In Part 1 of our interview with Ole Norheim, he discusses the short and long-term goals of his work in the ethics of fair and efficient priority setting in health as well as the effect that COVID-19 has had on his field. Here he further unpacks the implications that the pandemic has had on the road to achieving the Sustainable Development Goals (SDGs).
The Sustainable Development goals are inspirational and incredibly ambitious. Among many things, they collectively urge the world to achieve rapid development, sustainable growth, fair distribution, climate action, gender equality and stronger institutions. If we could attain the SDGs, we would truly live in a better world.
As our former Norwegian Prime Minister, Gro Harlem Brundtland, has said: this is "...a pattern of development that meets the needs of present generations, without compromising the rights of future generations to fulfil their needs." The impressive thing is that all countries have actually signed up to show their commitment to the SDGs. This is no longer only a development agenda.
The way the goals are set up shifts responsibilities from international actors to states. Thus national governments are responsible for making sure their citizens, as well as their citizen’s children and grand-children, can experience sustainable development.
The goals are meant to be achieved universally. If they are properly integrated, they will reinforce one another. For example, we know that extreme poverty has been substantially reduced globally over the last decades. This has led to reductions in hunger and malnutrition, followed by improved health and reduced mortality. We also know that better education of girls leads to reduced child mortality and better family planning. This could have a positive impact on population growth and even climate change. Even goals that seem unrelated may have an impact on each other. The philosopher and economist Amartya Sen famously observed after studying the Bengali famine, that there have been no famines in democracies. If achieved, the SDGs can be transformative.
I realize that I may sound overly optimistic. But, coming from one of the Nordic welfare states, I know such a world is possible. The challenge is that we don’t know enough about how to get there. I am also mindful of the fact that even the Nordic countries have not done enough when it comes to climate action. This is why the idea of sustainability is so important.
With COVID-19, of course, the world has experienced a huge setback. There have been more than 2 million deaths due to COVID-19 alone. The impact of the pandemic has caused economic recession and has pushed millions back into poverty, hunger and inequality.
The pandemic has shown us how important health, health care and public health are. From my point of view, at least, it seems fair to conclude that in general, countries with well-functioning, universal, publicly financed health systems, have coped better than other countries – perhaps with the exceptions of the UK and Sweden. I do not classify the US as having a universal health care system, despite Obamacare. Countries such as New Zealand, Vietnam, and South Korea have done remarkably well, and the reasons remain to be explored in full. What seems clear, though, is that political leadership, trust in well-functioning public institutions, universal health care and compensation for unemployment have been crucially important for success, in addition to those determinants of health equity we know so well: income equality and education.
I cannot say my research is only concentrated around one of the SDGs. The SDG for health is of course at the core of my work, but I am also deeply concerned about distributive justice, fairness and inequality. I realize that improved health, fairly distributed, cannot be achieved without improvements across the board in many of the other SDGs.
The SDG target 3.8 on Universal Health Coverage (UHC) is a good example. Countries cannot achieve this target by simply building more health centers and hospitals, or by educating more nurses and doctors, or by offering increasing numbers of advanced services such as transplants, dialysis and cancer care. Achieving UHC also includes financial risk protection. By paying out of pocket, millions of people every year are experiencing catastrophic health expenditures and are often pushed deeper into poverty. I would argue that UHC is primarily about economic reform. Financing UHC has to be fair, and the only way to make health coverage universal is that everyone pools some of their economic resources before they become ill and receive services when they become ill, or they receive preventive services, such as vaccines, even before they become ill. Such a system has to be redistributive in three ways: a redistribution from the better off to the worse off in terms of income and wealth, from the healthy to the sick, and from the young to the old and frail. As such, UHC is closely linked to SDG 10, which is about reducing inequality within and among countries.
COVID-19 has clearly made it more difficult to achieve the SDGs. With economic recessions, unemployment, deaths and increasing poverty, many of the improvements we saw before the pandemic have been reversed.
One small glimmer of hope is that COVID made us realize that we are together in being vulnerable to global threats. We are interlinked via our globalized economy, and if the pandemic is not curbed everywhere, none of us are safe.
The response from the scientific community has been, in this respect, remarkable. The race to develop a COVID vaccine is one example. The race to identify valid knowledge amidst great uncertainty is even more remarkable. Never before have we seen scientists coming together, collecting data, analyzing, publishing and sharing results at such a speed. Journal editors have changed their practice and policies and made research available more quickly than has been previously possible. This has attracted the notice of politicians, media, and the general public. In many ways, the role of science in society has been fundamentally changed and this is recognized – at least in many countries. We have of course also witnessed places where there is growing mistrust in science, and this is deeply worrisome.
Like Bill Gates, I am an impatient optimist! Like the late Hans Rosling, I say: look at the data and the larger trends. Extreme poverty and hunger have declined, global income inequality is high, but declining, the number of armed conflicts has declined, gender inequality is on the agenda, the rights of LGBT people are being recognized more widely. And look at life expectancy. Between 1970 and 2015, average global life expectancy increased from 57 to 72 years: that is four months of increase per year! Inequality in life expectancy between countries has also decreased. Even COVID may not substantially alter this picture. And I trust we will have widespread distribution of approved vaccines and that we will slowly return back to a new normal.
I am also a realist and I see three trends that deviate from this optimistic scenario. First and foremost, is climate change. It is a shame that a young girl, Greta Tunberg, is the most consistent voice challenging us to acknowledge the facts and act upon them. Without climate action, there cannot be sustainable development. Second, the ideals of democracy are under threat by populists and autocratic rulers. The number of countries classified as being well-functioning, stable democracies is actually declining. Finally, we are not on track to reach the SDGs by 2030. The ambitious timeline is, frankly, unrealistic unless today’s global inequalities fundamentally change. Trade-offs have to be made. Growth cannot be the same everywhere. I am afraid that the SDGs may set up some countries for failure. Failing states and the poorest countries cannot achieve these goals in 10 years. Financing the SDGs requires non-trivial public and private investments, and already in 2016, The World Economic Forum estimated the annual average funding gap to be 2.5 trillion USD. And we all know the countries where this gap is largest.
Researchers have a responsibility to engage with the world.
We do not know where innovation and new technologies may take us, so we need to support basic, independent research that can continue introduce and test new ideas that will bring the world forward. We also need the social sciences, political scientists, and humanists who can help us understand the world, interpret the facts, and generate new ideas. I don’t think I am in a position to say what researchers should prioritize now, but under the wide umbrella of SDGs, there are issues well worth exploring. Based on what I have said above, research for climate action, and research on drivers, threats and enablers of democracy would be high on my priority list.
Look out for the final part of this interview, publishing next week.
About Ole Norheim
Norheim’s wide-ranging research interests include theories of distributive justice, inequalities in health, fair priority setting, and how to achieve Universal Health Coverage and the Sustainable Development Goal for health. He chairs WHO’s Technical Advisory Group on Essential Health Benefit Packages.
Norheim chaired the World Health Organization’s Consultative Group on Equity and Universal Health Coverage (2012-2014) and the third Norwegian National Committee on Priority Setting in Health Care (2013-2014).