Health in the post-2015 development agenda

While the UN is trying to develop a framework of global goals for sustainable development for the years following 2015, neoliberal economic policies currently being implemented are leading to widening inequalities and ecological destabilisation. In working to achieve the goal of Health for All, it is imperative, says David Legge, to address the root causes of the global health crisis, including the global economic and political architecture, as the starting point for designing the post-2015 development agenda.

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IN the airless world of global health policy the role of 'health' in the post-2015 development agenda is a hot topic. Local community activists might be forgiven for seeing this gaggle of reports and consultations1 as just the latest exercise in Orwellian doublespeak. However, behind the shadow play the structures and dynamics of global power can be discerned and openings for substantive engagement identified. Real questions are at stake which will affect the prospects for development and ecological sustainability. However, reading past the ritual and the rhetoric requires close attention to the politics of the debates as well as the arguments presented. 

At the Millennium Summit in September 2000 a set of eight global Millennium Development Goals (MDGs) were adopted by the UN (UN Millennium Declaration, UN General Assembly, 2000), with 20 targets and corresponding indicators. Several of these goals dealt with major health issues: maternal health, infant mortality, sanitation and water supply, and access to preventive programmes and treatment for AIDS, malaria and other diseases.

Over the next decade there was a dramatic increase in the flow of 'development assistance for health' (Ravishankar et al., 2009) which has been widely welcomed, in particular, by the affected populations, by the government beneficiaries and by the institutions which have been involved in the disbursement of these funds. 

The MDGs set 2015 as the year when the various targets were to be achieved (they will not be; see United Nations, 2013). In the years leading to this deadline, there has been increasingly hectic technical and diplomatic activity around what might follow the MDGs. There are two separate processes currently underway focused on the 'post-2015 development agenda' (initiated by the UN Secretary-General and working through the UN agencies) and the 'sustainable development goals' (SDGs) (initiated in the context of the Rio+20 process). There is still no clarity about exactly whether and how these processes are going to be merged.

The flurry of manoeuvring in official global health circles has been particularly urgent because of the fear that the huge increases in funding flows that were associated with the MDGs might move away from 'health'. The global health establishment has campaigned around two broad themes: firstly, 'universal health coverage' (UHC) and secondly, continued funding of the various health programmes developed under the MDGs. (Behind the slogan of UHC are deep contradictions about what kind of 'health coverage' is to be universalised. We shall return to this below.)

MDG myth

However, before considering the current debates around health post 2015, it is useful to draw some lessons from the MDGs experience. We shall do so through an examination of the central contradiction and the central myth of the MDGs and the hypocrisy involving the use and misuse of the term 'development'.

The central contradiction of the MDGs is that while the Millennium Declaration contains some admirable, even inspiring, language, the goals that were adopted were largely about North-South charity: mobilising funds from the rich world to assist poorer countries to ameliorate the nutrition, health, education, infrastructure and environmental burdens they were facing. It is not plausible that international charity is the most appropriate pathway to the goals of human development, social development and sustainable development. But if the MDGs were not designed to achieve 'development', what were they designed to achieve? 

The central myth of the MDGs was that the dramatic increases in charitable funding which flowed after September 2000 were due to the intrinsic persuasive power of the Millennium Declaration and its goals. It has been widely assumed, at least in the official rhetoric, that the adoption of the MDGs somehow propelled this increased flow of funding. However, two of the major sources of new funding were the Gates Foundation and the US President's Emergency Fund for AIDS Relief (PEPFAR). It is hardly plausible that the adoption in the UN of a set of 'development goals' would somehow be sufficient to motivate Bill Gates and George W Bush to redirect billions of dollars to the treatment of AIDS and tuberculosis and control of malaria. But if the expansion in 'development assistance' funding was not driven by the inspirational power of the MDGs, what was it driven by?

