A local lens on a planetary issue
Authors: Zoë Mullan
Journal: The Lancet Global Health (2015)

The goals are set; the targets laid out. The fighting is over. In just over a week's time, heads of state worldwide will commit to the 2030 Agenda for Sustainable Development, with its 17 Sustainable Development Goals (SDGs) and 169 associated targets. Country representatives will resolve to do everything from ending poverty and hunger everywhere by 2030 to recognising the importance of sport in sustainable development. There will be no doubt be relief, euphoria, and celebrations. But what happens next? Come Jan 1, 2016, what will countries be doing differently?The Millennium Development Goals and their numerical targets were global in nature and not meant to be achievable by every individual country, but they were inevitably taken as such, leaving countries that had no realistic hope of achieving the targets to do as best they could. The sense of futility inherent in this sort of arrangement must have been hard to overcome. As we now know, the SDGs will also be numerical and global in nature, as in “By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births”. Taking maternal mortality as an example, studies have already suggested how the feeling of futility for countries could quite easily continue. One study showed that, even if all low-income and middle-income countries were able to equal the aspirational rates of decline in maternal mortality seen in the best-performing such countries between 1990 and 2013, fewer than half would meet the Lancet Commission on Investing in Health's more conservative maternal mortality target of 90 per 100 000 livebirths. Another study confirmed that, if every country progressed from 2010 to 2030 at the same rate as the top performer in the region between 1990 and 2010, only six of 43 sub-Saharan African countries would reach the SDG target of 70 per 100 000 livebirths.Suggestions on how to guide national policy makers have been made. One group raised the idea of setting individually designed and tracked 5-year milestones for countries, informed by their initial maternal mortality rate. Countries with ratios lower than 100 per 100 000, for example, could focus on population subgroups within which the maternal mortality ratios are higher than the national one. Others have proposed individualised targets based on each country's past progress and projected economic growth. Yet the draft 2030 Agenda document merely encourages in the vaguest of terms “all member states to develop as soon as practicable ambitious national responses to the overall implementation of this Agenda”.Each SDG contains at least one “means of implementation” target, ostensibly setting the new goals apart from the Millennium Development Goals. For health, these include strengthening implementation of the Framework Convention on Tobacco Control, supporting the research and development of vaccines, providing access to affordable essential medicines and vaccines, increasing the recruitment and retention of the health workforce, and strengthening the capacity for management of health risks. None of these strike one as practical guides to policy making.And what of funding? Again, the commitment is vague: “Strengthen domestic resource mobilization”; “Mobilize additional financial resources for developing countries from multiple sources”. What of the role of civil society and non-governmental organisations (NGOs)? UN Secretary-General Ban Ki-Moon told a meeting of global parliamentarians last month that they should “continue to ensure that the voices of the people are heard and included in the development process”. Yet recent signs point to a dangerous move in the wrong direction for many countries. Increasingly paranoid and nationalistic governments in countries including India, China, Russia, Egypt, and Uganda have recently enacted or are about to enact new laws that crack down on the activities of civil society groups and NGOs. In October, new draft regulations in China will require foreign NGOs (including the Bill & Melinda Gates Foundation, Yale University, and Médecins Sans Frontières) to register with the police or be expelled from the country. Registration is expected to severely curtail activities that local activists say are essential to fill gaps in government programmes, to keep ethics and rights on the agenda, and to ensure accountability.The latter goes short of mention in the 30-page Agenda. The UN has no “teeth” and any revitalised global partnership is voluntary. The question remains: after the hoopla of the New York Summit, how will individual countries act differently, and who is keeping watch? The goals are set; the targets laid out. The fighting is over. In just over a week's time, heads of state worldwide will commit to the 2030 Agenda for Sustainable Development, with its 17 Sustainable Development Goals (SDGs) and 169 associated targets. Country representatives will resolve to do everything from ending poverty and hunger everywhere by 2030 to recognising the importance of sport in sustainable development. There will be no doubt be relief, euphoria, and celebrations. But what happens next? Come Jan 1, 2016, what will countries be doing differently? The Millennium Development Goals and their numerical targets were global in nature and not meant to be achievable by every individual country, but they were inevitably taken as such, leaving countries that had no realistic hope of achieving the targets to do as best they could. The sense of futility inherent in this sort of arrangement must have been hard to overcome. As we now know, the SDGs will also be numerical and global in nature, as in “By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births”. Taking maternal mortality as an example, studies have already suggested how the feeling of futility for countries could quite easily continue. One study showed that, even if all low-income and middle-income countries were able to equal the aspirational rates of decline in maternal mortality seen in the best-performing such countries between 1990 and 2013, fewer than half would meet the Lancet Commission on Investing in Health's more conservative maternal mortality target of 90 per 100 000 livebirths. Another study confirmed that, if every country progressed from 2010 to 2030 at the same rate as the top performer in the region between 1990 and 2010, only six of 43 sub-Saharan African countries would reach the SDG target of 70 per 100 000 livebirths. Suggestions on how to guide national policy makers have been made. One group raised the idea of setting individually designed and tracked 5-year milestones for countries, informed by their initial maternal mortality rate. Countries with ratios lower than 100 per 100 000, for example, could focus on population subgroups within which the maternal mortality ratios are higher than the national one. Others have proposed individualised targets based on each country's past progress and projected economic growth. Yet the draft 2030 Agenda document merely encourages in the vaguest of terms “all member states to develop as soon as practicable ambitious national responses to the overall implementation of this Agenda”. Each SDG contains at least one “means of implementation” target, ostensibly setting the new goals apart from the Millennium Development Goals. For health, these include strengthening implementation of the Framework Convention on Tobacco Control, supporting the research and development of vaccines, providing access to affordable essential medicines and vaccines, increasing the recruitment and retention of the health workforce, and strengthening the capacity for management of health risks. None of these strike one as practical guides to policy making. And what of funding? Again, the commitment is vague: “Strengthen domestic resource mobilization”; “Mobilize additional financial resources for developing countries from multiple sources”. What of the role of civil society and non-governmental organisations (NGOs)? UN Secretary-General Ban Ki-Moon told a meeting of global parliamentarians last month that they should “continue to ensure that the voices of the people are heard and included in the development process”. Yet recent signs point to a dangerous move in the wrong direction for many countries. Increasingly paranoid and nationalistic governments in countries including India, China, Russia, Egypt, and Uganda have recently enacted or are about to enact new laws that crack down on the activities of civil society groups and NGOs. In October, new draft regulations in China will require foreign NGOs (including the Bill & Melinda Gates Foundation, Yale University, and Médecins Sans Frontières) to register with the police or be expelled from the country. Registration is expected to severely curtail activities that local activists say are essential to fill gaps in government programmes, to keep ethics and rights on the agenda, and to ensure accountability. The latter goes short of mention in the 30-page Agenda. The UN has no “teeth” and any revitalised global partnership is voluntary. The question remains: after the hoopla of the New York Summit, how will individual countries act differently, and who is keeping watch?