Zsuzsanna Jakab, WHO Regional Director for Europe, on the importance of the 17 Sustainable Development Goals for the health sector, why we are currently living at the expense of the present and future generations and for which reason health diplomacy is critical to lead us through a period of considerable uncertainty. A short version of the interview is part of an article on page 10 + 11 of the print magazine “Healthy Europe”.
Director Jakab, the 17 Sustainable Development Goals (SDGs)of the 2030 Agenda for Sustainable Developmentof United Nations are meant to end all forms of poverty, fight inequalities and tackle climate change over the next 15 years while ensuring that no one is left behind. What is the importance of the SDGs asa whole for the health sector?
The adoption of the 2030 Agenda and the universal commitment to the SDGscreateunique momentum for public health. The implementation of the SDGs will contribute to the full realization of human rights and fundamental freedoms for all, including the right of everyone to the highest attainable standard of physical and mental health.
Also, the adoption of the 2030 Agenda has clearly shown that the vision of the international community is converging, and that there are growing signs of solidarity in the world. We have unprecedented political determination to strengthen health systems towards universal health coverage, strengthen primary health care, combat major diseases and address the multiple determinants of health through the achievement of all SDGs. With these essential elements in place, we have an excellent opportunity to make major progress in achieving better health and well-being for all people at all ages. The point is that now we have to act together to live up to the pledges we all made in 2015.
What can the health sector contribute to reaching all the SDGs together?
Obviously,its main contribution is the implementation of SDG 3, the “health goal”, which is the most powerful tool for operationalizing health in all policies. This is underpinned by universal health coverage, which is the flagship of the new global vision for WHOapproved by Member States at the World Health Assembly in May this year.But health targets are not limited to SDG 3– almost all of the other 16 goals are directly related to health or contribute to health indirectly, reflecting the complex pattern of health contributions to SDG implementation.
If I have to pick a few key elements that have a strong impact on the implementation of the 2030 Agenda, I would like to highlight the main elements of the SDG roadmapendorsed by European Member States. The first is strengthening health systems towards universal health coverage. By building strong health systems we contribute to reducingpovertyand toincreasing social cohesion and inclusive economic growth.
Another isadvancing governance for health.Implementing the 2030 Agenda requires a high level of political commitment and a whole-of-government, whole-of-society approach. Health ministers and public health authorities play key roles in setting agendas, providing evidence and proposing policies. They can, for example, seek the commitment of heads of state and leaders of other sectors to improve population health and well-being by considering investments in public health, health in all policies and equity.
Ensuring that no one is left behindisanother major focus area.The health sector itself can ensure that everybody has access to quality care and that it does not discriminate against anybody, but it can also lobby for universal social protection, for example.
In addition, advocating forimproving the environmental, social, economic, commercial and cultural determinants of health through a health-in-all-policiesapproachandembedding health promotion and disease prevention in communitiescan probably reduce half of our burden of disease.It is particularly necessary, for example, to tackle the burden of disease from environmental exposures, climate change and unhealthy food systems; to address the risk factors for noncommunicable diseases; to meet the challenges of emergencies, communicable diseases and antimicrobial resistance; to strengthen the factors that promote social protection; and to empower people through education and training.
Plus, the health community can offer expertise, evidence and tools to assessthe effects of health and health equity policies, programmes and processes.
The health sector and health promotion are connected to all other societal sectors, such as agriculture, infrastructure, education, city planning and landscape architecture. Should health therefore be an overarching goal in the context of the SDGs?
Health is an overarching goal. Without health we cannot achieve the SDGs, and to achieve health we need to accomplish all of the SDGs. The SDGs have strong interconnections that extend to all sectors. If properly implemented, actions to achieve the SDGs should span many spheres of governance (such as legal, institutional, technical and fiscal realms) and many sectors (such as those focused on agriculture, transport, energy, justice, welfare, education, security, industry and housing). Ultimately, this will improve people’s living conditions; increase capacity; improve social, environmental and financial protection; create a greener society; and increase security at all levels.
Yet, effective multisectoral action also requires policy coherence across sectors as well as effective multistakeholder governance for health. This means that actors across health and other areas must regularly engage with each other in structured dialogue and, where appropriate, plan and act jointly to maximize shared gains and minimize tradeoffs.
Let me offer an example to show that allSDGs are strongly interconnected and indivisible, meaning that each depends on the success of the others.Poverty (which SDG 1 specifically addresses) is linked to poor health, low salaries, unemployment and low educational outcomes. Without effective and universal education, health coverage and social protection, the risk of poverty is passed from one generation to the next. The implementation of social protection floors that provide universal access to basic social guarantees such as healthcare, disability benefits, unemployment benefits and old-age pensions reduces the risk of poverty and social exclusion.These are specific targets of SDG 1 and SDG 10, but strongly connected to target 3.8 of universal health coverage.
