Anyone needing evidence of how the global health agenda has shifted in recent years just needs to look at the Millennium Development Goals. The predecessor to the Sustainable Development Goals (SDGs), agreed at the turn of the millennium, set a focus squarely on child and maternal health, and prevention of HIV and malaria. There were no targets for non-communicable diseases (NCDs) such as heart disease and cancer.
Fifteen years later, when the SDGs were signed in September 2015, the heavy social and economic burden of NCDs had become all too clear. Cardiovascular diseases - which include heart disease and stroke - were found to be responsible for one-third of all deaths in the world, while cancer had risen to be the second leading global cause of death.
The international community drawing up the SDGs shifted their focus to reflect the threat. SDG3's overarching promise is to "ensure healthy lives and promote well-being at all ages", but its sub-targets take aim at heart disease, cancer, respiratory disease, diabetes, mental health, substance abuse, and illnesses from hazardous chemicals and air, water and soil pollution and contamination. It's a major leap from the relatively narrow targets contained in the MDGs.
But the health considerations of the SDGs do not stop at SDG3. The goals are all interlinked, and 14 health-related targets in fact lie under the other goals, according to the World Health Organisation (WHO) which has mapped all the goals against each other in a recently published document.
If we don't address the health targets, we won't reach the other targets - Dr Mariângela Simão, WHO
"Health is not just about SDG3. It's also about gender equality - for example, girls' access to education affects health, and violence against women is related to worse health outcomes," says Dr Mariângela Simão, assistant director-general for drug access, vaccines and pharmaceuticals at the World Health Organisation (WHO).
Health systems need to function from before people are born until after they die, and as such, health needs to be addressed in an integrated manner, she notes. "If we don't address the health targets, we won't reach the other targets," she says.
But progress so far has been patchy, commentators observe, particularly when it comes to environmental factors. In the UK, a report published in July by the UK Stakeholders for Sustainable Development (UKSSD) found the UK was at risk of not meeting health targets relating to air pollution and preventable mortality from NCDs.
An estimated 40,000 premature deaths a year in the UK are attributed to air pollution, and the European Commission is set to take legal action against the government for nitrogen dioxide concentrations being persistently above legal limits since 2010, the report noted. To meet the SDG target on air quality, cross-sector coordination across SDGs on clean energy, infrastructure, sustainable cities and responsible consumption is needed, it said.
The report's findings reflect the need for society to think more holistically about the causes of NCDs - many of which lie in areas outside the direct influence of the health system, such as air pollution, and physical inactivity, it notes.
"The UK health system focusses on treatment, not prevention," says Emily Auckland, director and co-chair of the UKSSD Network. "SDG3 encourages us to think about how to maintain health and prevent the development of ill health in a very joined up way," she adds.
However, when it comes to business involvement in SDG3, relatively few are so far thinking about connections between SDGs on health and other areas, Auckland argues. "It's easy to pick a goal like health and say it is operationally very important to the business because it wants its staff and customers to be healthy, but that's not the point. It's not about health in isolation," she says.
The SDGs were not centred on a single business having an initiative, but rather aimed to drive whole market transformation, she says. For example, many companies promote cycling to work as a health initiative, but that has not changed the transport system, or the fact that cities are designed largely for single-occupancy vehicles, rather than public transport, she points out.
Emma Spencelayh, senior policy advisor at the Health Foundation, and author of the chapter on health in the UKSSD report, says that although the concept of 'health in all policies' had been talked about for some time in the health sector, it has had been difficult to push through, she says.
"People have said that other issues, such as education, are just as important. This is where the SDGs provide a framework to promote better inter-sectoral working," she says.
The growing body of evidence underscoring the benefits of holistic change could help. In December a major new report from the World Health Organisation found that in the world's 15 highest greenhouse gas emitting countries, the health impacts of air pollution cost more than four per cent of their GDP, yet taking necessary actions to meet the Paris Agreement goals would cost only around one per cent of GDP. The research is some of the clearest evidence yet of the close relationship between a low-carbon economy, a healthy planet, and saving lives.
Business takes on SDG3
Despite patchy pick-up, SDG3 is one of the goals most highly prioritised by business, according to a study by consultants at KPMG, which analysed company reports from the world's 250 largest companies. Healthcare companies are, unsurprisingly, particularly enthusiastic about making progress against SDG3, it observed.
Will Evison, director at consultancy PWC, says SDG3 is an obvious goal for health sector companies to engage with. "Their capabilities and main value drivers are focused around making people healthier," he points out.
