International Development CommitteeWritten evidence submitted by Action for Global Health UK

Background

1. Action for Global Health (AfGH) was established in October 2006, bringing together fifteen non-governmental organisations (NGOs) based in France, Germany, Italy, Spain, the Netherlands and the United Kingdom—with a coordinating office in Brussels. It aims to monitor how the actions and policies of European governments affect health in developing countries and to influence decision-makers to improve their practice and support developing countries to achieve the health Millennium Development Goals (MDGs).

2. In the UK, AfGH is coordinated by the International HIV/AIDS Alliance and Interact Worldwide. Since 2007 these organisations have been working with other UK-based development and health NGOs and professional associations to share information and undertake joint advocacy under the auspices of the AfGH UK network.

3. We welcome the opportunity to contribute to this International Development Select Committee (IDC) inquiry on the global development framework to follow-on from the MDGs. This submission has been coordinated by the core members of AfGH in the UK—Interact Worldwide and the International HIV/AIDS Alliance—with contributions from other members of the AfGH UK network. It provides input specifically on health, building on the broader inputs of the Beyond 2015 UK campaign, in which AfGH is playing a strong role. This submission represents the shared views of the organisations listed at the end.

Chapter 1: Effectiveness of the MDGs

4. The MDGs have contributed to greater global awareness of health-related poverty inequalities and their consequences. They have been at the heart of key improvements in health outcomes globally and a considerable increase in financial resources committed to global health.

5. While not all success can be attributed to the MDGs, progress on health in the last decade includes.1

Child deaths declining.

Access to treatment for people living with HIV increasing in all regions.

The world is on track towards reversing the spread of tuberculosis.

Global malaria deaths declining.

6. The MDGs have also led to the development of global health funding mechanisms, such as the Global Fund to Fight AIDS, Tuberculosis & Malaria (GFATM), the GAVI Alliance, the Global Strategy on Women’s and Children’s Health and UNITAID, which mobilised significant financial resources to address global health problems. Through the support of the UK and other donor governments to the GFATM, its programmes are achieving real and measurable impact. For example, an estimated 8.7 million lives have been saved through Global Fund supported interventions.2

7. The UK has made significant contributions to health systems, aid effectiveness and the health-related MDGs, including through its focus on maternal and neonatal health, malaria and most recently through its commitments to immunisation, neglected tropical diseases, water and sanitation, family planning and addressing undernutrition.

8. At the same time, decreases in maternal mortality are far from the 2015 target.3 There is much to critique in the MDGs, for example as a result of the separate goals much of the subsequent funding has promoted vertical interventions rather than cross-sectoral coordination. They are also not grounded in a rights-based approach to development and they have failed to address inequality. Progress towards meeting the MDGs has been uneven between and within countries, within different population groups as well as between the different targets.

9. Inequalities have been masked by a focus on global and aggregate figures. Realising the rights of the poorest and most marginalised in the next global development framework will require a renewed focus on the groups, regions and targets that have fallen most behind in development efforts related to the MDGs.

10. The MDGs are unlikely to be met in fragile states, where factors such as poor governance, poverty, lack of funding, failed health systems and policy neglect pose considerable constraints. DFID calculates that while they are home to only 14% of the world’s population, fragile states contain a third of the world’s poor, a third of the world’s maternal and under-5 mortality cases and a third of those living with HIV/AIDS in developing countries. If the MDGs are ever to be met at a global level, fragile states must be engaged and supported to draw them out of their cycle of fragility4.

11. Varied success of the different goals undermines broader progress as many of the targets are interrelated and can only be supported through cross-sectoral action and a holistic approach to development. While not all of the differences in progress can be blamed on the structure of the MDGs, some responsibility must be attributed to the “siloed” approach of the goals.

12. The “health” MDGs (4,5,6) are inseparable from each other and interlinked with many of the other targets, including nutrition, gender equality, water and sanitation, economic development and education. For example, access to clean water and sanitation can reduce child deaths from pneumonia and diarrhoea, leading causes of child mortality. AfGH has worked as part of an intersectoral coalition, which includes End Water Poverty and Action Against Hunger, to highlight positive examples of how poverty and disease can be effectively addressed through integrated approaches—bringing together a range of interconnected interventions.5

13. Even within the health-specific MDGs, drawing distinct lines between child survival, maternal health and tackling infectious diseases, rather than recognising the interconnectedness of these health outcomes, has had strong implications. As an example of the interconnectedness of the health-related MDGs, children who lose their mothers after childbirth are up to ten times more likely to die before their second birthday than children whose mothers are alive. And meeting family planning and maternal and newborn health needs simultaneously would reduce maternal deaths by 70–72% and newborn deaths by 44%.6

14. A limited group of health issues each with their own Goals has led to a competition for resources rather than seeking ways to effectively integrate and strengthen health systems as a whole to achieve improved health outcomes rather than disease-specific outputs. This does not mean that action leading to progress made on specific diseases, notably HIV/AIDS and Malaria, should be halted, rather it is critical to ensure integration of specific disease interventions with other health services by building on the foundations of strong health systems and cross-sector coordination.

