International Development CommitteeWritten evidence submitted by NCD Alliance

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. The NCD Alliance was founded by four international NGO federations representing the four major non-communicable diseases (NCDs)—cancer, cardiovascular disease, chronic respiratory disease, and diabetes—and unites a network of 1,000 member associations and a further 1,000 civil society organisations in more than 170 countries. As an NGO network that is influential on the global health and development stage and is grounded in the work of our national member associations, the NCD Alliance recognises the importance of the MDG framework in keeping health at the top of the global development agenda and driving progress in health at the national level.

2. However, while the MDGs have undoubtedly driven progress in health in low- and middle-income countries (LMICs), the absence of NCDs in the MDG framework, and the narrow interpretation of the MDGs by donors and countries, have resulted in a disease-specific, vertical, and siloed approach to health. Impressive gains have been made with combatting certain diseases, but often at the expense of a holistic approach to health. LMICs are now faced with distorted health systems that are ill-equipped to respond to the growing NCD burden and people with multiple conditions.

3. NCDs are the leading cause of morbidity and mortality, accounting for two out of three deaths and half of all disability worldwide.1 80% of NCD deaths are occurring in LMICs, exacting a heavy and growing toll on physical health, economic security, and human development. NCDs perpetuate and entrench poverty within households and increase inequalities within populations. Out of pocket payments for NCD treatment and care can trap poor households in cycles of catastrophic expenditure and impoverishment, particularly in LMICs that lack social and health insurance. NCDs diminish household earnings and hinder a family’s ability to provide for and educate children. NCDs affect all areas of human and economic development and are threatening progress towards the achievement of the MDGs.

Valuable Features and Elements of the MDGs

4. The MDG framework has been valuable in setting a global agenda for development. The MDGs themselves are clear and concise. They are simple and have narrative power with eight goals that provide a clear vision towards universal poverty eradication. They are intuitively understood and easily communicated to a general audience.

5. The MDGs have raised awareness and built a constituency for development, reflected by increases in aid pledges, greater political priority for poverty reduction in developing countries, and the development of popular movements against poverty in many countries.

6. The MDG framework improved monitoring in development, particularly increasing national capacity in statistics. Through the strengthening of data collection, a clearer picture has been formulated on the state of development in countries.

7. The MDG framework focused on human development and recognised the centrality of health to human development, with three of the eight goals directly related to health. This vision must continue through to post-2015, but the definition and scope of health must be realigned to reflect the current epidemiological trends in LMICs, particularly the accelerating epidemic of NCDs.

Challenging Features and Elements of the MDGs

8. The current framework has led to the global NCD epidemic remaining severely under-prioritised and under-funded as a health issue at the global, regional, and national levels over the last decade. While Development Assistance for Health (DAH) has grown over the past decade, multiple analyses show that it is not being allocated in relation to the burden of disease. Although NCDs account for 60% of the global burden of disease, they receive less than 3% of the $22 billion spent on Official Development Assistance (ODA) allocated to health.2

9. This skewed distribution of ODA has led to vertical disease-specific programmes in LMICs and distorted health systems that focus on acute care and respond to the end stage of disease, rather than taking a more preventative and holistic approach to health. National policies on essential medicines and technologies have been similarly influenced by priorities in the MDGs, with a severe lack of adequate access and high cost of essential NCD medicines and technologies in many countries increasing morbidity and mortality.

10. The omission of NCDs as a threat to global health, well-being, and development is a critical gap in the MDG framework. NCDs are linked to, and affected by, all aspects of human development, including poverty, gender equity, and other health issues such as infectious diseases and maternal health. NCDs also share many risks and solutions with sustainable development issues, such as climate change, urbanization, food security, clean energy, and water and sanitation.

How should the “Sustainable Development Goals” be established following Rio+20 and relate to the “Development Goals” being considered by the High-Level Panel?

11. The Sustainable Development Goals (SDGs) and the post-2015 development processes must be viewed as complementary and harmonised. These two processes should be merged by the UN system and its Member States.

12. The UN Conference on Sustainable Development (Rio+20) and the resulting Declaration recognised that “health is a precondition for and an outcome and indicator of all three dimensions of sustainable development.”3 Further it reinforced that, “sustainable development goals can only be achieved in the absence of a high prevalence of debilitating communicable and non-communicable diseases.”4 Due to the linkages between health, NCDs and sustainable development issues such as food insecurity, nutrition and energy, both the SDGs and the post-2015 goals need to ensure NCDs are fully integrated.

