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Article

Interactions between Health and the Sustainable Development Goals: The Case of the Democratic Republic of Congo

by
Landry Egbende
1,2,*,
Daniel Helldén
2,
Branly Mbunga
1,2,
Mattias Schedwin
2,
Benito Kazenza
1,
Nina Viberg
2,
Rhoda Wanyenze
3,
Mapatano Mala Ali
1,2 and
Tobias Alfvén
2
1
Department of Nutrition, Kinshasa School of Public Health, Kinshasa P.O. Box 11850, Democratic Republic of the Congo
2
Department of Global Public Health, Karolinska Institutet, 17177 Stockholm, Sweden
3
Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
*
Author to whom correspondence should be addressed.
Sustainability 2023, 15(2), 1259; https://doi.org/10.3390/su15021259
Submission received: 2 November 2022 / Revised: 26 December 2022 / Accepted: 5 January 2023 / Published: 9 January 2023
Browse Figures
Review Reports Versions Notes

Abstract

:
A systematic and contextualized assessment of the interactions between the Sustainable Development Goals and health in the Democratic Republic of Congo is currently lacking. This study aimed to characterize and classify the linkages between the Sustainable Development Goals in the DRC with a focus on health and well-being. In this semi-qualitative participatory study, 35 experts assessed 240 interactions between 16 of the 17 SDGs during a two-day workshop in Kinshasa, Democratic Republic of the Congo, using a scale from +3 (strongly promoting) to −3 (strongly restricting). SDG 16 (Peace, justice, and strong institutions) had the strongest promoting influence on other goals and was identified as a key priority for the DRC to attain the SDGs. Progress on SDG 3 (good health and well-being) was perceived as promoting progress on most SDGs, and through second-order interactions, a positive feedback loop was identified. Furthermore, progress on the other SDGs was deemed to promote progress on SDG 3, with SDG 16 having the greatest positive potential when second-order interactions were taken into account. Our results show the importance of recognizing synergies and trade-offs concerning the interactions between health and other SDGs and that it is imperative to set up structures bringing together different sectors to accelerate work towards achieving the 2030 Agenda.

1. Introduction

In response to the overwhelming scientific evidence that the current state of the world requires a significantly more sustainable approach, the 2030 Agenda and the Sustainable Development Goals (SDGs) were agreed upon by all UN states in 2015 [1,2,3]. Furthermore, the 2030 Agenda explicitly acknowledges that the SDGs are indivisible [1]. However, there are no instructions in the 2030 Agenda regarding how the interactions between the goals should be taken into consideration [4,5]. Interactions between goals can have both positive and negative effects [6]. A better understanding of positive interactions would strengthen the prospect of identifying synergies that lead to achieving outcomes with heightened an impact, while understanding negative interactions would allow for mitigating and managing conflicts between goals or targets and should be carefully considered [7].
While SDG 3 (good health and well-being) focuses only on human health, the SDGs are interrelated [3,6,8]. For example, the 2016 World Health Organization report estimated that 23% of all deaths could be attributed to environmental issues such as air pollution, poor sanitation, exposure to radiation, and other environment-related causes [7]. It is almost impossible to separate sustainable health development from social, environmental, and economic development, as the health of people can improve, stagnate or regress depending on inputs from other sectors [2,9]. Similarly, progress on health is essential for enabling and accelerating progress in other sectors [2].
The Democratic Republic of Congo (DRC) is committed to achieving the SDGs, despite the country’s emerging and ongoing challenges. The DRC has adopted important policies, such as the National Strategic Development Plan (NSDP) in 2019, as well as the SDG Acceleration Framework based on the SDG model developed by the Millennium Institute to accelerate progress on the SDGs [10]. Important structures exist, such as the “Observatoire Congolais du Développement Durable (OCDD)”, a governmental and technical structure of the Ministry of Planning, whose mission is to ensure the monitoring and evaluation of the implementation of the SDGs [10]. However, not all stakeholders are equally informed about the 2030 Agenda and the SDGs, resulting in a lack of ownership in different government ministries and inclusion of other sectors such as the private sector, civil society, and academia [10].
In terms of health, the DRC has generally seen an improvement in reproductive, maternal, neonatal, and child health indicators. However, the maternal and under-five mortality ratio remains high, at 473 deaths per 100,000 live births and 70 deaths per 1000 live births, respectively [11,12]. Furthermore, the country is repeatedly affected by epidemic health emergencies, and there are great health disparities in the country [10,13,14]. There are examples of efforts at the national level to promote multisectoral collaboration to address health issues such as the multisectoral nutrition plan developed to address nutrition issues [15].
Several studies have shown the importance of collaboration between actors from different sectors to promote sustainable development [16]. The method of assessing the synergies between the SDGs has been used in several countries to guide policies in order to identify priorities and the key actors that need to be involved to accelerate improvements in health and well-being [6,16,17]. However, until now, there has not been a systematic and contextualized assessment of the interactions between the SDGs in the DRC. Such an assessment could assist policy-makers in prioritizing the most cost-effective interventions and provide a fuller understanding of important synergies and trade-offs between goals and priorities, while allowing for the development of efficient multisectoral strategies to advance action on achieving the SDGs. Hence, this study aims to characterize and classify the linkages between the SDGs in the DRC, with a focus on how progress on SDG 3 affects and is affected by progress on the other goals.

