Original research•

Finding linkages between the Sustainable Development Goals in Uganda: a key to attain health and well-being for all

Abstract

Introduction While Uganda has made significant strides towards the 2030 Agenda, several development challenges persist, including a high disease burden, poverty and the effects of climate change. Multisectoral collaboration is critical in achieving Uganda’s Sustainable Development Goals (SDGs); however, most sectors in the country still operate in isolation. Understanding the linkages between the goals in Uganda is critical for accelerating progress on health and the SDGs. This study aimed at taking initial steps in investigating the linkages between health and other SDGs in Uganda.

Methods A 2-day workshop with 29 multisectoral stakeholders was conducted to explore the nature of linkages between the SDGs nationally in Uganda. Results were analysed using the SDG synergies approach and presented using a cross-impact matrix to show the nature and strength of linkages between the goals.

Results Overall, there were more positive linkages between the SDGs than negative ones. Progress on SDG 10 (reduced inequalities) was considered to have the most positive influence on the 2030 Agenda. SDG 3 (good health and well-being) was the goal that was perceived to be most positively affected if progress was made on other goals. The economic goals, SDG 8 (decent work and economic growth) and SDG 9 (industry, innovation and infrastructure) were the goals that promoted other goals the least. Negative linkages were perceived between SDG 13 (climate action) and the economic goals (SDG 8; SDG 9).

Conclusion The findings reveal that promoting linkages were perceived to be the majority, but some restricting linkages between the SDGs also exist. The promoting linkages suggest a need for integrated approaches in attaining SDG 3 and other SDGs in Uganda. Further addressing inequalities in their different forms, policy reforms, local community engagements and continuous monitoring are critical for sustainable development in Uganda.

What is already known on this topic

  • The Sustainable Development Goals (SDGs) are integrated and indivisible; cross-sectoral actions are critical to reaching the 2030 Agenda.

What this study adds

  • This study gives essential initial insights into the nature of SDG linkages in Uganda, showcasing that they are, for the most part, synergetic and identifying key trade-offs that should be carefully handled.

How this study might affect research, practice or policy

  • These findings can guide policy-makers on coordinated action between different actors towards planning, prioritising resources and implementation of SDGs in Uganda to achieve the 2030 Agenda. This work is a basis for further research on specific SDG targets and geographical settings in the country to accelerate sustainable development.

Introduction

The 2030 Agenda is a framework for all countries to work towards a sustainable future for everyone. It comprises 17 goals to guide countries towards addressing world challenges for the people and the planet.1 The Sustainable Development Goals (SDGs) are ‘an Integrated and Indivisible whole’ rather than a set of independent components; hence, national, regional and global implementation strategies must focus on the goals as a unified entity.2 While the 2030 Agenda is universal, the UN recognises that specific countries face unique challenges. However, the 2030 Agenda or the SDGs do not guide how context-specific linkages should be approached in practice.

Multisectoral approaches allow for a holistic and integrated systems approach to achieving the SDGs and have been considered critical.3 However, the SDG linkages that might underpin such efforts have yet to be identified or well understood at a country or subcountry level.4 5 Understanding the nature of the linkages between the SDGs allows policy-makers and decision-makers to implement governance strategies and coherent policies that ensure that synergies are optimised while carefully considering potential negative trade-offs to support planning and prioritisation of efforts in settings with limited resources3 6 such as Uganda.

Uganda, a low-income and landlocked country in East Africa, has been working towards achieving the SDGs since 2015 when it adopted the Agenda. By 2016, the country had already aligned and localised 70% of its national development plans and the SDGs.7 In 2016 and 2020, Uganda voluntarily submitted its first two National Review Reports, where it documented its progress towards the SDGs. Since its adoption, Uganda has registered progress towards achieving the SDGs in some areas, including health and education.7

Nonetheless, the country still records limited improvements on several goals, and progress could be more satisfactory regarding SDG 3 (good health and well-being). For instance, while the maternal mortality ratio reduced from 435 deaths in 20068 to 336 deaths per 100 000 live births in 2016,9 maternal mortality is still above the expected SDG target of 140 deaths per 100 000 by 203010 with primarily preventable deaths.11 Achieving the ambitious SDG targets in Uganda will require significant effort and innovative implementation approaches.

