Situating Health Within the 2030 Agenda—A Practical Application of the Sustainable Development Goals Synergies Approach

Abstract

Background: The Sustainable Development Goals (SDGs) are integrated, indivisible and interdependent and interact and affect each other directly and indirectly. However, the 2030 Agenda does not attempt to identify or characterise these interactions.
Evidence: The SDG Synergies approach was developed to enable the investigation of the strength and nature of interactions between SDGs based on the perception of a multistakeholder group. Two examples are given to concretely demonstrate how this approach overcomes present challenges and can be applied to situate health within the 2030 Agenda.
Policy Options and Recommendations: There are clear benefits to situate desired health policy outcomes within the 2030 Agenda, and the SDG Synergies approach can be used as lever for including health aspects in traditional non-health sectors. Although focusing on specific health policies cannot be substituted with multisectoral policies alone, utilizing tools and methods such as the SDG Synergies approach can help policy makers put health at the centre of the SDGs.
Conclusion: SDG Synergies is an impactful approach for policy makers to gain a systemic understanding of how broader sustainable development shape the health and well-being of people and vice versa.

Full text

Situating Health Within the 2030
Agenda—A Practical Application of
the Sustainable Development Goals
Synergies Approach
Daniel Helldén
1
*, Nina Weitz
2
, Måns Nilsson
2
,
3
and Tobias Alfvén
1
,
4
1
Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden,
2
Stockholm Environment Institute, Stockholm,
Sweden,
3
Department of Sustainable Development, Environmental Science and Engineering, Royal Institute of Technology,
Stockholm, Sweden,
4
Sachs’Children and Youth Hospital, Stockholm, Sweden
Background: The Sustainable Development Goals (SDGs) are integrated, indivisible and
interdependent and interact and affect each other directly and indirectly. However, the
2030 Agenda does not attempt to identify or characterise these interactions.
Evidence: The SDG Synergies approach was developed to enable the investigation of the
strength and nature of interactions between SDGs based on the perception of a
multistakeholder group. Two examples are given to concretely demonstrate how this
approach overcomes present challenges and can be applied to situate health within the
2030 Agenda.
Policy Options and Recommendations: There are clear benefits to situate desired
health policy outcomes within the 2030 Agenda, and the SDG Synergies approach can be
used as lever for including health aspects in traditional non-health sectors. Although
focusing on specific health policies cannot be substituted with multisectoral policies alone,
utilizing tools and methods such as the SDG Synergies approach can help policy makers
put health at the centre of the SDGs.
Conclusion: SDG Synergies is an impactful approach for policy makers to gain a systemic
understanding of how broader sustainable development shape the health and well-being
of people and vice versa.
Keywords: sustainable development goals, agenda 2030, network methods, interactions, policy coherence
BACKGROUND
Although off to a slow start, the Millennium Development Goals (MDGs) introduced in 2000 were a
resounding success, mobilising resources and functioning as an accountability measure and report
card for low and middle-income countries to track progress to end poverty and improve health. The
shortfalls of the MDGs were inherent in the structural set up of the goals, as they were dedicated to
low- and middle-income countries and focused on narrow goals which led to a siloed approach to
development [1].
With the introduction of the 2030 Agenda in 2015, the–to date–most ambitious goals framework
for the world in 2030 were agreed upon by all UN member states. The 17 Sustainable Development
Goals (SDGs) and 169 targets that make up the agenda can be seen as an integrated and
Edited by:
Kaspar Wyss,
Swiss Tropical and Public Health
Institute (Swiss TPH), Switzerland
*Correspondence:
Daniel Helldén
daniel.hellden@ki.se
This Policy Brief is part of the PHR
Special Issue “Health in all Sustainable
Development Goals”
Received: 16 July 2021
Accepted: 14 March 2022
Published: 07 April 2022
Citation:
Helldén D, Weitz N, Nilsson M and
Alfvén T (2022) Situating Health Within
the 2030 Agenda—A Practical
Application of the Sustainable
Development Goals
Synergies Approach.
