International Development CommitteeWritten evidence submitted by the Malaria Consortium

Introduction

Malaria Consortium is one of the world’s leading organisations dedicated to the comprehensive control of malaria and other communicable diseases in Africa and Southeast Asia. As an international non-governmental organisation, we undertake programmes in prevention, diagnosis, treatment, operational research and health-system strengthening in Nigeria, Uganda, Zambia, Ethiopia, South Sudan, Mozambique, Ghana, Senegal, Thailand, Cambodia and Myanmar/Burma. While malaria control is at the heart of our strategy, we also work on child health including integrated community case management of childhood illness (ICCM), malnutrition and the control of neglected tropical diseases (NTDs).

Malaria Consortium welcomes the opportunity to input into this important inquiry. While health impacts upon all nine areas currently being considered as separate themes by the UN-led consultations on the Post 2015 framework,1 we have focussed our submission on those aspects of the Millennium Development Goals (MDGs) and Post 2015 Development Agenda that relate specifically to health, the area in which our organisation’s expertise is most acute.

Submission

1. 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:

1. Malaria Consortium views the impact of the MDGs over the last 10 years as positive. There are a number of clear lessons to be learned from this process, outlined below:

2. The Millennium Development Goals (MDGs) undoubtedly focussed international attention towards achieving a set of tangible results, backed by the UN system.

3. The goals made donor countries more ambitious in tackling developmental issues and offered a useful mechanism by which they could put pressure on each other to deliver in the specified areas.

4. The selection of certain issues and targets facilitated greater coherence amongst donors.

5. The goals provided southern governments with a focus for their poverty reduction efforts and accelerated the move towards outcome-driven developmental programmes.

6. The MDGs were articulated in a way that the general public, not just those actively engaged in the development sector, could understand, facilitating efforts to mobilise large numbers of people in support of poverty reduction and other development priorities.

7. However, the experience of the MDGs has not been entirely optimal:

8. That the MDGs outlined national level targets meant that some partners tended to focus on “low-hanging fruit” or opportunities that offered the best chance of success, rather than maximum impact on poverty reduction.

9. While Malaria Consortium feels that great progress was made in the areas targeted by the MDGs, inevitably, those issues that were excluded from the process did suffer in terms of attention and funding, with NTDs and mental health two notable examples from the health sector.

10. The manner in which the MDGs look at aggregated results has masked regional and inter-group inequalities.

11. There have been criticisms that the MDGs led to vertical funding for diseases that has been perceived by some as unhelpful. It is Malaria Consortium’s view that vertical funding was a trend already in ascendance prior to the creation of the MDGs and was largely necessary to address major elements of the burden of malaria and the HIV/AIDS epidemic of the 1980s and 1990s, including the high mortality particularly prevalent among children.

12. In response to these lessons, in the Post 2015 framework, the articulation of general, measurable goals should be balanced with the need for context specificity. The goals should be sufficiently flexible to be globally applicable, but nationally and locally adaptable.

2. How should the “Sustainable Development Goals” being established following Rio +20 relate to the development goals being considered by the High-Level Panel?

13. Malaria Consortium feels strongly that these two processes should be unified in order to produce one set of goals. This would draw together the accountability systems and avoid both duplication and the potential for important issues to fall between the remits of the two processes.

14. Conceptually, the two processes ought to be dealt with together. For example, it is essential that debates about nutrition, hunger and food security consider the sustainability of farming.

15. The MDGs successfully created a global brand and reference point. The creation of two separate sets of goals would dilute this characteristic. In fact, bringing the processes together offers the opportunity for the SDGs to be imbued with the energy and global attention that the MDGs effectively harnessed.

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

16. The MDGs should cover the poorest and most vulnerable people, not nation states.

17. The establishment of a global framework for monitoring progress towards development goals would challenge the existing dynamics within the international system and embed the idea that poverty reduction is a shared responsibility.

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

18. The Post 2015 framework must be driven by southern as well as northern voices. Every effort should be made to draw these voices, and particularly those of the poor, into the numerous country consultations being conducted through the UN system. This may even imply the funding of southern civil society organisations to enable participation in this process. In aggregating the consultations in its final report, the UN High Level Panel should give more weighting to those consultations at the national level that have drawn upon the views of the poorest and most vulnerable people.

19. A global consensus must include a framework where southern civil society feels ownership of legitimate global development goals.

20.  If a truly global dialogue emerges assumptions around what a set of global development goals might be, are likely to be challenged.

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

21. Malaria Consortium believes that the targets featured in the MDGs have helped to achieve and demonstrate tangible progress. Over the past decade, efforts to control malaria have delivered significant results, with WHO estimates highlighting that “malaria mortality rates have fallen by more than 25% globally since 2000, and by 33% in the WHO African Region.” It is unlikely that such progress would have been achieved without the targets outlined in the MDGs.2

22. Despite this progress, targets are not a silver bullet, and the fifteen year time frame is too short for disease elimination. While advances against malaria have been profound, there is still much work to be done, with the disease continuing to kill 655,000 people every year,3 to degrade education levels and household incomes and to have a negative impact on the economies of the worst affected countries by 1.3% per annum.4

23. As referenced in paragraph 11 above, there have been criticisms that the target-driven approach of the MDGs has led to unhelpful vertical funding for disease control. Malaria Consortium recognises the need to avoid unnecessary competition between diseases and feels the Post 2015 framework should provide incentives for collaboration between all partners working in different areas of the health sector.

