On 25 September 2015, the United Nations (UN) General Assembly adopted the 2030 Agenda for Sustainable Development, a general pledge to “transform our world” and “leave no one behind” in terms of the economic, social, and environmental dimensions of sustainable development, (UN, 2015). The 2030 Agenda established 17 Sustainable Development Goals (SDGs) with a long list of targets and indicators that were to be collected, shared, and monitored by the UN Member States.
Despite all these there remain a number of key challenges relating to implementation of the strategies and action plans required to achieve the goals. The 2030 Agenda is a form of goal based global governance. According to Fakuda-Parr & McNeill, 2018), the goals are instruments that “translate norms from the language of words to that of numbers, coupled with setting time bound targets”.
For their part Van Zanten & van Tulder, 2018 ) argued that since the SDGs are voluntary, lack sanctions, and have few mechanisms to ensure their achievement, the 2030 Agenda therefore are a form of “soft” international law.
Progress on the 2030 Agenda has been slow and criticisms have begun to appear. Different literature sources provide the main challenges of SDGs and these are: coordinating local, national and global responses, accessing information and resources to understand the goals and how to respond and monitoring, evaluating and assessments of progress at all scales in particular sectors. Many scholars and editorials have dismally dismissed SDGs in that they are not on track and thus have a bleak future. Some even indicated that only two targets are close to being achieved, and have even predicted that most SDGs would miss their 2030 target date.
Lack of funding and lack of government commitment were suggested as possible causes. There are also other reasons why the SDGs may be off track.
For example, scholars have argued that many SDG targets are so conceptually complex that they cannot be translated into measurable indicators. The SDGs themselves may be a problem, both their lack of prioritization and their number; there may be “too many goals, too little focus” for meaningful policymaking. The prospects for achieving the SDGs by 2030 have now become significantly worse since the COVID-19 pandemic.
Challenges to implementing the SDGs are particularly acute for example in Botswana where the awareness of the SDGs amongst the government, the private sector and the public is generally low. This may be because the government of Botswana and media generally focus on socio-economic and political issues over environmental or sustainability concerns. The efforts in Botswana relating to the SDGs and President Masisi’s Reset Agenda are not bad at all, however, more needs to be done in implementation, mobilizing communities deeply and the private sector as relevant stakeholders.
There is also an urgent need to develop deliberate policy response on ESGs and ensure for sustainability impact.For their part, Rittel & Webber, 1973, Alford & Head, 2017, stated that the slow progress on the 2030 Agenda was inevitable, even before the coronavirus pandemic, because the issues the UN are addressing are wicked problems (WPs). WPs are systemic in nature, complexly interrelated, and materialize at the interface between public / private and profit / nonprofit interests”; as a result, they cannot be handled with “old management or leadership mindsets, or with old organizational structures.
If WPs cannot be solved, policymakers may instead need to focus on managing or coping. Assuming WPs scholars are correct, and slow progress on the SDGs was inevitable, what can policymakers do to ensure that the SDGs get back on track, or given the global crisis now unfolding that the SDGs are not derailed permanently?
What are Wicked Problems?
According to various literature sources as well as (Rittel & Weber, 1973), indicate that the WP literature began as a critique of the systems approach to policymaking. In the systems approach, the planner implements a policy cycle with several steps, understand the problem, gather and analyze evidence, generate and assess solutions, and implement, test, and modify the solution. Webber, 1973 criticized the systems approach, arguing that it could only handle “tame” problems.
Since WPs were inherently unsolvable, their solutions could only be good or bad, not right or wrong, thus, a systems approach was unlikely to be successful. Various scholars have observed that since the late 1970s, the WP literature has grown dramatically, in terms of both the number of scholarly disciplines and policy areas. WP scholars believe that most policy problems have some degree of wickedness, so they cannot be solved using rational-scientific methods.
According to (Alford & Head,2017), complexity is viewed as a key driver of wickedness, both the complexity of the problem (factual uncertainty) and of the actors/institutions involved. As the number and diversity of stakeholders and institutional contexts rise, so does the heterogeneity of preferences and interests, increasing the likelihood of conflict noted (Bannink & Trommel, 2019). Uncertainty and ambiguity exacerbate both complexity and conflict, increasing the degree of wickedness.