2. Materials and Methods

We used a semi-qualitative and participatory study design, based on the SDG synergies approach, to systematically assess the interactions between the SDGs in the DRC. This methodology, which was initially developed by the International Council for Science and the Stockholm Environment Institute [18,19], allows for network theory analysis of numerous interactions as well as the investigation of specific interactions [5,17].
In this study, we assessed the interactions between the SDGs focused on the goal level, including all SDGs except SDG 17 (Partnership for the SDGs), since this goal is less tangible and more difficult to discuss in the specific context of the DRC. This led to 240 unique interactions being considered between the other 16 SDGs. A total of 35 experts from the health and non-health sectors participated in assessing these unique interactions during a two-day workshop held on 2–3 November 2021.
Participants were purposively selected based on having expertise in working with the SDGs as well as collaborating with different sectors. The participants represented academia (7), the private sector (1), civil society organizations (4), international NGOs (6), and the following government ministries: Ministry of Health (8), Ministry of Justice (1), Ministry of Agriculture (1), Ministry of Water Resources, Energy and Electricity (3), and Ministry of Planning (OCDD) (4) (Table 1).
During the two-day workshop, the participants were divided into five groups, where each group consisted of a diverse set of participants with regard to background and expertise. Each group was assigned three to four SDGs and asked to assess their interactions with all other goals. Interactions were assessed on a scale from +3 (strongly promoting) to −3 (strongly restricting) (See Table 2). The groups were provided with short written explanations of the SDGs in question with regard to the DRC’s national context as well as a general document outlining the definition of SDGs. Apart from that, they based their assessments on the collective expertise of the group. The discussion was assisted by one facilitator per group, and the score, together with a short justification, was derived using a consensus approach. The groups switched SDGs with one other group and verified the scorings by making their own assessments and noting where discrepancies between the groups arose. All discrepancies were thereafter discussed and agreed upon in a plenary setting with all participants. If a final score and justification could not be derived by consensus, simple voting was used.
The final interactions are presented as a cross-impact matrix, which showcases the individual interactions. The column total of the matrix displays the amount that all other goals in the network directly impact the goal, and the row sum denotes the goal’s net first-order direct influence on the network. The input network analysis also uses the cross-impact matrix to determine the second-order effects that achieving one SDG has on the other SDGs. There are numerous sources that go into great detail about the network analysis that was used [20]. Freely available custom-made software (https://www.sdgsynergies.org/, accessed on 23 November 2021) was used to collect the scores and justifications, as well as to perform the network analysis.
The workshop was carried out in strict compliance with the barrier actions against COVID-19. Ethical approval was obtained from the Ethics Committee of Kinshasa School of Public Health with referral number ESP/CE/149/2021 and from the Swedish Ethical Review Authority Dnr 2021-05015.

