Partnerships for child health: capitalising on links between the sustainable development goalsBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k125 (Published 23 January 2018) Cite this as: BMJ 2018;360:k125
- Yulia Blomstedt, researcher1,
- Zulfiqar A Bhutta, professor2 3,
- Johan Dahlstrand, researcher4,
- Peter Friberg, professor45,
- Lawrence O Gostin, professor6,
- Måns Nilsson, professor7 8,
- Nelson K Sewankambo, professor9,
- Göran Tomson, professor4 10 11,
- Tobias Alfvén, associate professor4 11 12
- 1Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- 2Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
- 3Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- 4Swedish Institute for Global Health Transformation (SIGHT), Royal Swedish Academy of Sciences, Stockholm, Sweden5Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
- 6O’Neill Institute for National and Global Health Law Georgetown University Law Center, Washington, DC, USA
- 7Stockholm Environment Institute, Stockholm, Sweden
- 8KTH Royal Institute of Technology, Stockholm, Sweden
- 9Makerere University, School of Medicine, College of Health Sciences, Uganda
- 10Departments of Learning, Informatics, Management, Ethics, and Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- 11Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- 12Sachs’ Children and Youth Hospital, Stockholm, Sweden
- Correspondence to: T Alfvén
In 2015 the UN General Assembly adopted the sustainable development goals (SDGs) as part of a transformative universal framework for global development: the 2030 agenda.1 Since the goals are interconnected,23456 they have to be tackled in an integrated way. As well as ensuring that goals are reached efficiently, integration can avoid adverse effects from action to meet other targets and highlight trade-offs.4
Integrated action relies on national and international partnerships with a broad range of organisations—including national governments, local authorities, international institutions, business, civil society organisations, foundations, philanthropists, social impact investors, scientists, and citizens.7 However, it is not always clear who should partner with whom and on what grounds. Making these decisions—and developing integrated action plans, strategies, and policies—requires an understanding of the patterns of interaction between SDGs.
We use the example of child health to explore how assessment of the links between SDGs can be used to guide multisectoral partnerships. The importance of partnerships within the health sector is well established for child health, given the role of maternal health and nutrition in stillbirths, newborn health, and survival, as well as early child growth and development. By contrast, partnerships with other sectors have received much less attention. Efforts to include social determinants of health in development of health systems and public health have begun to provide crucial information. For example, the health in all policies (HiAP)8 initiative assessed multisectoral public policies, their health implications, synergies, and potential adverse outcomes. The SDGs offer a new opportunity for collaboration between the health sector and the rest of society and, hopefully, the momentum to move from mostly talk to action.
SDG links as lever for improved child health strategies
The connections between child health (0-18 years old) and development and other priorities in the SDGs are strong and reciprocal. The survival, health, and wellbeing of children are essential to end extreme poverty and promote development and resilience.9 At the same time, social, economic, political, environmental, and cultural determinants have important effects on child health.1011 Consequently, interventions beyond the health sector will accelerate progress on child health10 while investments in child health are crucial to reach multiple SDGs. However, this interdependence is not reflected in the formulation of SDG targets and indicators.
Although many SDGs have overlapping areas of concern, few of the goals directly integrate other sectors and reflect all three dimensions of development (social, economic, and environmental) either in the goals themselves or in the targets. This lack of integration risks reinforcing the current silo approach to development.12 For example, all too often people with a medical or public health background do not reach beyond the health sector to find effective and efficient solutions to health challenges. This was a problem in the implementation of the millennium development goals.13
Highlighting the interdependence between the health goal (SDG3) and targets in the other SDGs has the potential to transform the approach to child health. Once we have identified the connections we need to create bridges between them and develop and facilitate multisectoral interventions.
Although the 2030 agenda is not legally binding, virtually all UN member states have agreed to implement it.1 Concrete guidance on linking child health with other SDGs in the agenda would provide a lever to push governments to take multisectoral action in this and other areas. It would also provide a substantive basis for creating multistakeholder partnerships on child health.
Identifying suitable partners in other sectors
Sectors outside healthcare that are of crucial importance for child health include education, finance and social protection, labour and trade, agriculture, and transport.9 The first step to ensure multisectoral action is to identify key interventions in these non-health sectors that contribute to health outcomes.10 Besides SDG3 on health, 24 targets specifically mention children (box 1) and have the potential to improve child health.