15. Achieving further progress on health outcomes, and the health-related MDGs, will require the underlying shortfalls of weak health systems to be addressed. This requires urgent action to increase the provision of comprehensive primary care and prevention services, and addressing the weaknesses in health service delivery caused by huge shortages of human resources, drug and therapeutic feeds stock-outs, weak data systems and inadequate funding. At the same time concerted action is needed to ensure joined-up action and policy coherence on the social determinants of health, such as gender inequity, conflict and education.

Chapter 2: Relationship Between SDGs and Post-MDG Processes

16. In order to secure the level of political will necessary to deliver on any ambitious global commitments, it is essential that after the work of both the Open Working Group (SDGs) and that of the High-Level Panel (post-MDGs) are complete, we are left with one cohesive global development framework with strong buy-in from all actors. This is important not only to ensure the success of the framework but also because drawing a line between sustainability and development is an artificial division.7

Chapter 3: Voices Involved in the Process

17. We agree with the Beyond 2015 campaign that the next global development framework should result from a Southern-led process that includes participatory dialogue with those directly affected by poverty and injustice. Only through the meaningful engagement of a broad range of stakeholders, including civil society and local communities, will the next framework be effective and have legitimacy. Specific efforts should be made to support the engagement of vulnerable or marginalised populations8 in this participatory dialogue and to ensure the framework addresses the challenges they face in accessing healthcare and other services. Given that those living in fragile states have benefitted least from the progress that has been made on health, it is particularly important that communities and civil society in fragile states are actively engaged.

18. The global health architecture provides good examples of how to meaningfully involve and empower civil society in governance structures. For example, the International Health Partnership and Related Initiatives’ (IHP+) independent monitoring function has developed internationally agreed indicators for the health sector, adapted from the Paris Declaration on Aid Effectiveness, to monitor and report on progress towards commitments, using an annual survey and scorecard approach. Donors and country partners participating in the process use the scorecards to report annually on their IHP+ commitments. These scorecards are a useful means for civil society to hold governments and donors to account.

Chapter 4: Measuring Progress (Success of Target Approach)

19. Having concrete, measurable and time-bound goals, targets and indicators in the MDGs has helped to measure and galvanise progress. The key question for the MDG targets, those on health or for any of the other Goals, is whether they are really measuring the right thing, capturing the scope of an issue and constructed so that they measure the health outcomes progress. Health outcomes are greatly influenced by behavioural change, socio-cultural barriers and education. Sexual and reproductive health and rights for instance have in the MDGs been treated solely as a health issue rather than also being about behavioural change, education and information, socio-cultural barriers, empowerment and rights.

20. The next global development framework should not only include quantitative targets but rather a mix of quantitative and qualitative measures. This could mean for example that we strive to capture the quality of health services. To address quality requires investment in stronger health data systems, weaknesses of which hamper health progress in many low income countries.

21. Finally, the future framework should ensure strengthened accountability mechanisms that are universal. They should apply to both developing and developed countries as the MDGs provided no means for holding donor countries to account for their impact on MDG achievement. Increased transparency will be critical to strengthening the monitoring and accountability of any future framework.

Chapter 5: Financing Global Goals

22. The next global development framework needs to ensure long-term sustainable funding for development, clearly recognising both national and global responsibilities. The framework should capture a broader view of development cooperation, going beyond aid to include issues of policy coherence for development, and build on the development effectiveness principles as decided in Busan in late 2011.

23. UN figures9 on the health MDGs show an overall financing gap, for the 49 lowest income countries, of US$26 billion per year in 2011 and US$42 billion in 2015. Low and middle-income countries are making progress towards increasing their spending on health, which in Africa means progressing towards the commitment of the Abuja Declaration to spend 15% of the national budget on health. Even with this however, a clear financing gap still exists and until domestic resources, either through taxation or sources of innovative financing, are able to meet the full need donor countries must maintain their commitment to spend 0.7% of their GNI on official development assistance. A forthcoming AfGH report10 on European donor assistance for health has found that the level of Official Development Assistance for health is falling and the gap between global health needs and resources available to address them is increasing.

24. In addition to meeting their aid commitments, donor countries such as the UK should support innovative financing instruments. Mechanisms such as a Financial Transactions Tax (FTT), also known at the Robin Hood Tax, have broad political support in Europe and are ready for implementation. In one year a global FTT on selected products traded by the financial sector, such as equities, bonds, foreign exchange and their derivatives could raise around £216 billion for poverty alleviation. Just £6.2 billion of this could provide free healthcare for 227 million people in the world’s poorest countries.11

Chapter 6: The Content of Future Goals

25. Health goals and progress indicators should be at a minimum equally ambitious as those in the MDGs and they should be supported by clear, time-bound targets that have been agreed upon through a participatory process. Within the framework AfGH would like to see the provision of universal coverage and access to high quality health care services via a rights-based approach. There should be an in-built assumption of sustainability, such that available services or increased human well-being has a demonstrably lasting and predictable impact.

