Making the SDGs useful: a Herculean task
Authors: Devi Sridhar
Journal: The Lancet (2016)

The Sustainable Development Goals (SDGs) have been called "senseless, dreamy, garbled",1Easterly W The SDGs should stand for senseless, dreamy, garbled.Foreign Policy (Washington, DC). Sept 28, 2015; (accessed Sept 1, 2016).http://foreignpolicy.com/2015/09/28/the-sdgs-are-utopian-and-worthless-mdgs-development-rise-of-the-restGoogle Scholar given that they include 17 goals, 169 targets, and 230 indicators, in contrast to the Millennium Development Goals (MDGs) that focused on eight goals, 18 targets, and 48 indicators. Among the earliest sceptics of the SDGs was the Bill & Melinda Gates Foundation, which argued that any new goals should be specific, measurable, attainable, relevant, time bound, and easy to communicate.2Suzman M "SMART" goals will help reduce poverty.Impatient Optimists. June 6, 2013; (accessed Sept 1, 2016).http://www.impatientoptimists.org/Posts/2013/06/quotSMARTquot-Goals-Will-Help-Reduce-Poverty#.V8P-WmXiqgAGoogle Scholar The Institute for Health Metrics and Evaluation has taken on the unenviable task of assessing whether the SDGs are indeed measurable and attainable in 188 countries by drawing on their Global Burden of Disease (GBD) database.3GBD 2015 SDG CollaboratorsMeasuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015.Lancet. 2016; (published online Sept 21.)http://dx.doi.org/10.1016/S0140-6736(16)31467-2Google Scholar Has the leading institute in this area been able to achieve their goal of helping to make the SDGs relevant and useful? The simple answer is yes. The GBD 2015 SDG Collaborators have created a health-related SDG index, which is a function of the GBD measures of 33 of 46 health-related SDG indicators. The index is measurable and clearly helps to communicate countries' progress, with Iceland ranking the highest (85·5 [95% uncertainty level 84·2–86·5] on a scale of 0–100) and Central African Republic the lowest (20·4 [15·4–24·9]). The complicated answer to whether the SDG index is relevant and useful depends on whom in global health we are talking about. Is it useful for major donors who fund international cooperation? Yes. Donors—particularly the USA, the UK, and the Gates Foundation—are increasingly insisting that any money invested in health must directly demonstrate progress.4Clinton C Sridhar D Governing global health: who runs the world and why? Oxford University Press, New York2017Google Scholar This stance is particularly relevant to their contributions to international institutions such as the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, and GAVI, The Vaccine Alliance, which need to show results to attract further replenishment in funding. Similarly to how global estimates of mortality, morbidity, and risk factors help to raise the attention and priority given to various health conditions, the SDG index is a powerful tool to communicate to the public the merits of investing in health by showing gains evidenced by one (at face value) simple number.5Das P Samarasekera U The story of GBD 2010: a "super-human" effort.Lancet. 2012; 380: 2067-2070Summary Full Text Full Text PDF PubMed Scopus (41) Google Scholar Is the SDG index useful for governments in low-income and middle-income countries? The answer is not immediately clear, especially since the SDG index relies on GBD data, which have been criticised for having limited use at the national level. Bloomberg Philanthropies in fact launched a US$100 million Data for Health initiative in 2015 to develop national data for mortality and morbidity, since its public health team felt that global estimates of disease were not sufficiently useful for governments in terms of planning purposes, tracking disease control and disease management, or for funding priorities.6Igoe M For better health, countries must understand death.Devex. Aug 23, 2016; (accessed Sept 1, 2016).https://www.devex.com/news/for-better-health-countries-must-understand-death-88669Google Scholar Igor Rudan and colleagues7Rudan I Campbell H Marusic A et al.Assembling GHERG: could "academic crowd-sourcing" address gaps in global health estimates?.J Glob Health. 2015; 5: 010101Crossref Scopus (12) Google Scholar outlined several other critiques of GBD at the country level, including its heavy reliance on modelling where reliable information is scarce. Is the SDG index useful for poor communities worldwide? The experience of Go4Health, a consortium funded by the European Union seventh framework programme, suggests no, or even that global priorities risk over-riding local concerns and priorities. The consortium undertook community consultations with marginalised groups about the MDGs and the post-2015 agenda in Uganda, Bangladesh, Australia, and Guatemala.8Ruano AL Friedman EA Hill PS Health, equity and the post-2015 agenda: raising the voices of marginalized communities.Int J Equity Health. 