While the government of Uganda emphasises the need for cross-sectoral synergies and coordinated action with an inclusive approach to the SDGs,12 little is known about the nature of linkages between SDGs in Uganda. As a result, most stakeholders tackle the SDGs in isolation,12 significantly hampering the possibility of coordinated efforts and delaying their achievement. In response to this knowledge gap and the need for concrete evidence, this study aimed to identify, classify and document the nature and strength of linkages between the SDGs, focusing on SDG 3 (good health and well-being) in Uganda.

Methods

Study design

To assess the linkages between the SDGs in Uganda, the SDG synergies approach13 was used. This semiqualitative approach provides a practical understanding of linkages between SDG goals through a collaborative three-step process. The three steps involve determining the scope and context where it will be applied, scoring the interaction and analysing the results.6 The approach relies on context-specific expert knowledge from different stakeholders to provide a practical tool to engage stakeholders and to support understanding of the interactions between the SDGs and their complex nature, considering the real-world complexities of making progress on the SDGs.14

Participant identification and recruitment

Participant recruitment took place from September to October 2021. Purposive sampling was used to identify and select participants based on anticipated knowledge of SDG implementation and cross-sectional activities in Uganda. 29 stakeholders (14 women and 15 men) from public, private, civil society and academia, both health and non-health sectors, participated in the workshop. Participants aged 18 years and above with expertise in at least one SDG area were recruited (see online supplemental table 1).

Data collection

A 2-day workshop from 28 October 2021 to 29 October 2021 in Kampala, Uganda, was conducted to score the interactions between the SDGs. The interaction scoring was set at the goal level to allow for a feasible number of interactions to be assessed while enabling a broader generalisation of the interactions and subsequent results. All SDGs except SDG 17 (partnership for the goals) were included as this goal was deemed too broad to be useful for meaningful assessment. In total, 225 unique interactions between the 16 SDGs were assessed. Before the actual scoring began, participants were introduced to the SDG synergies approach. A few interactions were tried to ensure all participants understood the approach and assessments. For the list of the assessed SDGs and their definitions, see online supplemental table 2.

Participants were then divided into five cross-sectoral groups of 5–6 and collectively assessed each linkage based on their knowledge or experience in implementing particular SDGs in Uganda. The scoring was guided by asking the following question: ‘If advances are made for SDG X, how will this influence progress for SDG Y?’. A 7-point scale to score was used where +3 meant strongly promoting and −3 meant strongly restricting according to the scale by Weimer-Jehle15 (See table 1). Each group discussed a set of interactions, agreed on a score and provided a brief justification for the score. Facilitators guided the discussion process and supported the participants in reaching a consensus score and providing justifications.

Table 1
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Definition of the 7-point Weimer-Jehle according to the SDG synergies approach6

After the initial group scoring, each of the group scores and justifications was reviewed by a different group. When the review group did not agree with the original score, they suggested a different score and justification. Further, the research team reviewed the scores and justifications for the interactions, and where inconsistencies were found or potential mistakes thought to be made, clarifications were requested. All interactions where groups disagreed or in the case of unclear scores were brought up in the plenary session for discussion with all participants until a consensus score was reached. If a consensus approach did not lead to a definitive assessment of an interaction, voting was used to determine the final score of the interaction. At the end of the workshop, the final score and justification were collected for all 225 unique interactions.

The individual interactions were presented using a cross-impact matrix. The cross-impact matrix visualises both the net influence scores, which show how a particular SDG influences other SDGs and the influenced degree score which shows how other goals influence the mentioned SDG. The row sum shows the net influence score while the column sum shows the influenced degree score Additionally, network analysis was applied to determine the indirect or second-order interactions of the SDGs with a focus on SDG 3 (good health and well-being). These can showcase how a change in one SDG can ripple through the network. The details of the network analysis used here are described extensively by Weitz et al.3 6 16 17 The scores, justification, cross-impact matrix and network analysis were imputed and analysed using the free-to-use custom-made software provided by Stockholm Environmental Institute.6

Public involvement

Stakeholders who represented the public engaged in different aspects of this study. They participated in the assessment and scoring of the goals. After analysing the collected data, the findings were disseminated to the stakeholders to validate and share their feedback.

Results

Direct linkages between SDGs in Uganda

The score of the direct linkages between the SDGs in Uganda is illustrated in the cross-impact matrix (figure 1). Holistically, the results depict that positive linkages dominate the network (85%) compared with negative linkages. SDG 3 (good health and well-being) was the single goal perceived to be most positively influenced by the other SDGs. In addition, SDG 2 (zero hunger) and SDG 8 (decent work and economic growth) were also strongly promoted when progress was made on other goals. The least promoted goals included SDG 14 (life below water), SDG 15 (life on land) and SDG 13 (climate action).