The key to answering both questions lies in the idea of 'legitimation': the increases in charitable funding transfers would serve to reaffirm the 'legitimacy' of the contemporary regime of neoliberal globalisation against the threat of 'delegitimation' which was increasingly salient in the late 1990s. Three events epitomise the concern of the global elites at this time. The first of these was the global backlash against the pharmaceutical companies (and their US backers) which sought to prevent South Africa from utilising 'parallel importation' to procure drugs for HIV/AIDS at market prices in other countries at a time when the originator companies were charging prices in South Africa which effectively denied access to treatment for the bulk of infected people in the country. The Treatment Access Campaign in South Africa (1997-2001) started out as a local movement but attracted global support. The second event was the formation of the Global Compact (between big business and the UN) in June 1999, 'giving a human face to the global market'. Finally, the collapse of the World Trade Organisation Ministerial Conference in Seattle in 1999 (the 'battle of Seattle') reflected the growing awareness of many different constituencies of the risks associated with the 'free trade' agenda.

Palliative economics

However, while the mobilisation of funds may have reflected legitimation pressure, politicians and officials in many low- and middle-income governments took the MDGs very seriously and worked hard to demonstrate that the 'development assistance' they attracted was achieving its promised purposes. Likewise the international NGOs (which mediated much of the funding) and the practitioners and activists on the ground (who put the programmes into action) were also inspired by the possibilities of increased funding to address the crises with which they were confronted.

Nonetheless, the relation between the increased funding and the fundamental challenges of development is highly problematic. Paragraph 5 of the Millennium Declaration declares:

'We believe that the central challenge we face today is to ensure that globalisation becomes a positive force for all the world's people. For while globalisation offers great opportunities, at present its benefits are very unevenly shared, while its costs are unevenly distributed. We recognise that developing countries and countries with economies in transition face special difficulties in responding to this central challenge. Thus, only through broad and sustained efforts to create a shared future, based upon our common humanity in all its diversity, can globalisation be made fully inclusive and equitable. These efforts must include policies and measures, at the global level, which correspond to the needs of developing countries and economies in transition and are formulated and implemented with their effective participation.'

In contrast, the goals and targets which were adopted were overwhelmingly about charity and amelioration. The appalling maternal and child health challenges in Africa and South Asia were to be addressed through 'development assistance'. The treatment and prevention of HIV/AIDS and malaria were to be achieved through 'development assistance'. Funding of sanitation and clean water was to be boosted through 'development assistance', and the new 'partnership for development' (MDG8) envisaged new and improved structures for the mobilisation and delivery of 'development assistance'. Erik Reinert (2006) has described this as palliative economics, 'alleviating the symptoms of poverty, rather than attacking its real causes'.

It is not to diminish the commitment and hard work of the politicians, administrators, practitioners and activists to ask: if the 'central challenge' was inequitable, unstable and unsustainable globalisation, what was the relationship between the MDGs with their associated funding flows and the central challenge of moving towards a fully inclusive and equitable globalisation?

This question points towards a structured hypocrisy on the part of the governments of the rich countries, in particular, the US and European Union. During the 14 years to date of the MDGs, the US and Europe have developed and implemented policies in the fields of trade, investment and finance designed to shore up the regime of globalisation which paragraph 5 of the Millennium Declaration identifies as the 'central challenge'. A raft of policies have been introduced which have exacerbated the inequities, instabilities and catastrophic environmental impacts of contemporary globalisation, even while diverting a relatively small portion of the rents received to 'development assistance'.

In the field of trade, the US and the EU are pushing a new generation of trade agreements (actually economic integration agreements) which are designed to increase the rents flowing to corporations from intellectual property rights [notwithstanding increasing price barriers to accessing pharmaceuticals and industrial (including green) technology]; are designed to prevent the use of cost-effectiveness criteria in pricing of pharmaceuticals for public procurement or subsidy; and give new powers to transnational corporations to challenge national policies (e.g., tobacco control or food labelling) which might impact on corporate profits.

