International Development CommitteeWritten evidence submitted by Health Poverty Action

Health Poverty Action

1. Health Poverty Action (www.healthpovertyaction.org) has a vision of a world in which the poorest and most marginalised enjoy their right to health. The organisation was first formed in 1984 and today employs around 500 staff worldwide. We work in partnership with poor and marginalised communities in 13 countries across Africa, Asia and Latin America as well as campaigning for change at the international level.

2. Health Poverty Action’s role is to strengthen poor and marginalised people in their struggle for health. We have a distinct approach, summarised as a combination of three factors: 1) We emphasise the need for justice rather than charity. We work to tackle not just the symptoms of poor health, but its root causes. In particular, we recognise the importance of the social and economic determinants of health. 2) We prioritise those missed out by others. They may be living in hard to reach areas, or difficult to support for some other reason. 3) We specialise in providing a holistic approach. This is especially important for the poorest and most marginalised with little support. Tackling numerous threats to health together can bring lasting improvements—and also give rise to creative linkages and innovations.

3. Health Poverty Action is a member of both the Action for Global Health (AfGH) UK Network and the Beyond 2015 UK coalition and has also contributed to these alliances’ submissions.

Introduction

4. Health Poverty Action welcomes the opportunity to provide input into the International Development Committee’s (IDC) inquiry on the post-2015 development goals. The rapidly growing debate regarding the objectives, scope and monitoring of a new framework for development offers a watershed moment to harness progress on the Millennium Development Goals (MDGs) as well as address the shortcomings of the previous framework.

5. The backdrop to the creation of a new development framework is completely different to that of the MDGs. An era of economic boom and political optimism has given way to much more uncertain times, with recent economic and financial crises and “austerity” policies in many historically resource-rich countries. While this carries the risk that a less ambitious set of narrowly-defined development goals will be agreed, there is also a potential opportunity in the current context. The new framework should take account of the concept of Sustainable Development, and policy debates about replacing income measures of development with broader understandings of human wellbeing. The human development index1 and recent ideas such as the Happy Planet Index2 could provide some references for this. Such an overarching approach, accompanied by more specific targets, could help prevent some of the negative consequences of the narrow, target-based approach of the MDGs thus far.

Lessons learned from the adoption of the International Development Targets and the Millennium Development Goals: in particular how effective has the MDG process been to date.

6. As the UN System Task Team on the Post-2015 UN Development Agenda notes in its Thematic Think Piece on Health “the way goals are defined inevitably influences how the world understands development and the ways in which it can be advanced. Goals are thus interventions in their own right, shaping the meaning of development and influencing resource transfers within and between nations and institutions”.3 This reflects that many of the problems associated with the MDGs lie within their design and that we now have the opportunity to learn from those shortcomings for the new framework for development.

7. The Millennium Development Goals have provided huge momentum to address some of the most pressing challenges created by poverty and inequity. Attention was focussed on the plight of the poorest, more financial resources were raised and clear targets set for governments to work towards. Significant improvements have also been made to people’s lives, in particular regarding income poverty and access to water.

8. However, while the target-based approach of the MDGs has ensured a clear focus on outcomes and is partly responsible for the achievements made, it has also created many problems. In health, the selectivity of the targets on specific disease areas has exacerbated the non-integration, inefficiency and unsustainability of vertical interventions. In particular the necessary foundation of strong health systems has been neglected at the expense of a limited number of health issues with their own Goals. Achieving further progress on health requires the strengthening of health systems: provision of comprehensive primary care, addressing the huge health worker shortages, tackling weak data systems, drug shortages, and inadequate funding.4

9. Overall some key areas where progress has been limited or indeed hampered during the 12 years of the MDGs’ implementation so far, and which must be addressed in any future development framework include:

The MDGs have been widely criticised for neglecting equity.

There are several issues, including those affecting the elderly, disability, chronic diseases and mental health, which have been neglected because they are not the focus of specific Goals.

The specific nature of the Goals has led to a verticalisation of efforts, particularly in health, which runs counter to the need for a comprehensive, holistic approach.

The root causes of poverty and inequality have been overshadowed by the focus on particular outcomes. The limited attempt to address underlying causes, through MDG 8, has suffered from vague indicators, compared to clearly defined targets and indicators under most of the other MDGs. Issues such as unfavourable terms of trade, international debt, and the consequences of policies such as the “war on drugs” have been sidelined.

The coverage of future goals: should they be for developing countries only or should progress be monitored in all countries?

10. There are two key ways in which future goals are applicable to us all.

(a)The first is the universality of human rights. We all have human rights, including the right to health, and we all share a responsibility to seek the realisation of these rights. A rights-based approach enshrined in any future set of goals would underline the importance of citizens from every country being able to hold their governments to account for their fulfilment, and would highlight the importance of participation and non-discrimination.

(b)Secondly, future goals need to recognise the interconnected nature of our world. Policy and practice in resource-rich countries, and at the global level, have an impact on the lives, health and wellbeing of the poor. Examples include the effect of intellectual property aspects of free trade agreements on access to affordable generic medicines; the loss of potential funds for health and other public services in developing countries from corporate transfer mispricing and tax evasion; and the effects of commodity speculation in the financial markets on food prices, and thus hunger and nutrition. Goals that set out to tackle these global structural issues must be more specific, measureable and achievable than the rather vague assertions in the current MDG 8 on creating a global partnership for development.