Figure 1
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Figure 1

Cross-impact matrix for SDG interactions in Uganda. SDG, Sustainable Development Goal.

SDG 10 (reduced inequalities) had the most positive influence on the network. It either strongly or moderately promoted all the SDGs except SDG 12 (responsible consumption and production), which it only weakly promoted. SDG 10 was followed by SDG 11 (sustainable cities and communities) and SDG 15 (life on land), and SDG 12 (responsible consumption and production).

The SDGs with the least promoting influence on the network included SDG 8 (decent work and economic growth), SDG 9 (industry, innovation and infrastructure) and SDG 14 (life below water). Negative linkages were perceived on the climate-related goals, SDG 13 (climate action), SDG 14 (life below water) and SDG 15 (life on land) when progress was made on the economic-related SDGs, SDG 8 (decent work and economic growth), SDG 9 (industry, innovation and infrastructure). Furthermore, participants believed that making progress on SDG 13 (climate change) might negatively impact SDG 10 (reduced inequalities). As mentioned in the scoring justification, ‘Climate action activities may increase income inequality, evicting poorer households to plant trees. People will lose jobs’. Other justifications are included in online supplemental table 3. Additionally, the network diagram extracted from the study results (figure 2) revealed no clear clusters indicating the close interlinkages between all the SDGs in Uganda, according to the participants.

Figure 2
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Figure 2

Network diagram showing interlinkages between SDGs in Uganda. SDGs, Sustainable Development Goals.

Indirect linkages between SDGs in Uganda

The results are further explored using the row sum and column sum scores from the indirect interactions to show a bigger picture of how the interactions ripple through the network. Table 2 shows that SDG 10 (reduced inequalities) maintains the highest positive influence on the rest of the SDGs regardless of whether the linkages are direct (first order interaction) or indirect (second order interaction) while SDG 8 (decent work and economic growth) and SDG 9 (industry, innovation and infrastructure) had the lowest positive influence on the other goals in the first and second order interactions.

Table 2
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Ranks of SDGs influencing the network in Uganda based on direct and indirect interactions

SDG 3 (good health and well-being) and its interactions with other SDGs in Uganda

As presented above and depicted in figure 3, SDG 3 (good health and well-being was the single goal that was perceived to be most positively influenced by making progress on other SDGs. The results do not show any negative interaction between SDG 3 (good health and well-being) and other goals in any direction. All goals either strongly or moderately promoted SDG 3, except SDG 11 (sustainable cities and communities) and SDG 14 (life below water,) which had a weakly promoting linkage. The goals with the most influence on SDG 3 included SDG 10 (reduced inequalities), SDG 1 (no poverty), SDG 2 (zero hunger), SDG 4 (quality education), SDG 6 (clean water and sanitation), SDG 7 (affordable and clean energy) and SDG 12 (responsible consumption and production) using first-order interactions (figure 3A). When taking into account the second-order interactions as well (figure 3B), SDG 10 (reduced inequalities) seems to have the greatest net-positive effect on promoting progress on SDG 3 (good health and well-being).

Figure 3
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Figure 3

(A) First order (direct) influence of other SDGs on SDG 3. Colour according to scale. (B) First and second order (indirect) influence of other SDGs on SDG 3. Colour according to scale. Size of circle indicates magnitude of net effect. SDGs, Sustainable Development Goals.

Progress on SDG 3 (good health and well-being) was perceived to promote progress on several SDGs (figure 4A) moderately. Specifically, SDG 1 (no poverty), SDG 2 (zero hunger), SDG 4 (quality education) and SDG 8 (decent work and economic growth), SDG 5 (gender equality), SDG 10 (reduced inequalities), SDG 11 (sustainable cities and communities), SDG 12 (responsible consumption and production) and SDG 15 (life on land) were weakly promoted. From the second-order interactions perspective (figure 4B), a positive feedback loop is observed where progress on SDG 3 (good health and well-being) promoted progress on several SDGs that in turn promoted progress on SDG 3 (good health and well-being) as stated by participants’ justification ‘Good health will influence productivity and subsequently improve wealth. Increases productivity, reduced expenditure on health’ (see online supplemental table 4). Further still, SDG 3 (good health and well-being) had a strong indirect positive influence on many SDGs, but mostly on SDG 2 (zero hunger), SDG 4 (quality education), SDG 1 (no poverty) and SDG 5 (gender equality).