Public Health Rev 43:1604350.
doi: 10.3389/phrs.2022.1604350
Public Health Reviews | Owned by SSPH+ | Published by Frontiers April 2022 | Volume 43 | Article 16043501
Public Health Reviews
POLICY BRIEF
published: 07 April 2022
doi: 10.3389/phrs.2022.1604350

interdependent system of goals and targets that affect each other
directly and indirectly. However, while explicitly acknowledging
this indivisibility in its preamble, the 2030 Agenda does not
provide any guidance on how the synergies and trade-offs
between goals and targets should be identified, characterized
or handled.
There is a long tradition with regards to health and well-being
(SDG 3) of people to look beyond the diseases and try to study the
root causes of ill-health within public health. The most used
framework to understand how health is affected by other factors
is the social determinants of health approach. The framework
links the socioeconomic and political context (governance,
economic, social and public policies as well as culture and
societal values) with the socioeconomic position of an
individual (social class, gender, ethnicity, education,
occupation and income) and the unique material, biological
and psychosocial factors of each person [2]. Moving from
theoretical frameworks to hard evidence, multiple studies have
shown the excess ill-health from inequalities in income or
nutrition [3]. Similarly, it has been demonstrated that
approximately 50% of the decrease in under-five deaths in
low-income countries between 1990 and 2010 can be
attributed to factors outside of the health care system [4].
As evident by the social determinants of health framework,
policy makers must consider not only the health-specific factors
that determine the health and well-being of people when
designing health policies, but also the more distant factors.
However, policy makers are often reluctant to adopt a
multisectoral approach to health, partly because of a lack of
common understanding between sectors and the complexity of
trying to estimate all the possible indirect effects and provide an
overall sense of the possible end result [5,6]. With the 17 SDGs
policy makers now have a universally adopted and societal-wide
framework for understanding the more distant factors that
influence health and vice versa. However, an easy to use and
intuitively simple approach for characterizing the interactions
between the goals and their potential for synergies or trade-offs to
occur has been lacking. In this policy brief we present the
argument for explicitly taking into account the possible direct
and indirect effects of making progress on one goal or target on
other sustainable development goals or outcomes and illustrate
how the semi-quantitative SDG Synergies approach can facilitate
a fuller understanding of the interactions with regards to health
which is essential for situating health within the SDGs.
EVIDENCE
Traditionally there has been a focus on viewing interactions as
being either beneficial or harmful to a certain policy goal within
the SDG policy discourse. Moving beyond this binary view,
researchers have tried to assess the interactions between SDGs
through only looking at a limited number of SDGs or a single
policy area and how it is connected to the SDGs [7,8]. Going even
further Le Blanc et al [9] analyzed the interactions based on
wording of the SDGs and their targets through network theory
illuminating how the SDGs seem to be more or less interrelated.
There exist some attempts at conducting quantitative assessments
of the linkages between different SDG areas, however primarily
concerning environmental policy areas and leading to ambiguous
results [10,11]. A myriad of methods and approaches from
modeling tools [12] to document analysis [13] have been
applied in more recent years to explore the area of SDG
interlinkages primarily with the aim to inform policy
coherence. Although a detailed description of them is beyond
the scope of this policy brief, remarkably few have focused on
health (see Bennich et al [14] and Miola et al [15]). However,
some examples exist, van Zanten and van Tulder [16,17] used
network theory to conclude that some economic activities seem to
have detrimental effects on health related targets. Using
simulation modelling, Collste et al [18] showcased that
increased investment in photovoltaics in Tanzania could
positively affect life expectancy.
