Sustainable development goals for global health: facilitating good governance in a complex environment

Abstract

Increasing complexity is following in the wake of rampant globalization. Thus, the discussion about Sustainable Development Goals (SDGs) requires new thinking that departs from a critique of current policy tools in exploration of a complexity-friendly approach. This article argues that potential SDGs should: treat stakeholders, like states, business and civil society actors, as agents on different aggregate levels of networks; incorporate good governance processes that facilitate early involvement of relevant resources, as well as equitable participation, consultative processes, and regular policy and programme implementation reviews; anchor adoption and enforcement of such rules to democratic processes in accountable organizations; and include comprehensive systems evaluations, including procedural indicators. A global framework convention for health could be a suitable instrument for handling some of the challenges related to the governance of a complex environment. It could structure and legitimize government involvement, engage stakeholders, arrange deliberation and decision-making processes with due participation and regular policy review, and define minimum standards for health services. A monitoring scheme could ensure that agents in networks comply according to whole-systems targets, locally defined outcome indicators, and process indicators, thus resolving the paradox of government control vs. local policy space. A convention could thus exploit the energy created in the encounter between civil society, international organizations and national authorities.

Résumé

La complexité croissante est une conséquence de la mondialisation rampante. La discussion sur les objectifs du développement durable (ODD) exige donc de nouvelles idées qui s’écartent de la critique des outils politiques actuels dans l’exploration d’une approche adaptée à la complexité. Cet article avance que les ODD potentiels devraient : traiter les acteurs, tels que les États, les entreprises et la société civile, comme des agents à différents niveaux intégrés de réseaux ; inclure des procédures de bonne gouvernance qui facilitent la participation précoce de ressources pertinentes, ainsi que la participation équitable, les processus consultatifs et les études régulières de la mise en łuvre des programmes et des politiques ; ancrer l’adoption et l’application de ces règles sur les procédures démocratiques dans des organisations comptables de leurs actes ; et inclure des évaluations complètes des systèmes, notamment des indicateurs de procédures. Une convention cadre internationale pour la santé pourrait être l’instrument adéquat pour relever certains des défis liés à la gouvernance d’un environnement complexe. Elle pourrait structurer et légitimer la participation gouvernementale, associer les parties prenantes, organiser les processus de délibération et de prise de décision avec une participation appropriée et des analyses régulières des politiques, et définir des normes minimales pour les services de santé. Un plan de suivi pourrait veiller à ce que les agents dans les réseaux agissent conformément à des objectifs systémiques, des indicateurs de résultats définis localement et des indicateurs de processus, ce qui résoudrait le paradoxe du contrôle gouvernemental par opposition à l’espace politique local. Une convention pourrait ainsi exploiter l’énergie créée par la rencontre entre la société civile, les organisations internationales et les autorités nationales.

Resumen

Tras una globalización desenfrenada, la situación es cada vez más compleja. Por lo tanto, la discusión sobre los Objetivos de Desarrollo Sostenible (ODS) requiere una nueva forma de pensar que se aleje de una crítica de las herramientas actuales de políticas para explorar una estrategia que abrace la complejidad. En este artículo se arguye que los posibles ODS deberían: tratar a las partes interesadas, tales como Estados, empresarios y actores de la sociedad civil, como agentes en diferentes niveles agregados de redes; incorporar procesos de buena gobernanza que faciliten la participación temprana de recursos pertinentes, así como participación equitativa, procesos consultivos y revisiones periódicas de la aplicación de políticas y programas; anclar la adopción de dichas reglas en los procesos democráticos de organizaciones responsables e imponer su cumplimiento; e incluir evaluaciones integrales de sistemas, que incluyan indicadores de procedimientos. Una convención del marco mundial para la salud podría ser un instrumento adecuado para abordar algunos de los retos relacionados con la gobernanza de un ambiente complejo. Podría estructurar y legitimar la participación del gobierno, incluir a las partes interesadas, coordinar procesos de deliberación y de toma de decisiones con la debida participación y revisión periódica de políticas, y definir los niveles mínimos para los servicios de salud. Un esquema de monitoreo podría asegurar que los agentes de las redes cumplan acorde a las metas de sistemas completos, indicadores de resultados definidos a nivel local e indicadores de procesos, y así resolver la paradoja de control gubernamental contra espacio local de políticas. Por lo tanto, una convención podría aprovechar la energía creada en el encuentro entre la sociedad civil, organizaciones internacionales y autoridades nacionales.