13. The SDGs and the post-2015 development goals should be concise, action-oriented, universally applicable, and reflect all three dimensions of sustainable development. These dimensions have been echoed in the UN Task Team (UNTT) Report on the post-2015 development agenda Realizing the Future We Want for All5 with the addition of a fourth dimension: peace and security. The inclusion of health indicators in the goals associated with each of these dimensions will be useful in measuring both health gains and overall progress toward sustainable development.

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

14. The future development framework must retain its function as a clear and concise roadmap for international development, which can be adapted to the various regions and countries. The development framework should be applicable to every country, given that this process will be merged with the SDGs. Universal relevance and application is also of the utmost importance for the health goals, given the global nature of the NCD burden and many other diseases and health conditions.

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

15. There has been justified criticism over the formulation of the MDGs. The MDGs were reportedly developed behind closed doors by a small, elite group of experts, and without developing country participation or engagement with other stakeholders. This arguably led to a development framework that is largely donor-driven. The post-2015 process should be more inclusive, fully engaging both hemispheres and all stakeholders, including civil society.

16. One of the constraints for post-2015 is that the landscape for international cooperation has changed dramatically in the last twenty years. The landscape now boasts many more international actors and political blocs with competing priorities; and a cluttered global health and development architecture that pose many challenges for consensus building and international cooperation. The post-2015 process will need to accommodate for this, and consider how best it can leverage global governance to promote regional and national-level action.

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

17. The MDG target-based approach was beneficial in providing a clear vision for countries. The selection of goals and targets for the new framework needs to be succinct and concise. The structure needs to avoid hierarchies that place one health challenge above another, and the targets need to be intuitively understood and easily communicated to attract popular support.

18. As the UNTT Report recommends, these goals should be built around four core dimensions: inclusive social development; environmental sustainability; inclusive economic development; and peace and security. While health and NCDs intersects with all dimensions of development, the rightful place for health within post-2015 is within the social development dimension.

19. The MDGs’ focus on outcomes has been a major strength. The UNTT Report’s recommendation of an overarching outcome goal for health—of reducing preventable morbidity and mortality—is measurable, would reinforce health as a global concern for all countries, and attract political leadership. However, having an overarching goal should not be interpreted as collapsing the health goals and thereby minimising the position of health within post-2015.

20. To underpin this broader vision of reducing premature morbidity and mortality, there needs to be a selection of disease- or health sector-specific goals. The health goals and targets should be based upon the relative burden of disease, measurable and feasible, a combination of relative and absolute benchmarks, able to accommodate differentiating national circumstances, and politically appealing. Where possible, the targets should dovetail with, and support progress toward, existing commitments and goals adopted by Member States in UN declarations or resolutions. Based upon these criteria, the inclusion of NCDs is justified and fully validated.

21. The MDGs have been important in improving monitoring and data collection. The future development framework must have a strong monitoring framework to increase accountability. It should build on existing frameworks, as well as draw synergies with new monitoring frameworks such as the global monitoring framework for NCDs which will be adopted in 2012.

Financing global goals: Are new mechanisms needed?

22. The new development framework could expand on MDG 8—a global partnership for development—and make development financing more predictable, sustainable, and accountable. The principles of the Paris Declaration of Aid Effectiveness (2005) and the Accra Agenda for Action (2008), to which all bilateral agencies and donor countries are signatories, should be maintained throughout the post-2015 process.

23. The Paris Declaration is a key point of reference for improvements in aid. It is founded on five core principles: aid recipients in the development community need to draft their own national development strategies (ownership); donors need to support these strategies (alignment), and to work to streamline their efforts in-country (harmonisation); development policies need to have clear goals and progress towards these goals needs to be monitored (results); and donors and recipients alike need to be jointly responsible for achieving these goals (mutual accountability).6

24. In the context of post-2015 and the global financial crisis, greater accountability and effectiveness of aid for health needs to be a priority. The principles of the Paris Declaration have been undermined during the MDG era, by bilateral aid agencies not responding to requests for financial, human and technical resources for NCDs from recipient countries. As evidenced by a recent WHO Analysis of Country Cooperation Strategies, prevention and control of NCDs has been prioritised as of the highest concern at national level in 136 countries—most of them LMICs. Yet less than 3% of ODA for health is allocated to NCDs.

25. Moreover, the way that ODA for health and development is reported, monitored and tracked needs to be improved. The standard source for data on ODA is the OECD Creditor Reporter System (CRS) database maintained by the OECD/DAC. The way that ODA for health is reported and monitored creates difficulties in tracking expenditure. OECD tracks health ODA with broad categories such as “basic health” and “health systems”. Insufficient detail on project titles and descriptions under these categories does not allow analysis of aid expenditure on NCDs.

