Potential and challenges of health monitoring in the 2030 Agenda in Brazil

This article has two integrated objectives: (i) to identify the representation of health in the 2030 Agenda from health-related indicators implemented by international and national institutions; and (ii) to compare the potential of platforms for monitoring Brazilian health commitments in the SDGs. It is argued that there are still important controversies brought about by the greater complexity of the 2030 Agenda, particularly in the operationalization of health-related indicators, whose determinants permeate many other objectives and goals. Finally, even though the pic-ture of the country currently available on national and international platforms is already broad, im provements are required for more effective monitoring and evaluation of Brazilian commitments in the SDGs, with greater disaggregation and stratification of indicators in the population.


Introduction
Ratified by heads of state in the United Nations General Assembly in September 2015, the 2030 Agenda established a set of 17 Sustainable Development Goals (SDG) and 169 objectives. These objectives are monitored and assessed through a system of 232 indicators that passed through a harmonization process to allow comparability of different territorial levels and groups of people around the globe 1,2 .
The thematic breadth of commitments and the recognition of the integrality of goals, with interdependency in the economic, social, and environmental dimensions for sustainable development, stand out between the aspects that make the 2030 Agenda different from other international agreements 1,3 . Even more so, the Agenda is based on the principle of "not leaving no one behind", which reinforces the development commitment in all nations and peoples, as well as all segments of society 1 . In fact, one of the most important lessons of the initiative that precedes it, the Millennium Development Goals (MDG), was the need for reaching populations in the territory, abandoning the goals' aggregate character. In the maturity of international debate, local and regional monitoring became a priority within SDGs 4 .
These characteristics of the Agenda bring operational challenges to the SDG implementation, monitoring, and assessment, including the transposition of restrictive frameworks on the goals themselves. Among them, this paper highlights the challenges contained in health monitoring (SDG 3), and their interdependency with other goals. In seeking to explore the possibilities of monitoring health-related goals of the 2030 Agenda in Brazil, this paper has two aims. They are: (i) to identify different views of health that emerge from the choices of themes and indicators for monitoring SDGs made by a set of key institutions for the 2030 Agenda, namely: the World Health Organization (WHO), Pan American Health Organization (PAHO), World Bank, Global Burden of Disease (GBD-IHME), and Sustainable Development Solutions Network (SDSN); and (ii) to present comparatively the monitoring possibilities of the country and its subnational units, discussing the still existing gaps of data and the platforms' potential.
The next section highlights the methodology used for identifying convergences and divergences between institutions in health themes and collecting data to monitor Brazilian health in the SDG. The ensuing section gives a brief overview of the monitoring challenges brought by the 2030 Agenda, highlighting health. Finally, it contextualizes the main findings of the study, highlighted in the results section, which emphasizes the platforms for health monitoring and the challenges of the health-related SDG in Brazil.

Methods
The present study followed two distinct paths to fulfill its objectives of delineating the place of health in the 2030 Agenda and identifying possibilities for monitoring Brazilian health commitments in SDGs.
The first empirical part of the study was based on an exploratory descriptive analysis of implementation strategies of the SDG indicators made by five key institutions for global health. In particular, individual choices of indicators for representing health were evaluated, highlighting the degree of consensus in the indicators and health themes represented by the totality of institutions.
Those evaluated institutions were the same highlighted by Silveira et al. (2021) 5 . The choice was due to their prominent role in promoting the SDG, which included the publication of their own set of health-related indicators in specific documents. Furthermore, all those institutions hold platforms of their own for monitoring the SDG. Among them are regional and global sanitary authorities, respectively Pan American Health Organization (PAHO) and World Health Organization (WHO); World Bank, one of the main promoters of the 2030 Agenda; and global networks in health research, the Global Burden of Disease (GBD-IHME), and in sustainable development, Sustainable Development Solutions Network (SDSN).
The second empirical part of the study sought to map platforms that allow SDG monitoring in Brazil, particularly those related to health. The survey sought to include all online databases built specifically for monitoring the SDG goals, comparing the strengths and limitations of each solution. The survey highlights the number of health-related indicators available and the availability of information by the unit of analysis or level of disaggregation, territorial coverage, and characteristics of information available (raw data, graphical information, historical evolution of indicators, performance index, projections, rankings of units, simulator of goals, and reports describing the indicators made available).

