The 2030 Agenda and Sustainable Development Goals: Placing Environmental Health in a Larger Ethical Framework

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ABSTRACT

"Healthy lives" is one of the 17 Sustainable Development Goals (SDGs) adopted with the 2030 Agenda at a UN summit in September 2015, and many of the SDG targets relate to environmental health. There are 13 targets under the health goal, and 17 relevant targets under other goals. These show how the SDGs are an integrated set that must be implemented together. The World Health Organization has prepared a detailed assessment of health within the SDGs. Environmental health is also placed in a larger framework encompassing the economic, social and environmental dimensions of human well-being and planetary sustainability. Advancing on these dimensions will also contribute to improved health. The UN has adopted indicators for each of the SDG targets to monitor progress at the global level. Governments now need to adapt this framework to the national level and priorities. One challenge is data disaggregation to identify marginalized groups and those missed in present data collection. Ultimately, this should make it easier to identify determinants of environmental health and populations at risk. Ethical principles are inherent in the SDGs, which aim to eliminate poverty, reduce inequalities and leave no one behind. An ethical approach will be important to win wide public support for the SDG process, and environmental health will be one of the most immediate and relevant goals for the general public. This is also an opportunity for the environmental health community to build broader support for its work.

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INTRODUCTION TO THE SUSTAINABLE DEVELOPMENT GOALS

The 17 Sustainable Development Goals adopted with the 2030 Agenda at a UN summit in September 2015 (UN 2015) represent a set of challenges for everyone. They provide an ambitious agenda accepted by governments at the highest level to achieve justice and equity in the world by 2030, leaving no one behind. Unlike the Millennium Development Goals, they are as relevant to industrialized countries and service-based economies as to developing countries, and to the wealthy as well as the poor. They include a strong focus on environmental health, while integrating health into a broad agenda including economic, social and environmental dimensions.

In 2014, the UN Secretary-General stated, "sustainable development must be an integrated agenda for economic, environmental, and social solutions. Its strength lies in the interweaving of its dimensions. This integration provides the basis for economic models that benefit people and the environment; for environmental solutions that contribute to progress; for social approaches that add to economic dynamism and allow for the preservation and sustainable use of the environmental common; and for reinforcing human rights, equality, and sustainability. Responding to all goals as a cohesive and integrated whole will be critical to ensuring the transformations needed at scale." (UN 2014)

There are different synergies and trade-offs between goals and targets, with progress on some necessary to achieve others, or advancing on some, like continuing economic growth, even incompatible in some cases with others like staying within planetary limits (Nilsson et al. 2016). This is why an integrated approach combining all the goals is so important. Different national circumstances will require differentiated responses, sometimes in opposite directions, to achieve the global goals. The environmental health challenges of cities are different from those of rural areas, and of the rich from the poor. It is also important to recognize that the framework of targets and indicators underlying the SDGs is far from finished. Work is needed to refine the targets, to strengthen their scientific foundations, and to complete the set of appropriate indicators. Many refinements will be needed in the years ahead (Dahl 2015).

The International Council for Science and the International Social Science Council reviewed the targets for the Sustainable Development Goals from a science perspective. Of 169 targets beneath the 17 goals, 29% were well defined and based on the latest scientific evidence, 54% needed more work, and 17% were weak or non-essential. Many targets suffered from a lack of integration, from repetition, or had vague, qualitative language. The scientists emphasized the need for hard, measurable, time-bound, quantitative targets. They pointed out that the goals were presented in ‘silos’ without interlinking, and that there was a danger of conflicts between different goals, such as in the trade-offs between overcoming poverty and moving towards sustainability (Dahl 2015; ICSU/ISSC 2015).

The focus on an integrated approach will be especially difficult at the national level, since governments are not structured to integrate easily across ministries and departments, and seldom take a broad long-term view of their responsibilities. A whole new culture of consultation and collaboration needs to be developed to overcome the silos in which government ministries usually function. This needs to be part of the development of the SDGs at the national level, in both the design of national goals and indicators, and in the monitoring process.