Keywords:

• globalization
• complexity science
• sustainable development goals
• global health governance
• global health convention

“Let us develop a new generation of sustainable development goals to pick up where the MDGs leave off. Let us agree on the means to achieve them.” (UN Secretary-General Ban Ki-Moon, 2011)¹

Despite the UN Secretary-General’s call for a new generation of sustainable development goals (SDGs), the MDGs will not lose their relevance post-2015. But where the MDGs were mainly directed towards the developing world, the SDGs will have bearing in all countries, as part of an agenda that goes beyond development for the world’s poorest populations to achieving the goal of planetary sustainability. Thus, the SDGs could be seen as complementary to the MDGs – offering an opportunity to fulfil the Millennium Declaration. Following the Rio + 20 Conference, the international community has included in the SDG discussion the development of a possible set of indicators to measure progress:

“The development of SDGs and indicators is likely to have the best development impact and ownership if they emerge from a transparent, participatory, and consultative process.” ²

As this article argues, not only the process of developing SDGs and indicators, but also the final goals and indicators, should be directed at facilitating transparent, participatory, and consultative processes, including incorporation of principles from complexity theory and networked, or multi-centric, governance. A complexity-based approach builds on evolution and the study of complex systems dynamics. In contrast to the Cartesian tradition,^* which emphasizes the study of each part in a system, a complexity approach sees the system as a whole. Instead of studying isolated cause-and-effect mechanisms, the objects of study are patterns (simple and complex), links, communication, and mutual dependencies in networks of actors, or agents.³ A social system is considered complex when there are high levels of interaction and interdependence between different individuals’ actions and the effects they create. In a complex adaptive system like global health, this is a particular challenge as the Newtonian notion of cause-and-effect gradually has to give way to an acknowledged break in logic, where cause and effect are determined by multiple factors, feedback mechanisms and emergence – and where the future is in principle uncertain.⁴ By utilizing complexity theory as part of a new scientific paradigm, complex adaptive behaviour can be facilitated to create coherence. A suggested global health convention facilitating incremental regime development could be a way to reconcile bottom-up and top-down governance processes.³ In this respect, it would demand a change of mind-set among global health stakeholders, as well as new values and skills.

Critique of outcome-indicator-driven development

The debate on choice of indicators for the SDGs is problematic because it depends on varying notions of what the SDGs should be – or whether there should be something else, like a broad health systems strengthening approach as endorsed by WHO through the concept of universal health coverage,⁵ or recommendations on a Global Partnership to enable a transformative, people-centred, and planet-sensitive development agenda following from the 2012 UN Secretary-General’s High-Level Panel Report,⁶ mandated by the 2010 United Nations MDG Summit.⁷ Despite this confusion, there is a difficulty in that there is currently: “no single, universally accepted definition or assessment metrics for sustainable development… [and] no internationally agreed sustainable development indicators that would help monitor progress.” ²

The ongoing debate, though, seems to be based on a belief that such metrics and indicators are possible to come up with given time, effort and data power.² There are, however, sound reasons to critique and question developments driven by outcome indicators on methodological grounds. In what has become known as Goodhart’s law, after Charles Goodhart, a former adviser to the Bank of England, it is stated that:

“As soon as the government attempts to regulate any particular set of financial assets, these become unreliable as indicators of economic trends.” ⁸

