Quantifying convergence on health-related indicators of the 2030 agenda for sustainable development

Abstract The extended scope and complexity of the United Nations 2030 agenda entail important challenges for the operationalization of the health-related sustainable development goal (SDG) indicators. Divergences in concepts, agendas and implementation strategies among institutions have fostered the parallel development of alternative and concurrent indicators. We aim to determine the convergences and divergences between five key institutions: the Global Burden of Disease Study (GBD), the Pan American Health Organization, the Sustainable Development Solutions Network, the World Bank and the World Health Organization (WHO). Of the 104 health-related indicators listed by these five institutions, 60 are consistent with official Inter-agency and Expert Group SDG indicators. Our analysis considers the indicators included, and the themes these indicators cover, in each institution list and each institution online platform. We quantified convergence in indicators between the institutions themselves, but also between the institutions and the official Inter-agency and Expert Group. Our results indicate important divergences; only 22 of the 60 indicators are included in the lists of all five institutions. The level of adoption of the official metrics varies from 40.5% (15/(47−10)) for the GBD to 86.2% (25/(29−0)) for the World Bank. WHO, the official curator of the Inter-agency and Expert Group SDG indicators, is only convergent with the official metrics by 72.1% (31/(45−2)). Our analysis, and the resulting awareness of the differences, potentialities and limitations of indicators and platforms, provides important contributions to enable the achievement of the health-related SDGs and deliver the promise of the 2030 agenda.


Introduction
The United Nations (UN) 2030 agenda for sustainable development is organized into 17 complex and interdependent sustainable development goals (SDGs), encompassing 169 targets related to aspects of socioeconomic and environmental determination. The official SDGs framework is described by 231 globally harmonized monitoring indicators, designed by the Inter-agency and Expert Group to enable multilevel global comparisons across time and avoid misinterpretation of the targets. 1 The Inter-agency and Expert Group also has the official mandate for establishing and periodically reviewing the official indicator framework for the SDGs, in addition to monitoring the global coverage of these indicators. 2 However, regardless of the establishment of globally harmonized monitoring indicators, divergences in concepts, agendas and implementation strategies among the institutions promoting the SDGs exist. Further, the methodological challenges brought by newly developed indicators and a lack of official and/or comparable data for many countries have fostered the parallel development of alternative and concurrent indicators. 3 Although this parallel development has led to an increase in the number of countries and subnational units working towards the 2030 agenda, 3 such a nonuniform approach can reduce the capacity of the agenda to effect changes at the global scale; indeed, this competitive rather than collaborative environment among the stakeholders contradicts the very principles of the 2030 agenda. 4 The level of progress in official SDG indicator operationalization is represented by its tier classification. Currently, 53.7% (123/229) of the indicators are classed as Tier 1, that is, "conceptually clear, has an internationally established methodology and standards are available, and data are regularly produced by countries for at least 50 per cent of countries and of the population in every region where the indicator is relevant". 5 Since the last revision in April 2020, there are no indicators currently classed as Tier 3 (Fig. 1), for which "no internationally established methodology or standards are yet available for the indicator, but methodology/standards are being (or will be) developed or tested". 5 However, the fact that 45.9% (106/231) of the indicators are currently classified as Tier 2 -"conceptually clear, has an internationally established methodology and standards, but data are not regularly produced by countries" 5 -highlights how the availability of comparable data is the biggest challenge for statistical agencies worldwide. This challenge reinforces the UN global call for governments to improve statistical capacity and data collection, strengthen cooperation and international partnerships, and agree on collective action to deal with the complexity and interdependence of planetary demands. 3,7 In this paper, we aim to determine the convergences and divergences in the operationalization of the health-related SDG indicators according to five key global institutions -the Global Burden of Disease Study (GBD), the Pan American Health Organization (PAHO), the Sustainable Development Solutions Network, the World Bank and the World Health Organization (WHO) -selected for inclusion in our analysis for their international prestige and preeminent role in 2030 agenda initiatives. By understanding where the aims of these institutions diverge and converge, we provide important insights for the strategic organization of the international community in the achievement of the 2030 health targets.