Similarly, out-of-pocket payments for health care(addressed in SDG 3) can have detrimental effects on families, individuals and society by contributing toimpoverishment. Out-of-pocket payments as a proportion of total health expenditure are still high in many countries of the WHO European Region, ranging from 11% to 49% (our benchmark goal is 15%). The outcome statement “Health systems for prosperity and solidarity: leaving no one behind”,adopted by all 53 Member States in Tallinn, Estonia, in June this year, stresses that in order to include everybody, we need to extend coverage to the whole population, improve access to medicines and carefully redesign policies on user charges to protect all households from financial hardship. This has to be addressed throughout a whole-of-the-government approach.
One more example of the interconnectivity of the SDGs involves preserving Earth’s ecosystems on which human societies depend. Climate change and environmental degradation are increasing the risk of extreme weather events and creating greater food and water insecurity, all of which contribute to a higher burden of disease. Approximately 16% of all deathsin the Regionare attributable to environmental factors that could have been prevented and/or eliminated. Much progress could be achieved by focusing on strengthening the implementation of the many national and international commitments that Member States have already made in these areas. In our Region, we have the Ostrava Declarationon environment and health, the implementationof which will contribute to achieving SDGs 3, 6, 7, 9, 11, 12, 13, 14 and 15.
Sustainability means not living at the expense of future generations. Is this currently the case – in Europe and globally?
Let me clarify: sustainability means not living at the expense of future or present generations. How societies live, consume and produce continues to be disconnected from natural environments as a result of long-standing patterns and practices in policies, institutions, technologies and lifestyles. Despite improvements in the last decades, Europe’s ecological footprint is large. If everyone on the planet had the same ecological footprint as the average resident of the European Union, we would need approximately 2.6 Earths to support our demands on nature.
We are living not only at the expense of future generations, but also at the expense of the present generation. Climate change already contributes significantly to the global burden of disease, and its health effects are projected to increase in all countries and regions. The rising numbers of deaths and losses from more frequent heat waves, floods and wildfires that we are already observing are related to our unsustainable lifestyles.
Every year, at least 1.4 million premature deaths in the Region are attributable to environmental risk factors – especially air pollution – and 14 people every day die from diarrhoeal disease due to inadequate water supplies, sanitation and hygiene. This situation is worrisome and the challenges are multifaceted, since the systems that account for a large proportion of our environmental pressures are also linked in complex ways to benefits and interests such as jobs, investments, lifestyles and values.
Yet,the future is hopeful. Europe has some of the world’s highest environmental standards and has set a vision to “live well, within the planet’s ecological limits” by 2050.Adequate investments in environmental and climate policies can generate innovations and sustainable solutions, which can be implemented and exported to help address international environmental and climate challenges more effectively.
Unsustainable lifestyles are damagingto health in various ways. For example, rising rates of obesity, physical inactivityand consequent noncommunicable diseases are results of these health-damaging lifestyles. More than 50% of adults (in 46 countries accounting for 87% of the Region) are overweight or obese, and in several of these countries the rate is close to 70%. Of particular concern are high rates of childhood obesity.Preliminary unpublished data from the WHO European Childhood Obesity Surveillance Initiative (COSI) reveals that in some countries almost 50% of 8-year-old boys were overweight and more than 25% were obese in 2016. Regional estimates for 2016 show that more than 40 million and 5 million of disability-adjusted lifeyears lost per year are attributable to dietary risks and low levels of physical activity, respectively. Based on trends from surveys of adolescents and adults, the Region is unlikely to achieve a 10% relative reduction in prevalence of insufficient physical activity.
Which aspects of sustainability should have priority? Where should we start?
The SDGs are indivisible. This makes prioritizinga single SDG difficult. But a range of so-called accelerators can help to achieveone SDG with multiple benefits for all other SDGs. I will mention just a few.
The first is collective action to achieve shared goals. The 2030Agenda provides the opportunity to strengthen intersectoral and multistakeholder cooperation. The good news is that extensive coordination efforts are scaling up to, for example: meet specific health priorities (such as disease outbreaks);ensure more effective emergency responses; standardize data collection; increase access to priority medicines through joint work on product development, registration, approval, prequalification and distribution; and support universal health coverage.