2014; 13: 82Crossref PubMed Scopus (12) Google Scholar Notably, community priorities differed from global blueprints such as the MDGs; for example, members of one community argued that dental care should be a top three health priority. The common thread was that the communities consulted wanted to determine their own health priorities based on their values and needs, and rejected the notion that global metrics, especially those based on estimated models, should govern what health services they could access. This view raises a larger question of why heavily modelled numbers exported from Seattle or Washington, DC, USA, are taken as the benchmark for what poor people require, over their own voices, and whether global health has moved to such abstraction that statistical models, imputations, and programming no longer resonate with the reality of people's lives.9Sridhar D The Battle against hunger: choice, circumstance and the World Bank. Oxford University Press, Oxford2008Crossref Scopus (13) Google Scholar Is the SDG index useful for academics and global health technical experts? Yes. The GBD 2015 SDG Collaborators provide a starting point for what can be done using current GBD data to assess whether the world is achieving the SDGs and suggest future collaboration to identify strategies for capturing further data (eg, for the 13 indicators not included in the analysis because they are not presently measured). The larger debate is whether we should keep any measure of improved health incredibly simple, or make it so complex that the modelling behind the index is not understood by anyone but the most technical scientists. For example, Francis Omaswa10Garrett L The challenge of global health.New York Times (New York). Jan 2, 2007; (accessed Sept 1, 2016).http://www.nytimes.com/cfr/world/20070101faessay_v86n1_garrett.htmlGoogle Scholar has proposed the use of maternal mortality as a measure of the strength of health systems and Laurie Garrett10Garrett L The challenge of global health.New York Times (New York). Jan 2, 2007; (accessed Sept 1, 2016).http://www.nytimes.com/cfr/world/20070101faessay_v86n1_garrett.htmlGoogle Scholar has proposed life expectancy as a measure of the strength of public health services, while I have proposed child malnutrition as a measure of the impact of social determinants of health and level of health inequality.9Sridhar D The Battle against hunger: choice, circumstance and the World Bank. Oxford University Press, Oxford2008Crossref Scopus (13) Google Scholar The SDGs, and the assessment of their progress in health, are incredibly complex even for the most astute development and health experts. But whether we like it or not, the SDGs have been agreed on. The best we can do is to acknowledge (as the GBD 2015 SDG Collaborators do in their conclusion) that they are mostly vague, largely immeasurable, somewhat attainable, and definitely relevant, and then put together the smartest minds and resources to communicate their importance through one index. Once again, the Institute for Health Metrics and Evaluation should be applauded for leading the way in figuring out how to make the impossible possible. See Online for infographic http://www.thelancet.com/infographics/SDG See Online for infographic http://www.thelancet.com/infographics/SDG I declare no competing interests. Measuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015GBD provides an independent, comparable avenue for monitoring progress towards the health-related SDGs. Our analysis not only highlights the importance of income, education, and fertility as drivers of health improvement but also emphasises that investments in these areas alone will not be sufficient. Although considerable progress on the health-related MDG indicators has been made, these gains will need to be sustained and, in many cases, accelerated to achieve the ambitious SDG targets. The minimal improvement in or worsening of health-related indicators beyond the MDGs highlight the need for additional resources to effectively address the expanded scope of the health-related SDGs. Full-Text PDF Open AccessGBD 2015: from big data to meaningful changeThe Global Burden of Diseases, Injuries, and Risk Factors Study 2015 ( GBD 2015 ) brings together the most recent epidemiological data according to year, age, and sex from 195 countries and territories. In a continuation of the partnership between The Lancet and the Institute for Health Metrics and Evaluation ( IHME ), this year marks the first of an annual commitment to publish the four capstone GBD papers—on global mortality, years lived with disability, disability-adjusted life-years, and risk factors—in a single issue. Full-Text PDF Measuring progress towards the SDGs—a new vital scienceA new statistical methodology has emerged to gauge progress towards reaching the 2030 deadline of the UN's Sustainable Development Goals. John Maurice reports. Full-Text PDF