This is because investors will try to anticipate effects of interventions according to indicators, and invest so as to benefit from this – in other words, they become a self-enforcing mechanism that skews resources. A famous example are the Soviet factories that, when rewarded for producing a large number of nails, ended up with manufacturing micro-nails; or, when rewarded for producing nails by weight, ended up manufacturing giga-nails. While Goodhart’s law originated in the context of market responses, it has profound implications for the compliance with high-level policy goals, like the suggested SDGs. If governments were to agree on a set of SDGs with targets that prescribe certain outcomes (measured by a relevant outcome indicator), such as countrywide pay-per-performance vaccination regimes, or information campaigns about oral rehydration therapy, representatives on the ground will be more interested in meeting those specific targets than in strengthening the health system overall so that it can adapt to changing circumstances and cater for other essential survival needs as well, which fosters a feeling of local ownership.

Another problem is that any measurement of the optimal level of health for the world’s people is dubious. Even taking into account individual populations or segmented parts of them, agreed-upon outcome indicators will not show whether the general level of health is good, even if a population scores high on those indicators. The more one takes into account that health is a result of a continuous, complex interplay between individuals, social systems, and environments, the less fruitful it becomes to centre attention on proximate risk factors, or particular targets. Instead, the system and emergent health effects must be seen as a whole. The problem is that comprehensive outcome evaluations are currently under-utilized because of limited technical capacity, awareness, appreciation of value, as well as perceived costliness, combined with scepticism on the part of funders of research who want quick and easily measurable results.⁹

Complexity and the SDGs

Changes in human societies have been perceived to develop bottom up because of many small fluctuations at the ground level.¹⁰ Value, in this respect, is created as a result of individual interactions between actors and networks, or “agents”, and often the emergent result is more than, or qualitatively different from, the sum of individual actions. Order, innovation, and progress develop naturally from such interactions, and following simple rules within a system; they do not need to be imposed centrally or from the outside.¹¹ According to a WHO Flagship Report,¹² systems thinking of this kind is highly relevant for global health governance:

“…systems thinking has huge and untapped potential, first in deciphering the complexity of an entire health system, and then in applying this understanding to design and evaluate interventions that improve health and health equity. Systems thinking can provide a way forward for operating more successfully and effectively in complex, real-world settings. It can open powerful pathways to identifying and resolving health system challenges, and as such is a crucial ingredient for any health system strengthening effort.”

Thus, in an increasingly interrelated and interdependent world, governance at all levels is typically complex, and various governance systems that interact lead to even greater complexity.¹³ This has led to challenges with relation to coordinating the overlapping and competing governance regime clusters in global health. This is especially true for the MDGs that require cooperation between overlapping circles of governance which compete for control, and ultimately, for resources. Complexity also influences how we generate and relate to “knowledge”. Because uncertainty is a defining factor of complex systems, and especially for emergent effects, it is impossible to envisage or determine what is ahead, including to identify and utilize relevant outcome indicators that predict what a much later state of a system must look like. Thus, traditional knowledge is challenged in two ways:

	in a system with multiple variables, emergent qualities and late systemic effects defy unpacking by analysis or exhaustive mapping, and
	if problems change faster than new solutions can be optimized, optimized solutions are always obsolete before they can be applied.4

This means that the tenets of governance are changing in profound ways. Today, governance is characterized by a levelled playing field with a plurality of actors forming more or less dense networks, a multitude of mechanisms, rapid change, and uncertainty about the future.¹³ In relation to these changes, the multilateral global health diplomacy represents both a constraint and an opportunity. The opportunity lies in the inclusion of complexity-based principles in the diplomatic code of conduct, e.g. ground rules for participation, transparency, accountability, etc., that could expand the global health constituency and transform the communication between national representatives, international governmental organizations and civil society. The constraint lies in the often state-centred, interest-based and near-sighted exchange that takes place in international negotiations, e.g. failures of the state-based negotiation system for health-related issues, especially evident after the stalemate at the 2009 Copenhagen Summit on Kyoto Protocol commitments¹⁴ and the shelving in 2012 of the WHO-initiated treaty on medical research and development to support poor populations.¹⁵