3. Results

3.1. Cross-Impact Matrix and First- and Second-Order Interactions of the SDGs in DRC

The cross-impact matrix with the 16 goals and 240 interactions is illustrated in Figure 1. The cross-impact matrix shows that there are overall promoting interactions between the SDGs in DRC. There are a few weakly restricting interactions, particularly with regard to SDG 8 (Decent work and economic growth) and SDG 11 (sustainable cities and communities). From the row sums, it becomes clear that SDG 16 (peace, justice, and strong institutions) has the greatest first-order promoting influence on the network, while SDG 1 (no poverty), 2 (zero hunger), 8 (decent work and economic growth), and 3 are promoted the most by progress on other goals.
The column net sum demonstrates how much the goal is influenced by all other objectives in the network, while the row sum suggests the goal’s net influence on the network.
Table 3 shows the row sum when these second-order interactions are taken into account, extending the network beyond just direct first-order interactions. As such, we can see that SDG 16 is more strongly perceived as the most positively influencing goal of the network. SDG 8 and SDG 7 (affordable and clean energy) were also found important for the realization of the other SDGs. Notably, SDG 3 has the fourth-lowest rank.
The goals and their interactions can be visualized as a network, illustrating that the goals are closely interlinked (Figure 2).

3.2. Health and Well-Being in the Context of the DRC

Participants perceived that making progress on SDG 3 (good health and well-being) would moderately promote progress on SDGs 1, 2, 4 (quality education), 8, and 10 (reduce inequalities), while weakly promoting progress on SDGs 5 (gender equality), 6 (clean water and sanitation), 7, 9 (industry, innovation, and infrastructure), 13 (climate action), and 16, as illustrated in Figure 3. Notably, the participants did not believe there was any direct promoting or restricting influence of SDG 3 on SDG 11 (sustainable cities and communities), 12 (responsible consumption and production), 14 (life below water), or 15 (life on land). Taking into account the second-order interactions (Figure 4), it can be observed there is a positive feedback loop where it seems that progress on SDG 3 promotes progress on other SDGs, which in turn promotes progress on SDG 3. All other SDGs are also net-positively influenced by progress on SDG 3 when taking second-order interactions into account, but the greatest positive influence seems to be on SDG 4, 1, and 8.
Conversely, when examining how other SDGs influence SDG 3, it can be seen that SDG 16 and SDG 8 strongly promote progress on SDG 3, while SDGs 1, 2, 4, 5, 6, 10, 11, 12, and 15 are moderately promoting SDG 3. SDGs 7, 9, 13, and 14 are seen as weakly promoting progress on SDG 3 (Figure 5). When including the second-order interactions (Figure 6), all the SDGs have a net positive influence on SDG 3, with SDGs 16, 7, and 10 having the largest net positive influence.

4. Discussion

In this semi-qualitative participatory study exploring linkages between health and other SDGs in the context of the DRC, we found that most interactions between the SDGs were perceived as promoting progress.

4.1. SDG and Their Interlinkages in DRC

SDG 16 was seen as having the strongest promoting influence on other goals. This SDG encapsulates the importance of effective, accountable, and inclusive institutions for sustainable development [21]. The goal is one of the more innovative aspects of the development framework, focusing on advancing government accountability, building trust, and sustaining peace, and it provides insight into how we might hold leaders to account and achieve all the SDGs by 2030 [22,23]. The importance of SDG 16 in our study is similar to Whaites [21] and Ronald Hope [22] who found that SDG 16 is crucial to reaching the overall 2030 Agenda and that confirmed the need to address the obstacles limiting the achievement of SDG 16 to meet the 2030 Agenda.
The DRC has been in various states of conflict since the 1990s, and this continues to cause suffering and to hamper development [10]. The resource-rich eastern part of the country, which could be used to sustainably drive economic growth, has been in almost constant conflict during this time [24,25]. The high levels of violence in the country reduce foreign direct investment and hinder broader macroeconomic environment development, which in turn increases poverty and reduces life expectancy and education outcomes [22,26,27,28,29,30].
Further, the DRC has one of the highest rates of corruption in the world, with around 70% of Congolese having recently experienced acts of corruption [10]. Corruption is an important barrier to development since it inhibits distributive justice and increases inequality, especially in the context of a weak justice system [31]. In the context of the DRC, insecurity due to conflicts and violence, a lack of a well-functioning judicial system, and a high incidence of corruption serve as major obstacles to development and are reflected in the importance of SDG 16 found in our study. In this context, progress on SDG 16 would contribute to solving problems in several other sectors and would be a factor promoting sustainable development.
Besides SDG 16, SDG 7 and SDG 8 were seen as important for promoting progress on the 2030 Agenda in DRC. Only 30% of the population has access to electricity [10], and sustained economic growth can be seen as the bedrock enabling investments and progress in other sectors [32]. As such, SDG 7 and SDG 8 can be seen as important levers for accelerating sustainable development in the DRC. Weitz et al. found in their study that the targets 16.6 (effective institutions), 12.1 (sustainable production), and 8.4 (resource efficiency) generate the most positive influence on the rest of the SDGs in Sweden [5].