Contextualization: the monitoring of health in the SDG
The SDG official indicators are considered an important instrument for ensuring the implementation of the goals, giving them a central and political role inside the Agenda's governance structure 6 .
There is, however, a series of challenges that need to be overcame for this instrument to reach its full potential. In its conception itself, a series of political disputes and methodological challenges were observed in constructing and defining globally harmonized indicators 7,8 . It was also observed a scarcity of official data for a large part of the indicators proposed in more than half of the States 9,10 . Some authors relate the scarcity of data to the technical and financial insufficiency of the States' statistical capacity, which involves lack of disaggregated data and monitoring capacity 3,11,12 , lack of knowledge or capacity in systems analysis and integrated planning of public policies 13 , and lack of effective structure for prioritizing goals and technical training adapted to innovations proposed by the SDG 14 .
Such challenges promoted the development in parallel of alternative and/or temporary indicators, from official and non-official sources, by institutions promoters of the 2030 Agenda to broaden the database of States and subnational units with comparable information 15 . Notwithstanding, the indiscriminate use of proxy indicators brings as a consequence the risk of change in the SDG original intent, with remoteness from the goals and objectives of initial conceptions and loss of the innovative characteristics of the commitment 7 .
Even with good data collection systems, the challenge of systemic comparability and integrated analysis within the 2030 Agenda still needs to be solved 11 . Furthermore, it is important to recognize that, because of its quantitative reductionism, the monitoring of indicators is not sufficient in itself to guarantee the success of the 2030 Agenda implementation. It is also necessary to create accountability models for the goals that surpass what is "quantifiable" by indicators, which requires the recognition of phenomena immensurable only in numbers and damages that may come from trade-offs, structural problems, and development processes 7,16,17 .

Health in the 2030 Agenda
Health is explicitly represented in SDG 3, which seeks to "ensure a healthy life and promote well-being at all ages", from 13 targets and 28 single indicators 2 . By recognizing the complexity and interdependency of sustainable development, the 2030 Agenda wishes to address the health theme beyond SDG 3 [18][19][20][21] , in the same direction established from the concept of Social Determinants of Health (SDH), in 2006 22,23 , in this way spanning a much larger set of objectives, goals, and indicators of the Agenda. However, these indicators are still in dispute by virtue of the need for the SDG tools adaptation to specific contexts of countries and their territories and populations, and for interests and distinct views as to the socioeconomic determinants of health. In a way, the partnership of state actors, international organizations, academia, private sector, and other interested parties represents -and in some situations aggravates -the heterogeneity of approaches in dispute for each issue dear to health 24 . Such differences feed global health networks with structures very diverse among themselves 24 , which adds difficulties to the holistic view defended by the Agenda.
In large part of the classical literature about public health, the notion of collaboration implicitly assumes a degree of consensus and interest in common among the participants. However, recent authors have started to focus on the several conflicts of interest that permeate the public health domain 25 . The first third of the SDG mandate has already shown signs of political interference with the mobilization and use of indicators in building public policies. Considering these factors requires understanding the circumstances and problems of using indicators relative to public policies, an area normally neglected both by academics and users of the indicators 6 .
It is up to governments at the federal, state, and municipal levels to know how to deal appropriately with the perspective differences within institutions and government bodies of the health system. Moreover, the global health community recognizes the need for multisectoral collaboration actions. Nevertheless, this interlocution often refers to specific diseases or services, treating the intersectoral collaboration as a subproduct for particular solutions and not as the main focus of health interventions. This diverts attention from the broader understanding of the capabilities necessary for developing and sustaining multisectoral collaborations 26 .
The gaps in this debate demand a critical eye on the different health views in the 2030 Agenda to better position health as an element in the intersection between well-being and sustainable development [26][27][28] .

