A stakeholder group assessment of interactions between child health and the sustainable development goals in Cambodia.

Background: With the implementation of the Sustainable Development Goals, a systematic assessment of how the goals influence child health and vice versa has been lacking. We aimed to contribute to such an assessment by investigating the interactions between child health and the Sustainable Development Goals in Cambodia.
Methods: Based on the SDG Synergies approach, 272 interactions between 16 Cambodian Sustainable Development Goals and child health were evaluated by an interdisciplinary Cambodian stakeholder group. From this a cross-impact matrix was derived and network analysis applied to determine first and second-order effects of the interactions with a focus on child health.
Results: We show that with the exception of Cambodian Sustainable Development Goal 15 (life on land) the interactions are perceived to be synergistic between the child health and the Cambodian Sustainable Development Goals, and progress on Cambodian Sustainable Development Goal 16 (peace, justice and strong institutions) could have the largest potential to contribute to the achievement of the Cambodian Sustainable Development Goals, both when it comes to first and second-order interactions. Conclusions: In this stakeholder assessment, our findings provide novel insights on how complex relationships play out at the country level and highlight important synergies and trade-offs, vital for accelerating the work toward the betterment of child health and achieving the Sustainable Development Goals.

Introduction

The world has experienced an impressive decline in global child mortality over the last decades, however still 5.2 million children die before they reach their 5th birthday[1]. The 17 Sustainable Development Goals (SDGs) represent the global community’s most comprehensive and people-centered set of universal targets to date that have been endorsed by governments[2]. The health and well-being of children stand to benefit, stagnate, or regress depending on progress in other sectors of society toward the attainment of the SDGs. It is nearly impossible to untangle the health of children from their social, natural and economic environments[3]. For example, it has been demonstrated that approximately half of the reduction in under-five mortality between 1990 and 2010 can be attributed to investments outside of the health sector[4].

Without losing sight of the unfinished progress on reducing global child mortality, the global strategy for women´s, children´s and adolescents‘ health implore researchers and decision makers to aspire beyond a world in which all children not only survive but thrive in order to realize their potential to transform communities[5]. Social, economic, political, environmental, and cultural determinants have important effects on child health[6-8] while the survival, health and well-being of children are crucial to reach multiple sustainable development outcomes[9,10].

The SDGs are presented in the 2030 Agenda as integrated, indivisible and interdependent and can be seen as a large system of goals that interact and affect each other directly and indirectly. However, the 2030 Agenda does not attempt to identify or characterize the interactions. A field of SDG interactions studies has emerged where a range of mostly quantitative methods have been applied to try to distinguish these interactions and subsequent network effects[11]. One such method, the SDG Synergies, a semi-quantitative participatory approach originally developed by the International Science Council and the Stockholm Environment Institute[12-14] can be used for untangling the direct and indirect effects of interactions between the SDGs. Through the scoring of relevant interactions by a multidisciplinary stakeholder group, the method allows for context-specific analysis of interactions since these vary in position and nature depending on the context within which the interaction occurs[15]. Furthermore, the framework can serve as a basis for more complex analysis and visualization of the interactions through network analysis[14,16]. The approach has previously been applied in a variety of policy contexts, ranging from global policy issues such as climate change to interactions within a specific country[12,14,16-19]. Using this approach, Blomstedt et al.[20] showed that several SDGs, including SDG 1 (no poverty), 2 (zero hunger), 4 (quality education), 5 (gender equality), 8 (decent work and economic growth and 17 (partnership for the goals) have strong and reciprocal links with child health. Their theoretical analysis also suggested that multisectoral collaboration on some targets are essential for sustainable progress on child health, while it found few negative interactions indicating the limited number of trade-offs with health. The method quantifies expert opinions through the scoring of the interactions, and although the subjectivity of the SDG Synergies approach can be in contrast to the classical paradigm of rational and data driven decision making[21,22], real world prioritization processes are influenced by many different factors and biases[16,23,24]. To some extent, the SDG Synergies approach integrates real world human behavior into prioritization and decision making models which is necessary for understanding complex context dependent systems[24,25], forming a bridge across sectors and promoting evidence informed policy, particularly given the absence of quality quantitative data to assess the SDGs[26].