Key issues in the WP literature are how to address a WP and how to define success. Since WPs “are never solved. At best they are only resolved over and over again” policymakers cannot achieve first-best solutions, Rittel & Webber, 73).The Sustainable Development Goals (SDGs) are now steering the global development agenda and are key drivers of international action on social and environmental determinants of health. The 17 goals cover poverty reduction, hunger, health, education, inequalities, sanitation, energy, social justice, the environment, and climate change. Like their predecessors, the Millennium Development Goals (MDGs), the SDGs include specific targets, but additionally emphasise broader interlinked aspects, such as sustainability and social justice, promoting a more integrated development agenda.
Notably, the SDGs contain no mention of primary health care (PHC), one of the principal strategies for reshaping health care, promoting health-enhancing policies across sectors, and developing more equitable and fairer societies.Sept 12, 2018, marked 40 years since the Alma-Ata declaration, the bold and ambitious statement that proposed PHC as a platform for improving global health.
The 1978 Alma-Ata declaration’s vision for societal health included reorienting health systems towards primary care and addressing the social and environmental determinants of health and inequality. It emphasised social justice and equitable access to healthcare services, key elements of the modern universal health coverage (UHC) agenda and advocated for empowering communities to participate in health care planning and delivery. Notably the SDGs contain no mention of primary health care, reflecting the disappointing implementation of the Alma-Ata declaration of 1978. The Astana declaration (Alma-Ata 2·0), released in June, 2018, restated the key principles of primary health care and renews these as driving forces for achieving the SDGs, emphasising universal health coverage.
Despite efforts to revitalise Alma-Ata in 2008, with WHO’s World Health Report on PHC on Alma-Ata global action remains disappointing. This disappointing uptake stemmed from misinterpretation of Alma-Ata, minimal as noted by various scholars.
Confusion between primary care and PHC led to criticism that Alma-Ata was too broad, with the misinterpretation arising from the perspective that primary care should be responsible for addressing broader determinants of health and advancing social justice, far beyond the remit of health services. Primary health care (PHC), as set out in the 1978 Alma-Ata declaration, is a comprehensive approach to health system organisation and intersectoral action for health. It arose from health system inadequacies present in the 1970s, many of which persist today.
These inadequacies included, disease-orientated technology, which was expensive, promoted consumerism, and delivered minimal wider population benefit, the overspecialisation and lack of person centred approaches among many health professionals, poor understanding of the importance of health in social and economic development, and inadequate commitment to primary care as the core of health systems.
Importantly, Alma-Ata proposed a role for PHC in addressing social and environmental determinants of health, by considering health a human rights, equity an essential value, and community participation a necessary condition for a just society. Alma-Ata also first articulated what has since been termed the Health in All Policies approach, which recognised that all sectors have a role in promoting and coordinating efforts to improve health.
The PHC approach emphasised responsiveness adapting to local economic, social, and political realities with a strong community focus. Importantly, the Alma-Ata declaration highlighted the responsibilities governments have in improving the health of their populations. Today, these principles remain ever more pertinent with major global efforts underway to promote progress towards them. Within the health sector, PHC is often implemented through primary care services. These services are a vital component, yet only comprise the service-fronting elements of the broader PHC concept. They are provided to and are in collaboration with populations, and include promotive, preventive, curative, and rehabilitative services; health education; maternal and child health care including family planning, and immunisation.
Primary care is the locus for integrated referral systems that facilitate access to comprehensive health care, and services are staffed by multidisciplinary professionals. It also integrates public health actions towards improving food supply and nutrition, ensuring safe water and sanitation, and communicable disease control, and should be able to resolve most health needs. PHC is a requisite for strong primary care, as it facilitates equitable and intersectoral approaches to health, community-orientated services, and participatory governance structures.
*Thabo Lucas Seleke, Doctoral Candidate LSHTM, UK
