Global health policy in Sustainable Development Goals

SDGs and ‘governance for health’

The WHO has already reflected on the implications and challenges of the SDGs for health policies with the proposition that ‘used creatively, the SDGs can enhance governance for health’. This proposal is made recognizing the fact that the MDGs had contributed to a more competitive global institutional landscape and fragmented vertical delivery system within countries. The more ‘integrated’ nature of the SDGs is hoped to allow a strengthening of the institutional role of the WHO, in particular, as related to health promotion and social determinants of health. Ilona Kickbush (2015) has emphasized opportunities in relation to governance for health, which has also been reflected in the Lancet and Oslo University Commission Focus on Governance for Health (2014).

However, it remains unclear to what extent the SDGs will improve governance for health or global health policy governance, beyond seeking to change policies with relevance to determinants of health or operating through a more intersectoral approach. In this respect, health is different from broader social policies, as through the WHO, global health policy has had a recognized normative role and institutional presence at global level; this role can be gained, but also lost as a power base for global policymaking if the SDGs become a key reference to global health policies. While the International Labor Organization (ILO) has in practice formed a key forum for a number of social policy issues, including social protection policy debates as part of global normative policies, the institutional presence of global social policy has remained fragmented and often tied to predominantly developmental approaches. The institutional basis of social policies under the United Nations has remained development focused and with limited presence.

Health policies may not have gained substantial ground under the United Nations, but the WHO has, in spite of all criticism, remained a functional forum for ministries of health with a common basis for understanding health-related policy issues and recognition of the global nature of policy discussions under the WHO. The danger is that articulation of the SDG agenda will push decision-making on health from the WHO to the United Nations and more developmental financing focus at a time when global health governance needs a stronger normative global health policy presence and focus. It is also at a point when the WHO struggles with financing (Chan, 2016). One further key challenge for global health policy is to avoid further fragmentation in global health institutional presence and power contest between different institutions and donors. Furthermore, a number of stakeholders and global industries are seeking presence and influence on the normative global health agenda through private and separate funding initiatives and capacities. This would of course serve the agenda of those interested in de-regulatory measures and/or further dismantling the WHO normative presence at global level.

There is clearly scope and potential in the SDGs to address social determinants of health and risk factors for non-communicable diseases, but there still is a danger of undermining, once again, support for health systems. The SDGs are likely to be weak in terms of support for health systems, but there is scope for common interests and policy change as a result of focus on social protection policies. Universal health coverage has remained rather low in the list of targets. The role of the WHO can also become more marginalized in the process as the SDGs are governed under the United Nations (UN) and ministries of foreign affairs rather than ministries of social affairs and health. In global health policy, the poor financing situation of the WHO is already putting its existing responsibilities in danger, including with respect to coordination and antimicrobial resistance (Chan, 2016). As the SDGs are shared goals with many international agencies and stakeholders, it is likely that funding for health will become channeled through several routes. Thus, the strong presence of health-related goals might be good for health in other policies, but not necessarily for the WHO.

The politics of the SDGs will be ‘large tent’ politics. As time goes by, we might realize that some targets and goals proved to be more important than others. The Agenda 2030 is also still based on the development agenda, which is likely to limit the impact of the SDGs in global policymaking within high-income countries. However, even if we accept these limitations, a large tent is good for those who would not otherwise be in the tent at all. For example, in Finland, the SDGs helped to recognize obligations arising from international commitments at a time when the government was keen to reduce the focus of development aid. In this context, the SDGs proved useful in legitimizing a focus on social development and health as part of multilateral cooperation and development aid. In terms of health, there was also a clear danger during the process that health would not be part of plans for a more limited number of goals and targets in support of the SDGs. It is thus better to be inside than outside the tent. Furthermore, new mutually supportive alliances can be built and could emerge, for example, in the area of care policies.

Opening ground for new transformative politics

The SDGs have a strong and explicit focus on the reduction of inequality and an active approach to gender equality, social protection and care, which will remain crucial for health. The value of unpaid care and domestic work is explicitly discussed in Target 5.4. The eradication of extreme poverty and achieving substantial coverage of social protection by 2030 are targets that could be reached and can be essential in supporting universal health coverage as part of broader global social policies.

