Introduction

The Sustainable Development Goals (SDGs) and the Global Health Security Agenda (GHSA) are leading frameworks for guiding policy and program development to improve health globally. In 2015, 193 countries adopted the SDGs as global development goals for 2030 to achieve a more equitable, healthy, and prosperous world.1 The SDGs are comprehensive and diverse, and focus on people, the planet, prosperity, dignity, justice, and partnerships.2 The GHSA focuses specifically on health, and even more narrowly, on the threat of infectious diseases to global security.3 Following the Ebola outbreak in 2014, the GHSA has received much attention. The outbreak revealed serious gaps in implementation and compliance with the International Health Regulations (IHR).4

The GHSA facilitates identification of these gaps through external assessments of what are called “core IHR capabilities” or core capabilities of countries to prepare and respond to outbreaks. In defining a framework for building capacity of countries to comply with the IHR, the GHSA outlines eleven “action packages” through which to strengthen capacity to prevent, detect, and respond to human and animal infectious diseases threats.3 In 2014, 30 countries adopted the GHSA to improve global health security. (For an updated map of participating countries, see https://ghsagenda.org/where-ghsa.)

There are gaps in both agendas that limit their potential. SDG 3 addresses health, but no goal specifically mentions building capacities to tackle epidemics.5 Epidemics pose massive risks to development and can rapidly unravel decades of development gains. Development experts express concerns that the SDGs may prove expensive to meet with 17 goals, 169 targets, and 230 indicators. Distributing the SDG financial pie among so many elements means the share for each will be small.6 In the competition for resources, major donors may ignore the GHSA because of its relatively limited scope.7

The GHSA and SDGs Complement Each Other

The scope and intended outcomes of the two agendas are quite different, but the goals and actions to achieve them are compatible. The agendas have much in common: both call for multi-sectoral collaboration and coordination, and action from governments, civil society, academic institutions, and the private sector.8 Both agendas are globally inclusive: efforts to achieve sustainable global development will benefit from and are the responsibility of all countries, regardless of income level. Global security can only be achieved if all nations strive to improve control of infectious diseases within their own borders and work together to do so outside of them. Thus, both agendas represent a “grand convergence” for global health9 , 10 supported by multi-sectoral initiatives. Important synergy between them is possible—if implementers work together. “Global health” is a term that has been replacing “international health.” A consensus is emerging that global health is about worldwide health improvement, reduction in disparities, and protection against global threats that disregard national borders.11 , 12

Both the SDGs and the GHSA promote global public goods and require global solidarity and cumulative action—by all stakeholders together—by governments, donors, and civil society organizations, etc.13 , 14 In a world that has seen blurring of boundaries between security and development, activities to improve health globally impact both international security and counterterrorism efforts.15 , 16 In 2016, attacks on health systems in Aleppo, Syria, and the bombing of a United Nations (UN) aid convoy in Syria17 demonstrate how warfare can be waged on global health programs and accentuate increasing interplay between foreign policy and global health.

Thus, it becomes increasingly important to practice “smart global health”, that is, to design global health programs that leverage diplomacy and foreign policy alignment in a strategic manner to improve health and security outcomes cost-effectively.18 Multilateral organizations such as the United Nations are increasingly practicing smart global health. The UN has combined conflict resolution with its humanitarian efforts and in concert with the World Bank.18 , 19 Smart global health initiatives that cut across “vertical” (or problem-specific) activities to achieve spillover effects beyond health outcomes include programs such as WHO’s Universal Health Coverage (UHC).

The Lancet Global Health 2035 initiative advocates for global health investments to be used as tools to improve economies along with resilience and economic sustainability of countries in the face of health emergencies.20 Investing in synergistic alignment of objectives of GHSA and SDGs can take advantage of a window of opportunity to enhance global health diplomacy, that is, “bringing together the disciplines of public health, international affairs, management, law and economics and focuses on negotiations that shape and manage the global policy environment for health” (www.who.int/trade/diplomacy/en/) and promote formation of strong alliances between countries and donors to achieve resilience and better global health outcomes. While the GHSA intends to advance health security by building sustainable societies, the SDGs promote human security (a comprehensive concept that combines health security with human development).21 , 22

Achieving goals from both agendas promises mutual benefit. Stable and economically growing societies facilitate improving infrastructure and political will through which to implement the GHSA. By addressing poverty, rapid urbanization, climate change, and economic and health disparities, the SDGs should mitigate many of the risk factors pertaining to epidemics.23 When people are healthy, including free from infectious diseases, they are more productive members of society and can contribute to economic and social development. The GHSA also addresses obvious gaps in the SDGs pertaining to acute public health emergencies, such as epidemics. GHSA adoption can complement SDG efforts by narrowing the inequality gap amplified by epidemics (SDG 10). The GHSA facilitates capacity building and strengthening of data monitoring and reporting—key targets of SDG 17 about promoting partnerships for sustainable development.