The UN Statistical Commission was charged by the UN General Assembly to agree on the indicators to measure progress on the Sustainable Development Goals (SDGs). The initial 241 indicators were approved at the Statistical Commission Forty-seventh session on 8-11 March 2016 (IAEG-SDGs 2016). In selecting the indicators, the criteria used by the IAEG were relevance, methodological soundness and measurability. They considered the need for the total number to be limited and for the indicators to be easy to communicate.

The indicators will require an unprecedented amount of data to be produced and analyzed. There are many indicators for which data are not yet available. In some cases, work on the statistical standards and methodologies needs to be undertaken before the necessary data can be collected.

The global indicator framework will be the basis for the Secretary-General's annual progress report on the Sustainable Development Goals. Refinements and improvements will be needed over the years, as knowledge improves and new tools and data sources become available.

Two major issues have been identified: interlinkages across goals and targets, and data disaggregation and the coverage of particular groups of the population in order to fulfil the main principle of the 2030 Agenda of leaving no one behind. Interlinkages and the use of indicators that cover a number of goals and targets are subject to research at the present time. This is not of immediate concern for monitoring by governments at this stage in implementation.

Disaggregation, however, is an overarching principle and an immediate priority if the intention of the 2030 Agenda is to be realized. The General Assembly decided that “Sustainable Development Goal indicators should be disaggregated, where relevant, by income, sex, age, race, ethnicity, migratory status, disability and geographic location, or other characteristics, in accordance with the Fundamental Principles of Official Statistics.” (General Assembly resolution 68/261, quoted in SC 2016 §26). This should be particularly useful to improve our understanding of environmental health and its determinants and to identify populations at risk.

Many of the targets specify that the indicators should cover specific groups of population and other disaggregation elements. Often these groups are those, like the poor and marginalized, women and children, or workers in the informal economy, that usually escape from normal statistical data collection, yet are those that should not be left behind. The IAEG-SDG will further discussion on how to operationalize data disaggregation in the implementation of the global indicator set.

The big challenge now is to complement the global indicators with indicators at the regional and national levels to be developed by Member States. Member States are expected to develop their national indicators in line with the principle of the 2030 agenda that targets are defined as aspirational and global, with each Government setting its own national targets guided by the global level of ambition but taking into account national circumstances. Indicators for thematic monitoring are also being developed in a number of areas. This process is only just beginning, and will require a major effort by all governments. This is an opportunity for the environmental health community to build broader support for its work.

SUSTAINABLE DEVELOPMENT GOAL 3 HEALTH

"Healthy lives" is the third of the Sustainable Development Goals, and many of the SDG targets relate to environmental health. These are placed in a larger integrated framework encompassing the economic, social and environmental dimensions of human well-being and planetary sustainability. The World Health Organization has made a detailed analysis of SDG 3 Health (WHO 2015), from which the following review is largely drawn.

Paragraph 26 of the 2030 agenda for sustainable development (UN 2015) addresses health as follows:

“To promote physical and mental health and well-being, and to extend life expectancy for all, we must achieve universal health coverage and access to quality health care. No one must be left behind. We commit to accelerating the progress made to date in reducing newborn, child and maternal mortality by ending all such preventable deaths before 2030. We are committed to ensuring universal access to sexual and reproductive health-care services, including or family planning, information and education. We will equally accelerate the pace of progress made in fighting malaria, HIV/AIDS, tuberculosis, hepatitis, Ebola and other communicable diseases and epidemics, including by addressing growing anti-microbial resistance and the problem of unattended diseases affecting developing countries. We are committed to the prevention and treatment of non-communicable diseases, including behavioural, developmental and neurological disorders, which constitute a major challenge for sustainable development.”

SDG 3 devoted specifically to health, is framed in deliberately broad terms that are relevant to all countries and all populations: “Ensure healthy lives and promote well-being for all at all ages”. The health goal is associated with 13 targets, including four means of implementation targets labelled 3.a to 3.d. (TABLE 1)

The MDG goals on maternal mortality (3.1), child mortality (3.2) and infectious diseases (3.3) have been retained in the SDG framework, augmented by new and more ambitious targets for 2030, and expanded to include neonatal mortality and more infectious diseases such as hepatitis and waterborne diseases. The targets on access to sexual and reproductive health-care services (3.7) and access to vaccines and medicines (3.b) are also closely related to the MDG targets. Sexual and reproductive rights are addressed under MDG 5 on gender equality.