26. The current OECD/DAC reporting system needs to be expanded to include markers that reflect the changing global health and development landscape. More specificity in what donors are funding, and by how much, will allow for greater scrutiny and ensure that donors are fulfilling their commitments to aid recipient countries. While there are disease-specific markers for HIV/AIDS, TB, Malaria, and reproductive health, there is not one for NCDs.

27. With new donors emerging, there is a greater challenge in monitoring development assistance since they are not part of the OECD/DAC. Thus there must be a monitoring framework in place to able to track how aid assistance is distributed and for what. The OECD would be best suited to integrating emerging donors in its already established framework and then improving on it as stated above.

28. Given the economic strain in many countries, the new framework should explore sustainable and innovative financing mechanisms and harness new funding sources. This would include increasing public-private partnerships (PPPs) and revenue collection through taxation, particularly in terms of NCD funding.

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

29. The challenges of ill-health and poverty are so complex and resource intensive that governments and other stakeholders cannot tackle them on their own. Because of this, the global health landscape has changed markedly and sources of funding have diversified. New donors have emerged, including from the BRICS; PPPs have proliferated, and global funding mechanisms and innovative financing mechanisms have been established.

30. The private sector is a major funder of global health initiatives and global health partnerships have become a fixture, offering new mechanisms to leverage resources and expertise to bear on global health challenges like NCDs. With certain parameters and safeguards in place, it has been shown that harnessing the capabilities and resources of the private sector is integral to driving progress in HIV/AIDS, TB, Malaria and maternal and new-born child health. The Global Fund, GAVI, PMNCH are just some examples of effective PPPs in global health.

31. Given the NCD burden is so large and the cost of development challenges remains so overwhelming, it is essential the post-2015 development framework engages new actors and donors. No single sector or actor can solve these challenges alone. However, due to the potential for conflicts of interest when engaging with the private sector in pursuit of public health goals, there may need to be clear partnership parameters, ethical frameworks and a code of conduct.

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

32. The 15-year timescale of the MDGs, with regular reporting intervals, provided an adequate amount of time for all stakeholders to develop, implement, monitor, and evaluate policies and programs towards the achievement of the MDGs. However, there has been criticism around the delay in this process, with real progress toward the MDGs only beginning five years after the agreement of the MDGs, in 2005. Hence any timescale should take into consideration the number of years necessary to build adequate capacity, in addition to institutional and programmatic progress.

33. Any timeline proposed for the post-2015 goals must be in alignment with the targets and goals already agreed. For example, the post-2015 timeline should recognise the May 2012 agreement by Member States to a global target to reduce premature mortality from NCDs by 25% by 2025.

The content of future goals: What would be a good set of global goals? What continuity should there be with the MDGs?

34. The influence of the MDGs on global and national health policy is clear. Therefore defining the next iteration of the global development framework is an important opportunity to realign priorities with the current epidemiological trends in LMICs and globally, including NCDs.

35. For the post-2015 development framework to safeguard progress made on the MDGs and drive sustainable and equitable development, health must continue to be at the heart of the framework. The rightful place of health within post-2015 is within the inclusive social development dimension.

36. An overarching focus on health within post-2015 should be on preventable morbidity and mortality, with a selection of specific health-related global and targets that would include NCDs. The inclusion of NCDs is justified and validated. The evidence of changing demographics and shifting disease burdens in LMICs is clear, the UN Political Declaration on NCDs provides the political mandate and lists cost-effective interventions to prevent and control NCDs, and a process is currently underway to define global NCD targets that the post-2015 development framework can draw upon.

37. As well as health-related targets, the post-2015 development framework would benefit from health indicators across all dimensions. Key measurements of health can help track advancements in sustainable development, identify barriers and highlight inequities. This was emphasised at Rio+20 and there is a wealth of existing health-specific indicators to draw from, including from a recent WHO expert consultation on health indicators for sustainable development.

38. There should be a renewed focus on universal health coverage and health systems strengthening. The importance of a comprehensive well-functioning health system is to deliver prevention and care to people with all diseases, bringing together a trained workforce with appropriate skills, affordable technologies, safe and reliable supplies of medicines and technologies, referral systems, and empowerment of people for self-care is now well recognised.

How should the unfulfilled MDGs be taken forward?

39. The importance of the MDGs and the progress toward their achievement must not be compromised by the post-2015 agenda. Unfulfilled or unmet goals must not be lost. Future goals must account for progress thus far, and re-set goals to reflect progress.

October 2012