4.2. Health and the SDGs and the Context of DRC

While being one of the SDGs with the least net influence on the other SDGs, progress on SDG 3 was perceived as promoting progress for most SDGs, and through second-order interactions, a positive feedback loop was identified. Furthermore, progress on the other SDGs was deemed to promote progress on SDG 3, with SDG 16 having the largest positive potential when second-order interactions were taken into account in the DRC. Progress on SDG 3 promoted some SDGs directly, and through the second-order interactions, all SDGs were seen to be positively influenced by progress on SDG 3. This is in line with similar research noting the overall tendency for health to mainly promote progress on other SDGs [20,33,34,35,36,37,38]. For instance, Pradhan et al. found that improvement in health and well-being, in general, has been correlated with progress in SDGs 1, 4, 5, 6, and 10 [2]. While being net positive, the influence of SDG 3 on other SDGs was among the lowest when compared to other SDGs; this relatively low net influence of SDG 3 was also found in a study in Cambodia by Helldén et al. [20] and might be a result of the emphasis on direct interactions in the assessment and the relative low possibility of better health and well-being to promote progress on some broader sustainable development issues.
SDG 3 was perceived as being promoted directly by progress on other SDGs; more specifically, the nexus of sectors traditionally seen as closely related to health such as SDG 1, SDG 2, SDG 4, and SDG 6 were perceived as moderately promoting progress on SDG 3. With approximately 70% living below the poverty line in the DRC, increases in income alleviate some direct health needs. Income increases would increase access to care and reduce malnutrition and child morbidity and mortality [39]. Similarly, it has been shown that improved education enables better hygiene practices [40] and adherence to COVID-19-preventive measures in the DRC [41]. As a response to the multifaceted nutritional challenges, the country has adopted and adhered to the Scaling-up nutrition movement and tried to form a multisectoral platform for promoting multisectoral collaborations between the agriculture and education sector as well as specific interventions such as iron supplements for improving the nutritional status of the population [42]. Although the interventions are seen to be cost-effective, the actual commitment to the platform by different stakeholders is uncertain [43]. The interactions between various SDGs and SDG 3 observed in this study emphasize the need for developing a collaboration mechanism between these goals.

4.3. Restricting Interactions in DRC

We found that most interactions had a promoting effect, while there were a few weakly restricting interactions. The restricting interactions were due to the participants perceiving SDG 8 and SDG 11 as weakly restricting progress on the environment-related SDGs—SDG 13, SDG 14, and SDG 15—when only focusing on the direct interactions. This weak restriction could be a reflection of the trade-off between the interest in economic development and industrialization versus protecting the environment and acting on climate change [32,44]. Specifically, nearly 90% of greenhouse gas emissions in the DRC are due to deforestation and shifting cultivation [10], although efforts are now being undertaken to try to reduce deforestation and promote sustainable forestry and land use [45]. However, it is clear that the potential cost of inaction on the environmental SDGs might lead to long-term human capital deprivation, while substantial synergies exist if the right pathways can be found [44,46].