The SDGs include new targets on Non-Communicable Diseases (NCDs) and mental health (3.4), substance abuse (3.5), injuries (3.6), health impact from hazardous chemicals, water and soil pollution and contamination (3.9) and the implementation of the WHO Framework Convention on Tobacco Control (WHO FCTC) (3.a). Target 3.d addresses reducing and managing national and global health risks, and health financing and health workforce issues in least-developed countries and small island developing states are addressed by Target 3.c. Universal Health Coverage (UHC) is also a new target (3.8), which provides an overall framework for the implementation of a broad and ambitious agenda in all countries. UHC is the only target that cuts across all targets of the health goals, as well as addresses linkages with health-related targets in the other goals.

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TABLE 1 – TARGETS AND INDICATORS FOR HEALTH (GOAL 3)

Goal 3. Ensure healthy lives and promote well-being for all at all ages

3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
3.1.1 Maternal deaths per 100,000 live births
3.1.2 Proportion of births attended by skilled health personnel
3.2 By 2030, end preventable deaths of newborns and children under five years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-five mortality to at least as low as 25 per 1000 live births
3.2.1 Under-5 mortality rate (deaths per 1,000 live births)
3.2.2 Neonatal mortality rate (deaths per 1,000 live births)
3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, waterborne diseases and other communicable diseases
3.3.1 Number of new HIV infections per 1,000 uninfected population (by age group, sex and key populations)
3.3.2 Tuberculosis incidence per 1,000 persons per year
3.3.3 Malaria incident cases per 1,000 persons per year
3.3.4 Number of new hepatitis B infections per 100,000 population in a given year
3.3.5 Number of people requiring interventions against neglected tropical diseases
3.4 By 2030, reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being
3.4.1 Mortality of cardiovascular disease, cancer, diabetes or chronic respiratory disease
3.4.2 Suicide mortality rate
3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol
3.5.1 Coverage of treatment interventions (pharmacological, psychosocial and rehabilitation and aftercare services) for substance use disorders
3.5.2 Harmful use of alcohol, defined according to the national context as alcohol per capita consumption (aged 15 years and older) within a calendar year in litres of pure alcohol
3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents
3.6.1 Number of road traffic fatal injury deaths within 30 days, per 100,000 population (age-standardized)
3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes
3.7.1 Percentage of women of reproductive age (aged 15-49) who have their need for family planning satisfied with modern methods
3.7.2 Adolescent birth rate (aged 10-14; aged 15-19) per 1,000 women in that age group
3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all
3.8.1* Coverage of tracer interventions (e.g. child full immunization, antiretroviral therapy, tuberculosis treatment, hypertension treatment, skilled attendant at birth, etc.)
3.8.2* Fraction of the population protected against catastrophic/impoverishing out-of-pocket health expenditure
3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination
3.9.1 Mortality rate attributed to household and ambient air pollution
3.9.2* Mortality rate attributed to hazardous chemicals, water and soil pollution and contamination
3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate
3.a.1 Age-standardized prevalence of current tobacco use among persons aged 15 years and older
3.b Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all
3.b.1 Proportion of the population with access to affordable medicines and vaccines on a sustainable basis
3.b.2 Total net official development assistance to the medical research and basic health sectors
3.c Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least-developed countries and small island developing States
3.c.1 Health worker density and distribution
3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks
3.d.1 Percentage of attributes of 13 core capacities that have been attained at a specific point in time

[* indicator lacks adequate methodology or data for implementation]

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Health in other goals

Health is linked to many of the non-health goals, reflecting the fact that health affects, and is in turn affected by, many economic, social and environmental determinants. Progress in health is dependent on economic, social and environmental progress. Well over a dozen targets in other goals can be considered health-related and should be given special attention in strategies, policies and plans to achieve the health goal and in monitoring progress (TABLE 2). Goal 17 is about means of implementation and links to the four means of implementation targets of the health goal.

One of the strengths of the SDGs is the breadth of their embrace, which seeks to encompass communicable diseases, NCDs and injuries as well as determinants of health such as increasing urbanization, pollution and climate change. The SDG agenda emphasizes the close links between health and sustainable development. Health policy can contribute to sustainable development and poverty reduction if people have access to the information and services they need to promote and protect their health and are protected from catastrophic expenditure when they fall ill. Sustainable development, in turn, limits the adverse impacts of environmental degradation and climate change, which have the highest relative impact on the poorest countries and the least healthy and poorest groups within countries.