Sustainable development goals (besides SDG3) that mention children
SDG 1: No poverty
1.2 By 2030, reduce at least by half the proportion of men, women, and children of all ages living in poverty in all its dimensions according to national definitions
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
Indicator 1.3.1 Proportion of population covered by social protection floors/systems, by sex, distinguishing children, unemployed people, older people, people with disabilities, pregnant women, newborns, work injury victims, poor people, and vulnerable groups
SDG 2: Zero hunger
2.1 By 2030, end hunger and ensure access by all people, in particular the poor and people in vulnerable situations, including infants, to safe, nutritious, and sufficient food all year round
2.2 By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older people
SDG 4: Quality education
4.1 By 2030, ensure that all girls and boys complete free, equitable, and quality primary and secondary education leading to relevant and effective learning outcomes
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
4.4 By 2030, substantially increase the number of youth and adults who have relevant skills, including technical and vocational skills, for employment, decent jobs, and entrepreneurship
4.5 By 2030, eliminate gender disparities in education and ensure equal access to all levels of education and vocational training for the vulnerable, including people with disabilities, indigenous peoples, and children in vulnerable situations
4.6 By 2030, ensure that all youth and a substantial proportion of adults, both men and women, achieve literacy and numeracy
4a Build and upgrade education facilities that are child, disability, and gender sensitive and provide safe, non-violent, inclusive, and effective learning environments for all
SDG 5: Gender equality
5.1 End all forms of discrimination against all women and girls everywhere
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
5.3 Eliminate all harmful practices, such as child, early and forced marriage, and female genital mutilation
5c Adopt and strengthen sound policies and enforceable legislation for the promotion of gender equality and the empowerment of all women and girls at all levels
SDG 6: Clean water and sanitation
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
SDG 8: Decent work and economic growth
8.5 By 2030, achieve full and productive employment and decent work for all women and men, including for young people and people with disabilities, and equal pay for work of equal value
8.6 By 2020, substantially reduce the proportion of youth not in employment, education, or training
8.7 Take immediate and effective measures to eradicate forced labour, end modern slavery and human trafficking, and secure the prohibition and elimination of the worst forms of child labour, including recruitment and use of child soldiers, and by 2025 end child labour in all its forms
8b By 2020, develop and operationalise a global strategy for youth employment and implement the global jobs pact of the International Labour Organisation
SDG 11: Sustainable cities and communities
11.2 By 2030, provide access to safe, affordable, accessible, and sustainable transport systems for all, improving road safety, notably by expanding public transport, with special attention to the needs of those in vulnerable situations, women, children, people with disabilities, and older people
11.7 By 2030, provide universal access to safe, inclusive, and accessible green and public spaces, in particular for women and children, older people and people with disabilities
SDG 13: Climate action
13b Promote mechanisms for raising capacity for effective climate change-related planning and management in least developed countries and small island developing States, including focusing on women, youth, and local and marginalized communities
SDG 16: Peace, justice, and strong institutions
16.2 End abuse, exploitation, trafficking, and all forms of violence against and torture of children
16.9 By 2030, provide legal identity for all, including birth registration
Indicator 16.9.1 Proportion of children under 5 years of age whose births have been registered with a civil authority, by age
However, the health sector should go beyond being a passive recipient and monitor of health effects generated by action on other SDGs. Health is not merely an outcome but also a driver of change in other sectors and has the potential to help achieve multiple SDGs (table 1). For example, improved child health removes resource constraints for households and communities (SDG 1), such that parents can spend time on employment (SDG 8) and spend money on non-health needs (eg, SDGs 2 and 4). Actors in sectors traditionally responsible for these SDGs would directly benefit from collaborating with the actors in child health. Box 2 gives an example of such synergetic collaboration.
Synergistic effects of multisectoral action: case study of conditional cash transfer strategies
Conditional cash transfer (CCT) programmes provide a cash payment to poor families or individuals in exchange for them taking actions intended to improve their wellbeing. The conditions, evidence based interventions, may include such things as consistent school attendance, prenatal health check-ups, and vaccinations for children. Hence, the programmes have potential to diminish poverty (SDG1) and improve the health outcomes (SDG3) and socioeconomic status of children and their families (SDGs 4, 5, 8).
The first larger scale CCT programmes was PROGRESA in Mexico. It began in 1997, partly in response to the large economic downturn in late 1994 that especially threatened Mexico’s poorest citizens. The multisectoral focus of PROGRESA recognised the integrated nature of education, health, and nutrition, and therefore the programme encouraged several government ministries, including health, to work together to implement it.