Convergences and divergences in the representation of health
While explicitly represented in SDG 3, health is directly and/or indirectly related to a broader set of other SDG. Yet, in the absence of an official definition of this relationship, the indicators chosen and lately implemented in platforms monitoring health-related indicators reflect the SDG-promoting institutions' different views and traditions. Therefore, understanding where there is consensus and the greatest points of divergence between institutions, in what concerns health-related themes and indicators, is fundamental for sectoral organization and, consequently, achieving goals until 2030.
In total, the five analyzed institutions listed 60 of the 232 official indicators of the SDG, among those directly related to health 5,29,30 . It sums to eight SDGs and 37 targets, which indicates a health association of 46% of goals, 22% of targets, and 25% of indicators.
It is worth stressing that, in many cases, there exist differences between official indicators and those effectively implemented by these institutions. The basis for choosing an indicator lies in the traditions and expertise of these institutions to find alternatives for implementing the official indicators in their archives. Those differences may happen at different levels: be they smaller, such as the absence of data stratification by sex, age group, etc., or the exchange of ratios for rates (and vice-versa); or in a more acute way, as a divergence of concepts relevant to the indicator, even though the broader theme is usually preserved. Chart 1 allows observing the level of convergence between indicators adopted by the institutions assessed in health themes. The thematic division of indicators follows the proposal carried out by WHO in the report "World Health Statistics 2019", which includes (i) "Maternal and reproductive health"; (ii) "Child and newborn health"; (iii) "Infectious diseases"; (iv) "Non-communicable diseases"; (v) "Injures and violence"; (vi) "Environmental risks"; (vii) "Uni-versal health and health systems coverage". An additional category (viii) "Others" was included to allow the inclusion of indicators that do not fit into any of the above themes. The complete list of those institutions' selections of health-related indicators can be found in the Supplementary Material (available from: https://doi.org/10.48331/ scielodata.IIERZY).
Chart 1 shows the number of indicators effectively implemented by the institutions in their platforms. In general, the number of indicators contained in the platforms is smaller than the institutions' lists because of the lack of data for all presented indicators. Only the World Bank has more health-related indicators in its platform than its list of health-related indicators, implementing alternative/complementary indicators related to the official indicators.
Among the 60 health-related indicators, only 22 (36.6%) are consensual between the five institutions, 18 of them (30.0%) from SDG 3. Figure  1 below highlights the degree of consensus of the indicators and topics that they represent: Eight topics were observed to stand out among the 22 consensual indicators, namely, (i) Maternal-child health, which measures not only mortality rates, but also the number of adolescent mothers; (ii) infectious diseases of HIV, tuberculosis, malaria and hepatitis B; (iii) non-communicable diseases, attributed to cardiovascular diseases, cancer, diabetes, chronic respiratory diseases, and suicide; (iv) consumption of harmful substances, such as alcohol and tobacco; (v) health services, such as coverage of essential health services, household expenditures, vaccinal and health professionals coverage; (vi) mortality by exogenous factors, due to traffic accidents and air pollution; (vii) child nutrition, represented by height and weight deficits among children under five years of age, both in SDG 2; (viii) environmental health coverage, represented by safe access to drinking water and sanitation services, both from SDG 6. Interestingly, eight of these indicators belonged to MDGs, which reinforces the role of tradition for consensuality in producing indicators.
Significant dissensus was observed for several indicators, with each institution promoting different health topics. These choices denoted their particularities within their practice and research tradition in the field of health. The PAHO was the only one to include indicators of migration management and statistical capacity, while only WHO positioned government spending in essential services and official assistance to the environ-  mental health development as related to health. GBD was the only one to select the themes of work-related accidents and sexual violence of minors. It was observed great similarity between WHO and GBD, which share indicators of gender violence, reproductive health, and access to clean fuels. On the other hand, the World Bank exclusively selected the indicator of the population's undernutrition. Finally, the SDSN list added the greatest intersectoral integration, with practically half of the indicators from different SDGs, including extreme poverty, social protection systems, sanitary facilities in schools, and electricity. Such differences reflect part of the current implementation dispute of an expanded health concept inside the 2030 Agenda 31 .