4.4. Strengths, Limitations, and Future Research

As with any study, there are limitations to ours. First, the scoring of the interactions is based on the number of participants that participated in the study and their respective expertise. Hence, a different set of participants might have assessed the interaction in another way. Second, since the study was focused on the DRC at a country level, sub-national differences that exist in how these interactions act out could not be captured. Third, given the subjective nature of the scoring, no causal relationships or associations could be asserted. With the application of the SDG Synergies approach, with a focus on health at a country level in the DRC and the results from this study giving a broad overview of the synergies and trade-offs between the SDGs in the DRC, researchers have the opportunity to deepen their understanding of the interactions between the SDGs and provide many venues for scientific inquiry. Future research could make more in-depth investigation of individual interactions to better understand the underlying drivers of synergies and trade-offs between the SDGs in the DRC context. A different set of participants or a focus on a sub-national context using the SDG Synergies approach could also provide new insights. Additionally, statistical analysis of the change in SDGs indicators over time could complement the findings from this study.

4.5. Policy and Practical Implications

Our study provides a broad overview of the interactions between the SDGs in DRC, taking into consideration the whole 2030 Agenda not presented before and providing concrete evidence for policymakers to act on. In particular, identifying key synergies and trade-offs can assist in planning and prioritizing activities that are cost-effective. From a management perspective, the SDG Synergies approach could serve as planning tool to understand which sectors are important for what goal and hence which actors should be identified and engaged in multisectoral collaborations. Recognizing the synergies and trade-offs further emphasizes the interdependence of different sectors and the need for collaboration. Specifically, we found that SDG 16 is the most important SDG for improving health and well-being. Policymakers should recognize and act on this, including improving leadership and promoting peace and security [22]. Additionally, multisectoral collaboration at different levels in the DRC could harness synergies and handle trade-offs and accelerate the work toward achieving sustainable development.

5. Conclusions

In this first-ever assessment of the interactions between the SDGs in the DRC, we show that most interactions were deemed as promoting and that SDG 16 had the strongest promoting influence on the 2030 Agenda as a whole and on SDG 3 specifically. Furthermore, progress on the other SDGs was deemed to promote progress on SDG 3 and vice versa.
Our results can help in planning activities or prioritizing interventions and provide an unprecedented overview of the interactions between the SDGs in DRC for policymakers and other stakeholders to act on.
The SDGs synergy tool used in our study is a good planning tool at the country level. It will help the different sectors to collaborate when developing their strategic plans because each sector will recognize the importance of the other sectors in achieving the expected results. In a practical way, health actors will understand through this study that in order to fight against the health problems of the population, it will be necessary to collaborate with other actors outside of the health sector.
This study is very important to scientists as it provides evidence for the linkages between the different SDGs in a specific context. It would be interesting to repeat the study in a different setting to see if that would yield very different results. Further, more in-depth research is needed to analyze the linkages between SDGs in DRC.
The interlinkages between the SDGs demonstrated in this study are evidence of the importance of multisectoral approaches to make progress on the 2030 Agenda. Further, our results show the importance of recognizing synergies and trade-offs in the interactions between other SDGs and health specifically. Additionally, it is imperative to set up structures that bring together different sectors to accelerate the work towards achieving health and well-being, as well as the whole 2030 Agenda.

Author Contributions

Conceptualization, L.E., D.H., N.V. and B.M.; methodology, L.E. and D.H.; software, D.H.; validation, L.E., D.H., B.M., N.V. and M.S.; formal analysis, D.H.; investigation, L.E.; resources, L.E.; data curation, D.H.; writing—original draft preparation, L.E.; writing—review and editing, L.E., D.H., B.M., M.S., N.V., B.K., M.M.A., R.W. and T.A.; visualization, supervision, project administration and funding acquisition, N.V. and T.A. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by SIDA (Swedish International Development Cooperation Agency), Project no 14353.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Kinshasa School of Public Health ethical committee (ref: ESP/CE/149/2021).

Informed Consent Statement

Informed consent was obtained from the participants involved in the study.

Data Availability Statement

The dataset of this study can be made available on reasonable request to L.E.

Acknowledgments

We thank all individuals who participated in this study and especially the entire Karolinska Institutet team for their support in this study.

Conflicts of Interest

The authors declare no conflict of interest.