In the field of finance, the banks have been deregulated and bizarre forms of speculation encouraged but have not been reversed despite the global financial crisis; a complex system of tax avoidance (including tax havens, transfer pricing and false invoicing) has been created; and countries have been pressured to adopt low-tax, small-government regimes in order to be more hospitable to the transnational corporations.

The financial outflows from low- and middle-income countries associated with capital flight, tax evasion through transfer pricing and corrupt invoicing far outweigh the flow of 'development assistance'. However, 'development assistance' gives legitimacy to the governance structures which reproduce such outflows. If such 'development assistance' is not accompanied by structural changes in global finance, trade and investment, the claim to be assisting in 'development' is truly Orwellian.

The post-2015 agenda

The contradictions and myths and the hypocrisy of the rich-world elites in relation to the MDGs provide important warnings regarding the treatment of health in the post-2015 development agenda.

Among health officials it is widely repeated that the MDGs 'brought massive new funding into health' and there is fear that the post-2015 sustainable development goals might bypass 'health'. ('Health' in this context refers to institutions and programmes rather than population health outcomes.) A recent report by the World Health Organisation (WHO) secretariat (January 2014) stated that 'the prime concern for WHO at this stage is to support an approach that allows a wide variety of interests within the health sector to be accommodated as part of a single framework. This strategy reduces competition between different health conditions, different health interventions and different population groups' (WHO document EB134/18, paragraph 28).

There is a strong lobby within WHO for adopting 'universal health coverage' for this purpose. 'The narrative on goals that is emerging is inclusive, based on maximising health at all ages with universal health coverage either as a means and/or as an end itself' (EB134/18, paragraph 27). UHC has also been adopted as the leading theme in relation to health in the SDG process (WHO, 2013).

UHC as a slogan is relevant to many countries, particularly low- and middle-income countries, where large sections of the population face cost barriers to treatment and the risk of disease-induced poverty. It is also relevant to the donors who have hitherto preferred to support vertical disease-focused programmes widely criticised for fragmenting health systems, overburdening administrators and encouraging internal brain drain. For the big vertical donors to show that they are worrying about UHC could be presented as their responding to these criticisms. 

The meaning of UHC is open to various interpretations although the core idea is to overcome financial barriers to accessing health care and to prevent disease-induced poverty. However, among the 'interests' to be accommodated under this slogan there are some very wide differences of interpretation, ranging from primary health care (PHC) advocates to the World Bank. PHC advocates would generally argue for single-payer systems with a predominant role for the public sector and an emphasis on the principles of primary health care as elaborated at the Alma-Ata Conference in 1978. The World Bank, on the other hand, has traditionally argued for multipayer systems ('competitive insurance markets'), stratified levels of health cover (at the bottom of which is a very limited safety net) and a dominant role for the private sector. From the World Bank perspective the goal of UHC would be met if everybody had some level of financial assistance in accessing health care, even if it were a very restrictive health benefits package and was mediated through a competitive health insurance market.

The lobbying for UHC through WHO remains tied to 'development assistance' although arguing for less rigidity in vertical disease programmes and wider support from donors for health system development.

Building better health systems is certainly part of development. However, there are limits to the extent to which health systems can promote healthy populations, as opposed to providing preventive, diagnostic and therapeutic services to individuals. Health is created before and beyond the health system; it is created in the social conditions in which we grow, live, learn, work and play (Commission on Social Determinants of Health, 2008). The primary health care model recognised the social determination of health and argued for health care practitioners to work with their communities to recognise, consider and take action around the social determinants of health. This transformative dynamic of PHC is now pass‚ within WHO, as is concern for the social determination of health, in both cases because of WHO's financial crisis. WHO is so dependent on its donors that it cannot afford to challenge their ideological and policy assumptions. 

However, real progress in population health will depend on a rigorous and robust analysis of the links between health and development. This will involve:

    relating population health challenges to the wider economic and political environment and the economic, institutional and cultural dimensions of development;

    developing an explicit analysis of the dynamics of the global economy which promote widening inequality and the unsustainable use of the earth's resources and capacities; and

    undertaking an explicit analysis of the regulatory settings, power relations and decision loci through which the global economy is regulated and through which it can be transformed.