Policies made in all sectors can have a profound effect on population health and health equity. The health of people is not solely a health sector responsibility; it is also impacted by issues such as transport, agriculture, housing, trade and foreign policy. To address the multisectoral nature of health determinants requires the political will to engage the whole of government in health. The health sector should promote “Health in All Policies”, an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve population health and health equity and address the social determinants of health. (WHO 2015)

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TABLE 2 – HEALTH TARGETS AND INDICATORS IN OTHER GOALS

1.3 Implement nationally appropriate social protection systems and measures for all, including floors, and by 2030 achieve substantial coverage of the poor and the vulnerable
1.3.1 Percentage of the population covered by social protection floors/systems, disaggregated by sex, and distinguishing children, the unemployed, old-age persons, persons with disabilities, pregnant women/newborns, work injury victims, the poor and the vulnerable
2.2 By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under five years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons
2.2.1 Prevalence of stunting (height for age <-2 standard deviation from the median of the World Health Organization (WHO) Child Growth Standards) among children under 5 years of age
2.2.2 Prevalence of malnutrition (weight for height >+2 or <-2 standard deviation from the median of the WHO Child Growth Standards) among children under 5, disaggregated by type (wasting and overweight)
4.2 By 2030, ensure that all girls and boys have access to quality early childhood development, care and pre-primary education so that they are ready for primary education
4.2.1 Percentage of children under 5 years of age who are developmentally on track in health, learning and psychosocial well-being. Disaggregations: sex, location, wealth (and others where data are available)
4.2.2 Participation rate in organized learning (one year before the official primary entry age)
4.a Build and upgrade education facilities that are child, disability and gender sensitive and provide safe, non-violent, inclusive and effective learning environments for all
4.a.1 Percentage of schools with access to: (a) electricity; (b) the Internet for pedagogical purposes; (c) computers for pedagogical purposes; (d) adapted infrastructure and materials for students with disabilities; (e) single-sex basic sanitation facilities; and (f) basic handwashing facilities (as per the Water, Sanitation and Hygiene for All (WASH) indicator definitions)
5.2 Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation
5.2.1 Proportion of ever-partnered women and girls aged 15 years and older subjected to physical, sexual or psychological violence by a current or former intimate partner, in the last 12 months, by form of violence and by age group
5.2.2 Proportion of women and girls aged 15 years and older subjected to sexual violence by persons other than an intimate partner, in the last 12 months, by age group and place of occurrence
5.3 Eliminate all harmful practices, such as child, early and forced marriage and female genital mutilation
5.3.1 Percentage of women aged 20-24 who were married or in a union before age 15 and before age 18
5.3.2 Percentage of girls and women aged 15-49 who have undergone female genital mutilation/cutting, by age group
5.6 Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences
5.6.1 Proportion of women aged 15-49 who make their own informed decisions regarding sexual relations, contraceptive use and reproductive health care
5.6.2 Number of countries with laws and regulations that guarantee women aged 15-49 access to sexual and reproductive health care, information and education
6.1 By 2030, achieve universal and equitable access to safe and affordable drinking-water to all
6.1.1 Percentage of population using safely managed drinking water services
6.2 By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations
6.2.1 Percentage of population using safely managed sanitation services, including a hand-washing facility with soap and water
6.3 By 2030, improve water quality by reducing pollution, eliminating dumping and minimizing release of hazardous chemicals and materials, halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally
6.3.1 Percentage of wastewater safely treated
6.3.2 Percentage of bodies of water with good ambient water quality
10.4 Adopt policies, especially fiscal, wage and social protection policies, and progressively achieve greater equality
10.4.1 Labour share of GDP, comprising wages and social protection transfers
11.5 By 2030, significantly reduce the number of deaths and the number of people affected and substantially decrease the direct economic losses relative to global gross domestic product caused by disasters, including water-related disasters, with a focus on protecting the poor and people in vulnerable situations
11.5.1* Number of deaths, missing people, injured, relocated or evacuated due to disasters per 100,000 people
16.1 Significantly reduce all forms of violence and related death rates everywhere
16.1.1 Number of victims of intentional homicide per 100,000 population, by age group and sex
16.1.2* Conflict-related deaths per 100,000 population (disaggregated by age group, sex and cause)
16.1.3 Percentage of the population subjected to physical, psychological or sexual violence in the previous 12 months
16.1.4* Proportion of people that feel safe walking alone around the area they live
16.2 End abuse, exploitation, trafficking and all forms of violence against and torture of children
16.2.1 Percentage of children aged 1-17 who experienced any physical punishment and/or psychological aggression by caregivers in the past month
16.2.2 Number of victims of human trafficking per 100,000 population, by sex, age group and form of exploitation
16.2.3* Percentage of young women and men aged 18-24 who experienced sexual violence by age 18
16.6 Develop effective, accountable and transparent institutions at all levels
16.6.1 Primary government expenditures as a percentage of original approved budget, disaggregated by sector (or by budget codes or similar)
16.6.2* Proportion of the population satisfied with their last experience of public services
16.9 By 2030, provide legal identity for all, including birth registration
16.9.1 Percentage of children under 5 whose births have been registered with a civil authority, disaggregated by age
17.18 By 2020, enhance capacity-building support to developing countries, including for least-developed countries and small island developing States, to increase significantly the availability of high-quality, timely and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location and other characteristics relevant in national contexts
17.18.1 Proportion of sustainable development indicators produced at the national level with full disaggregation when relevant to the target, in accordance with the Fundamental Principles of Official Statistics
17.18.2* Number of countries that have national statistical legislation that complies with the Fundamental Principles of Official Statistics

