁷. UHC is a critical tool to enhance the legitimacy of national governments and reduce the threat of fragility by making citizens feel that they are being cared for in the most personal ways – health touches our lives like nothing else. International cooperation on improving the health of those left-behind, especially the worst-off, also has the potential to enhance the legitimacy of international institutions and forums like the G20.

• G20 governments should adopt and implement UHC in their countries – as well as support it in the least developing countries particularly – in the most comprehensive form possible. Exclusions of coverage should be exceptions rather than the norm. Strategic approaches will be needed from all governments to ensure that coverage is equitable, and that inequities are avoided in health outcomes.
• G20 countries should prioritize the health and well-being of the most vulnerable and marginalized within their own national contexts, rather than aiming for the “lowest hanging fruit” as a way of demonstrating more rapid success in meeting targets. This should also be the key criterion for  monitoring the performance of UHC and measuring its success⁸.
• G20 governments should identify marginalized populations based on the criteria of health (access and outcomes) as well as wealth (health as human capital),and show leadership and develop health strategies for these populations. All the dimensions of marginality (availability, accessibility and affordability) should be taken into consideration while designing appropriate policies^8,9.
• G20 governments should accept responsibility for citizens’ health, promote accountability and ensure transparency of health systems. UHC cannot be efficient or fiscally sustainable without responsibility, accountability and transparency at various levels of health system governance¹⁰.
• G20 countries contributing towards development goals in the low and middle income countries should focus on health service delivery, where an enormous burden of disease, disability and premature mortality is concentrated among the worst-off¹¹
• G20 countries should keep inclusive growth and health for all, including health for the most vulnerable, at the core of their agenda. This is key to ensuring legitimacy of governments.

2. 3) Engage Citizens in a Whole-of-society approach

The SDG mantra of “leaving no one behind” applies resoundingly to the pervasive health inequities that challenge all countries, including the G20 nations. The SDG framework provides a platform for G20 countries to take the lead on a reconfiguration of public policy processes that engage citizens and empower communities inclusively, in a whole-of-society approach. Without such a transformative measure, we believe the SDGs, and specifically the Goal of health and well-being for all, will not be attained. The 1978 Alma Ata Declaration emphasized the mainstreaming of health equity on the international political agenda and its focus on primary health care and people centered care¹²: “People have a right and duty to participate individually and collectively in the planning and implementation of their health care”. Since then, the concept of primary health care has become a core concept of the World Health Organization’s (WHO) goal of health for all¹².

We believe that engaging communities in decision-making, planning, and implementing programs and policies that are about their own health and well-being can lead to sustainable change^13-16. Engagement goes beyond broad participation of citizen groups, however, and the inclusion of women and the most vulnerable groups in these processes as key stakeholders and agents of change is crucial in solving health inequities.  We argue that citizen knowledge, for example on perceptions of quality of local health care services that go beyond providing data only on access to services¹⁷, is essential if we are to not only focus on achieving health outcomes, but also to understand the mechanisms by which these are achieved. Regular dialogue and relationship building between health system actors and service users are central to addressing tensions, changing mindsets and fostering respectful and culturally appropriate health care practices¹⁶.

• We urge G20 countries to promote citizen engagement in public policy processes to help improve health and well-being, and to increase state effectiveness. There is very strong evidence to show that effective, inclusive citizen engagement supports positive social outcomes¹⁸.
• G20 countries should encourage citizen-led ownership of strategies and processes for health improvement, since these are more likely to lead to positive health outcomes. Although citizens in many national contexts are frustrated about the barriers preventing their engagement in the policy processes and decisions that affect their daily lives, evidence shows (for example in recent efforts to mobilise communities around prevention of spread of Dengue fever) ¹⁵ that when spaces are created and their voices are heard citizens and communities can mobilise to bring about transformative change.
• We urge G20 countries, given the scale and complexity of global health-related challenges, to contribute to both global and local efforts to build international alliances between countries, cities, civil society organisations and citizens to address the economic, social and political determinants of health⁶. They should pay particular attention to support for strong and effective action not only by national governments but by citizens – through mobilisation of communities, and particularly through inclusion of women, and representation of marginalised societal groups.
• G20 countries should put in place processes and mechanisms to facilitate citizen engagement in data collection, monitoring and feedback mechanisms, in order to increase public accountability, and to help make progress towards complex health challenges. There is growing evidence for the value of gathering user evidence of the problems community members experience regarding health care and services¹⁶ and increased availability of tested digital technology for G20 countries to implement these feedback mechanisms.
• We urge G20 countries to work closely with trusted conveners and “honest brokers”, such as think tanks and policy research institutions, to not only bring evidence, data and analysis to bear on health policy issues, but also to convene spaces and platforms where different societal actors can engage in these debates in an informed, equitable and inclusive way. To achieve a “whole of society” approach, we believe that G20 nations should support such enabling actors, and prioritize more systematic, ongoing integration of citizens’ inputs into health priority setting and health governance that eventually leads to sound health policies, and to their effective, and accountable implementation.

2. 4) Fill the health data gaps

The Global Partnership on Sustainable Development Data (2017) states: “Whether for reasons of convenience, cost, or corruption, important decisions about how money and resources are allocated to services helping the poorest people in the world’s least developed countries are too often made based on data that is incomplete, inaccessible, or simply inaccurate — from health to gender equality, human rights to economics, and education to agriculture” ¹⁹. Access to quality data will make an enormous contribution to progress to achieving the SDGs. In many countries, however, there are still persistent problems related to health data availability, quality, and reliability.

In order to enhance health care coverage, for example, there needs to be an understanding of existing gaps, in particular data on who currently does not have access and who is being impoverished because of health care costs. Across and within countries, lack of data comparability remains a challenge to monitoring global progress against the forty-plus health-related SDG indicators. It is clear that better data and statistics will help governments track progress, ensure decisions are evidence-based, and strengthen accountability. A major limitation is the insufficient disaggregation of data at sub-national levels. To increase odds that “no one is left behind”, significant efforts will also be needed to fill gaps in the disaggregation of national-level data.

There is also a crucial need for well-functioning civil registration and vital statistics (CRVS) systems, which provide policy makers with reliable, up-to-date data in real time and at the lowest administrative level of the population. Without a CRVS system registering all births, deaths, and causes-of-death (at a minimum), policy makers are relying on surveys, census and other sources of incomplete data; health information systems may then not capture the entire population, and may miss the most vulnerable members of society.

• G20 countries should urgently address the challenge of health data gaps, adopt an inter-sectoral approach to data collection, and put in place mechanisms to collect data across all sectors for the SDGs.
• We urge G20 countries to expand data collection geographically, and ensure the varied social determinants of health are represented through inclusion of relevant indicators in data collection.
• G20 countries should create mechanisms for easy and free access to data to maximize data utilization in research and policy-making, for example by strengthening institutions responsible for data collection and storage, or through establishing data dashboards and portals. They should also establish quality control mechanisms to reduce the risks associated with data duplication and unreliability.
• G20 countries should support the establishment and strengthening of civil registration and vital statistics (CRVS) systems both domestically and internationally via foreign aid investments.
• G20 countries should involve citizens and communities in generation, collection, analysis and use of health-related data, to contextualize information and generate local solutions that are workable and are owned and driven by the people themselves.
• We urge G20 countries to liaise with a diverse set of stakeholders to benefit from their comparative advantage in addressing the health data gap; including the private sector to ensure that health data collected by business and private companies is more widely available for public policy making processes and accountability, and with think tanks and policy research institutions as convenors of different stakeholders in Global Health to promote evidence-based policy making.

References

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