The role of Global Health Diplomacy in advancing the Sustainable Development Goals

The Millennium Development Goals

The Millennium Development Goals (MDGs), established in 2000, represented a concerted effort by all 191 members of the United Nations to address the world’s most critical issues. The MDGs were eight clear global goals set to be achieved by 2015. Each goal had multiple measurable targets that varied from eradicating extreme poverty and hunger to ensuring environmental sustainability. Three out of the eight MDGs were directly related to health. MDG 6 prioritized the fight against HIV/AIDS, malaria, and other diseases. MDG 4 and MDG 5 aimed to reduce child mortality and improve maternal health. The MDGs were interdependent, as MDG 1 (eradicate extreme poverty and hunger), MDG 3 (promote gender equality and empower women), and MDG 8 (develop a global partnership for development) all influenced and were influenced by health.

The final MDG Report highlights the successes of the 15-year project. Progress has been made in the fight against HIV/AIDS, malaria, and tuberculosis. According to the report, cases of HIV infections have decreased from 3.5 million to 2.1 million. The number of HIV-infected people receiving antiretroviral therapy has increased from 800,000 to 13.6 million. More than 6.2 million malaria deaths have been prevented, and an estimated 37 million lives have been saved by tuberculosis prevention and treatment. Furthermore, there has been a significant improvement in reducing maternal and child mortality rates. Global maternal mortality ratio has declined from 380 to 210 deaths per 100,000 live births; the global percentage of births attended by skilled medical personnel has increased from 59 percent to 71 percent; and the use of contraceptives among women aged 15–49 has increased from 55 percent to 64 percent. Between 1990 and 2015, the global under-five mortality rate decreased from 90 to 43 deaths per 1,000 live births. ²

Nonetheless, out of the six measurable targets of MDGs 4, 5, and 6, only one was achieved. Despite the progress made in maternal and child mortality rates, all countries failed the goal of cutting the under-five mortality rate by two-thirds (target 4.A) and the maternal mortality rate by three-quarters (target 5.A). While the target 5.B aimed to achieve universal access to reproductive health by 2015, only 52 percent of pregnant women had access to adequate antenatal care, and 64 percent of women aged 15–49 had access to contraceptives by the deadline. The goal of having HIV/AIDS halted by 2015 (target 6.A) also failed, as 2.1 million new cases still occurred per year. Finally, global access to HIV/AIDS treatment (target 6.B) increased from 3 percent to 45 percent, instead of targeted 100 percent. Reversal of malaria and tuberculosis incidence (target 6.C) was the only target achieved from the health-related MDGs. ³ In general, UN statistics show that more than 400 million people still lack access to essential health services, 15 million HIV-infected patients are still waiting for antiretroviral treatment, 7 million deaths every year are caused by pollution, and every two seconds someone aged 30–70 dies from noncommunicable diseases. ⁴

The lack of success in the MDGs is most evident in the poorest regions. While some countries improved significantly, the most vulnerable communities were left behind. There remains a 33-year difference between the life expectancies of Japan and Sierra Leone, the countries with the longest and the shortest life expectancies. In sub-Saharan Africa, the chances of a child dying before the age of five are 15 times higher than in high-income countries, and the most vulnerable children of sub-Saharan Africa still lack access to sanitation facilities. ⁵ UNICEF’s executive director Anthony Lake noted that “in setting broad global goals the MDGs inadvertently encouraged nations to measure progress through national averages. In the rush to make that progress, many focused on the easiest-to-reach children and communities, not those in greatest need.” ⁶ Even though the MDGs were not fully achieved, the overall performance can be used to evaluate where the focus needs to be concentrated.

The Sustainable Development Goals

As a follow-up to the MDGs, the UN Member States created a new set of global goals—the Sustainable Development Goals (SDGs). The SDGs were created in 2012 at the UN Conference on Sustainable Development in Rio de Janeiro, and are set to be achieved by 2030. The SDGs comprise 17 goals that build on the successes and shortcomings of the MDGs, and aim to continue the UN development agenda without compromising the well-being of future generations. The SDGs are based on three core principles: economic growth, social inclusion, and environmental protection. ⁷ The overall result depends on the success of each of these elements.

Like the MDGs, some of the SDGs are health related and look to advance the progress made by the MDGs in life expectancy, child and maternal mortality rates, clean water and sanitation, and the fight against diseases such as malaria, tuberculosis, polio, and HIV/AIDS. SDG 3 (good health and well-being) has 13 specific targets and aims to achieve universal health coverage, eliminate major and tropical diseases, battle substance abuse, minimize the injuries from traffic- and work-related accidents, and strengthen the capacity of all countries to manage national and global health risks. ⁸ Other SDGs aim to advance health-related goals by eradicating hunger, increasing access to clean water and sanitation, encouraging responsible consumption and production, taking action to combat climate change, and strengthening the global partnerships for sustainable development.