While the UN is trying to develop a framework of global goals for sustainable development for the years following 2015, neoliberal economic policies currently being implemented are leading to widening inequalities and ecological destabilisation. Provisions being included in trade agreements to further extend patent durations are going to maintain high prices for medicines; the 'free trade' agreements now being debated are going to protect the interests of transnational corporations at the cost of reducing the regulatory and policy space of sovereign governments. New economic relations and new forms of regulation are therefore critical prerequisites for addressing the challenges of today and the post-2015 era.

WHO appears to be locked into irrelevance through its dependence on donors, its preoccupation with institutions and interest groups rather than health outcomes, and its inability to relate health in any rigorous sense to sustainable development.

Clearly, improving the health of the world population will depend on achieving important goals in other sectors, and intersectoral competition (to ensure that 'the position of health is . well established') does not facilitate cooperation to this end. The final result risks a framework with different goals and indicators reflecting different pressures instead of one coherent set of demands coming out of a deep analysis.

The People's Health Movement urges WHO member states to address the root causes of the global health crisis, including the global economic and political architecture, as the starting point for designing the post-2015 development agenda and to return to a comprehensive primary health care approach as a major strategy to harness the resources of the health system in working to achieve Health for All.                                  

David Legge is co-chair of the global steering committee of the People's Health Movement. PHM is a global network of community organisations working for Health for All in various sectors, on different issues and at all levels. More about PHM at www.phmovement.org.

Endnote

1.    See UN General Assembly resolution 66/288 'The future we want' (July 2012) at: http://daccess-dds-ny.un.org/doc/UNDOC/GEN/N11/476/10/PDF/N1147610.pdf?OpenElement; the report of the UN system task team (2012) at: http://www.un.org/millenniumgoals/pdf/Post_2015_UNTTreport.pdf; the report of the high-level panel of eminent persons (2013) at http://www.un.org/sg/management/pdf/HLP_P2015_Report.pdf; the thematic consultation on health at http://www.worldwewant2015.org/health and the report of the thematic consultation on health at http://www.worldwewant2015.org/file/337378/download/366802; the UN Secretary-General's Action Agenda (June 2013) at http://unsdsn.org/files/2013/11/An-Action-Agenda-for-Sustainable-Development.pdf; and the outcome document from the Special Event on progress towards the MDGs in New York in September 2013 at http://www.un.org/millenniumgoals/pdf/Outcome%20documentMDG.pdf.

References

Commission on Social Determinants of Health. 2008. Closing the gap in a generation: health equity through action on the social determinants of health, Geneva, WHO.

Ravishankar, N., Gubbins, P., Cooley, R.J., Leach-Kemon, K., Michaud, C.M., Jamison, D.T. & Murray, C.J.L. 2009. Financing of global health: tracking development assistance for health from 1990 to 2007. The Lancet, 373, 2113-24.

Reinert, E.S. 2006. Development and Social Goals: Balancing Aid and Development to Prevent 'Welfare Colonialism', New York. Available: http://www.un.org/esa/desa/papers/2006/wp14_2006.pdf [Accessed 26 April 2014].

UN General Assembly. 2000. United Nations Millennium Declaration, New York. Available: http://www.un.org/millennium/declaration/ares552e.htm [Accessed 23 April 2014].

United Nations. 2013. The Millennium Development Goals Report, 2013, New York. Available: http://www.un.org/millenniumgoals/pdf report-2013/mdg-report-2013-english.pdf.

WHO. 2013. Monitoring the achievement of the health-related Millennium Development Goals: Health in the post-2015 United Nations development agenda, Geneva. Available: http://apps.who.int/gb/ebwha/pdf_files/EB134/B134_18-en.pdf [Accessed 26 April 2014].

*Third World Resurgence No. 283/284, Mar/Apr 2014, pp 45-48