26. It is essential that health be recognised as a right in and of itself as well as a key driver of poverty eradication and economic growth. As was made clear in the outcomes of the Rio +20 United Nations Conference on Sustainable Development health is integral to sustainable development:

We recognize that health is a precondition for, an outcome of, and an indicator of all three dimensions of sustainable development. We understand the goals of sustainable development can only be achieved in the absence of a high prevalence of debilitating communicable and non-communicable diseases, and where populations can reach a state of physical, mental and social well-being. We are convinced that action on the social and environmental determinants of health, both for the poor and the vulnerable and the entire population, is important to create inclusive, equitable, economically productive and healthy societies. We call for the full realization of the right to the enjoyment of the highest attainable standard of physical and mental health.12

27. The UN-led consultation process on the next global development framework provides a unique opportunity to reflect and apply key lessons from the successes and failures of the MDGs. The next framework needs to better recognise the interconnectedness of all the MDG targets and take a holistic approach to development. Success in realising the right to health will only be achieved if health outcomes are pursued in a comprehensive way, recognising their interconnectedness and the social determinants of health. This also enables other health needs, such as non-communicable diseases and mental health, to be addressed. It is also critical to ensure continued attention for priority diseases, which will overwhelm a health system without targeted action, alongside the building of strong health systems with adequate human resources that make long-term progress possible. Furthermore health systems can be overwhelmed by other factors, such as disaster or conflict, and the interconnections between building sustainable resilient health services and security or Disaster Risks Reduction frameworks should be recognised.

28. The starting point for the next development framework should be a rights-based approach with attention to sustainability, equity and accountability. This approach must create a structure that incentivises countries to address the human rights violations impeding the success of various targets and goals. Importantly we cannot undermine progress that has already been made by abandoning the MDGs that were not achieved or leaving behind those who weren’t reached by the more successful MDGs.

29. There are various options emerging for an overarching goal on health in the next development framework. The key for any of these options is to ensure a focus on equity and an integrated approach to achieving better health outcomes. Global health goals should have a focus on the social determinants of health and be based on the principles of universality and measurability. Goals and targets should be the balance of health outcomes and health systems targets.13

30. One of the options put forward, and around which civil society support is building,14 is universal health coverage (UHC). UHC is when all people have access to health services (promotion, prevention, treatments and rehabilitation), without fear of falling into poverty. Health coverage is determined not only by the direct cost of health services to the patient, but the financing mechanism that is used to pay for it, for example user fees can create a barrier to access, whereas progressive public financing from tax income, including specific taxes for health financing, is widely seen as a more progressive model. The availability of health services, the quality of care and predictability of costs that will be incurred also influence health care coverage. As India’s High-Level Expert Group on UHC says, “UHC is linked firmly to the right to health, and it converts this aspirational goal into an entitled provision.”15

31. The World Health Organisation (WHO) has proposed a set of indicators to measure UHC that include those on health service coverage, health outcomes, financial risk protection and selected health system determinants of health service coverage.16

32. It should also be noted that community mobilisation and community systems strengthening17 should be at the core of the sustainable development agenda. The Community Systems Strengthening Framework puts those most affected at the centre of development.

33. As the next development framework takes shape it is essential to recognise the relationship of health with other development sectors and to not see its role limited to a specific health goal(s). This work needs to be embedded firmly in the UN Platform on Social Determinants of Health’s work in order to tackle not only ways to address poor health through vital health services but also the deeper causes of ill health such as poverty. These often coincide with the causes of the lack of access to health care and social protection.

Chapter 7: Looking Ahead

34. We recommend the following:

AfGH would like to see improved health outcomes of the poorest and most marginalised communities globally through the provision of universal coverage and access to high quality health care services. This should be via a rights-based approach with a focus on equity, taking into account the needs of the poorest and most marginalised and on the particular challenges of fragile states, where no MDG has been achieved to date.

Health is a key determinant of economic growth and development, it is imperative that health remains a focus within the post-2015 framework. A health goal that looked at the inter-relationship and cross cutting nature of key health issues would have a significant positive impact on the lives of millions of people dying from infectious, non-communicable and chronic diseases.

Despite improvements in reporting it will be some time after 2015 before the achievement of the existing Goals can be fully assessed. The new framework must ensure continued and substantive progress against the current set of health related goals. Unfulfilled MDGs should be carried forward and integrated appropriately into the new framework.

The framework should consist of clear, concrete and binding goals with measurable indicators, which have been agreed upon through a participatory process. They should be time-bound and universal to gather global support, while being adapted to national and local targets with common indicators for transparency and accountability

The UK government must retain its commitment to 0.7% of GNI for Official Development Assistance.

October 2012