“Securitization of health” or viewing epidemics as a threat to national and international security has increased both political awareness and funding for epidemic responses, for example the recent Ebola and Zika epidemics. In an increasingly shrinking global village (due to globalization), health stretches beyond the realm of the health sector to impact all key areas of foreign policy: diplomacy, trade, development, human dignity, security, political and legal institutions.24 , 25 Thus, it is essential to optimize the delivery of any donor-driven global health program to take into account foreign policy and diplomatic perspectives, to ensure downstream gains to both donor and recipient countries.18 Health-related ceasefires in conflict areas26 and the US government’s President’s Emergency Plan for AIDS Relief (PEPfAR)18 are two examples of synergistic diplomatic and global health gains achieved with global health programs. Both SDGs and GHSA adapted at the national level to ensure alignment with country priorities offer huge potential to advance diplomatic goals and improve health outcomes and resilience both locally and globally.

As the world enters the Anthropocene era due to the increasing impact of human activities on Earth’s ecosystems and geology,27–29 challenges posed by climate change, economic inequity, and poor infrastructures will compound the threat posed by epidemics.30 SDGs are unique in their recognition of the importance of “planetary health”—integration of the interconnected human health systems and natural systems—to achieve equity, sustainability, and security.31 Changing planetary trends related to human-induced changes have contributed to increasing incidence of neglected tropical diseases (NTDs) as well as emergence of newer ones such as Zika, Ebola, and Chikungunya in geographical regions where they had previously not been detected.32 Global health security programs need to address the complex nature of future epidemics. Aligning implementation of SDGs and GHSA will allow just that health. Security requires a focus beyond preparedness to respond to disease—to address key factors in epidemics—namely poverty and the increasing impact of humans on biosphere.

Recent studies have shown that climactic disasters amplify the threat of armed conflicts.33 These are among the major factors inducing NTDs.32 Conflict regions are the most vulnerable to diseases, in part because health systems there are often inadequate.34 The GHSA addresses this concern by helping countries develop capacities for the prevention, detection, and management of epidemics, thereby bolstering progress for SDG target 3.d (Goal 3: Ensuring healthy lives and promoting the well-being for all at all ages; Part 3d:, the response to global risks.) With a focus on security, the GHSA increases attention to conflict states and helps address the special challenges of epidemic response in these locations.

Obstacles to Optimal Implementation

The goals of both agendas will be challenging; some obstacles are unique, others are similar. The all-inclusive nature of SDGs leaves no clear priority areas for development on which to focus national and donor political support.2 , 6 Countries intending to meet the exhaustive list of SDG targets and indicators may find the tasks overwhelming. The focus of the GHSA on security may not interest donors who do not see an immediate connection between health and security.7 , 35 , 36

Successful implementation of the SDGs and the GHSA will require extensive mobilization of international and national political support, as well as effective governance and political accountability from countries.35 , 37 , 38 A key challenge for the GHSA pertains to global health governance, specifically the lack of binding mechanisms to ensure political accountability for compliance with IHR. Nor are there mechanisms to ensure accountability for SDG implementation. Implementation of both the SDGs and the GHSA by states would face “grand challenges of governance”39—collaboration, corruption, stewardship, and accountability.

Even with full political commitment to both agendas by governments, financing remains a major concern for countries implementing the agendas. The estimated annual cost of implementing the SDGs worldwide could reach $5 trillion USD40 and investments and measures for global pandemic preparedness could require $4.5 billion USD/year.41 , 42 While the GHSA provides countries assessment and tools for strengthening health systems in their responses to outbreaks, there are limited financial incentives for countries to adopt GHSA.

Distortion of country priorities in the face of donor and political influence also pose major challenges (for example, a focus on disease-specific programs rather than on strengthening health systems—if the former is driven by donor funding). Thus, we offer the following recommendations.

Recommendations

Recommendation 1

Increase financial support for SDGs and GHSA implementation by enhancing private sector engagement and domestic resource mobilization and allocation.

Governments could pursue earmarked taxation aimed at health and development outcomes, such as a Tobacco Tax, an Environmental Tax, or a Sugar Tax. Additional tax revenue can be used to finance the SDGs and to implement the GHSA. Given that businesses suffer substantial losses during and following an epidemic, there is ample potential for public–private sector collaborations within the GHSA. For example, the private sector can support the SDG efforts through in-kind and in-cash donations.

Recommendation 2

Increase fiscal support for SDGs and GHSA by encouraging OECD countries to achieve their target Overseas Development Aid (ODA) of 0.7 per cent as agreed by donor nations at high-level international development conferences and by mobilizing G20 nations (an international forum for the governments and central bank governors from 20 major economies founded in 1999 to study, review, and promote high-level discussion of policy issues about international financial stability) to allocate greater resources toward health.