SDGs for the governance of networks: new epistemology, new indicators

Clearly, our existing models of governance do not work satisfactorily. Conceptually, the clearest anomaly is the prevailing hierarchical model of command-and-control, or top-down, which has been demonstrated by the critique of so-called vertical global health initiatives. Despite documented success with limited interventions, e.g. vaccination, HIV or malaria treatment, the narrow attention to a specific disease or problem has led to a skewing of local resources, and thus proved detrimental to a more comprehensive and sustainable health systems strengthening approach.¹⁶ Applied to networks, the top-down model leads to unsolicited results, delays, suboptimal resource utilization, and general discontent.³ Another anomaly is that our current models of causality attribution do not take into account the dynamic relationships, based on culture, values, status, preferences and goals, that exist between agents in a network.¹⁷ Such problems are caused by the fact that in networks consisting of inter-related and interdependent agents, governance is not about giving and following instructions, but continuously and strategically adapting to a complex, but local, environment by maximizing fitness.³

Importantly, agents and networks differ in their capacity to achieve goals, and in the factors that confer fitness. Strong business networks can wield undemocratic power to achieve economic benefits to the detriment of others. One example was the negotiation of the TRIPS treaty, where a few pharmaceutical companies managed to sway authorities into establishing an international legal regime that prioritizes intellectual rights over human rights.¹³ Other networks can collaborate to achieve societal gains by empowering civil society organizations to educate, resolve conflicts, or provide health services.¹⁸ The latter can be illustrated by the international campaigns to fight HIV/AIDS, and to rid the world of landmines.¹⁹ Historic examples are the US civil society’s call to end the Vietnam war, the call to end segregation of the races in the 1960s, and the pan-European evolution of workers’ rights. The adaptations that such networks undergo to reach their goals can be seen as forms of substantive regulation that eludes formalized legislative procedures on the international and national level.

For states, which are central agents in the global network, and the main consignees of potential SDGs, the question is how to recognize their formal power and sovereignty through global governance, while steering towards better health, granting policy space for other actors in the networks to flourish. One way to do this is for state representatives to incorporate globally agreed upon and overarching SDGs that prescribe early participation in policy design for the national arena, as well as rendering policy space for civil society to prioritize, assess and solve implementation barriers, and, if desirable, agree on local outcome indicators. In this respect, a complexity approach is about endowing global health stakeholders with learning and adaptive capabilities, so that they are prepared and empowered to tackle the unexpected. This would entail a values-based negotiation mandate, a holistic policy outlook, and advanced communication skills.

To ensure democratic performance, the network governance processes should be anchored to existing democratic structures of government, including control by elected representatives, accountability towards national authorities, and compliance by the following of democratic rules.²⁰ In a review of health systems strengthening interventions Adam et al. found the most comprehensive evaluations to involve assessments of interventions using participatory approaches in designing, monitoring and continuously improving the intervention. They speculate that this is because participatory evaluations lead to a more comprehensive “system-wide” approach to assessing the intervention’s impact.⁹ Based on this, and on the need for more comprehensive evaluations, process indicators should be incorporated and utilized more broadly. Such indicators could control for e.g. early involvement of stakeholders, relevant, fair and equitable representation, and regular, future-oriented policy review. Balanced responsibilities for countries and other actors in the network can be achieved by organizing governance in “recurrent global policy loops”,²¹ where actors on all levels go through dynamic processes of policy review in which responsibilities are allocated to the right actors, and according to capacity. This can be achieved by regular stakeholder meetings where actors from all levels and sectors participate in cyclical deliberation processes, including participation in decision-making processes.

