A HUB FOR IDEAS, DEBATE AND RESOURCES ON HOW THE WORLD IS DOING ON INTERNATIONAL DEVELOPMENT GOALS
What’s good for health is good for development. Or is it?
Who have been the winners and losers from the MDG health agenda and how should this inform the post-2015 goals? This blog is the first in a series of contributions on the role of the MDGs in keeping health issues on the global agenda. We will also be publishing a working paper on the importance of tackling Neglected Tropical Diseases to contribute to this debate.
Andrew Rogerson is an ODI Senior Research Associate.
On the surface, the question seems trivial. Good health is both essential for wider development progress, and a key development result in its own right. Most of us buy into this proposition intuitively. Across the world, when people choose their top priorities for the future, staying alive and healthy invariably come near the top of the list.
But when it comes to the health-related Millennium Development Goals (MDGs) – the targets that countries have pledged to reach by 2015 – we need to ask ourselves a different question: has the ‘what’s good for health is good for development’ approach actually advanced development progress? To contribute to debate on this question, I'll explore what is on the MDG health list (and what is not) and then examine how international health and broader development finance may be inter-related.
MDG4 requires a two-thirds reduction in child mortality; MDG5 a three-quarters reduction in maternal mortality, plus universal access to reproductive health; and MDG6 requires a halt to, and the beginnings of a reversal of the incidence of HIV and AIDS, malaria and other major diseases, plus universal access to HIV and AIDS treatment. Other health-related targets include halving hunger (MDG1), achieving universal primary education and eliminating gender gaps (MDG2 and MDG3), while the MDG7 targets water, sanitation, and slum improvement. Taken as a whole, the MDG package is a manifesto for health progress across a wide spectrum. It can even be argued that health itself is the MDGs’ dominant underlying thread.
But the package has gaps, chiefly non-communicable diseases (NCDs) like diabetes, cancer and high blood pressure, or indeed mental illness. These are often related to life-style trends beyond the reach of the health professionals who have to deal with the results. They can also be seen, like climate change, as negative side-effects of material progress.
NCDs already account for the bulk of the disease burden both globally and in every region except Africa. But in Africa, deaths resulting from NCDs are projected to become dominant by 2030. This is, in part, it must be said, because of Africa’s relative success in containing major infectious disease pandemics, which will throw NCDs into sharp relief. This illustrates how the perennial human quest to postpone ill health and death is now shifting to confront new challenges and harder-to-reach groups, as once familiar health problems – the ‘low-hanging fruit ’ of communicable diseases – recede into the background.
A second gap is a more balanced emphasis on morbidity and the chronic loss of productivity related to protracted ill health, especially in adults, as distinct from averting deaths. Apart from the implicit quality-of-life benefits of MDG6 (say, from sustained antiretroviral therapy) and MDG5 (by reducing the long-term burdens of teenage pregnancy), this preoccupation is muted or absent in the current framework. The fact is that malaria and neglected tropical diseases (NTDs) wreak havoc in the working lives of millions of adults who survive the onslaught of such diseases. By under-emphasising productivity, the current MDG package may inadvertently play into the hands of those who see contradictions between ‘social welfare’ and ‘growth’ agendas.
It is almost impossible to credit the existence of any health MDG, or the entire MDG package, with improvements in health outcomes, given the complex chains of attribution involved. For example, safe motherhood, as shown by recent research in Nepal for Development Progress, is as much about improvements in communications and livelihoods, as well as increases in girls’ education and smaller family size, as it is about sustained efforts to improve access to skilled birth attendance.
There is no way to tell whether and how the mere existence of the health MDGs has prompted, shifted or accelerated specific national priorities. From interviews with national stakeholders in settings like Nepal, however, we know that the health-related MDGs were important political rallying-points for local demands in many instances.
We also know about the trends of international health assistance (what the Institute for Health Metrics calls 'development assistance for health', DAH), especially through the ‘golden age’ of aid (roughly 2004 to 2010). This age saw the fastest rise in DAH ever, until it plateaued early in this decade. It also saw the creation and expansion of new health funds and health-related foundations, such as the Global Fund, the GAVI Alliance, PEPFAR and the Bill & Melinda Gates Foundation. The share of health aid in total aid also increased, and sharply so for the largest bilateral actors such as the UK and the US.
But there is no direct evidence that this ‘health boom’ crowded out other aid, as it coincided with an even larger increase in aid overall. In fact, it seems that health aid actually bolstered public support for development aid overall. The argument is that compelling evidence from concrete health interventions, such as immunisation, anti-malarial bed nets, or de-worming to enable school attendance, persuades the public that ‘smart’ aid can work. Such interventions are not just effective, they are often excellent value for money, and this cost-effectiveness lens becomes crucial as austerity bites.
What does all this mean for the future? First, the job of health in ‘bolstering the case’ for development is far from over, and needs to be reiterated forcefully in the development framework that succeeds the MDGs. Second, that case will call for even more links with wider areas of progress, including tackling NCDs and emphasising positive health-growth effects, as argued here.
And finally, we need greater flexibility and creativity in the health arena, and especially in balancing support for entire health systems and for the fight against specific diseases during an age of austerity, as any easy choices – if they ever existed – disappear.