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Monitoring the overarching health goal

There is a need to monitor the SDGs at the global level. The overall health SDG is to, “Ensure healthy lives and promote well-being for all at all ages”. WHO has considered several overarching indicators that might serve to monitor that goal, including life expectancy, number of deaths before age 70, and healthy life expectancy. If it could be measured reliably, healthy life expectancy would be a suitable single indicator that captures both mortality and years of life lived in less than good health (i.e. with a disability). There is increasing interest in the accurate measurement of health, disability and well-being, especially given the context of ageing populations and the growing prominence of chronic diseases as causes of disability and premature mortality. There is some evidence that life expectancy in high-income countries is increasing faster than healthy life expectancy. The monitoring efforts being undertaken in the European Union are interesting in this regard, setting a target for Members States of achieving an additional two healthy life years by 2020.

However, while many attempts have been made to measure population health status in addition to the underlying causes of declines in health, challenges remain with regard to the availability of data on population level functional status that are comparable over time and across populations and collected through regular surveys. Despite the large gaps in coverage of global mortality information systems, mortality is more amenable to accurate measurement than disease or disability. Several cause-specific mortality targets are proposed for the post-2015 agenda, many focusing on reducing or ending “preventable” deaths.

Life expectancy is an attractive summary measure of mortality rates at all ages, and all health and health-related programmes contribute to it. WHO has estimated that achievement of the major SDG health targets for child, maternal, infectious diseases and NCDs would result in an increase of global average life expectancy of around four years by 2030. The gap between high- and low-income countries would narrow from around 17.5 years in 2015 to around 13–14 years. Also worthy of consideration is a proposal for a measure of premature mortality with a target of reducing the number of deaths before age 70 by 40% by 2030 globally and in every country.

Countries at different stages of development could achieve such gains by bringing down mortality due to HIV, malaria, TB or child mortality or NCD deaths between ages 30 and 70 – depending on their relevant priorities. A 40% reduction in premature mortality by 2030 would be achievable by: averting two thirds of maternal and child deaths; two thirds of HIV, TB and malaria deaths; one third of premature deaths from NCDs; and one third of deaths from other causes (other communicable diseases, undernutrition and injuries). These challenging subtargets would halve under-50 deaths, avert one third of the (mainly NCD) deaths at ages 50–69, and so prevent 40% of under-70 deaths. Such a reduction would result in a global increase in life expectancy of five years, assuming mortality rates at age 70 and over also decline, as projected by WHO. Concerted action to reduce NCD deaths before age 70 is likely to also reduce NCD death rates for people age 70 and over.