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Figure 1. Cross-impact matrix of the 16 goals; color according to scale.
Figure 1. Cross-impact matrix of the 16 goals; color according to scale.
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Figure 2. Illustration of the full network of 16 goals and 240 linkages based on the cross-impact matrix. The color of the linkages corresponds to the direct first-order interaction.
Figure 2. Illustration of the full network of 16 goals and 240 linkages based on the cross-impact matrix. The color of the linkages corresponds to the direct first-order interaction.
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Figure 3. First-order interactions from SDG 3 to the other SDGs. Color according to scale.
Figure 3. First-order interactions from SDG 3 to the other SDGs. Color according to scale.
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Figure 4. Second-order interactions from SDG 3 to the other SDGs. Color according to scale. Size of the goals corresponds to the net influence.
Figure 4. Second-order interactions from SDG 3 to the other SDGs. Color according to scale. Size of the goals corresponds to the net influence.
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Figure 5. Influence of other SDGs on SDG 3. Color according to scale. Size of the goals corresponds to the net influence.
Figure 5. Influence of other SDGs on SDG 3. Color according to scale. Size of the goals corresponds to the net influence.
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Figure 6. Second-order interactions from the influence of other SDGs on SDG 3. Color according to scale. The size of the goals corresponds to the net influence.
Figure 6. Second-order interactions from the influence of other SDGs on SDG 3. Color according to scale. The size of the goals corresponds to the net influence.
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Table
Table 1. List of participants in the two-day workshop on Interlinkages between SDGs.
Table 1. List of participants in the two-day workshop on Interlinkages between SDGs.
StakeholdersNumber
Ministry of Public Health8
Ministry of Justice1
Ministry of Agriculture1
Ministry of Water Resources, Energy and Electricity3
Ministry of Planning (OCDD)4
Kinshasa School of Public Health7
Civil society organizations (Femmes plus, Santé pour les prisonniers, SCONUTAL, SOS nourrissons)4
International NGOs (AFROHUN, WHO, UNICEF, CICR, Save the Children, SANRU)6
Private sector1
Table
Table 2. Scoring according to the seven-point scale used in the study.
Table 2. Scoring according to the seven-point scale used in the study.
ScoreMeaningExplanation
+3Strongly promotingThe goal is inextricably linked to the achievement of another goal
+2Moderately promoting The goal aids the achievement of another goal
+1Weakly promotingThe goal creates conditions that further another goal
0No influenceNo significant positive or negative interaction
−1Weakly restrictingThe goal limits conditions that further another goal
−2Moderately restricting The goal makes it more difficult to reach another goal
−3Strongly restricting The goal makes it impossible to reach another goal
Table
Table 3. Net influence of SDGs on the network based on first and second-order interactions in DRC.
Table 3. Net influence of SDGs on the network based on first and second-order interactions in DRC.
RankFirst-Order InteractionsSecond-Order Interactions
SDGNet InfluenceSDGNet Influence
1st164016841
2nd7288615
3rd8277600
4th15251538
5th12315526
6th92310523
7th10239513
8th4214454
9th122012433
10th111911423
11th5185416
12th6186386
13th2163373
14th3162372
15th141614319
16th131013212
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Egbende, L.; Helldén, D.; Mbunga, B.; Schedwin, M.; Kazenza, B.; Viberg, N.; Wanyenze, R.; Ali, M.M.; Alfvén, T. Interactions between Health and the Sustainable Development Goals: The Case of the Democratic Republic of Congo. Sustainability 2023, 15, 1259. https://doi.org/10.3390/su15021259

AMA Style

Egbende L, Helldén D, Mbunga B, Schedwin M, Kazenza B, Viberg N, Wanyenze R, Ali MM, Alfvén T. Interactions between Health and the Sustainable Development Goals: The Case of the Democratic Republic of Congo. Sustainability. 2023; 15(2):1259. https://doi.org/10.3390/su15021259

Chicago/Turabian Style

Egbende, Landry, Daniel Helldén, Branly Mbunga, Mattias Schedwin, Benito Kazenza, Nina Viberg, Rhoda Wanyenze, Mapatano Mala Ali, and Tobias Alfvén. 2023. "Interactions between Health and the Sustainable Development Goals: The Case of the Democratic Republic of Congo" Sustainability 15, no. 2: 1259. https://doi.org/10.3390/su15021259

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