Cambodia was among the few low- and middle-income countries that achieved the Millennium Development Goal 4 and reduced the under-five mortality from 116 to 27 deaths per 1000 live births between 1990 and 2019[1,27]. However, an estimated 12,000 children still die from preventable causes every year and mortality rates among low income, less educated and more rural populations have not declined as much[1,28]. Investments outside of the health sector in education, nutrition, water and sanitation, and poverty reduction measures together with multisectoral planning and collaborative initiatives between non-health sectors have been key to the betterment of child health in Cambodia[29,30]. However, multidimensional poverty and non-monetary deprivation such as overcrowded housing, suboptimal water and sanitation facilities and lack of school attendance are still prevalent with almost half of all children under 18 years of age experienced three or more deprivations in 2018[31]. The development and adoption of the Cambodia Sustainable Development Goals (CSDGs) with its 18 goals and 88 targets offers a comprehensive framework for sustainable development localized to the country context and holds the promise of delivering for children in Cambodia[32]. The country has improved the health and well-being of children, however the role of different sectors in this achievement has not been systematically assessed. Furthermore, the interactions between the SDGs and child health have not been examined at a country level before. The aim of this study was therefore to contribute to such an assessment by determining the strength, position and nature of interactions between the SDGs and child health in Cambodia. We show that with the exception of CSDG 15 (life on land) the interactions are perceived to be synergistic between the child health and the CSDG, and progress on CSDG 16 (peace, justice and strong institutions) could have the largest potential to contribute to the achievement of the CSDGs, both when it comes to first and second-order interactions.

Methods

The semi-quantitative SDG Synergies approach[14], applied to the Cambodia national-level context and with a primary focus on child health was utilized in this study. In brief, the SDG Synergies approach follows three overarching stages that enable the investigation of the strength, position and nature of interactions in a network, as outlined below. Further, we provide some additional analysis to ground the results in the country context.

Identification of goals

Between the 169 targets of the SDGs there are almost 300,000 possible pairwise interactions, hence the first step is to limit the scope of the analysis and select the goals or targets of interest. Through matching SDG priorities with national developmental goals, ministry consultations and investigations into possible data sources, the Royal Government of Cambodia has put forward the CSDGs as 18 nationalized goals and a localized set of 88 targets from the 2030 Agenda. On a goal level, the CSDGs include one additional goal (number 18) on the ending of the negative impact of Mine/Explosive remnants of war (ERW) and promote victim assistance, while the targets for each goal are fewer but designed so that data indicators can be obtained to measure the progress toward the targets[32]. Guided by CSDGs[32], the analysis done by Blomstedt et al. [20] and the relevant SDG targets identified by UNICEF[33] as well as in-depth discussions within the research team and with local partners to ensure relevancy to the Cambodian context, it was considered most adequate to include all CSDGs with the exception of CSDG 17 (partnerships for the goals) since the goal was deemed too broad for meaningful assessment. It was further decided to limit CSDG 3 (good health and well-being) to only representing child health, which we defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity among human beings below 18 years. The list of CSDGs and their definitions are detailed in Table 1. The selection led to a total of 17 goals, translating into 272 interactions.

Table 1

List of included Cambodia sustainable development goals and their definitions.