Comparison methods
The five institutions that we consider here, listed in Box 1, have selected and adapted a set of health-related indicators Operationalizing the health-related indicators of the 2030 agenda Fabrício Silveira et al.
based on their area of expertise, statistical capacity, traditions and views on health determinants. Of the 104 health-related indicators listed by these five institutions, 60 are consistent with official Inter-agency and Expert Group SDG indicators. In addition to the 13 targets and 27 indicators included in SDG 3 (ensuring a healthy life and promoting well-being at all ages), the five institutions also consider a further 33 health-related indicators included in SDGs 1 (poverty), 2 (hunger), 4 (education), 5 (gender equality), 6 (sanitation), 7 (energy), 10 (inequalities), 11 (sustainability), 16 (strong institutions) and 17 (partnerships).
Our analysis considers the indicators included, and the themes these indicators cover, in each institution list and each institution online platform. We compared indicators between the institutions themselves, but also between the institutions and the official Inter-agency and Expert Group. We also compared the methodological choices made by the institutions in operationalizing the indicators, that is, the convergence in indicators with the official indicators as designed by the Inter-agency and Expert Group. For example, although the Sustainable Development Solutions Network included the indicator for malnutrition among children younger than 5 years in their list, their platform shows obesity among adults as the indicator; this means that this particular indicator is not considered to be convergent with the official metrics.
The SDG information platforms provided by the various institutions are the main tools for converting the 2030 agenda to policies. These platforms aim to fill analytical gaps by focusing on different perspectives of the tasks of promoting, monitoring and evaluating the challenges of the 2030 agenda, that is, operationalizing their institution's health-related SDG indicators. We therefore also assessed the general characteristics of the platforms provided by the five institutions. In comparing these platforms, we considered: (i) temporal and geographical coverage of the database; (ii) indicators (i.e. whether official SDG indicators or alternatives resulting from an institution-specific interpretation); (iii) methods of presentation and dissemination (e.g. visual aids, reports); and (iv) methods of global assessment (e.g. international comparisons, temporal analysis, performance indices, trends and projections).

Convergences and divergences Themes
We illustrate the thematic convergence between the institutions in Table 1, adopting the thematic classification for the health-related indicators devised by WHO for themes. 13 We devised an additional category, that is other themes to reflect new topics introduced by the other institutions. As anticipated, due to the number of inherited indicators from the millennium development

Pan American Health Organization
Created in 1902, it is the oldest health organization in the world. It currently has 52 member countries and two simultaneous institutional functions, being both the specialized health agency of the Inter-American System and the Regional Office for the Americas of WHO. 9

Sustainable Development Solutions Network
This independent global network of 800 member institutions, including technical institutions, research centres and universities, aims to mobilize available technical knowledge to resolve sustainable development issues. It received a UN mandate in 2012 to support the 2030 agenda. 10

World Bank
This independent specialized agency of the UN acts as a major financier of developing countries, with 12 000 projects to support world development. 11

WHO
The UN's specialized health agency comprising 194 member countries. 12 SDG: sustainable development goal; UN: United Nations; WHO: World Health Organization.

Policy & practice
Operationalizing the health-related indicators of the 2030 agenda Fabrício Silveira et al.

goals (MDGs)
, the themes reproductive and maternal health, newborn and child health, infectious diseases, and noncommunicable diseases are relatively consensual. Themes on injuries and violence and environmental risks include a larger number of indicators, explaining the slightly lower levels of agreement between the institutions than for themes inherited from the MDGs. The least consensual themes (as measured by the number of indicators in the theme adopted by the institutions) are: universal health coverage and health systems, which contains indicators that have been less studied in recent years due to the presence of a vertical disease approach to health interventions; 14 and other themes, which includes five new topics.