The “promote well-being” component of the overall health SDG also presents an interesting monitoring challenge, as does health Target 3.5, which refers to “promote mental health and well-being”. While health and self-reported well-being are intricately related (health status is a critical determinant of subjective well-being, for example) they are not synonymous. Measurement of self-reported well-being shares many of problems encountered in the measurement of non-fatal health outcomes. The field of measuring subjective well-being is rapidly expanding and distinguishes different aspects including: (i) evaluative life satisfaction: a reflective assessment on a person’s life or some specific aspect of it; (ii) affective or hedonic: a person’s feelings or emotional states, typically measured with reference to a particular point in time; and (iii) eudemonic: a sense of meaning and purpose in life, autonomy and self-realization. It may, however, be too early to adopt an indicator as part of the SDG monitoring.

Monitoring equity

Ethical principles are inherent in the SDGs, which aim to eliminate poverty, reduce inequalities and leave no one behind. An ethical approach will be important to win wide public support for the SDG process, and environmental health will be one of the most immediate and relevant goals for the general public.

Equity is at the heart of the SDGs, which are founded on the concept of “leaving no one behind”. The overall health SDG calls for healthy lives for all at all ages, positioning equity as a core, cross-cutting theme, while SDG 10 calls for the reduction of inequality within and among countries, and Target 3.8 calls for the establishment of Universal Health Coverage, founded on the principle of equal access to health without risk of financial hardship. A movement towards equity in health depends, at least in part, on strong health and health financing information systems that collect disaggregated data about all health areas and health expenditures. This fact is recognized in Target 17.8, which calls for efforts to build capacity to enable data disaggregation by a number of stratifying factors, including income, gender, age, race, ethnicity, etc. Disaggregated data enable policy-makers to identify vulnerable populations and direct resources accordingly.

MDGs were focused on national progress and on specific populations, notably mothers and children and people affected by HIV, TB and malaria. In contrast, the health SDGs address health and well-being at all ages, including in newborns and children, adolescents, adult women and men, and older persons. Not only is the goal to be monitored much broader, but it is also extended over time, and will thus require a comprehensive, life course approach. Needless to say, such an approach will also be relevant in monitoring progress towards Universal Health Coverage. (WHO 2015, p. 10-11)

CONCLUSIONS

The international process to put the SDGs in place is well under way. Governments face the challenge to increase their statistical capacity to collect and assess the data required to report on all these global indicators, and environmental health will be part of this.

A more significant challenge will be the requirement for governments to develop their national indicators in line with the principle of the 2030 agenda that targets are defined as aspirational and global, with each Government setting its own national targets guided by the global level of ambition but taking into account national circumstances. This means putting into place at the national level the same kind of process as has been followed at the global level, ideally with both expert input and the involvement of all stakeholders. Effective implementation requires broad public understanding and ownership of the goals and a commitment to see them achieved in the next 15 years. As progress is monitored, efforts can be ratcheted up if the results fall short of expectations.

Countries have a diversity of stages of development, economies, cultures and value systems, resource endowments and governance institutions. Their pathways to sound environmental management, health and sustainability as measured by the SDGs will inevitably be different, although they need to converge towards the same goals. There will not be “one size fits all” but many national sets of targets and ways to monitor progress.

For civil society, it is important to remember what their governments agreed to at the UN General Assembly Summit: "It is “We the Peoples” who are embarking today on the road to 2030. Our journey will involve Governments as well as Parliaments, the UN system and other international institutions, local authorities, indigenous peoples, civil society, business and the private sector, the scientific and academic community – and all people.... It is an Agenda of the people, by the people, and for the people – and this, we believe, will ensure its success." (UN 2015) Local governments, the scientific community, civil society organizations, the private sector and the public in general all have potential roles in both agreeing to goals and targets, and in monitoring their implementation. Governments should not expect to do it all by themselves, but should build wide partnerships for the SDGs.

Finally, the SDGs could supply a new vision and narrative around which to strengthen unity between countries. There is a need for creative new approaches to governance and institutional innovation, balancing supra-national coordination and subsidiarity as appropriate, while building solidarity and cohesion in implementing the SDGs. (Dahl 2015)

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