To mobilize political support for both agendas, higher income countries must recognize their roles and responsibilities for implementation and financing—as well as the more vulnerable countries in which epidemics, among other challenges, are often most destabilizing. The 0.7 per cent ODA goal for donor countries is imperative to promote sustainable development and human security. Creating incentives, such as making achievement of 0.7 per cent a criterion for permanent membership in UN Security Council, could facilitate external financing for global public goods as outlined by the SDGs and the GHSA. Few donor countries have achieved their targets of allocating 0.7 per cent of their gross national income (GNI). G20 countries that account for 85 per cent of world’s gross domestic product (GDP) are home to more than 50 per cent of global NTD burden and have high levels of poverty.32 , 43 , 44 Given the large population and fiscal power of the G20 nations, these countries need to assume greater responsibility for allocating resources for health, especially to research and development for disease control. Acceleration and intensification of advocacy and political lobbying, and pressuring countries to set plans and time frames are all important.

Recommendation 3

Engage civil society for GHSA advocacy and support.

Civil society organizations are actively engaged in development of the SDGs; thus, the SDGs are more people centered (from the perspective of local communities) and inclusive than previous efforts (unlike the Millennium Development Goals or MDGs). The GHSA is less so; it focuses on how governments can improve health systems and strengthen capacity for disease detection, control, and response. For the GHSA to be fully effective in building global epidemic resilience, more countries need to participate. By utilizing tools such as social media, civil society can mobilize a powerful advocacy base to pressure the public and private sectors to act. Engagement of civil society in advocacy can play a crucial role in putting GHSA on the agenda of more countries.

Recommendation 4

Facilitate implementation of SDGs and the GHSA through incentives and by developing five-year plans.

Economic incentives for reporting outbreaks and implementing the five-year external assessment of the GHSA plan can facilitate GHSA adoption by countries. Donors can utilize aid packages as economic incentives for countries that implement the GHSA plan. Donor countries can also commend countries that adopt the GHSA—and add financial aid packages to further strengthen health systems. Assembling international emergency funds for support in times of crisis to compensate for economic loss during an outbreak can also promote adoption of GHSA and encourage early reporting of outbreaks by countries.

Donors should encourage countries to develop five-year SDGs plans focusing on SDGs most relevant to national priorities of each. Performance-based incentives for countries that achieve their five-year SDGs plans should enhance country ownership of the SDGs.

Recommendation 5

Enhance governance structures to include political accountability for IHR implementation during outbreaks and ensure transparency for SDG implementation.

Government heads must publicly show their commitment to achieving the goals of both the GHSA and the SDGs. Country leaders can facilitate adoption of both by signing declarations of support for target-related initiatives. Governments must monitor progress toward agenda targets and make results available to the global community. Although IHR is a set of international laws, there are no built-in incentives for compliance, nor are there governance structures to ensure it. An external WHO-WTO accountability commission with power to impose sanctions for IHR defiance during an outbreak could improve compliance substantially. It could also contribute to implementation of GHSA/IHR targets with IHR compliance score cards in a manner similar to that of the Trade-Related Aspects of Intellectual Property Rights (TRIPS), the international agreement on intellectual property regulation that is administered by World Trade Organization (WTO).

Recommendation 6

Explore synergies between GHSA and SDGs to ensure maximum benefit.

Because the GHSA and SDGs address important gaps in previous arrangements, donors and countries should explore synergies for joint implementation activities.37 Investment in IHR core capacities such as surveillance via GHSA could strengthen health systems and vice versa. That is, building capacity of staff of ministries of health and health facilities and programs could achieve the dual goals of supporting surveillance and providing trained workforce for quelling epidemics. Strong information systems are required for surveillance and monitoring outbreaks. Availability of universal health coverage and primary health care to ensure equitable access to health services represents the first line of defense for limiting epidemics.

To overcome the narrow focus on infectious diseases of the GHSA, stakeholders in the health sector must stress the benefits that SDGs impart for implementation of the GHSA and vice versa. This approach can facilitate collaboration and prevent duplication of efforts to meet GHSA and SDG targets. To promote multi-sectoral collaboration for both agendas, certain projects and programs, such as building healthcare worker capacity or surveillance, can be jointly financed and implemented.

Recommendation 7

Enhance engagement between recipient countries and bilateral and multilateral donors as well as national ownership of goal setting by recipient nations to ensure bilateral donor interests does not distort national priorities.

Practicing ‘cultural competence,’ or the incorporation of appropriate cultural dynamics and context in health programs45 with greater local participation in implementation of GHSA and SDGs can ensure even-handed benefit for donors and recipient countries. Evaluating implementation of SDGs and GHSA from the vantage point of diplomatic and foreign policy goals can help to ensure sustainability of these programs. Increasing accountability of recipient countries and building on diplomatic successes of previous global health interventions (such as PEPFAR) can boost positive perceptions and reduce concerns about securitization of health (linking security objectives to those for improving health).

Conclusion

Both the GHSA and the SDGs use complex and horizontal approaches to strengthen health systems and to build IHR core capacities for a sustainable world resilient against infectious disease threats. Implementation of SDGs and the GHSA is still in the early stages. Opportunities abound to influence and guide their implementation. Obstacles to achieving the goals of the GHSA and SDGs are not insurmountable, and overcoming them would be greatly facilitated by recognition of the synergy between the two agendas, rather than by assuming they must be mutually exclusive.