International Development CommitteeWritten evidence submitted by Royal College of Nursing

Introduction

1.1 With a membership of more than 410,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional nursing union in the world. RCN members work in hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests, working closely with UK Governments and parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.

1.2 The RCN is a member of the International Council of Nurses which brings together nursing organisations across the world and works closely with the World Health Organisation (WHO) and other international bodies. We are members of the European Federation of Nurses’ Associations and the European Public Health Alliance. We participate as a trade union in the European social dialogue through our membership of the European Federation of Public Service Unions. We contribute to the policy and advocacy work of Action for Global Health in the UK. We also link with non-governmental organisations (NGOs) to promote nurse volunteering internationally.

1.3 The RCN welcomes the International Development Select Committee’s inquiry into post-2015 development goals and the opportunity to submit evidence.

2.0 Executive Summary

2.1 Health underpins sustainable development and has complex economic, environmental and social determinants. Realisation of the right to health requires co-ordinated policy action at different levels on the broad determinants of health and to strengthen health systems.1

2.2 The Millennium Development Goals (MDGs) provide an extremely useful and powerful tool to initiate improvements in specific areas of health in developing countries. However, care must be taken that their simplicity does not shroud the complexity of the problem they seek to address.

MDGs have had some tangible successes; however there are lessons that must be learnt when developing post-2015 Goals.

2.3 The wider social issues related with developing countries, such as poverty levels, opportunities and differing national governance systems, for example, should be appropriately recognised as having a huge impact on the success of MDGs.

2.4 The future goals must include appropriate, common-but-differentiated objectives for all countries, including a comprehensive rights-based approach to development.

2.5 Health is a global public good that can benefit from and contribute to policies across sectors which shape the determinants of health, particularly policies that promote equity of opportunity, access and outcome.

2.6 When formulating new MDGs it is vital that a comprehensive and genuine consultation takes place in order to set those priorities which should nurture a sense of ownership from participating countries.

3.0 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?

3.1 MDGs have captured political and public attention and become interventions which affect the meaning of development and influence resource investments. However, one framework cannot address the complexity of development, which shapes and is shaped by a broad matrix of relationships: macro-economics, demographic change, disasters, food security, governance, gender, human rights, inequality, migration, peace, security, science, technology, urbanisation and work, amongst others.

3.2 The MDGs focused the attention of governments on goals and targets for development financing and activity. The UK government developed an explicit theory of change for achieving the health-related Goals: strong health systems and appropriate human resources contributes to reduced child and maternal mortality and reduces infection and mortality rates for HIV, malaria and TB.

3.3 The Goals help the RCN articulate the need for, and the results of, strong health systems. They also allow us to make the case for the need for adequate numbers of professional staff with appropriate skills and have provided a shared basis for advocacy and policy work.

3.4 The MDGs are simple and easily understood, focusing efforts and increasing the scale of (a limited set of) interventions, including health. Goals with measurable indicators and a timeline have rallied public, private and political support for poverty reduction, including additional aid commitments. Citizens and civil society have made efforts to act to hold governments in the North and South to account for MDG commitments.

3.5 With improved statistical methodologies, data for analysis and policy on the MDGs, we know more about the social and geographic location of problems. We lack disaggregated data to support analysis of and responses to root causes. The MDGs enabled countries and other actors to develop co-ordination and coherence of interventions towards defined targets.

3.6 Goals and targets have driven progress in the past decade on poverty and health in many low and middle income countries. Income poverty has fallen and access to clean water has increased in more than 50% of countries, especially those least developed and in sub-Saharan Africa. Child and maternal mortality have fallen at record rates in many countries. Infectious diseases, including HIV/AIDS, TB and malaria, are also in decline.

3.7 Many countries have aligned national policies with the MDGs, including developing national MDGs which complement the global MDGs and is to be welcomed.

3.8 However, many countries have made significant progress on the MDGs without substantive change for vulnerable groups. Aggregate progress may mask MDG failure for the poorest and most marginalised. Addressing equity is essential for resolving structural problems that create and sustain poverty, vulnerability and marginalisation.

3.9 The RCN agrees with criticisms of a lack of consultation in defining the MDGs, and varying definitions of success. The MDGs centred on donors’ concerns, which entrenched aid dependence and exacerbated donor-recipient power differentials. The Global Fund is an exception and perhaps provides a model for future institutional arrangements.

3.10 The MDGs’ focus on social development deflected attention from a comprehensive, approach to development. More could have been made of the links between goals and the economic and environmental dimensions of sustainable development. Rights, equity, environmental sustainability, and conflict all influence health and health outcomes, but were not integrated.