24. Nevertheless, some of the criticisms of the impact of targets are overstated and underestimate the positive impact on the health system that these interventions have recorded. For instance, it should be recognised that the creation of the US President’s Emergency Plan for AIDS Relief (PEPFAR), and the emphasis on HIV/AIDS services actually contributed to the development of task-shifting, with health workers encouraged to provide care for patients with HIV/AIDS, tasks that were beyond their standard responsibilities. Support for home-based management of malaria has initiated approaches that have been broadened to enable community health workers to test for and treat malaria, treat diarrhoea and provide antibiotics for children with pneumonia as well as supply ready to use therapeutic foods to severely malnourished children through community based structures.

25. There is a risk in moving away from the specific target-based approach of the MDGs that success would be measured in terms of processes rather than outcomes.

26. The classification of support as either systems support or disease control programme support is not helpful, and is losing credibility, as it is recognised that disease control needs functioning systems, and systems must deliver results.

6. Financing global goals: are new mechanisms needed?

27. The OECD has estimated that there is an annual funding gap of $62.1 billion to achieve the MDGs in 20 Low-Income Countries.5

28. The Roll Back Malaria Resource Mobilization Sub-Committee has calculated a funding gap of US$9.7 billion for 2012–2015 in order to achieve global malaria prevention control and elimination (which could feasibly become part of the Post 2015 framework).6

29. In order to meet immediate developmental priorities, as well as those in the Post 2015 framework, new funding will need to be forthcoming from a number of sources, including aid from emerging economies and increased domestic spending on poverty reduction. In relation to health, it is crucial that those countries that are signatories to the Abuja Declaration deliver on their commitment to spend 15% of their national budgets on health.

30. Some innovative funding mechanisms such as UNITAID have been a great success.

31. As there is a large opportunity cost to developing and learning how to use new mechanisms, the scope for adapting current mechanisms to new goals should be considered.

7. The role of the private sector and other non-state organisations

32. The private sector must be involved in the process of establishing a post 2015 framework. World Bank figures indicate that private capital flows to developing countries amounted to $524.8 billion in 2010. This dwarfs the $128.7 billion in overseas aid given by the 22 governments that compose the OECD Development Assistance Committee.7 These figures alone demonstrate the financial impact that the private sector can have in the global south. The many organisations that make up this sector should be encouraged to feed into the UN consultation process in a similar way to the third sector.

33. Private sector organisations can act as donors, service providers, and recipients of development aid. Private sector organisations should therefore be included in all discussions regarding the Post 2015 goals in much the same way as civil society.

34. While a burgeoning private sector may contribute to poverty reduction, the development of the private sector should not be an end goal in itself. The metrics used to evaluate the private sector contribution to development priorities need to be much more robust. In relation to financing of the private sector, the World Bank’s independent assessment of the International Finance Corporation (IFC) indicated that only one-third of the private sector projects funded yielded any evidence of impacting upon the poor.8

35. If the sustainable development agenda is brought together with the Post 2015 framework, there may well be onus on private sector organisations to reduce carbon emissions to a certain level. This, however, would not be a different demand to public or third sector organisations.

8. Timescale: what period should the new framework cover? Was the 15-year timescale for the MDGs right?

36. Yes. 15 years would allow time for new inputs to bear fruit and would be a reasonable time to take stock of goals achieved and adjust inputs where needed. Any longer period would be difficult to maintain interest in seeing the result, although it is recognised that support beyond 15 years is needed for elimination of some diseases.

9. 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?

37. Universal Health Coverage (UHC) has been recommended by a number of agencies and groups as an appropriate health goal for the Post 2015 agenda. While Malaria Consortium agrees that UHC is an excellent option that would encapsulate many of the measures necessary to achieving improved health outcomes, the definition of UHC must be articulated with precision and incorporate tangible targets beneath the over-arching goal. Moreover, it ought to be recognised that the aim of UHC should not be coverage per se, but universal access to healthcare.

38. Any definition of UHC should focus on access to care, including prevention, diagnosis and treatment, including the following considerations:

Geographical.

Financial.

Social.

Availability.

Acceptability of care.

Use of services.

39. The UHC concept needs to be thoroughly developed to ensure that the benefits of universality in coverage are not at the expense of targeting interventions towards the poorest and most vulnerable. There is a concern that minimum standards of access need to be adapted to different contexts, or risk setting the bar far too low in certain situations. Senegal and South Sudan, for example, have very different basic levels of standards in terms of health provision.

40. Therefore, equity should be at the centre of the definition of UHC, specifically in relation to health outcomes. If the focus of the equity is upon outcomes then services, or coverage, must be tailored to the needs of different communities and social groupings.

41. In a model whereby specific targets sit beneath the goal of UHC, malaria should feature as well as the reduction of child and maternal mortality. In addition, those issues that have received a disproportionately poor amount of attention, such as disability, NTD control and mental health should be included in some form.

42. There should be an unwavering focus on “fragile” or “conflict” zones throughout all the Post 2015 goals, including any goals relating to health.

43. An understanding of the social determinants of health is critical to developing packages that enhance the health of the poorest and most vulnerable. Programmes such as the Integrated Community Case Management of malaria, diarrhoea and pneumonia (ICCM) have started to expand to include consideration of nutrition, water, hygiene and sanitation and education. In this way ICCM can be viewed as an avenue to bring the nine developmental themes together in a practical way and should be viewed as one of the most effective policy tools to deliver on the Post 2015 development goals, once established.

October 2012