CSDG Goal	Definition
1	End poverty in all its forms everywhere
2	End hunger, achieve food security and improved nutrition and promote sustainable agriculture.
3	Child health In line with the WHO definition of health and the United Nations Convention on the Rights of the Child, child health is defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity among human beings below 18 years.
4	Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.
5	Achieve gender equality and empower all women and girls.
6	Ensure availability and sustainable management of water and sanitation for all.
7	Ensure access to affordable, reliable, sustainable and modern energy for all.
8	Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all.
9	Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation.
10	Reduce inequality within and among countries.
11	Make cities and human settlements inclusive, safe, resilient and sustainable.
12	Ensure sustainable consumption and production patterns.
13	Take urgent action to combat climate change and its impacts
14	Conserve and sustainably use the oceans, seas and marine resources for sustainable development.
15	Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss.
16	Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels.
18	End the negative impact of Mine/Explosive remnants of war (ERW) and promote victim assistance.

Assessing the interactions

Over a 2-day workshop on the 24–25th of August 2020, taking place in Phnom Penh, 29 participants representing a range of governmental and non-governmental stakeholders (see Supplementary Table 1) assessed the interactions between the selected goals, taking advantage of the breadth of country expertize. The participants were purposively selected based on predefined criteria of having either expertize in child health in Cambodia, or being from a non-health sector (for example water and sanitation, agriculture, infrastructure etc.) reflecting the social, economic, political, environmental, and cultural determinants of health and working in a capacity that includes multisectoral collaboration in the country.

Based on the SDG Synergies approach, groups of 5–6 people discussed direct interactions between pairs of goals, by answering a guiding question: “In the Cambodia context, if progress is made on Goal X, how does this influence progress on Goal Y?”. The group arrived at a score according to the Weimer-Jehle seven-point scale[34], which ranges from strongly restricting (−3) to strongly promoting (+3). The participants also recorded a 1–2 sentence motivation for the score. The exercise was held in Khmer, official published Khmer CSDG descriptions of goals and targets were used and all documents were translated and back-translated for validity. As a basis for scoring, the participants used their expert and working knowledge, as well as a fact sheet for each goal with descriptions of the associated targets and key statistics derived from the latest Cambodia Sustainable Development Report[35]. It was emphasized that the participants should think about child health in a broad perspective, in line with the definition in Table 1, and not only on child mortality. After the first scoring of interactions, the groups double-checked their own scoring and also verified a set of interactions originally scored by another group. All identified discrepancies and differences were discussed in plenary session, where final scores were arrived at in consensus.

Cross-impact matrix and network analysis

All scores were directly entered into a tailor-made digital software[36] developed by the Stockholm Environment Institute, which also includes the statistical analysis features outlined below. From the final scoring of all interactions, a cross-impact matrix was developed, which served to illustrate the results and was the basis for applying network analysis. By utilizing a cross-impact matrix and keeping the analysis at the goal level, a whole of 2030 Agenda approach to child health and SDG interactions in Cambodia could be achieved. While the data presented in the cross-impact matrix provides information on the frequency of different types of interactions and how different goals influence the overall agenda, network analysis methods can be used to assert more systemic properties of the interactions. By using network analysis, where a goal is considered a node (N) and the interaction is considered a link (L) and the subsequent network can be described as G = (N, L), the network can be visualized, clusters of more related goals highlighted, and the impact of certain goals and/or interactions more clearly assessed[37]. Moving beyond the direct interactions that are evident from the cross-impact matrix, analysis of the second-order interactions shows the net influence of a certain goal on the network as a whole as well as on other individual goals. Following the method described by Weitz et al. [14], the net influence (I) of a goal (g) on the network as a whole including the second-order interactions was calculated according to [Eq. 1]where is the influence of goal g on its closest neighbors, I2nd is the influence from g’s neighbor’s on their neighbors, is the out-degree of goal g, I is the strength of link from goal g to goal j, and is the out-degree of goal j. Similarly, the aggregated second-order influence of a goal A on another goal D is estimated bywhere I runs over all goals connecting A and D, and w is the weight on the link between goal I and goal j. A more detailed explanation of the concepts outlined above is available in the Supplementary Methods.