One of the most interesting reflections on the Agenda 2030 comes from the United Nations Research Institute for Social Development (UNRISD) (2016) flagship report. UNRISD’s presentation of the SDGs as part of transformative change may be too optimistic, but it would be wrong to ignore that the SDGs can and need to be seen in the light of potential and new options. For example, UNRISD (2016) discusses Target 5.4 and transformative care policies, which are defined as ‘those policies that simultaneously guarantee the human rights, agency and well-being of caregivers and care receivers’. Indeed, large share of UNRISD (2016) work fits well under the SDG agenda; some refitting of the UNRISD agenda under the SDGs has also been managed as part of the 2016 flagship report. It might actually be interesting to consider a similar approach for global health policies in positioning, for example, a focus on social determinants of health more explicitly under the Agenda 2030 and the SDGs.

The UNRISD emphasis on new innovations and transformative policies builds on universal and rights-based policy approaches, which could be of more relevance in the context of health policies. This could be a paradigm shift and challenge for global health policies (Buse and Hawkes, 2015; Hawkes and Buse, 2016). A particularly timely task for health policies and global health would be to explore how rights-based approaches could be better utilized for health in the intersectoral policy context and as part of a ‘Health in All Policies’ approach. While the UNRISD enthusiasm for the SDGs as a means for transformative change can provide insights and grounds for cooperation, the context in which the SDGs and the whole United Nations system operate is increasingly contested in terms of power, relevance, and financing for the SDGs. This draws attention to the limits and challenges of the SDGs as a guiding global health policy agenda.

Power, politics, and policy space

In terms of goals and targets, it is clear that many of the targets are merely aspirational, lack precision, and will be hard – if not impossible – to achieve. It is of no surprise that after the MDGs, attention has been focused on targets and measurement (GBD, 2016). However, even if we take for granted that the SDGs and the Agenda 2030 merely provide a broad framework for action and need to be seen as a platform for opportunities, we have a problem if this is associated with limitations to the policy space for the SDGs in other global forums.

Trade and investment agreements have strengthened commercial and investor rights, and forum shifting on regulatory issues suggest efforts to shift toward a more commercial policy driven context of regulation (De Ville and Siles-Brugge, 2016; Mattli and Woods, 2009). If global norms defining policy space for broader public policies are governed under bilateral and multilateral trade and investment agreements, the scope of the SDGs to empower transformative change might become limited. Furthermore, while global investors might be given rights and means to push for realization of these rights through investment arbitration, or court systems as part of investment agreements, the realization of the SDGs will remain dependent on more elusive political will. The inclusion of sustainable development and labor chapters to trade and investment agreements represents part of this trend with the risk of strengthening the importance of trade agreements as key forums for all regulatory policies.

A further question which needs to be asked is to what extent the global health policy agenda should focus on the SDGs; will this have little relevance to policymaking within member states in practice? Could it be seen as a means to distract attention from the aspirational SDG agenda while allowing ‘real’ policies to become implemented in other forums defining the legal and regulatory context of public policies? Yet it is clear that if trade and investment policies define the terms of regulation and standard-setting, this will affect how the SDGs can be sought (Koivusalo, 2014; Koivusalo et al., 2009).

This discrepancy between means and aspiration can become worse if the SDGs and the agenda for change are watered down on the basis of how it is to be implemented. The last goal on Global Partnership for Sustainable Development is thus of particular interest in this context. As part of Goal 17, systemic issues are discussed. These focus on policy and institutional coherence. The emphasis on multi-stakeholder partnerships and the role of the private sector in the implementation of the SDGs has gained concern due to fears of dilution of the agenda and commercialization of how the SDGs are tackled. The focus on policy space is interesting in this context, as emphasis is placed on each country’s policy space and leadership to establish and implement policies for poverty eradication and sustainable development. In other words, no guidance is given on how governments will seek to achieve the set targets.

The SDGs and the Agenda 2030 can be important in supporting global health policies, continuity and legitimacy of action as well as bringing up new potential alliances and transformational change. However, it is important that the limits of the SDGs in supporting public policies for transformative change are recognized and that policy space for effective action toward the SDGs is also recognized as part of other polices, including economic, trade, and investment policies.