While it may have taken a while, Joel Negin’s 2012 call for comments on the SDGs has finally brought forth a steady stream of blogs with a variety of responses, ranging from chimeras and bumblebees, to country and western songs, and a dose of real-politik. At the risk of being branded a bumblebee, I offer a ‘systems view’ of the SDGs.
A good starting point is to go back to the origin of the SDGs. One of the key considerations was the lack of integration in the current approach to development. As Le Blanc [pdf] puts it,
‘Lack of integration across sectors in terms of strategies, policies and implementation has long been perceived as one of the main pitfalls of previous approaches to sustainable development. Insufficient understanding and accounting of trade-offs and synergies across sectors have resulted in incoherent policies, adverse impacts of development policies focused on specific sectors on other sectors, and ultimately in diverging outcomes and trends across broad objectives for sustainable development’.
This has particularly been an issue for health professionals and researchers, as we recognise that progress on the major global health problems, such as non-communicable disease, environmental health, and mental illness, requires action in a range of sectors outside health. We also recognise that these social, economic and political determinants are part of complex interacting systems, with interconnections at local, regional, national and international levels.
Having recognised this problem, how have the SDGs addressed it? Following an exhaustive process of consultation, we have 169 targets across 17 goals. What is important is that the goals and targets are explicitly inter-linked, with achievement of targets in one goal requiring contributions from targets in other goals. Le Blanc presents a useful analysis of the interconnections in the health sector, identifying nine targets under SDG 3, and seven additional targets under goals 2, 6, 11 and 12 that explicitly refer to health. The SDGs are thus a ‘network of targets’.
While we might hope, with LeBlanc, that this interconnection of targets will ‘facilitate integration and policy coherence across sectors’, as well as ‘real mainstreaming of dimensions that previously suffered from not having strong sectoral anchoring’, it is probably wise to retain a degree of scepticism, and consider how they will be implemented.
This is surely the crux. The SDGs are the result of both a political and a technical process. They have both ‘political value and instrumental value’, as LeBlanc expresses it. The political value is in the consensus and agreement. Can we now translate that to achieving instrumental value?
This is where systems thinking comes in. Systems thinking is not new, and has been applied in several sectors, notably in health and the environment. It ‘adopts a perspective that encompasses the inherent complexity of a public health problem and … takes into account the interrelations, reciprocity, discontinuity, and dynamic nature of influences on health and health behaviours within a broader context’ (Atkinson et al, 2015).
However, as Atkinson et al note, this does not mean a comprehensive strategy intervening at all possible system connections. Rather, a systems approach ‘seeks to identify where best to focus public health action’ to ‘inform more efficient targeting of resources… using particular interventions… projected to have greatest impact’. They note that ‘how we intervene in a system can be much more important than where we intervene’.
It also means moving away from the current simplistic approach of attempting ‘to systematically implement standard health interventions in different countries as suggested by [international agencies such as] the World Health Organization’ (Blanchet, 2015).
This will require more intensive individual country level analysis to identify how systems operate, characterise their interconnections and decide where to address them. Weitz et al suggest a ‘nexus’ approach, to explore and better characterise the types of interactions between targets in different sectors, and to identify potential trade-offs, synergies, and constraints. This is something we at the Nossal Institute hope to explore further in the nexus between mental health and non-communicable disease and disability. But clearly significant resources will be needed, both from within countries and from the international community, to support this type of analysis.
As Weitz et al note, ‘[c]ountries will face different trade-offs and synergies, and find different ways to improve development outcomes, emphasizing different targets. Thus, the targets can be seen as building blocks that each country will combine in its own way, balancing the need for ensuring access to resources, efficiency, and long-term sustainability to fit the local context and capabilities.’
The SDGs provide a new and stronger rationale to engage across sectors in addressing the complex interaction between social and economic determinants that are currently the major contributors to ill-health, and to use systems analysis to identify effective leverage points for interventions to achieve cross-sectoral targets and goals. The challenge will be to convert this into action. From a health perspective, the systems thinking embedded in the structure of the 2030 Development Agenda is what will allow the SDGs to take flight.
Krishna Hort is acting Chief Executive Officer, Nossal Institute Ltd, and senior advisor in the Governance and Financing Unit at the Nossal Institute for Global Health, University of Melbourne.