Although a purely quantitative approach has its advantages,
the lack of data makes it impossible to create viable models that
can yield evidence that policy makers can act on. Creating a
methodological middle way between qualitative and quantitative
methods for understanding and acting on the interlinkages
between the SDGs, researchers at Stockholm Environment
Institute and the International Council for Science developed
the SDG Synergies approach that utilizes the context-specific
knowledge of stakeholders to characterize and score interactions
between goals or targets [19,20]. Explicitly acknowledging the
subjectivity of the scoring, the analysis takes into account the
human behavior and prioritization that occur when policy
makers and stakeholders make decisions [21,22]. The scores
can be investigated further through network analysis, showcasing
the direct and indirect impact of progress on any singular goal or
target on the network as a whole and vice versa, allowing for a
health-centered focus [19].
The SDG Synergies approach consist of three steps:
(1) Identification and selection of goals or targets
(2) Assessment of interactions between the selected goals or
targets
(3) Analysis of the direct and indirect effects through network
theory
Identification and Selection of Goals or
Targets
Among the 17 SDGs there are 289 potential pairwise interactions,
and between the 169 targets there are nearly 30,000 potential
interactions even though many might be neutral. Similarly,
although the 2030 Agenda is universal, many countries and
regions have made contextual adaptations of the SDGs or
added important development outcomes not included in the
SDGs. For instance, Cambodia has localized the SDGs into the
Cambodian Sustainable Development Goals that include one
additional goal for mine eradication [23]. Hence, the goals or
targets of interest must be identified and selected to represent the
most relevant contextualized and clearly defined goals or targets
given the limitation of time and resources to assess interlinkages.
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Helldén et al. SDG Synergies Approach for Health

Preferably, a multistakeholder group should select the goals or
targets based on a pre-defined criteria for assessment and further
analysis. This stakeholder-driven process sets the system
boundaries of the assessment in terms of priority policy goals.
Assessment of Interactions Between the
Selected Goals or Targets
When the set of goals or targets have been decided, the
multisectoral stakeholder group is tasked with assessing each
interaction on a seven-point scale (see Figure 1) from strongly
restricting (−3) to strongly promoting (+3) based on the guiding
question “if progress is made on Goal/Target X, how does this
influence progress towards Goal/Target Y?”The forward-looking
focus of the question is suitable for analyzing SDG interactions as
the ambition indeed is progress on all goals and targets. The score
is noted, together with a motivation of the score including any
assumptions made, as these are important to assess the validity.
Importantly, the focus is only on the direct effect of the goal or
target, and that the interaction should be scored uniquely in each
direction since there can be a positive influence in one direction at
the same time as a negative one in the other direction. Further, it
is important to explicitly define the boundaries of the assessment
in terms of time horizon (e.g., from now until 2030) and
geographical context (global, regional, national, or sub-
national level) or other relevant dimensions as such factors are
critical for assessing how the interaction play out (see Barquet
et al [24] for a longer discussion on the issue of defining system
boundaries for the interactions assessment).
Analysis of the Direct and Indirect Effects
Through the assessment of the interactions across the selected
goals or targets, a cross-impact matrix can be constructed,
illuminating not only the pairwise interactions, but the overall
direct influence the goal or target has on the entire set of included
goals or targets and vice versa. Based on the information provided
in the cross-impact matrix, analysis can also move beyond the
direct interactions and present more systemic impacts. Using
network analysis methods one can explore and visualize how the
effect of progress on one goal or target ripples through the
network (see Newman [25] for a comprehensive review of
network theory and applications). These secondary or indirect
effects of progress are useful in order to avoid unintended effects
on other goals or targets, and to more fully understand the
influence a goal or target has on the whole 2030 Agenda.
Lastly, using network analysis it is possible to identify clusters
of strongly interrelated goals or targets, or those that seem to be
relatively uninfluenced by progress on other goals or targets. This
can be useful for guiding how to organize collaboration amongst
actors representing the different goals or targets. For a full
description of the network analysis methods, we refer the
interested reader to Weitz et al [19] and Järnberg et al [26].