In developing PROGRESA, Mexico relied heavily on expertise from researchers and other professionals in poverty alleviation and human development, including health and education. This helped to decouple programme design from more vested political interests. PROGRESA also adopted transparency and accountability in all programme activities, which were therefore open to scrutiny and evaluation.23
There has since been a gradual, but steady, increase in CCT programmes across the world and especially in Latin America. Evaluation of these programmes suggests that CCTs are effective in improving child health by tackling determinants such as access to healthcare, child and maternal nutrition, morbidity risk, immunisation coverage, and household poverty in developing countries particularly. Of importance to both policy and practice, it seems that CCTs work to promote child health only if there is an effective healthcare system in place.24RETURN TO TEXT
Finding common grounds for multisectoral partnerships
Another approach to establishing multisectoral partnerships is through understanding the patterns of interaction between SDGs. This could be achieved through the following steps:
Mapping interactions between targets—Links between, in this case, child health and targets in other SDGs should be guided by scientifically shown associations between child health and other factors. Such mappings reveal potential partners and areas of overlapping responsibility or interest. Child health targets include SDG 3.1 (maternal mortality), 3.2 (newborn and child mortality), 3.7 (universal access to sexual and reproductive health-care services).
Assessing the direction of the identified interaction is important for establishing the grounds for collaboration. Is child health an outcome or a prerequisite of achieving another target, or is the link reciprocal? Establishing collaboration on targets where the link is reciprocal would have synergetic effects, propelling the achievement of both child health and the linked target.
Assessing the strength of associationor identified interaction is important for prioritisation, identifying where multisectoral collaboration is crucial for achieving the target(s). As with any implementation, it is important to clarify the main groups involved as well as their power relations.
The SDG interactions framework developed by Nilsson and colleagues supports such explorative processes and suggests scoring connections on a seven point scale (box 3).14 The position and nature of the interaction may vary depending on the context within which the interaction occurs.
SDG interactions framework scoring
+3 Indivisible: The target is inextricably linked to the achievement of another target
+2 Reinforcing: The target aids the achievement of another target
+1 Enabling: The target creates conditions that further another target
0 Consistent: No significant positive or negative interactions
−1 Constraining: The target limits options on another target
−2 Counteracting: The target makes it more difficult to reach another target
−3 Cancelling: The target makes it impossible to reach another target
We used the framework to assess interactions with child health in other SDGs, informed by analysis of relevant sources.4910 Between us we have expertise in environmental science, law, medicine, paediatrics, health systems research, development economics, and global health. Each author assessed the linkage with the identified targets, and a final score was agreed by discussion.
Our generic (not context specific) analysis suggests that collaboration with those implementing SDGs 1 (no poverty), 2 (zero hunger), 4 (quality education), 5 (gender equality), 8 (decent work and economic growth), and 17 (partnerships for the goals) could be cost effective because of the reciprocal link with child health (Table 2 and supplement 2 on bmj.com) The last column of table 2 gives examples of such synergistic multisectoral action, taken from the Every Woman Every Child report.9
The analysis also suggested that multisectoral collaboration on the following targets is essential for sustainable progress on child health (score +3): 1.1 (eradicate extreme poverty), • 1.2 (reduce at least by half the proportion of men, women, and children of all ages living in poverty in all its dimensions according to national definitions), 2.1 (end hunger), 2.2 (end all forms of malnutrition), 4.1 (ensure that all girls and boys complete free, equitable, and quality primary and secondary education), 6.1 (achieve universal and equitable access to safe and affordable drinking water), 6.2 (achieve access to adequate and equitable sanitation and hygiene), and 11.1 (ensure access for all to adequate, safe, and affordable housing and basic services and upgrade slums).
An example where multisectoral collaboration has large potential is the water, sanitation, and hygiene (WASH) programmes (SDGs 6.1 and 6.2). Despite the large health benefits, these programmes are still often viewed as an infrastructure led issues, the responsibility for which lies outside health system. This perception is reinforced by the often curative focus of the health sector and acts as a barrier to integration of WASH aspects in health strategies and programmes (box 4). Another difficulty is that the benefits of WASH programmes may accrue over time and so investment may not provide short term health and nutrition benefits. More examples of successful multisectoral interventions on determinants of reproductive, maternal, newborn, child, and adolescent health can be found in the SDG knowledge platform (https://sustainabledevelopment.un.org/sdinaction).