3.11 Discrepancies also arose in regard to issues such as the payment of health professionals. For example, some NGOs paid health professionals more than government salaries, weakening already fragile government health systems. Anecdotally, we know of nurses migrating to nearby countries at the end of their NGO contracts. Migrating health workers tend to move to relatively richer countries,2 and most migration in sub-Saharan Africa is within the continent.3

3.12 Monitoring the MDGs has been difficult because of discrepancies and inconsistencies between national and international data. The MDGs measure outputs and quantitative indicators, but have struggled to demonstrate the quality and sustained impact of interventions on people’s lives, especially the poorest and most marginalised.

3.13 The MDGs do not recognise human rights as essential to sustainable development. To some extent, achieving the MDGs depends on charitable action that may be stigmatising and disempowering for recipients, relies on good will of the better off and fails to address structural causes of poverty. A rights-based approach requires the progressive realisation of rights for all, for example to secure the right to health.

3.14 MDG targets could, but did not, highlight the responsibilities of developed countries above and beyond providing Official Development Assistance (ODA), and particularly related to production and consumption.

3.15 The MDGs diverted attention from non-MDG issues crucial to sustainable development and from some factors key to achieving the MDGs, such as robust government institutions and democratic functions, and an enabling environment for civil society and the private sector. A narrow focus on MDG results risks producing quick wins at the expense of sustainable gains founded on, for example, improved governance. The MDGs largely ignored the health system strengthening required to achieve MDGs 4 (reduce child mortality), 5 (improve maternal health) and 6 (combat HIV/AIDS, malaria and other diseases). In time, these were recognised and championed by the WHO, NGOs and professional associations, including the RCN.4

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

4.1 Future goals should be global because the issues, problems and solutions, are global. Global goals will have legitimacy, ensure recognition of global responsibilities, and may promote accountability.

4.2 Global goals can address sustainability, wellbeing and societal progress, and allow comparison between countries. For example, many countries have experience of introducing universal health care, the resulting demands on health systems and health workers, and the benefits for individuals and populations.

4.3 Country obligations, like the goals, should be based on common-but-differentiated responsibilities, informed by national circumstances, capacities and levels of development. Leadership is required so that richer countries address the connections between poverty and extreme wealth and consumption.

4.4 New goals must focus on the poorest and most vulnerable who experience the worst health, no matter where they live. While the focus may be poor and fragile countries, the goals must include ending poverty in middle income countries and ensuring that richer countries move to sustainable production and consumption.

4.5 Overarching principles for coverage of the future goals:

A human rights-based approach.

Universal and common-but-differentiated responsibility.

People at the centre, including participation of citizens as a measure of success. People at the centre strengthens the case for equitable access to health care for all.

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

5.1 Broadly, the MDG target-based approach focused efforts towards demonstrable results (which sustained support), with greater accountability. However, they risk simplifying complex problems, ignore root causes, and limit attention and effort to what is measured.

5.2 New goals should preserve the positives of concrete, measurable and time-bound goals, while addressing the complexities of development including human rights, equality, sustainability and policy coherence.

5.3 Progress should be towards global-level goals reflecting global challenges and country goals, reflecting common-but-differentiated responsibility. Measures of progress should include qualitative, quantitative and other metrics, such as governance and regulation.

5.4 The new goals must not be a selection of problems, addressed in silos, chosen according to who shouts the loudest. The new goals must reinforce each other and allow for policy coherence that embeds sustainability, benefits people and joins up responses to interconnected problems.

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

6.1 The private sector and other non-state organisations are highly diverse, take a variety of roles and exercise different levels of responsibility and accountability. The RCN supports the inclusion of all stakeholders in agreeing, acting and reporting on progress on post-2015 goals.

6.2 Governments must retain responsibility for national health policy, health service and workforce planning and regulation. We believe that the best health systems involves universal health coverage, free at the point of use, with access based on clinical need not ability to pay and with risk shared collectively. The private sector and civil society organisations have roles in providing health care based on sophisticated planning and co-ordination to ensure that providers complement each other and promote equality.

6.3 The most appropriate health care provider is the one who delivers best care for individuals and populations. In many cases this is government health services.

Whoever provides services, health systems must have robust mechanisms to ensure, value for money, a level playing field for all providers, patient safety and equitable, universal access to basic health services.

6.4 Civil society groups have important roles in holding governments and others to account for a strong health system and health and other policies that produce improved health outcomes for all.