At this early stage in the implementation of the SDGs, the health community faces a critical opportunity to capitalize on this growing momentum. Our United NationsIssue-based Coalition on Health and Well-being provides a good example: more than 20 United Nations agencies work together in European countries to implement country health priorities through multistakeholder action.
Also, to achieve long-term sustainability and address sustainability challenges, we need fundamental transformations in how we produce and consume; inthe commercial determinants of innovative health technologies andregulations;in ourpractices and behaviours; and in our beliefs and values. For example, addressing the consumption ofultra-processed foods, sugar-sweetened beverages and tobacco requires multisectoral responses involving a range of public- and private-sector actors working in health, industry, finance, environment, media and other areas.
From the health perspective, major investments in health promotion and early disease detection and prevention will allow countries to limit the rising costs of health systems and enable savings if disease can be avoided. Member States are called to place a spotlight on people-centred primary health care as the means to move towards universal health coverageand serve the most disadvantaged, marginalized, stigmatized and hard-to-reach populations. We must carefully considereffectiveness, safety and efficiency; ensurethe continuity, integration and coordination of care; and fosterrespectful and compassionate relations between people and their health-care workers.
We must also ensure that more people are better protected from emergencies. Every country is vulnerable to epidemics and emergencies – these threats are universal. Global and regional earlywarningand event-based surveillance systems are now in place. Early detection, risk assessment, information-sharing and rapid response are essential to avoid illness, injury, death and economic losses on a large scale. However, not all countries have the same risk-preparedness and -management capacities for health emergencies. The implementation of the International Health Regulationsand the Sendai Framework for Disaster Risk Reduction 2015–2030will address this.
The SDGs are not legally binding, but governments are expected to take ownership and establish national frameworks for their achievement. What importance do the SDGs have in the realpolitik, the practical policy of nations?
The fact that the 2030 Agenda is universal, for high- and low-income countries alike, provides an unprecedented opportunity for global governance. Although it is not legally binding, we see more and more countries, international actors and stakeholders engaged in implementing and contributing to the2030 Agenda and achieving the SDGs.
We can see this commitment in, for example, the annual reporting of more than 100 countries worldwide and 36 countries in the Region at the United Nations High-level Political Forum on Sustainable Development. TheForum isan important process for strengthening assessment, review, dialogue, mutual learning and the science–policy interface. Development partners are more engaged in financing solutions for sustainable development, and countries are more and more interestedin aligning national priorities with sustainability principles.
Our analysis of the voluntary national reviews published until 2017 shows that, generally, countries show a willingness to address challenges relating to governance, leadership and engagement. Many countries state commitments to improve energy efficiency, reduce emissions, improve air quality, support renewables, reduce waste, improve recycling, develop information technology, and develop knowledge-based or green economies. However, countries have struggled to apply the broad principles of intersectoral work and to integrate the three dimensions of sustainability – environmental, social and economic – and have engaged in even less discussion on the potential health benefits of wider action on sustainability.
In Europe and globally, we are currently experiencing a conflict between sociopolitical concepts of nationalism and national self-interest and concepts that attach more importance to solidarity within and between nations. Are we currently standing at a crossroads in this regard? What does that mean for the health sector?
We are definitely in a time of emerging challenges, and these challenges are not unique to the health sector. We can be proud of the attributes we assign to European health systems: solidarity, equity and universalism – but, indeed, these are at risk.
The political and public debate is increasingly polarized on climate change, the globalization of hazardous products, terrorism, civil conflicts, vaccination, etc.These complex and sometimes interconnected problems require systemic approaches that involve a wide range of society and multiple levels of governance, from local to global – with recognition of the increasing relevance of regional and local levels.The biggest challenge in this context, however, is to nurture leaders with a strategic vision, technical knowledge, political skills, and an ethical orientation to lead the complex processes of policy formulation and implementation.
Health diplomacy is critical to lead us through this period of considerable uncertainty in Europe and the wider world. Meeting and working together to achieve the SDGs and the European policy framework for health and well-being Health 2020require more and more expertise from Member States and from many state and non-state actors. These efforts require close cooperation on health matters with the European Union and other European organizations. Public health professionals increasingly need a better understanding of the mechanisms of diplomacy, and diplomats engaged in health-related negotiations must be informed of the challenging dimensions of today’s public health.
WHO is committed tocontinue promoting the vital role of health in human development at all levels of government, as well as within the United Nations system and among a range of non-state actors and citizens. We must continue to use human rights-based principals to argue for public health measures to address issues ranging from climate change to tobacco control toadequate standards of living, and to ensurea wide range of civil, political, economic, social and cultural rights.