Figure 4
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Figure 4

(A) First order (direct) influence of SDG three on other SDGs. Colour according to scale. (B) First and second order (indirect) influence of SDG three on other SDGs. Colour according to scale. Size of circle indicates magnitude of net effect. SDGs, Sustainable Development Goals.

Discussion

The synergistic pattern observed within the SDGs in Uganda, dominated mainly by promoting interactions, depicted a high interdependency and interconnection between the goals. Similar results have been observed in other studies16–19 but not previously in Uganda. The findings affirm the need for the country’s deliberate efforts to pursue and optimise cross-sectoral approaches and policy cohesion to efficiently utilise the available limited resources to meet the fast-approaching 2030 Agenda goals.12 SDG 3 (good health and well-being) was the most promoted by progress on other goals, which may also indicate that health will be the most negatively affected SDG if progress is not made on other goals.

Relationship between the SDGs in Uganda

SDG 10 (reduced inequalities) was perceived to have the most significant positive outcome on the 2030 Agenda in Uganda. According to the United Nations, goal 10 plays a pivotal role in achieving the SDGs as it targets the inclusiveness of all people regardless of their sex, age and ethnic background to improve their social and economic statuses.20 In Uganda, however, inequality gaps remain evident despite government efforts to address inequalities and poverty through programmes such as the Poverty Eradication Action Plan.21 Based on the Gini index, a statistical measure of income and wealth disparities in a country,22 the inequality gap increased from 41 in 2012 to 42.7 in 201923 and is anticipated to get worse in the coming years.24 People living in poverty in Uganda increased from 8.03 million in 2016/2017 to 8.31 million in 2019/2020.21 Factors such as aggressive weather conditions and COVID-19 have further aggravated inequalities and poverty in the country, mainly affecting vulnerable groups such as children, women, and the youth and rural areas in Northern Uganda.21 This has several negative consequences on related SDGs, such as access to quality education, and further increases health inequities leading to poverty-related diseases25 As a result, poverty-related diseases may continue to strain the country’s health systems despite public, government, private and donor health interventions.26 For faster growth, strategies to address income inequalities in Uganda should target specific populations. For instance, children and older populations will benefit from social protection schemes27 while enhancing skilled labour will support women and the young population to increase productivity.28

Relationship between SDG 3 (good health and well-being) and other SDGs

How health affects other SDGs

Progress on SDG 3 (good health and well-being) was directly linked to promoting progress on other SDGs, predominantly SDG 1, 2, 4 and 8. The direct and indirect positive influence (and absence of negative linkages) strengthen evidence that health is critical for development.29 These findings are similar to other SDG assessment studies.16 30 Stakeholders, for instance, perceived health as a key determinant for a reduction in poverty and economic development due to its effects on productivity. Additionally, the positive feedback loop observed through the indirect interactions on making progress on good health and well-being highlighted that efforts to improve health and well-being could lead to a virtuous cycle of health advancement.

SDG 3 (good health and well-being) being the most promoted by progress on other goals aligns with findings from other studies and complements existing evidence that different social and economic SDGs determine health and well-being.31 32 The findings, however, may also indicate that health will be the most negatively affected SDG if progress is not made on other goals. In other words, while some success has been recorded in health, such as reducing maternal and child mortality,24 achieving the health targets might be impeded by the limited progress in other non-health areas, such as the increasing inequalities.21 In addition to increasing funding in the health sector, engagement of all actors, including private33 and civil society organisations,34 is also very critical. Further, adopting and adapting approaches such as ‘Health In all Policies’29 is essential to address health inequalities among marginalised groups.

Negative linkages between the SDGs in Uganda

Stakeholders perceived SDG 13 (climate action) as being associated with restricting progress on reducing inequalities. This was mainly attributed to poor climate change mitigation planning. Inadequate policies where efforts to conserve the environment may lead to the eviction of local people from their habitats or sources of income without alternatives. Most people in Uganda derive a livelihood from natural resources. Unplanned conservation limits access to these resources, which may exacerbate their predicament and increase poverty.35 As such, the results from our study point to the fact that addressing Uganda’s development challenges will require multidimensional efforts, including policy reforms to address deprivations and inequalities aggravated by climate actions, especially for the marginalised and considering gender imbalances. Evaluation of policies, local community engagement and sustainable conservation may prevent adverse effects of climate action enforcement.36