SDG3 will quite often come out as something major corporates can have an impact on and prioritise - Will Evison, PwC
Meanwhile Dr Jake Reynolds, executive director of sustainable economy at the Cambridge Institute for Sustainability Leadership, is working with pharmaceuticals company Astra Zeneca on a project to prevent respiratory disease in Kenya, and insists hitting SDG3 requires new types of intervention that healthcare businesses could be well-placed to support. "The ambitious targets in SDG3 are not achievable through the traditional treatment model, you have to get onto the front foot and treat the problem much earlier on," he says.
Encouragingly, Evison reports SDG3 also has "wide appeal and applicability" beyond healthcare companies, as it has broader relevance than some of the other goals, and resonates with senior people in business.
"SDG3 will quite often come out as something they [major corporates] can have an impact on and prioritise," he says. "It's also typically a way of scaling up and justifying activities that are already underway in relation to health and wellbeing." Engaging employees in health issues was good for morale and retention, he adds.
Elisabeth Lincoln, sustainability manager at Business in the Community, has also noticed greater involvement in SDG3 from the pharmaceutical sector, and food and drink companies.
However, she believes that since SDG3 contains targets on mental as well as physical health, a wider range of businesses will see the benefit of engaging with it, particularly in terms of productivity. "This is beginning to drive the agenda quite a lot, and chief executives in particular are starting to see that this needs to be tackled," she says.
One example of a non-healthcare company which has developed a strategy around SDG3 is Forster Communications, which has chosen SDG3 as one of three of the global goals it is working towards. As well as advising clients on how to boost the health of their staff and customers through communications, Forster encourages a healthy lifestyle from its own employees, and was named as one of Britain's healthiest workplaces in 2017 by VitalityHealth.
"We very much believe that employees need to be well, happy and engaged in order to work well," says Amanda Powell-Smith, chief executive of Forster Communications.
All Forster employees who walk or cycle to work or to client meetings can earn extra annual leave, up to two days a year, she says. The company has bikes that staff can use, and its induction process includes cycle training for new joiners.
Forster also has a history of working on mental health issues, having undertaken work for the UK government on the issue as far back as 2001. It talks to its clients about sleep, which Powell-Smith says is key to both mental health and preventing accidents. "Sleep wouldn't traditionally have been seen as an employer's problem," she says. "But it is now, with mobile phones giving people the ability to work all the time, as they'll be dealing with the fallout, such as poor productivity."
The business case for health
As well as improving morale and productivity, there are other business reasons for engaging with SDG3. Companies that invest in community health as well as employee health have much higher return on investment than those who engage with employees' health alone, according to a study published in the Journal of Occupational and Environmental Medicine in September.
Charlotte Ersbøll, senior advisor to the UN Global Compact (UNGC) on SDG3, explains: "Companies are not an island - if there isn't a healthy environment around employees once they're back in their community with their families, then the employee health and wellbeing programmes at the workplace won't have any impact."
The UNGC has spent 18 months consulting its members on the SDGs to identify where companies are focusing in terms of health, and how they are considering and tackling their impacts.
"What we've heard from companies which have started working on this is they believe that their ability to communicate about health, and account for impacts transparently, will be important for their licence to operate and their interaction with stakeholders," she says.
Understanding of a company's responsibilities for health is probably ten years further behind where it is with climate and water - Charlotte Ersbøll, UN Global Compact
The organisation is now working with "two handfuls" of companies that are very interested in linking health targets under SDG3 with other issues such as climate change and environmental protection, women's rights, and labour rights, which are the main gaps UNGC has identified in business strategies.
This is a challenge, she says. Many firms are generally far more tuned into their responsibility for climate change and the environment than they are for health, she believes, despite the obvious linkages between the different areas. "Understanding of a company's responsibilities for health is probably 10 years further behind where it is with climate and water," she says.
But Ersbøll has already noticed a number of companies thinking innovatively about how their products interact with both the environment and people's health. For example, Danish insulation company Rockwool is marketing its products not just in terms of how they make buildings more energy efficient leading to lower carbon emissions, but also how they can regulate humidity, which can cause respiratory problems if it is too high, and skin problems if it is too low. Insulation also reduces noise pollution, which affects stress, sleep and can increase blood pressure, the company says.
