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Keeping the value of the MDGs and addressing their shortcomings – the challenge post-2015 in health
Dr Kumanan Rasanathan (@rasanathan) is a public health physician who works in the Health Section at UNICEF in New York, where he is UNICEF’s focal point for post-2015 health. This blog represents his personal views and does not necessarily reflect the views of UNICEF.
While keeping in mind that the vast majority of the world probably still doesn’t know about the Millennium Development Goals (MDGs), among those who do, there is robust debate about their strengths and weaknesses and a high level of interest in what might succeed them, ‘post-2015’. Sweden, Botswana, WHO and UNICEF recently ran a post-2015 health consultation and whilst there was no shortage of views on what the MDGs had meant for health, a few key messages, if not a consensus, can be identified.
First, health is fundamental to the MDGs, with three specific health goals and several health-related targets among the other goals. There is a proud belief within the global health community that health has been particularly transformed by the MDGs - and vice versa.
Second, the health MDGs have mattered – in increasing political interest in global health, serving as a rallying point for civil society (particularly through the ability to compare progress globally), increasing the resources for development assistance for health, and contributing to dramatic progress in the specific health outcome targets. For example, under-5 mortality fell by 3.2% per year between 2000-2011, compared to only 1.8% per year from 1990-2000. It is difficult to conclusively claim attribution of these contributions to the MDGs; nevertheless, there is a weight of circumstantial evidence for positive impact.
Third, a number of failings have been identified of the MDGs, but for health, the crucial ones are that they have major omissions (such as noncommunicable diseases (NCDs)) and have failed to address equity and health as a human right (even contributing to increasing inequities within countries). Furthermore, it’s argued they’ve led to fragmented approaches to health goals and their relationship to development more broadly.
What do these lessons mean for the construction of the post-2015 agenda? Given it is unlikely that the world will meet all the MDG targets, a first step is to sustain work to achieve unrealised targets as soon as possible, with the next step being to ensure that the post-2015 agenda remedies their shortcomings.
The final report of the health consultation we ran was formally submitted to the High-level Panel (HLP) as an input to their report. In response to the HLP’s report, there has been dissent from some parts of the global health community about whether the HLP’s views on health sufficiently addressed the MDGs’ failings and, moreover, whether they represented sufficient ambition to address health challenges post-2015. Others have questioned whether the report reflected the vision of the health consultation.
Overall, I think the HLP has put forward an ambitious and coherent agenda that balances the different sectoral interests quite well. In particular, the calls to eradicate extreme poverty (despite quibbles over the threshold), move to a universal agenda, prioritise equity through disaggregating targets, emphasise governance, and improve monitoring through a ‘data revolution’ provide a substantial platform that builds significantly on the MDGs.
On health, considering the limitations of the HLP report should make us reflect on our own weaknesses as a health community. There is insufficient discussion in the HLP report about the links between health and other aspects of development (the ‘social determinants of health’), including both the role of health as a contributor to and an indicator of sustainable development. In particular, the strong links between addressing NCDs and sustainable development, with need for preventive action across all sectors, are underappreciated. In terms of the ‘illustrative goals and targets’ (noting these are included only as an Annex), the health goal and targets do seem slightly ‘MDG+’, with sound targets building on the health MDGs (including targets under goals for nutrition, sanitation and reducing violence) and the inclusion of NCDs in passing, but no targets for delivery of health services other than immunization. Our consultation proposed a single health goal (with similar wording to the HLP goal) with sets of targets for advancing on the MDGs, NCDs and universal health coverage (UHC).
But these deficiencies align to issues on which inputs to the health consultation were also relatively weak, particularly in terms of specific interventions and indicators. There are no widely agreed upon UHC targets that the HLP could have picked up to include unlike, say, for ending preventable child mortality. The HLP Report does emphasize UHC in the narrative, so those involved in developing UHC targets would be wise to present them as soon as possible. There is also an urgent need for credible targets relating to NCD risks, disability, injuries, mental health and adolescents if their omission in the debate so far is to be rectified.
The post-2015 process remains at an early stage. As a health community, we should build on the many excellent proposals the HLP has made, and constructively put forward means to address omissions that we perceive – increasingly doing so in national rather than global debates, because in the end the final decisions will be made by the governments of individual countries. We should consider again what we think a health goal, and its subsidiary targets, should be and ensure they reflect what people really value – foremost outcomes in terms of lives saved and quality of health. Any single health goal will need to be slightly vague to be comprehensive, but this is a reasonable outcome if it avoids excluding key health issues or equating health with only healthcare (which would be a major downside of having UHC as the overarching health goal).
The focus should, instead, be on the health targets selected. As a health community, we should aim to ensure that, at a minimum, the three broad areas identified in the health consultation are covered with ambitious, credible and intelligible targets. The HLP’s omission of UHC targets including financial protection can hopefully be resolved, especially given the strong support for UHC from many governments. Most of all, we need to ensure the final post-2015 agenda sets goals and targets that genuinely encompass the forces that create and destroy health, maintain the value of the MDGs in allowing comparisons of progress and lead to an implementation that increases the ability of people to have better health at all stages of life.