The role of GHD in advancing the SDGs

The MDGs targeted specific health problems that were prevalent in the 2000s. Therefore, global health actors participated mainly in disease-specific vertical initiatives that aimed to eliminate or contain diseases such as HIV/AIDS, malaria, and tuberculosis. Vertical programs are especially attractive to donors from developed countries who look for measurable returns on their limited investments. Vertical initiatives prioritize short-term results, and are often focused on the small geographic areas where the problems are threatening. The MDGs have been most successful in the fight against the diseases such as malaria and tuberculosis, as well as child and maternal mortality, but as the 2014 West African Ebola outbreak demonstrated, the international community is still ill-prepared for major health crises. Mistakes were made by national governments, global actors, and international organizations at almost every stage. Local health systems were quickly overwhelmed with patients, an emergency was not declared on time, and the international response was delayed.

Compared with the MDGs, the SDGs are universal and more interdependent. Jeffrey Sachs, the special advisor to the UN secretary-general on the SDGs, points out:

The MDGs were targets mainly for poor countries, to which rich countries were to add their solidarity and assistance through finances and technology. The SDGs will, necessarily, have a different feel about them. Sustainable development is eluding the entire planet. The SDGs should therefore pose goals and challenges for all countries—not what the rich should do for the poor, but what all countries together should do for the global well-being of this generation and those to come. ⁹

SDG 3 makes a bold promise of universal health coverage and good health and well-being. Promising everything to everyone is a risky venture, and requires a careful approach by health actors worldwide. GHD can play a central role in advancing the SDGs by serving as a platform of coordination between multiple levels of global health actors. In the globalization era, when migration and porous borders allow viruses like Ebola to be spread across countries, health problems cannot be dealt with by nation states acting in isolation. The role of GHD is to bring together states and private health actors to negotiate and make collective decisions. The next two sections will discuss how GHD can advance the SDGs by facilitating a multisectoral approach through the Health in All Policies (HiAP) framework and South–South cooperation.

Health in All Policies

Health problems are determined by a variety of social, economic, and political factors that are beyond the reach of health officials. SDG 3, for example, aims to minimize the deaths and injuries caused by road accidents. However, the issues surrounding transportation are outside the scope of health sectors, and are determined by the departments of transportation. It is not debatable that road accidents pose a significant risk to people’s health and safety and need to be considered in one way or another. Health problems also spill over to other areas and pose a threat to national security and economic well-being. Politicians are often reluctant to spend for prevention, as the funds directed at potential outbreaks are not always justified. Compared with the financial risks of pandemics, the costs associated with prevention are trivial. ¹⁰

Given that health problems are caused by various factors and spill over to other areas, a multisectoral approach that will apply a health lens to public policy is required. In order to build the capacity of intersectoral cooperation, health sectors should seek to cooperate with other departments to collectively address the health determinants. HiAP is a framework that advises policymakers across different sectors to consider the health implications of their decisions and avoid harmful effects in order to improve population health and well-being. Health is not always a priority over other goals, but policymakers need to take into account that their decisions have an impact on population health, and that it is necessary to protect people’s health. HiAP introduces health as an added value to public policies, helps identify unintended health outcomes, and increases accountability of policymakers toward people. ¹¹

The HiAP approach has been successfully implemented in South Australia, Finland, Thailand, and various other parts of the world. Developing countries like Suriname, Namibia, and Zambia have achieved substantial health gains by applying a health lens to public policy. HiAP was first adopted by South Australia in 2007, and since then it has gained support from the Australian government. The South Australian HiAP approach is based on two core principles: strong overarching governance, and flexible partnerships across the government sectors. The HiAP model in South Australia is focused on achieving progress in health and well-being through the policies of other sectors, by applying a health lens to the range of initiatives that can potentially improve population health. Health Lens Analysis (HLA) was a policy from the 2012–2014 period of South Australia’s mining-led economic development that required the department of state development to consider social and environmental impacts of their economic activity in the mining regions. HLA was a learning experience for the department on how to adopt evidence-based regional planning and how to better address the needs of the communities in rural areas. ¹² In Sweden, the Vision Zero program, initiated by the Swedish Road and Traffic Safety Agency, coordinated the partnerships between the transport, justice, environment, health, and education ministries to reduce road fatalities to zero by 2020. Road safety measures such as speed limits, seat belt use, and random breath testing, as well as the broader promotion of safe driving, resulted in the decrease of deaths from road crashes from 9.1 per 100,000 in 1990 to 2.8 per 100,000 in 2010. ¹³