Indicators and their metrics
We depict the convergences between the five institutions in terms of indicators included in Fig Table 2 shows a summary of the number of indicators considered between each individual institution and the Inter-agency and Expert Group; a more detailed table is available from the data repository. 22 For each institution, we define the level of adoption of the official metrics as the number of convergent indicators as a percentage of the number of health-related indicators less the number of non-operationalized indicators. The level of adoption of the official metrics varies from 40.5% (15/ (47−10)) for the GBD to 86.2% (25/ (29−0)) for the World Bank. WHO, the official curator of the Inter-agency and Expert Group SDG indicators, is only convergent with the official metrics by an amount of 72.1% (31/(45−2)).

Platforms
We summarize the main characteristics of the platforms of the five institutions, plus the official UN dissemination platform, in Table 2. For concision, we only reference the websites of the main platform of each institution (some may host more than one, providing individual websites for data visualization, material for promoting and/or evaluating the SDGs, or topic-specific solutions).
The platforms demonstrate different methodological perspectives and therefore occupy distinct, albeit complementary, roles in achieving the 2030 agenda. The platforms of the Sustainable Development Solutions Network and WHO highlight the latest data and provide international comparisons. The platforms of GBD, PAHO and the World Bank focus on the evolution of indicators, either for individual countries or in international comparisons. In terms of critical assessments of progress in achieving the 2030 agenda targets, the Sustainable Development Solutions Network platform provides measures of achievement of targets and goals, while the GBD platform provides projections for the next decade. Operationalizing the health-related indicators of the 2030 agenda Fabrício Silveira et al. Table 2 also describes the inconsistencies between the indicators included in the lists of institutions and those made available on their platforms. The number of operationalized indicators is less than the number of listed indicators for three of the institutions (GBD, PAHO and the Sustainable Development Solutions Network), indicating differences between aims and what is possible to put into practice. In contrast, the World Bank and WHO appear to have a higher number of indicators on their platforms than in their lists, as a result of deriving several platform indicators from a single list indicator; we also provide this expanded number of platform indicators in Table 2.
The GBD platform 15 provides interactive time-series visualizations using data constructed by their own consortium. 8 Although this platform stands out for presenting year-to-year projections until 2030 (disaggregated by age group and sex in most cases), the methods of data collection, use of sampling techniques, interpolation and eventual estimation of missing data have attracted criticism regarding their validity and consistency. 23 The PAHO platform 16 is an interactive dashboard with good graphical visualization of the indicators and a diversity of resources (e.g. international rankings, trends, country profiles and maps). The dashboard also enables the disaggregation of the data into various domains (e.g. demographic, economic, health care, risk factors, coverage and status) and subdomains (causes and mortality).
The Sustainable Development Solutions Network offers three integrated platforms to monitor and evaluate the SDG indicators. The first brings together annual reports produced from 2016 onwards with the aim of complementing the official SDG indicators and voluntary reports from member countries. 17 The second is an interactive dashboard that provides international ranks and country profiles that highlight the national performance and trend. Both initiatives are based on the institution's SDG index, calculated using official and unofficial data for variables distinct from those in the official indicators. The most recently launched (July 2020) platform 18 focuses on real-time SDG indicators.
The World Bank provides several platforms for monitoring and assessing SDG indicators, including an atlas and dashboard. Powered with data from the World Bank's officially recognized World Development Indicators, it provides a vast list of indicators for all SDGs. 19 The historical series for any given indicator may span many decades, reflecting the institution's long tradition of international data compilation.
WHO's platform, 20 part of the Global Health Observatory, provides global action plans, annual health monitoring reports, infographics and estimates of the costs of achieving health goals. Country-level data, in addition to maps and graphs, are also available for each indicator.

