In a September 2015 interview with Quartz, Bill Gates agreed the most important thing that the UN has done in the last 15 years is support implementation of the eight Millennium Development Goals (MDGs). In that same month, the UN General Assembly unanimously voted in the MDGs’ successor, the 17 Sustainable Development Goals (SDGs), an ambitious ‘Plan of Action’ to guide global development planning efforts for the next 15 years, until 2030.
From 2012 to 2016 I was fortunate to work on the Go4Health (Goals and Governance for Health) Project, a 13-institute interdisciplinary research collaborative tasked with advising the European Commission on the dynamic discourse around, and potential content of, the post-2015 global health goal(s). Along with performing empirical research on the unfolding post-2015 health agenda with grassroots communities and multilateral health policy officers, the Go4Health team also advocated that Universal Health Coverage (UHC) grounded in the right to health, prominently feature within the new health goal framework. Depending on whether you take a ‘glass half full or half empty’ approach, Go4Health’s advocacy objective was successfully or less than successfully achieved: in the global health goal SDG 3, Ensure Healthy Lives and Promote Well-Being for All at All Ages, UHC achievement (“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”) was included in SDG 3’s remit as the eighth of nine targets and four means of implementation.
More than two years on from the General Assembly’s SDG endorsement, I now find myself working in two correlating global health spheres. In one sphere, I continue focusing on the normative ‘gold-standard’ for health (the right to health in international law) and its intersection with global health policy. In the other sphere, I am knee-deep in civil registration and vital statistics (CRVS) and inter-related country CRVS and health and development implementation technicalities and pragmatics.
The point I want to make is, both spheres share a single, contextual backdrop. This is very dynamic,multi-layered, and political. While I will not go into its minutiae here, what I find most challenging about this complex backdrop are the growing complicated polarities shaping our world and impacting on facilitation of global health and development initiatives that ultimately seek to overcome health inequities and right to health breaches. This seems to me to be adversely impacting the most vulnerable and marginalised in all countries, everywhere; low, middle, and high-income nations alike. Divisive polarities are further creating spotlight, question and stigmatisation around individuals and groups that have otherwise enjoyed community inclusion. Harmful polarities will especially impact the well-being of the world’s women and girls.
Therefore, the SDGs must be the most important thing the UN does in the next 15 years. In fact, the SDGs might possibly be the most important thing the UN and its Member States do for planetary health and well-being, and global peace and security, this century.
Yes, there are many negatives about the SDG ambition. Too many goals, targets, and indicators (14 targets in the health goal alone!) and an unwieldy set of agendas and interests for countries (especially poor countries) to grapple with, let alone funding, governance, and technical challenges that appear in and of themselves insurmountable. And, where is the cogent link between rights and development in the SDG metrics framework? Countries will likely ‘cherry pick’ the goals and targets they pursue, MDG implementation silos will be reproduced, murky political and economic interests will win out. Who knows if high-income countries will take the SDGs’ Universal Agenda seriously and pursue SDG deficits in their own backyards.
The human rights side of me says this is unacceptable, the SDG agenda is indivisible and interdependent and all SDG goals (especially all of SDG 3’s targets) ‘ought’ to be incrementally pursued by all countries, everywhere. This is per the commitment made by the 180 plus countries that voted for the UN General Assembly resolution in September 2015, Transforming our world: the 2030 Agenda for Sustainable Development. Yet on the other hand, the political realist in me says at the very least, countries must seriously pursue achievement of SDG 3, SDG 4 (Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all) and SDG 5 (Achieve gender equality and empower all women and girls). But of course, that is my opinion – and such a moderated focus will not facilitate achievement of the three dimensions of sustainable development, not even a diluted form, nor global peace, security, or community inclusion that is also at the heart of the SDG agenda.