Situating of results

Situating the results from the cross-impact matrix and network analysis is relevant to ground the analysis in the country context. Due to the lack of data on the CSDGs an overview of relevant indicators for the SDGs are provided in Supplementary Fig. 1 and Supplementary Data 1, which form the basis for a Pearson paired-observational correlation analysis to assess the trends provided in Supplementary Fig. 2. Notably, included variables were re-coded to showcase progress toward the CSDGs similar to other correlation based assessments of SDG interactions[38,39]. An overview of key developmental and child health policies are further provided in the Supplementary Fig. 3 while the annual budget expenses for each ministry between 2000-2013 is also provided in Supplementary Fig. 4 and Supplementary Fig. 5. All available data on the indicators of the CSDGs and their SDG counterpart as well as the annual budget expenses has been compiled and can be found in the Supplementary Data 1.

Ethics approval

The study received ethical approval from the National Ethics Committee for Health Research in Cambodia (NECHR-023) and written informed consent was obtained from all participants.

Table 2

Rank of goals influencing the network based on first and second-order interactions.

First-order interactions			Second-order interactions
Rank	Goal	Net influence	Rank	Goal	Net influence
1	16	34	1	16	729
2	6	29	2	11	615
3	11	29	3	5	588
4	4	27	4	6	581
5	5	25	5	4	555
6	8	24	6	10	552
7	10	24	7	8	497
8	13	23	8	13	485
9	15	21	9	15	438
10	2	16	10	7	353
11	3	16	11	3	349
12	7	16	12	2	337
13	9	15	13	9	337
14	12	15	14	12	336
15	18	13	15	18	281
16	14	12	16	14	226
17	1	8	17	1	213

Table 3

Overview of key Cambodian sustainable development indicators.

CSDG	Indicator description	2000	2005	2010	2015	2019	Source
1	Proportion of population living below the national poverty line (%)	50 (2003)	45 (2006)	22.1	14 (2014)		SDG Indicator database
2	Prevalence of undernourishment (%)	24 (2001)	17	13	8.9	6.2	SDG Indicator database
3 – Child health	Under-five mortality rate, by sex (deaths per 1000 live births)	106	65	44	32	27	SDG Indicator database
	Proportion of children under 5 years moderately or severely stunted (%)	49	43	39.8	32 (2014)		SDG Indicator database
	Proportion of children under 5 years moderately or severely wasted (%)	17	8,5	11	9.7 (2014)		SDG Indicator database
4	Completion rate at primary level (%)	34	59	71	72 (2014)		SDG Indicator database
	Completion rate at secondary level (%)	17	27	37	41 (2014)		SDG Indicator database
5	Proportion of seats held by women in legislation institutions (%)	8.2	9.8	21	20	20	SDG Indicator database
6	Proportion of population using safely managed drinking water services (%)	17	19	22	25	27	SDG Indicator database
	Proportion of population with basic handwashing facilities on premises (%)			63	67	73	SDG Indicator database
7	Proportion of population with access to electricity, by urban/rural (%)	17	21	31	69	93	SDG Indicator database
8	GDP per capita (current US$)	301	474	785	1162	1643	World Bank
9	Proportion of population covered by at least a 3 G mobile network (%)			43 (2009)	70	85	SDG Indicator database
10	Gini index disposable income (0–100)	37	37	36			Standardized World Income Inequality Database
11	Proportion of urban population living in slums (%)		79		55 (2014)	45 (2018)	SDG Indicator database
12	Domestic material consumption per capita (tonnes)	2.2	2.7	6.1	4.9	5.3 (2017)	SDG Indicator database
13	Domestic fossile fuel consumption per capita (tonnes)	0.1	0.1	0.1	0.2	0.2 (2017)	SDG Indicator database
14	Sustainable fisheries as a proportion of GDP (%)			1,1 (2011)	0,8	0,6 (2017)	SDG Indicator database
15	Forest area as a proportion of total land area (%)	61		60	50	46	SDG Indicator database
16	Voice and Accountability (ranges from approximately −2.5 (weak) to 2.5 (strong) governance performance)	−0.8	−1.0	−0.9	−1.1	−1.2	The Worldwide Governance Indicators