The economic goals (SDG 8 and 9) were perceived to have the least positive influence on the Agenda and were associated with limiting progress on other goals especially those related to environment (SDG 13, 14 and 15). Stakeholders perceived that inadequate plans to improve the economy may lead to uncoordinated industrialisation and urbanisation, ultimately leading to the worsening of environmental pollution as stated by participants, ‘Deforestation for industrial land and emissions from industries affect life on land leading to non-communicable diseases’ (online supplemental table 3). These findings are similar to a previous study37 and while this linkage might not directly visible on the network, it may affect several other goals including health.31 32 Policies and actions to improve the country’s economic conditions must be well evaluated and weighed against the impact they may have on the environment,37 health and other SDGs.

Policy implications

The SDGs are context and geographic-reliant, hence a localised approach to their achievement is critical.5 The SDG synergies approach applied in this study created a platform for stakeholders from different sectors and seniority levels to engage and discuss SDG interactions in a localised setting in Uganda. Context-specific examples allowed participants to reflect pragmatically and realistically on the SDGs and the possibility of their progress in the country. Further, the cross-disciplinary discussions led to insights into each other’s contribution to development which enhanced their appreciation for multisectoral collaborations and the need to work together to address development challenges, including those specific to health.

Progress on SDG 10 (reduced inequalities) will likely be the most impactful goal in Uganda. Investment in this SDG could promote progress on other SDGs, including SDG 3 (good health and well-being). The study also identifies trade-offs between the economic and environmental-related SDGs. This must be handled carefully, and policy-makers should consider different options to mitigate the negative effects or find different forms of implementation that can turn trade-offs into synergies.37 The study findings also illustrate important knowledge gaps and the need for further research on a range of interactions between SDGs. Quantitative as well as qualitative research could complement this further to investigate and unearth insights into the associations between health, economic development, climate change and inequalities at a country and subcountry level.

Strengths and limitations

The study systematically assesses the interactions between the SDGs in Uganda. It provides a society-wide understanding of the nature of interactions compared with the siloed approach that has been a common practice. The findings from this study provide an essential starting point for a discussion on the prioritisation of resources. This study aimed to take initial steps towards understanding the nature of linkages between SDGs at the national level in Uganda, focusing on SDG 3 (health and well-being). The study used a semiqualitative approach where participants were purposively selected, and group discussions were based on the participants’ level of knowledge. The results, therefore, represent participants’ perceptions of the nature of interactions between the SDGs in Uganda, and findings could differ given a different set of participants. However, to ensure that all participants had a similar definition and baseline understanding of the SDGs, reference material with examples to guide discussions and inform the scoring was provided. In addition, the interactions were scored on the goal level rather than on the lower, target, level and the scoring of interactions was at the national level. The findings may, therefore, be different at regional or subnational levels or if focused on specific SDG targets, given the difference in nature of resources, priorities and settings.5 A narrower focus on the assessment and selecting a subset of targets at a subnational level may yield further insights and hence more research, based on such levels, might also contribute to informing interactions and implementation of SDGs in the context of Uganda. In addition, identified synergies and trade-offs, such as those associated with reduced inequalities and climate action, could be investigated further using disaggregated quantitative data and further stakeholder engagement to draw more insights and scope the challenges systematically. The results of this study should not be seen as a conclusive blueprint for how the SDGs are linked in Uganda. Rather, the findings offer insights and should be viewed as a basis for further dialogue and investigation to guide policy prioritisation and planning in Uganda.

Conclusion

We found a largely synergistic pattern between SDGs at the country level in Uganda. SDG 10 (reduced inequalities) had the most promoting influence on the network while SDG 3 (good health and well-being) was the most influenced by other SDGs. The synergistic nature of interactions suggests the need for an integrated and collaborative approach to implementing SDGs to accelerate the attainment in Uganda. Efforts to address inequalities in Uganda will promote several other goals while failure to make progress on other goals will mostly disrupt SDG 3. Therefore, the involvement of different stakeholders to achieve SDG 3 (good health and well-being) and other SDGs is crucial. In addition, the trade-offs found in the study may indicate the need for policy reforms and systematic monitoring and evaluation of SDG implementation to mitigate the short and long-term consequences of the achievement of the SDGs, such as those linked to climate action and inequalities. The SDG synergies approach demonstrated a practical way to trigger multisectoral dialogue and collaborations towards achieving health and other SDGs in Uganda.

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