Consequently, I return to the central principle that underlies SDG ambition, as set out in the preamble and introductory paragraphs of the Transforming our world resolution - “that no one will be left behind”:
“Recognizing that the dignity of the human persons is fundamental, we wish to see the Goals and targets met for all nations and peoples and for all segments of society. And we will endeavour to reach the furthest behind first… This is an Agenda of unprecedented scope and significance. It is accepted by all countries and is applicable to all… These are universal goals and targets which involve the entire world, developed and developing countries alike”
So, how does the world pursue an inclusive sustainable development agenda that captures everyone, everywhere, and knows no borders? This is especially so when governments and their agents are already overwhelmed by the litany of SDG goals, targets, and indicators, as well as resource constraints, and a multitude of other urgent priorities, and a challenging political landscape.
To respond, in my view the first step to support SDG achievement is for all governments (and global regions) to keep it straightforward, (ideally) apolitical, and methodical. To do this, I therefore recommend countries and their partner agencies begin by revisiting their CRVS data, urgently. CRVS is the permanent and continuous recording of vital events including births and deaths, as well as adoptions, marriages, and divorces. Civil registration involves the notification and recording of each of the vital events. For instance, by providing formal identity, birth registration provides legal status to people and allows individuals a formal relationship with the State and each other. In turn, death registration ensures identity in death while frequently acknowledging and enabling the identity and ensuing receipt of rights and entitlements for the living (such as insurance pay-outs, welfare entitlements, property and inheritance rights, etc), which, again, acknowledge individual human dignity and facilitate inclusiveness and empowerment.
To date, most focus on CRVS systems and data strengthening has come from the population health field. Population health practitioners and researchers advocate the crucial role that reliable mortality and morbidity statistics play, emanating from strong CRVS systems,for sound government health policy and planning efforts. CRVS data is crucial for mortality surveillance and research, to describe and inform policy action and resource allocation, and to decrease the in-country burden of disease (allowing governments and their partners to target priority diseases and risk factors requiring focused intervention). Reliable CRVS data also indicates to governments, communities, and other non-state actors the magnitude and distribution of health inequalities across a country, while birth and death certification importantly drive populations’ access to medical services and public health insurance, as well as facilitate UHC.
It follows that timely and good quality data are also needed to responsively monitor SDG metrics, and is an SDG target itself. Without CRVS data, the SDGs are likely to be much less well implemented and evaluated. Through the SDG lens, countries must ask, is everyone within their borders being counted? Countries then must further ask, are the most invisible and marginalised, poor and unwell individuals and communities within their borders - for whom the SDGs are most pertinent and applicable - being counted and part of the SDG roll-out?
Of course, CRVS is not the end all panacea to world, regional, and country woes. And, how CRVS data is being used (and abused) by countries and regimes must be closely monitored and the Office of the High Commissioner for Human Rights’ (OHCHR) Human Rights-Based Approach to Datain the 2030 Development Agendamust be applied. However, examining the status of a nation’s CRVS data is a way to begin examining SDG-related inequities – who is (and is not) being counted - for reasons well-beyond population health. Strong CRVS systems underscore government transparency and accountability.
It is not about the actualities of counting, the metrics, or the quantitative. Rather, it is about country recognition of the fundamental human dignity of each person within their borders, and (implicitly) such individual’s fundamental human rights. It is about country’s implementing an SDG agenda that truly does not leave anyone behind, or speak to Othering ‘us and them’ corrosive divides. CRVS in the long-term might just be the unexpected counterweight. In the short-term, improving CRVS systems is a pragmatic country SDG starting point.
*Dr Claire E. Brolan (PhD) is a Postdoctoral Research Fellow at the Dalla Lana School of Public Health, University of Toronto, and works in the Data for Health Initiative team at the School of Population and Global Health, University of Melbourne. She also holds an Honorary Adjunct Research appointment at the Queensland Centre for Intellectual and Developmental Disability, Faculty of Medicine and Biomedical Sciences, University of Queensland. Opinions expressed in this piece are solely her own and do not in any way express nor should they be attributed to the views or opinions of her employer and/or their partner agencies or funding bodies.
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Cover Image: [Napcwa]