Water, sanitation and hygiene—how multisectoral action can improve child health
Creating multisectoral interventions that address water, sanitation, and hygiene (WASH) and health, and integrating WASH into existing frameworks and agendas for health are critical for improving child health through reduced exposure to enteric infections and improved nutrition. The interventions may also improve gender equality (SDG 5) and human rights (SDG 16). Girls are disproportionally affected, missing school because of walking great distances to carry water for household use, as well as lacking adequate sanitation and hygiene facilities in schools to allow them to manage their menstruation. Inadequate WASH facilities are also associated with sexual assault and gender based violence, where toilets are unavailable or unsafe.15
Integrating programmes to improve WASH into existing health programmes has been shown to be successful. Childhood vaccination has one of the highest coverage rates among child survival interventions. In Kenya hygiene interventions and education were integrated into the vaccination services by nurses or community health workers with good results.16 The interventions led to an improvement in hygiene indicators such as knowledge and use of household disinfection of water and had high acceptance and uptake in both rural and urban communities.
Another example of multisectoral partnerships is Laos, where WASH and ECCD (Early Childhood Care and Development) programmes worked closely together at district and village level. In this model multiple sectors worked together in planning and monitoring, with implementation largely carried out individually by each sector—sometimes referred to as “think multisectorally, act sectorally.” The experience highlighted the importance of all sectors in multisectoral programmes having a shared understanding of purpose and equitable access to resources to do their work as well as having effective leadership and clear organisational arrangements in place.17RETURN TO TEXT
Our analysis found few negative interactions, and none scored −3. The limited number of trade-offs with health has been noted previously18 and contrasts with domains such as infrastructure development, export promotion, and ecosystem conservation. However, connections between SDGs are highly context dependent,19 and conflicts between child health and other targets may still arise during implementation. To be relevant and transferable to any single setting, our analysis therefore needs to be repeated with sensitivity to political, economic, geographical, and social context by a multidisciplinary and multisectoral group of local stakeholders. Although the direction of the associations between child health and other targets in most contexts will remain the same, the strength and nature of the interaction may shift.18
For example, the link between ensuring access to modern energy (SDG 7.1) and child health is evident and true globally. However, whether the pursuit of modern energy is positive or negative for child health depends on context (table 2). In places where basic energy access is already achieved, further efforts may not affect child health. If modern energy meant exclusively renewables, the link could be viewed as positive (+1 or +2). However, if energy access is instead pursued using polluting fossil or solid biomass fuels, they could have negative effect on child health (-2).
New ways of thinking
Our purpose here has been to introduce a way of thinking about interactions and start a debate about how such thinking can contribute to better dialogue and building partnerships. Through an integrated approach, the SDGs offer substantial opportunities to improve child health worldwide.20 The knowledge base for such action requires further development. Collaboration between the scientific community, decision makers, and implementers is vital21 to ensure that policies and action are evidence based and that child health takes its rightful place at the heart of the development agenda.
Understanding and communicating interconnections between SDGs as presented in this article can form a basis for bridging science and decision making. Various analytical and process oriented tools and methods can be used to support the identification and scoring, depending on the stakeholders involved and the exact purpose of the exercise. Academic institutions and think tanks can facilitate this process,22 providing the knowledge and evidence needed to government ministries and their implementing agencies, and supporting the exploration and communication of interactions across disciplines, sectors, and borders for transformative action on child health nationally and globally.
Progress on the sustainable development goals (SDGs), including child health, requires integrated multisectoral action
Multisectoral partnerships can be enabled through understanding, highlighting, and acting on links between the various targets and goals
Models to assess connections can be used to prioritise actions and facilitate evidence based decision making in implementing SDGs
Contributors and sources: All authors have contributed to this article with their expertise in global health, including global health law and justice (LOG), women’s and children’s health (ZAB, TA, PF, GT), health systems (GT, NKS), development economics (JD) and SDG linkages (MN, YB). Sarah Dickin at Stockholm Environment Institute provided important input to box 4 on water, sanitation and hygiene (WASH). All authors have read and approved the final draft. YB is the guarantor.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. The analysis was funded by the Bill & Melinda Gates Foundation OPP1162011.
Provenance and peer review: Not commissioned; externally peer reviewed.