The process: are the right voices being heard? What are the opportunities for and constraints to global consensus?

11. It is essential that Southern voices lead the process for the creation of a new global development framework. Specifically, there should be efforts to take account of the perspectives of marginalised groups. There is a huge “democratic deficit” in the involvement of groups such as indigenous peoples and cultural minorities in political processes at all levels. Marginalised communities must have the opportunity and confidence to articulate their own concerns and priorities to governments and within processes that seek to engage civil society in this process.

Targets: was the MDG “target-based” approach a success? Should it be retained? How should progress be measured?

12. The MDGs’ focus on aggregate, numerical targets for reducing poverty has been a major failing because it has led to a concentration on reaching the largest numbers of people, and therefore often the easiest to reach, such as large urban populations or mainstream groups. This carries the danger of actually reducing resources for the most marginalised, as resources are diverted towards meeting these aggregate targets in the easiest way.

13. Indigenous people or those from other cultural minorities are one example of populations frequently marginalised from the political and economic processes of their own countries, and experiencing worse poverty and health outcomes both nationally and globally. But because of the focus of the MDGs on overall targets, rather than on equity and reaching the most vulnerable, there has not been a concerted effort to improve the health and lives of these people. The focus on aggregate figures means that the most marginalised groups are not only neglected in terms of resources, but also in terms of monitoring and analysis. In fact there is extremely limited information on how much their lives have been affected by the development efforts of the last decade.

14. Future goals must focus on equity and on the most poor and marginalised. In particular, progress should be measured not just at the aggregate, national level, but data needs to be disaggregated by various factors including income, gender and ethnicity, to make inequities visible and allow better targeting of vulnerable groups.

Financing global goals: are new mechanisms needed?

15. While it is important to emphasise the continuing need for aid, and for resource-rich countries to meet their commitment to spend 0.7% GNI on aid, in the longer term there must be much more emphasis on building the capacity of developing countries to raise domestic revenues to fulfil the rights of their citizens. This must focus on strengthening governments’ tax collecting capacity; tackling the current flow of capital out of developing countries, in the form of debt repayments, tax evasion, transfer mispricing and corruption; and renewed efforts to adopt more progressive, redistributive forms of innovative finance, such as a global or regional Financial Transactions Tax. There need to be specific, focused goals addressing the structural economic factors, such as corporate tax evasion and unfair trade rules. Changes in these areas could free up far more resources for tackling poverty and inequality sustainably than overseas aid can ever achieve.

The content of future goals: what would be a good set of global goals? What continuity should there be with the MDGs, and how should the unfulfilled MDGs be taken forward?

16. We believe that any future development framework must adhere to the three principles outlined in “Realizing the Future We Want for All”: human rights, equality and sustainability.5 Human rights principles endeavour to achieve such important goals as equality and non-discrimination as well as rights to health, economic wellbeing or civil and political participation. This is to be undergirded by accountability, empowerment and the rule of law. The principles of equality and equity need to be embedded in the new development framework as central themes. This is especially important because the current MDGs have often hidden inequalities and pockets of extreme poverty, due to the nature of their reach and reporting mechanisms. Reducing inequalities between women and men, different ethnic groups, people of different ages, sexual orientation or physical and mental ability and in economic terms, promises to enhance the wellbeing of societies and individuals. These principles also resonate with the international community’s commitment to sustainable development which is comprised of the three dimensions of economic development, care for the environment and social wellbeing.

17. The right of everyone to enjoy the highest attainable standard of health can only be realised when the conditions in which people are born, grow, live, work and age; that is the social, political and economic determinants of health, are addressed. This requires addressing the causes of ill health through a wide range of policies, such as those on food, water and sanitation, environmental policies or women’s empowerment. It also points to the need for transformation of those economic and political structures which sustain poverty and discrimination, for example the social status of women, racism or land tenure and access to natural resources. So a new development framework should approach health as a cross-cutting issue, that shapes and it shaped by all policies.

18. At the same time, there should be a specific goal relating to health and wellbeing. One suggestion is that an overall goal could aim to reduce the number of years lost due to ill-health, disability or early death (disability-adjusted life years, or DALYs). This could be connected to a range of goals addressing the broad range of factors that affect mortality and morbidity. One of these should be specifically for universal health coverage. While we have noted that health and wellbeing goes much further than providing health services, nevertheless the provision of and access to these services is a vital component of achieving the right to health for all. Universal health coverage, ie access to an essential package of quality health services without the risk of financial hardship associated with paying for healthcare, remains elusive to many. A goal of universal health coverage should focus on providing access to marginalised groups and measuring this through the disaggregation of data.

Recommendations

19. In summary, Health Poverty Action recommends that:

The new framework should have an overarching holistic aim of improving human wellbeing, which could help mitigate against an overly narrow, target-driven approach.

The MDGs must address equity and in particular measuring progress must be disaggregated by factors such as income, gender and ethnicity.

Health should be seen as a cross-cutting issue across a range of policy issues which are determinants of health. A specific goal on health could include universal health coverage, but at the top level could focus on a broad measure of health and wellbeing such as disability-adjusted life years.

Neglected issues, including those affecting the elderly, disability, chronic diseases and mental health, must be given more attention.

The root causes of poverty and inequality must be brought to the fore and specific efforts taken to address them.

October 2012