Meanwhile Marks and Spencer is supporting 15 of the SDGs, including health, as part of the evolution of the retailer's "Plan A" sustainability programme. The health element of the strategy covers the impact of its food and clothing products on customers, its employees and supply chain. Targets include achieving 50 per cent of global food sales from healthier products by 2022, limiting calories in single serve portions of snacks, confectionary and ice cream to a maximum of 250 by December 2018, and raising £25m for charities that help people with cancer, heart disease, mental health or dementia by 2025.
In 2020, it is planning to launch a comprehensive health and wellbeing programme for employees, including mental health first aid training. It wants to provide health risk assessments for its employees worldwide, and will use the data to tailor its health programme and advice to employees. It will launch similar initiative for franchise partners and suppliers by 2022.
Other consumer goods companies have noted a trend for their customers to want more healthy food, and believe they need to change their product portfolio in order not to lose customers, according to Sharon Bligh, health and wellness director at the Consumer Goods Forum (CGF). "There's a growing awareness from our members, who are seeing changes in consumer purchasing decisions," she says. "Some companies are seeing that entire product portfolios are just no longer relevant." The surge in retailer interest around Veganuary this year, and the associated controversy, are obviously part of a growing trend.
Although the forum has run health programmes for a while, the creation of the SDGs has given its strategy new, longer-term focus, she says. For example, the CGF's 'Collaboration for Healthier Lives' programme, launched in 2017 in response to SDG3, encourages consumers to buy healthier food and lead healthier lifestyles through in-store campaigns including free health checks. Data on product choices will be collected and used to refine the design of campaigns.
The project is being led by manufacturer Danone and retailer Walmart and has been rolled out in cities in Colombia, the US, Japan, Costa Rica and Turkey. Plans are afoot to expand it to the UK, France, Singapore, with projects in China and South Africa also in the pipeline. Projects have involved collaboration with government health departments and universities.
Whatever form health strategies take, it is clear that global health problems are huge and multifaceted, and overcoming them will take years. US think tank the Brookings Institution analysed the pipeline of health products due to be released by 2030, the end date of the SDGs. It identified a shortfall in investment in new treatments for HIV, TB, and malaria alone of around £1.5bn per year.
And developments in medicine, technology, and prosperity will not be sufficient on their own to ensure the SDG targets are met. Life expectancy is rising in most countries around the world, but in developed countries the share of the population considering themselves to be in 'good health' is stagnant. Obesity and air pollution - two factors beyond the control of many state-run health services - are fast emerging as some of the biggest threats to health in around the world. It is clear the environmental and social challenge of SDG3 is just as great as the medical challenge.
"Our global health targets have become more ambitious, yet the global health community is going backward in supporting the innovations needed to achieve them," the Brookings study concluded.
The WHO's Simão argues public-private partnerships will be needed to drive real change. For example, to combat antibiotic resistance, new antibiotics for very specific conditions are needed and the rates of antibiotic use must be dramatically curbed. But developing a product with a restricted market is not necessarily in the pharmaceutical sector's business interest, she points out, nor is it an easy task to convince farmers to stop using antibiotics to keep farm animals healthy.
This is where business could help, she says, as the problems are too big for any government or NGO to solve alone, she says. "We need the private sector, including those that don't necessarily get involved in healthcare," she says. There are already good partnerships offering solutions at a local level, but they are not necessarily being brought up to scale, she adds.
Business in the Community's Elisabeth Lincoln agrees. "The key part here is for business to be on board with governments - the better they understand the global goals, the better they will work together to ensure healthy living and lifestyle. That will be the most productive partnerships to really move SDG3," she says.
Ersbøll meanwhile believes future solutions to health problems will lie in preventative approaches to healthcare largely championed by the private sector. "If you look at the demographic development of NCDs and other diseases, there will simply not be enough money in our healthcare systems to treat all these people," she argues. "Somehow we need to work ahead of the curve - and I think that's where we'll see the SDG3 agenda going."
"Corporate stewardship will play a role in building health resilience," she adds. "We're just in the process of understanding what the potential health impacts of climate change and environmental pollution might be, and that creates a whole new level of accountability for business."
The international health agenda has changed dramatically since the era of the MDGs. Targets under the SDGs reflect a far more sophisticated understanding of how environmental factors such as pollution, or lifestyle changes and changes in food production, feed into the picture of global health. The challenge now is for businesses to identify which levers they control in this vast, interconnected system. The links between a greener planet and a healthier population may not be obvious, but they are there - and it's up to sustainable businesses to find them.
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