Requiring every sector to consider the health impacts of their policies may not always yield win–win solutions, as policymakers rarely prioritize health outcomes over economic gains. Unlike the MDGs, which had eight goals and 21 targets, the SDGs have 17 goals and 169 targets, meaning that different actors will prioritize some goals over others, increasing the fragmentation of a global approach toward the SDGs. GHD provides an opportunity to create linkages between multiple sectors, and to facilitate negotiations between these sectors to shape public policies that take health effects into account. Success in the SDGs largely depends on the political will of the actors, and GHD will be instrumental in bridging the priorities of health and governance. The practice of health diplomacy will encourage the actors to consider mutual and opposing interests and develop responsible public policies that will lead to improved health outcomes.

South–South cooperation

Many achievements of the MDGs were concentrated in the easily achievable goals, and progress varied considerably across the geographic areas. Despite the improvements, the Global South, especially sub-Saharan Africa, still lacks reliable health systems and is unprepared for health crises. Inferior public health infrastructure, high levels of poverty, and frequent civil conflict make Africa the continent most vulnerable to disease outbreaks. The current global health system does not allow low-income countries to find their own solutions. While the Global South is ill-prepared to detect or contain disease outbreaks, the Global North seeks its own agenda and shows minimal interest until its own citizens are threatened. Besides, development aid provided by rich to poor countries often comes with ulterior political motives that produce dependence and potentially lead to negative consequences. Given these circumstances, the Global South should take an innovative route in advancing its health agenda.

Success in the SDGs requires a comprehensive approach that aims to strengthen health systems in the most vulnerable areas. In order to ensure that the SDGs are achieved, the Global South must overcome dependence on the Global North and create sustainable health systems to prevent the disasters caused by outbreaks. An alternative model to the unequal North–South relationship is South–South cooperation. After the end of the Cold War, former developing countries, such as China, Brazil, and South Africa, emerged as powerful economic and political centres within their regions. The redistribution of regional powers provides an opportunity for South–South cooperation to replace North–South dependence. Based on shared goals and experiences, South–South cooperation allows the development of interdependent relationships among equal actors. According to Paulo Marchiori Buss and Miriam Faid, cooperative activities between the Global South states involve the mutual exchange of strategic procedures and technical expertise, as well as “different mechanisms, including, for example, institution-building, capacity-building, the dispatch of human resources and technology, foreign aid or foreign direct investments.” ¹⁴

Organizations such as the Association of Southeast Asian Nations (ASEAN), the African Union (AU), and the Union of South American Nations (UNASUR) have already proved to be effective at advancing the health agenda in their respective regions. ASEAN countries started to recognize public health threats as national issues, and successfully responded to the SARS epidemic by applying diplomatic strategies. ASEAN’s main accomplishment is the ASEAN Strategic Framework on Health and Development, a 15-year, health-oriented project promoting cooperation among the ASEAN members. Multiple ASEAN countries began knowledge-sharing and strategy-building activities to improve rapid response capacity and ease the public’s access to healthcare. Negotiations by the AU resulted in initiatives such as the Abuja Declaration, an agreement by the members to contribute 15 percent of their national budgets to health. Health has also entered the priorities of the New Partnership for Africa’s Development, which shows that developing countries effectively use health diplomacy in their negotiations. UNASUR has established the institute to increase the knowledge of health governance and develop better preparedness for potential risks. ¹⁵

The practice of health diplomacy among the Global South states is imperative for the success of the SDGs. The majority of Global South countries are still far behind the developed world, and with the current capacity, it will take too long for them to catch up. Several African countries have found innovative ways to provide health services and train health workers by applying modern technology. Given that many developing countries experience similar health challenges, sharing and scaling up these solutions will have a profound effect on sustainable development. Implementation of GHD by the leaders of the Global South is vital for them to consolidate strategic partnerships and promote cross-country collaboration, instead of protecting their innovations. South–South cooperation will shift the focus from disease-specific to a more comprehensive approach, and allow developing countries to grow into active agents with a sense of control over their future well-being.

Conclusion

Moving ahead, success in the SDGs largely depends on learning valuable lessons from the MDGs and making appropriate adjustments in the areas of improvement. Globalization has changed the fundamentals of global health politics and made many established practices obsolete. The practice of GHD will be necessary to organize global health governance into a cooperative arena, in which health actors will complement each other to advance the SDGs collectively. The urgency of sustainable development must mobilize national governments, organizations, and civil society to unite in the fight for the SDGs, abandon outdated practices of governance, and protect future generations from the detrimental results of today’s selfish decisions.