The three steps of the SDG Synergies approach, including the
analysis of the direct and indirect effects, is available in an easy-
to-use custom made software at: https://www.sdgsynergies.org/.
Application of Sustainable Development
Goal Synergies Approach to Health: Sri
Lanka Example and Focus on Child Health
When it comes to health and the SDGs there is a need to situate
health within the overall agenda, and the SDG Synergies is a
promising approach for achieving this. Through following the
above approach, there is a possibility to focus on the health-
related goal or targets, showing direct and indirect interactions
and how health influences the possibility to make progress on
other sustainable development outcomes and vice versa as well as
finding more or less interrelated SDGs. With regards to health,
the SDG Synergies approach has been applied in two different
settings, yielding interesting results in both cases.
In Sri Lanka, the Stockholm Environment Institute together
with UN partners [26] applied the SDG Synergies approach to
map the interactions between the SDG targets on a country level.
An expert committee assigned by the Ministry of Sustainable
Development selected 36 SDG targets to be assessed based on
three criteria: applicability (relevance of the target to Sri Lanka),
implementability (the feasibility to implement the target in the
country context in the short term); and transformational impact
(potential transformational impact of the target in the country).
The selection was adjusted to ensure coverage across all 17 SDGs.
During a national consultation workshop that brought together
40 experts from government, civil society, UNDP and the UN
Resident Coordinator’sOffice, national experts and academia
direct interactions between pairs of the 36 targets (amounting to a
total of over 1,200 interactions) were assessed. Scoring was done
using the seven-point scale described above and network analysis
was applied to identify trade-offs and synergies in progressing on
the targets. Overall, at a country level the 36 selected targets were
FIGURE 1 | Characterization of interactions according to the Sustainable Development Goals Synergies approach, following the Weimer-Jehle seven-point scale
[30] (Stockholm, Sweden. 2022).
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Helldén et al. SDG Synergies Approach for Health

TABLE 1 | Example of direct generic interactions between the Sustainable Development Goal targets and child health. Adapted from Blomstedt et al [29] (Stockholm,
Sweden. 2022).
Goal Target Interaction Direction
1 1.1 Eradicate extreme poverty +3 Getting out of extreme poverty is strongly promoting better child
health, as health problems drive people into poverty and poverty leads
to, for example, reduced access to health services, both preventive and
treatment and also increased malnutrition
Reciprocal
2 2.1 Ensure access to safe, nutritious and sufficient food for all, including
infants
+3 Utilising sufficient, nutritious food is strongly promoting improved
child health
Health is an
outcome
4 4.1 Ensure quality primary and secondary education for all girls and boys +3 Progress in education, particularly of girls and women would be
strongly promoting all aspects of health, productivity and development
Reciprocal
5 5.1 End all forms of discrimination against women and girls +2 When women and children get better access to health services,
education, etc, children’s health is typically enabled. Attention to
women and children in various initiatives is vital given their central roles
in both social and biological reproduction and their need for access to
health-related services
Reciprocal
6 6.1 Universal and equitable access to safe and affordable drinking water
for all
+3 Strongly promoting better child health Health is an
outcome
7 7.1 Ensure access to modern energy for all (!) Note: Depending on which strategies for increasing access to energy
are chosen, the effect on child health can be positive or negative. For
example, +1 Modern energy replacing traditional solid biomass cook
stoves enables children’s respiratory health through reducing the
negative impacts of indoor air pollution and reduces outdoor pollution.