Discussion
The process of formulating the global indicators to monitor progress towards the SDGs was influenced more by   24 As a result, differences between the aspirational principles stated in the agenda and the actual monitoring indicators can be expected. Indeed, we observed four epistemological reductions (three qualitative and one quantitative) in the transition between the Rio Declaration (launched at the Rio+20 Conference) 25 and the SDG indicators operationalized by the institutions. The first two reductions occurred during the process of converting the declaration to goals and targets as a result of the inevitable translation in terms of both language and anchorage (i.e. philosophical and political principles) in preparing tangible policies. 26,27 The third qualitative reduction occurred as a result of the constraints of conceptional and algebraic representations of complex phenomena during the conversion of targets into official lists of indicators. The final (quantitative) reduction occurred when applying the indicators to available circumstances, that is, adapting the information in the benchmark Inter-agency and Expert Group SDG indicators into indicators consistent with the statistical traditions of the institutions and data availability. Our investigation focused on this final reduction, that is, the divergences and convergences between five key global health institutions in operationalized indicators.
Both the choice of health-related indicators, and whether operationalized indicators are convergent with official indicators, diverged significantly between the five institutions. This variety of aims increases the number of countries and regions working towards the 2030 agenda and also enhances discussion of the determinants of health. Indeed, this multidimensional nature can effectively contribute to a better conceptualization of public and global health. Including the views of governments and states on health-related themes and challenges, expressed in the Voluntary National Reviews, 28 is also important.
As data become more ubiquitous, aiming at a higher level of consensus should be seen as a central condition to leveraging the application of SDGs globally for two reasons: (i) divergences generate discrepancies in assessments and (ii) consensus simplifies navigation of the complex 2030 agenda. Standardization in reporting increases comparability, sending a more direct message to policy-makers and society. Likewise, the prioritization of consensual indicators, upon which clear targets can be set, increases usability. Ultimately, establishing a clear roadmap to achievement of the SDGs could help to break resistance where necessary.  There has been much progress to date; important initiatives have been launched to mobilize more (and improved) data to monitor the SDGs coordinated by the UN Department of Economic and Social Affairs, the Sustainable Development Solutions Network and other global institutions and governments. On the health theme, we note that WHO has recently introduced new and more metric-convergent indicators: 10 new indicators were added to the institution's platform during July 2019-October 2020. Over the same period, PAHO and the World Bank added three new health-related indicators while the UN Department of Economic and Social Affairs added five indicators.
A strength of our analysis is that we revealed some consolidated themes and indicators, but also large divergences be-tween the institutions in terms of either the chosen set of indicators, operationalization metrics and the use of data in monitoring and evaluating progress. A limitation of our study is that it was not exhaustive; different statistical methods and/or sources of data (especially with the increasing use of nonofficial data as a result of their greater availability) for the SDG indicators can also contribute to divergences in the analysis between the institutions. Ultimately, more research is necessary to understand the impact of choosing one metric or platform over another in the monitoring of progress towards the SDGs.
As we enter the final decade of the 2030 sustainable development agenda, it is time to take decisive steps towards transforming data into action. This transformation requires that govern-ments commit to greater adoption of the SDG framework, that is, incorporate SDGs into development programmes and increase efforts to implement policies targeting inequalities. Our analysis, and the resulting awareness of the differences, potentialities and limitations of indicators and platforms, provides important contributions to enable the relevant challenges to be met. The achievement of the health-related SDGs -for which the supply of timely and disaggregated information vital to the design and evaluation of adequate measures is essential -requires a data revolution at all levels. A coherent and unified view of global health challenges is necessary to achieve the SDGs and deliver the promise of the 2030 agenda. ■  (29-0)) для Всемирного банка. Значения ВОЗ, официального куратора показателей межучрежденческой и экспертной группы по показателям достижения целей в области устойчивого развития, совпадают с официальными показателями лишь на 72,1% (31/(45-2)). Наш анализ и вытекающая из этого осведомленность о различиях, возможностях и ограничениях показателей и платформ вносят важный вклад в достижение ЦУР, связанных со здоровьем, и выполнение обещаний повестки дня на период до 2030 года.