Platforms for the monitoring of health in Brazil: strengths and limitations
The creation of the 2030 Agenda counted with the participation of governments at different levels (local, regional, national), multilateral institutions, academia, companies, and other organizations from civil society 15,32 . These actors have their own role in implementing policies for achieving the objectives and monitoring progress in their territory and population. The importance of the collaboration between all parties is represented in SDG 17, a goal created to guide the SDG implementation from the coordination of international efforts. In addition, the targets for cooperation and mobilization of science, technology, and innovation seek to sustain the Agenda's ambitions and create new modalities of governance and public policies 1,33 .
Furthermore, while such actors have specific roles for the success of the 2030 Agenda, all share the promotion and monitoring functions. These functions are conducted by curating, producing, and organizing data and indicators in their platforms, in addition to developing methodologies for monitoring the SDG. These actors adapt the monitoring tools that best represent their views on the themes and the reality of territories and populations. This adaptation is essential to support specific policies and actions to accelerate results and achieve the SDG.
In fact, the existence of platforms dedicated to the SDG indicators promotion is a fundamental condition to make the 2030 Agenda an instrument of political actions for sustainable development and the achievement of global goals until 2030. While the platforms for SDG promotion, monitoring, and evaluation sometimes overlap, these initiatives have their own answers to fill analytical emptiness's, validating efforts within offi-cial agencies and widening the base of countries and subnational units with comparable information. This is reflected in the adoption of alternative indicators based on official and non-official sources, performance indexes, and methodologies based on diverse metrics.
Among the dimensions that differentiate those platforms, the following stand out: (i) basic analysis unit: municipality, Federated State (FD) and/or country; (ii) type of data: obtained by official sources or not; (iii) type of indicators: internationally harmonized (official indicators from the IAEG-SDGs) or alternative (one's own interpretation to the SDG goals); (iv) basic monitoring and assessment methodology: comparison with peers, evolutionary analysis, analysis of performance indexes and/or projections for the indicators; (v) visual resources and reports made available: which may vary greatly between the platforms, so as to draw attention to the strengths and challenges in meeting the objectives and goals; and (vi) temporal and cross-sectional coverage of the database. Chart 2 presents national and international platforms that fit into  this group and information for monitoring and/ or assessing the health-related SDG in Brazil. The first characteristic highlighted in Chart 2 is the platform's unit of analysis. The vast majority of initiatives allow only a more aggregated look at the SDG indicators at the national level. In the Brazilian case, only the initiatives of SE-SI-PR and National Confederation of Municipalities (CNM) had data for the 5,570 Brazilian municipalities. In considering cities with more than 200 thousand voters, recent initiative from Sustainable Development Index of the Cities, inaugurated in Brazil in 2021 by SDSN in partnership with Sustainable Cities Institute, shows data from 770 municipalities 34 . Information at the Federal States level is found only in some indicators available in the platforms of SESI-PR and the official portal for SDGs in Brazil, the "ODS Brasil" from the Brazilian Institute of Geography and Statistics (IBGE), with collaboration of the Economic and Applied Research Institute (IPEA). Despite having its database indicators for Brazilian states, IHME-GBD does not make them available at this analytical level in its platform.
The temporal and cross-sectional coverage of the series of indicators varies significantly both in the platforms and among indicators. Therefore, while most platforms provide historical series, there are indicators for which the series is well-balanced and others for which only temporal information, in general post-2015, is available. This occurs by the introduction of new indicators and by the adaptation of methodologies for global harmonization adopted in some indicators of the SDG.
The institution responsible for building globally harmonized indicators for Brazil and their publication is IBGE. It is worth noting that IBGE and IPEA provide permanent assistance to the National Commission for the Sustainable Development Goals 35 . Notwithstanding, the institution's platform is one of the most outdated re-Chart 2. Platforms for monitoring from Brazil and/or its subnational units in the health-related SDG.

Platforms
Unit garding the number of health-related indicators available. This gap is pointed out by Relatório Luz, produced annually by the Brazilian civil society about the implementation of the 2030 Agenda, which denounces the difficulty of access to up-to-date governmental statistics 36 . Over and above, most published indicators are not amenable to disaggregation at the FSs level, and none at the municipal level. This is in a context where Brazil has one of the world's most complete information collection systems which, if used, would allow a much broader, disaggregated evaluation, more efficient in time, than that offered currently in the ODS Brasil platform. The alternatives for understanding the health scenario for the SDG in Brazilian territory are today the platforms of SESI-PR and CNM, which have their own limitations, however. The latter, known as "Municipal mandala of the SDG" shows a very small number of health-related indicators (7), divided into the social and environmental dimensions of the index of its own. The SESI-PR platform, while using data from official statistical sources (the very IBGE and DataSUS, for the most part), does not follow the globally harmonized indicators, which precludes the application of comparative assessment strategies built for the SDG globally. Because of the scarcity of data at the level of analysis, the platform chose some "dimensions" in each SDG, offering an interpretation of its own of indicators for the goals. The main limitation of the approach is the loss of international comparability of these indicators and, with that, of goals defined for the country and methodological synergies with other platforms.
One central aspect differentiating the various initiatives for monitoring SDGs is the adopted methodological perspective. For example, the SDSN's and WHO's platforms highlight the most recent data for the indexes of performance and indicators, and allow assessing the SDG through the comparison of countries, even if the historical series are displayed by raw data, as occurs in the WHO portal. In turn, the portals of SESI-PR, World Bank, IBGE, PAHO and IHME-GBD allow an evolutionary analysis of the series of indicators and the comparison of trajectories between units, with different emphases on the indicator.
These platforms' coverage of SDG indicators for monitoring and assessing health in Brazil is strongly limited by the absence of disaggregated information for the subnational levels. While only one health-related indicator is not available at the national level, the 3.b.3, only 40% of the others are available disaggregated for the Brazilian municipal level. The coverage rises to 87% at the level of federated states. Yet, if GDB, whose base per FS was not published, is excluded, the coverage at FSs level falls to only 53%. It is worth stressing that, by considering only harmonized indicators with international comparability, the coverage drops drastically at all levels, especially for the municipal levels.
Moreover, the stratification available for those indicators is still very far from meeting an analysis of the fulfillment of the objective of territorial, racial, gender, and socioeconomic inequality reduction. Only 45% of the indicators have at least one stratifier at some level of aggregation. Of the total of indicators, 39% hold disaggregation by sex (only 4% of these at the municipal level); 13% allow disaggregation by age and other 13% by domicile (in both cases only at the national level). Lastly, only 4% of the indicators are disaggregated by race. Despite being a central element to the observation of existing inequalities, the income groups do not appear in the indicators available.