-2 For many countries, abundant energy means fossil energy, and
might thus be harmful for child health
Health is an
outcome
8 8.5 Full and productive employment, decent work and equal pay for all,
including young people
+1 the association between socio-economic status and health is
strong. Both enable each other
Reciprocal
9 9.1 Develop quality, reliable, sustainable and resilient infrastructure, to
support economic development and human well-being, with a focus on
affordable and equitable access for all (9.1)
(!) Note: Depending on which strategies are chosen for development of
infrastructure, the effect on child health can be positive or negative. For
example, +1 Developing infrastructure enables better access to health
and education facilities for children and their families. However, using
companies and labour of other countries to build infrastructure could
be seen as a kind of new colonialism, negatively affecting the socio-
economic situation of the population (score -1)
Health is an
outcome
10 10.4 Adopt policies, especially fiscal, wage and social protection
policies, and progressively achieve greater equality
+2 Equality reinforces health. Universal access to health care reinforces
greater equality
Health is an
outcome
11 11.6 Reduce environmental impact of cities, including air quality and
waste management
(!) Note: Depending on which strategies are chosen, the effect on child
health can be positive or negative. For example, +2 Reducing air
pollution reinforces children’s health by reducing pollution related
disease such as chronic pulmonary disease, heart disease etc., as well
as preterm births. However, the use of fossil fuels for development
might lead to negative health effects (score -1)
Health is an
outcome
12 12. 4 Environmentally sound management of chemicals and all wastes,
reduction of their release to air, water and soil
+1 These measures are needed to minimize chemical’s and waste’s
adverse impacts on human health and the environment
Health is an
outcome
13 13.2, 13.3, 13.b collectively as climate change measures +2 Reducing climate risk can reinforce the health of children and
adolescents through, for example, reducing severity of urban heat
waves and other extreme events
Health is an
outcome
15 15.1 Conservation of terrestrial and aquatic ecosystems including
wetlands
+1 Ecosystem protection is directly (e.g., access to nature positive for
cognitive and motor development) and indirectly (e.g., link to action
against climate change) associated with child health. Having access to
nature and wildlife positive for cognitive and motor development. (!)
Note: Conserving wetlands could counteract the fight against
epidemics (3.3) and the reduction of child mortality (3.2) as it may
enhance the exposure of children to vector-borne disease (score -1)
16 16.5 Reduce corruption +1 Reducing corruption enables improved child health outcomes since
more of the investments made in the health sector will go to its intended
uses
Health is an
outcome
(Continued on following page)
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Helldén et al. SDG Synergies Approach for Health

FIGURE 2 | Overview of the Sustainable Development Goals Synergies approach and potential benefits to policy makers (Stockholm, Sweden. 2022).
TABLE 1 | (Continued) Example of direct generic interactions between the Sustainable Development Goal targets and child health. Adapted from Blomstedt et al [29]
(Stockholm, Sweden. 2022).
Goal Target Interaction Direction
17 17.1 Strengthen domestic resource mobilisation/tax revenue +1 Improving state revenue enables investments in clinics and health
programmes for children. Conversely, improved child health frees up
time and resources for productive work which enables stronger tax
revenues. In countries with massive tax avoidance this SDG could be
as important as +3
Reciprocal
Notes: Scoring on a seven-point scale from -3, to +3. Interaction description is based on an assessment made on a global or generic scale from present until 2030 when the Sustainable
Development Goals should be achieved. All interactions assessed can be found in supplemental material in Blomstedt et al [27].
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Helldén et al. SDG Synergies Approach for Health

highly synergetic, with only 2% of the interactions being scored as
restricting. The targets that most strongly promote progress on
other targets were policy coherence for sustainable development,
reducing corruption and enhancing climate change capacity,
while housing and water targets had least promoting influence
on other SDGs and were shown to need particular mitigating
focus. Specifically, the included health target SDG target 3.5
(Prevent and treat substance abuse) was found to be overall
positively influenced by progress on other targets and vice versa,
with no restricting interactions. No specific clusters of more
closely related goals could be identified, which might speak to
the large interdependence of the goals in the Sri Lanka context.