6.5 Civil society also has a role in holding donors to account. In the UK the RCN works with the Action for Global Health alliance to lobby the UK government to include health system strengthening and human resources for health in its development programmes.5

7.0 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?

7.1 Health underpins sustainable human development and is essential to good global goals. Health benefits contributes to sustainable development and can be a proxy for measuring progress. Health highlights three agendas relevant to future goals and the achievement of unfulfilled MDGs:

The need to deliver the progressive attainment of rights, including the right to health.

The need for coherent policy and action on the multi-level, intersecting social, economic and environmental determinants of health.

Universal health coverage is important, but not sufficient, for improved health. It requires robust health systems with adequate, consistent and predictable finances, and appropriately skilled and distributed human resources.

7.2 Health can benefit from, and contribute to, policies in many sectors which shape the social, economic and environmental determinants of health, particularly policies that promote equity of opportunity, access and outcome. The RCN believes that good health policy ensures inclusion and access to services (particularly for poor women and girls), innovation and efficiency, and universal health coverage.

7.3 Strong health systems plan for the effect of changing disease patterns, eg the increasing incidence of non-communicable diseases, on populations and on the skills and capacities of the health workforce.

7.4 Most health systems address diseases more or less in isolation. Labelling MDGs 4, 5 and 6 as “health MDGs”, ignores the impact on health of clean water and gender equality, for example.

7.5 Nurses have a role in helping people and communities become healthier and avoid illness and premature death through provision of care and by participating in public health interventions.6 Focusing on prevention highlights the global challenge of supplying more trained health workers, especially nurses.

7.6 Good public health reduces disease burdens so fewer people need resource-intensive care. This cuts the costs of health systems and improves environmental sustainability.

7.7 The future goals must include appropriate development objectives for all countries, including human rights, climate change and sustainability. These global challenges require global action, founded on coherent policy for development.

7.8 Whatever the balance between development aid and international and domestic policy coherence and governance, two priorities must be addressed: the needs of the poorest and most vulnerable and ensuring a sustainable environment. While the focus should be on the poorest and most fragile countries, it must include ending poverty and structural inequality in middle income countries and ensuring richer countries move to sustainable production and consumption.

7.9 The poorest and most fragile countries have the highest poverty incidence. It is likely that no conflict-affected or fragile state will attain a single MDG. These countries need specific, sustained attention. A common feature of poor and fragile countries is insecurity and violence, as such the new goals must address the intersections of conflict, insecurity and poverty in order to create sustainable paths out of poverty.

7.10 The majority of poor people live in middle income countries. Social policy developments in emerging economies, eg Brazil, Mexico, India, China and South Africa, highlight universal health coverage as a means of linking equitable social and economic development. Nurses understand the effect of social and economic inequality on the health of communities. As we have said elsewhere, many differences in health outcomes are avoidable with policies that address the social determinants of health, increase equity and address absolute and relative poverty.7

7.11 The future goals must address production and consumption in the richer countries which continue to over-consume the earth’s resources.

7.12 Future goals should incorporate:

Progressive realisation of human rights.

Increasing equality and equity within and between countries to address absolute and relative poverty.

Ensuring production and consumption draws back from over-consumption, including reducing CO₂ emissions and addressing climate change.

Policy coherence for development: the actions and omissions of all actors do not hinder development objectives or the realisation of human rights, and preferably contribute to their achievement.

Accountability and transparency: governments and others are held responsible for their actions under the goals.

7.13 Future goals must also avoid becoming policy silos as though one policy has no impact, positive or negative, on another. Silo thinking leads to policy incoherence.

7.14 The RCN believes that reducing health inequity is fundamental to the future goals, requiring coherent action across sectors and at every level of government. For example, good health requires decent housing. UK local government can ensure housing stock is fit for purpose. National government can provide incentives for “green” buildings, while EU legislation sets standards for safe building materials.

7.15 A new framework must have a clear vision to guide action on poverty and a sustainable environment. A consultative process for developing new goals requires political leadership so that the goals are ambitious and achievable, while acknowledging that they do not respond to all the complexities of development. Leaders shaping the framework must have legitimacy with the UN leading the way.

7.16 Transparency and accountability must be prioritised. Accountability must be to people, not just upward to donors and international institutions. Governments must create space for individual and civil society voice. Transparency and accountability includes governance at every level. For example, a health programme may involve central decisions about funding training and facilities, provincial action to train workers and build facilities, and local communities in planning and managing health services.

October 2012