Paradoxes of sustainability with consequences for health
Authors: Eivind Engebretsen, Kristin Heggen, Sarthak Das, Paul Farmer, Ole Petter Ottersen
Journal: The Lancet Global Health (2016)

Earlier this year, the UN announced the 2030 Agenda for Sustainable Development with the aim of promoting global equity and justice. We claim that the success of this plan depends not only on measures taken, but also on how sustainable development is defined by policy makers. We argue that over the past three decades there has been a pronounced shift in the meaning of sustainability, to the extent that the current use of the term risks deflecting support away from the weakest to those who have the ability to self-improve. Our argument is based on analysis of documents published by the Organisation for Economic Co-operation and Development (OECD) in the period between 1990 and 2014. Using a conceptual historical1Koselleck R The practice of conceptual history. Timing history, spacing concepts. Stanford University Press, California2002Google Scholar approach we show three major shifts in the definition of the concept, which are shown in the figure. The core of the concept as defined by the Brundtland commission in 1988 is durability or "development which lasts".2UN World Commission on Environment and DevelopmentOur common future: report of the World Commission on Environment and Development. WCED, Switzerland1987Google Scholar A similar use also appears in DAC Principles for Project Appraisal from 1992: "A project can be said to be sustainable when it is able to deliver benefits for an extended period of time […]."3Development Assistance CommitteeDAC Principles for project appraisal. Organisation for Economic Co-operation and Development, Paris1992Google Scholar On a more practical level, this conception was reflected in development policy through an emphasis on long-term funding to donor-driven health-care programmes. An illustrative example of this is the Haydom Lutheran Hospital in Tanzania, run by Norwegian missionaries since its inauguration in 1955. Until the early 1990s, the hospital was considered to be sustainable with predictable long-term funding, strong bonded relationships, and contributions to the local community as well as to the socioeconomic development in the area. A different use of the concept is however apparent in the OECD document Participatory Development and Good Governance from 1995 where "values" such as "good governance" and "democratisation" are described as "integral to sustainable development".4Development Assistance CommitteeDAC Participatory Development and Good Governance, Development Co-operation Guidelines Series. Organisation for Economic Co-operation and Development, Paris1995Google Scholar A political dimension is thus added to the concept.5Ottersen OP Dasgupta J Blouin C et al.The political origins of health inequality: prospects for change.Lancet. 2014; 383: 630-667Summary Full Text Full Text PDF PubMed Scopus (348) Google Scholar Another important document, Shaping the 21st Century from 1996, emphasises the importance of strengthening "national capacities for sustainable development".6Organisation for Economic Co-operation and DevelopmentDAC Shaping the 21st century, the contribution of development co-operation. Organisation for Economic Co-operation and Development, Paris1996Google Scholar Sustainable development is thus referred to as a characteristic (a capacity) of the recipient rather than a common achievement or a goal that donors and recipients share the responsibility to obtain. In line with this conception, capacity building became the new key concept in global health during this period. A recurrent argument in the debate about the HIV/AIDS challenge was, for instance, that the delivery of antiretroviral treatment was not sustainable without better infrastructure and health systems.7Farmer P Léandre F Mukherjee JS et al.Community-based approaches to HIV treatment in resource-poor settings.Lancet. 2001; 358: 404-409Summary Full Text Full Text PDF PubMed Scopus (401) Google Scholar With the entering of the new millennium a new conceptual shift can be observed. In the DAC Strategies for Sustainable Development from 2001, sustainability was associated with "continuous improvement" as well as with "monitoring" and systems which are "domestically driven".8Organisation for Economic Co-operation and DevelopmentDAC strategies for sustainable development. The DAC Guidelines. Organisation for Economic Co-operation and Development, Paris2001Google Scholar Haldrup and Rosen have referred to an introduction of new key concepts in the development discourse during the same period. They point to a drift from an emphasis on standards from high-income countries of "good governance" towards "local ownership", "alignment", "resilience", and "harmonization" as endorsed by the Paris Declaration.9Haldrup SV Rosén F Developing resilience: a retreat from grand planning.Resilience. 2013; 1: 130-145Crossref Google Scholar However, the downplaying of the value of standards from high-income countries in development work does not necessarily imply an absence of interference. With the ideal of continuous improvement incorporated in the current concept of sustainability comes new expectations of self-management and self-assistance. Rather than reducing interference from high-income countries and maximising the freedom of the recipient country, this shift implies interfering in a new manner by imposing a new ideology of managing one's freedom in the right way.10Engebretsen E Heggen K Global Governance for Health: What about liberal power?.Lancet. 2014; 384: 664Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar As a result of the conceptual drift towards the ability to self-improve, donor-driven projects with long-term funding, which were considered sustainable according to the standards of the late 1980s, no longer matched the new sustainability standard because they were not self-supporting. Returning to the Haydom Lutheran Hospital in Tanzania, there has been considerable discussion about its funding since the early 2000s. What is interesting is that the argument that was originally used in favour of the hospital is now seen as a threat to its sustainability: the hospital is not considered sustainable because of its high dependency on donor funding. This dependency is viewed as a threat to local ownership and it has been argued that the funding should instead be given to the local community to support self-assistance. An important aspect of the conceptual transformations is that the term sustainability has gradually changed from being a goal (durability) to acquiring connotations that serve as a selection criterion for development aid. Using sustainability as a selection criterion risks privileging recipients who have the capacity to gain control over health and living conditions and exclude others as unworthy needy. It would be a paradox if emphasis on sustainability ended up in preventing global equity and justice instead of promoting it. We declare no competing interests.