Conclusions
The SDG reflects a significantly wider and deeper Agenda than that established in the MDG, increasing the complexity of the implementation challenges of the indicators in monitoring and assessing its goals. The different proposals and approaches presented in the present document allow identifying part of the debate about the health dimension in the 2030 Agenda and the dispute relative to its determinants, and provide alternatives for international comparison and evaluation of health conditions in a context of scarcity of data.
The monitoring and evaluation of health in Brazil demands overcoming limitations imposed by the available databases, especially in the level of disaggregation of information, fundamental for fulfilling the central objective of the 2030 Agenda of "not leaving anyone behind". For this purpose, the disaggregation of data at subnational levels (FSs and Municipalities) and also by gender, degree of individuals' socioeconomic vulnerability, and other dimensions that may impact the offer of health services and/or the mortality and morbidity by disease or injury, is indispensable. Although the main Brazilian platform shows some out-of-date indicators compared to its own databases and other national official sources, it is important to note that it is the Brazilian government's official initiative, coordinated by IBGE that holds the national custody for publicizing official indicators. Due to the work of excellence of IBGE and other data-producing agencies, Brazil has maturity comparable to that of developed countries in producing statistical data, which affords the country a leadership role in the methodological advance of indicators for the Agenda.
Some important considerations to the study emerge in this context. Firstly, it is fundamental that the definitions relative to indicators implemented in ODS Brasil be accelerated, especially those that have been long used in Brazilian studies and based on official sources of data. There is, in fact, a wide set of official information systems with compatible or similar data produced by agencies or national bodies that could significantly broaden the 21 indicators currently available by ODS Brasil and, more than that, reach Brazilian municipalities and more vulnerable populations. For example, we can cite the data systems of the Ministry of Health (MS), National Health Surveillance Agency (ANVISA), Ministry of Citizenship (MC), National Treasury Secretariat and Special Secretariat of Welfare, both from the Ministry of Economy (ME), National Water Agency (ANA), Applied Economic Research Institute (IPEA), and the very IBGE.
Beyond the greater data disaggregation, a series of other aspects are to be developed in the evaluation platforms of the health-related SDG for Brazil. It's necessary to integrate goals for a systemic analysis of the causes and impact of achieving health goals beyond other goals. Dedicating subnational methodologies for performance evaluation and projection of achievement of goals, disaggregated by public, is also needed so that public policies may be oriented to the reduction of inequalities. In this way, the platforms could dedicate themselves, beyond the evolutionary comparison or between units, to the production of information about the size of the effort today necessary for closing the existing gap.
Finally, it is fundamental that public administration and Brazilian academia propose to know and use the platforms and alternatives proposed by these institutional arrangements, not only for monitoring the 2030 Agenda, but also for planning and operating health policies in their broadest sense. Both WHO, at the global level, and PAHO, at the regional level, proposed to do this important exercise when revising their annual publications about the populations' health status in the post-2015. The evaluation of health in Brazil from the 2030 Agenda official metrics would bring comparability with the other countries of the region and of the world, providing important evidence to improve public policies.