For global health, the following principles have been suggested to operationalize a complexity approach to governance:

	broad participation in decision-making and future-oriented policy creation; including by governments, civil society, business, and local health representatives;
	dispersed governance structures to access and harness local know-how in relation to cultural, religious, technical, financial, and social conditions;
	good governance principles to facilitate self-organization and emergence of practicable solutions in a dispersed, but interrelated, network of actors; ground rules for accountability, transparency, cooperation, and allocation of resources;
	trial and error mentality and selection of what works; harnessing creative energies and capacity building through increased innovation and empowerment;
	coherence between top-down and bottom-up governance initiatives through regular policy adjustments, and learning from policy effects through regular review;
	definition of minimum health standards; facilitating local consensus on what are the fundamental survival needs of populations (e.g. clean water, essential medicines, basic sanitation and health systems infrastructure) so that resources can be used according to the real demand.3

With these principles as the basis of moving forward, governance post-2015 must deal with the challenge of managing distributed power in networks consisting of self-serving governments, business entities, and idealistic organizations, and where there are inherent power disparities as well as incomplete knowledge in the scientific sense. Thus, governance for the post-2015 era is about influencing the intimate relationship between authorities and other actors in the global network through networked, or multi-centric, governance.²² Existing governments are nodes in this network, and are posed with the dual challenge of adapting to an increasingly complex environment, while keeping a hand on the helm; leaving the rowing to subsidiaries – instead of being stuck at the oars.¹³ Thus, for the modern state, smart governance is about using their formal status as legislators to point out visions or goals (“steer”), while leaving policy space for other actors in networks with less formal power to do what they do best and adapt to changing conditions (“row”).

An international regulatory framework that sustains overarching visions or goals for the global, regional and national levels, while simultaneously facilitating local adaptation and capacity-building according to ever-changing conditions, represents an ideal governance compromise that moves away from command-and-control strategies, while adapting to a complex, networked environment.²²

Consequently, a potential set of SDGs would be about a specific commitment towards international cooperation to agree on overarching visions and goals, rendering policy space for local prioritizations and solutions to complex problems, including locally negotiated outcome indicators where this is useful, as well as globally defined process indicators to control for democratic anchorage, participation and cooperation. A further implication is that, given the lack of whole-systems indicators, monitoring of progress could be done also by process indicators, which brings the issue down to a basic question of trust in international policy processes. In relation to this, the concept of local policy space under a global health governance regime demands more thinking. Eventually, this could have implications for policy processes in global health governance, but also for the way national health systems are organized and managed. In practice, the SDGs suggested above might well be achieved through incorporation in a globally agreed upon, dynamic regulatory instrument, like a Framework Convention on Global Health (FCGH), as suggested by the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI), with the aim of greatly improving global health governance.²³

The reasoning behind the proposal for a future UN convention on health is the creation of a process by which states agree on certain basic principles for health assistance globally, with specific protocols in order to achieve goals that require negotiation. The protocol approach could help formulate minimum standards that a majority of the parties involved can endorse and all actors can gradually assume obligations. Minimum specifications, such as a joint definition of the basic needs for survival, provide room for innovations and encourage joint efforts, and are crucial to good future relations.²⁴ Such a framework convention may encompass purpose and objectives for constructive international cooperation; rules for coordination of processes, priorities and activities; specific financial commitments and funding mechanisms; institutional structures, such as a secretariat and technical consultants; monitoring schemes; and enforcement mechanisms and mediation in conflicts.²³

Finally, a global framework convention for health could be a suitable instrument for handling some of the challenges related to governance of a complex environment. It could structure and legitimize government involvement, engage stakeholders, arrange deliberation- and decision-making processes with due participation and regular policy review, and define minimum standards for health services. A monitoring scheme could ensure that actors in networks comply according to whole-systems targets, locally defined outcome as well as process indicators, thus resolving the paradox of government control and local policy space. A convention could thus exploit the energy created in the encounter between civil society, international organizations and national authorities, keeping governments at the helm, and subsidiaries at the oars.

Notes

* René Descartes is associated with the emphasis on reductionist logical analysis, mechanistic interpretation of physical nature, and dualistic distinction between thought (mind) and extension (matter).