In contrast to focusing on a specific country of analysis,
Blomstedt et al [27] assessed interactions between child health
and 34 targets among the non-health SDGs, informed by analysis
of relevant sources and consultations. Their generic analysis
suggests that progress on SDGs 1, 2, 4, 5, 8, 11, and 17 have
potentially synergetic links with child health. For instance,
progress on target 11.6 (reduce environmental impact) can
have positive effect on child health depending on the means of
the progress, with the transformation of the construction industry
being key [28]. The analysis also suggested that multisectoral
collaboration on some targets is essential for sustainable progress
on child health, for example target 1.1 (eradicate extreme
poverty) or 6.1 (achieve universal and equitable access to safe
and affordable drinking water). A selection of interactions and
their assessments are presented in Table 1. Interestingly, the
analysis found few negative interactions showing the limited
number of trade-offs with child health.
POLICY OPTIONS AND
RECOMMENDATIONS
Being able to identify and characterise the interactions between
the SDGs allows for a fuller understanding of health within the
SDGs and has a number of benefits (See Figure 2). First, it can act
as a guiding map, both contextualizing the global agenda on a
country or local level and suggesting stakeholders or partners
working with other SDGs that are essential for reaching the
health-related SDGs. Second, it makes multisectoral collaboration
explicitly necessary for reaching the 2030 Agenda. Thirdly,
prioritisation and policy planning can be made more
transparent, through effectively taking advantage of synergies
and carefully considering trade-offs and how they can be
mitigated. Lastly, it can be used as lever for taking health into
consideration when policies are designed and implemented,
allowing for enhancing policy coherence. Policy makers should
encourage and engage with efforts aiming to understand and
make use of interlinkages between the SDGs, projects such as
UniNEtZ [29] where 16 Austrian universities collaborate to
proposing options for the government of Austria to achieve
the SDGs is a model to be inspired by. On the other hand, as
demonstrated by the MDGs, focus on specific health related
outcomes can yield extraordinary results. Situating health
within the SDGs and utilizing the SDG Synergies approach is
not a silver bullet for solving all issues inherent with the health-
related SDGs and policy makers should balance the effort and
resources with potential gain of insight from making these types
of analyses. However the SDG Synergies approach can embolden
and strengthen policy makers in their efforts to reach the SDGs,
and emphasises that it should be people and all factors
influencing their health and well-being that are the centre of
the SDGs. As such, the SDG Synergies approach can be a useful as
a starting point to gain an overview of systemic interactions and
identify potentially interesting synergies and trade-offs that can
be explored in more detail in subsequent analysis. The results also
benefit from being verified with additional information sources
complementing the expert judgments used as the primary data in
the SDG Synergies approach.
CONCLUSION
In this policy brief, we argue that one of the largest challenges of
the SDGs are their integrated and indivisible nature, together with
the up-to-now lack of practical guidance on how to handle the
interactions between the SDGs related to health and other SDGs
in their implementation. As a response to this, we presented how
the SDG Synergies approach can help situate health within the
SDGs and the practical applicability of the approach with two
examples. We showcase that SDG Synergies is an impactful way
for policy makers to gain a systemic understanding of how
broader sustainable development shape the outcome good
health and well-being and vice versa, and the potential benefits
of using the approach.
AUTHOR CONTRIBUTIONS
DH wrote the first draft of the manuscript. NW and MN reviewed
and revised the manuscript. TA wrote and revised the
manuscript. All authors approved the final version of the
manuscript.
CONFLICT OF INTEREST
NW and MN are affiliated with Stockholm Environment Institute
which is an international non-profit research and policy
organization that has developed the SDG Synergies approach
and host the open source website https://www.sdgsynergies.org.
The remaining authors declare that the research was
conducted in the absence of any commercial or financial
relationships that could be construed as a potential conflict of
interest.
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Helldén et al. SDG Synergies Approach for Health

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Public Health Reviews | Owned by SSPH+ | Published by Frontiers April 2022 | Volume 43 | Article 16043507
Helldén et al. SDG Synergies Approach for Health