The Battle for Global Health & Movers and Shakers vs Inequality Warriors

Progress on global health is a contentious subject. While some celebrate progress in key health indicators, others warn that gross global inequalities are still responsible for 20 million deaths every year. A group of experts and civil society that holds the latter view has proposed a Framework Convention on Global Health to ensure health coverage for all. The proposal is both interesting in and of itself, because of the consultative process involved, and because of its potential implications for the discussions around a post-2015 successor to the Millennium Development Goals.

Last month I had the pleasure of meeting public health law Prof Lawrence Gostin of Georgetown and Johns Hopkins universities, sometime adviser to Presidents Clinton and Obama, and former director of Liberty in the UK (the National Council of Civil Liberties, as was). Prof Gostin had addressed an audience at the Department of Public Health, University of Oxford, to present the idea of a framework convention on global health which he originally proposed and has been instrumental in building a movement for.

Prof Gostin spoke of there being two ‘realities’ in global health. One, held by the ‘movers and shakers’ (i.e. USAID, Pepfar, Global Fund and so on) but perhaps somewhat less securely now than it once was, is the view (supported by e.g. stats on HIV) that there has been stunning progress, and that it makes real sense to be thinking about the ‘endgame’. USAID apparently has projections for various indicators for convergence to (close to) rich country rates over 10-20 years.

{To see how the evidence could support both convergence and non-convergence views, below is an adapted version of figure 6 from a really interesting recent paper from Anna-Maria Aksan and Shankha Chakraborty. The first scatterplot shows that countries with lower life expectancy at birth in 1970 saw greater improvements over the next twenty years (before the major impact of HIV), while the second scatterplot shows the complete absence of any convergence in adult mortality.}

global health

The other reality, seen by Gostin and many of the southern civil society groups with which he is working, is that while the goal would look something like a rough, global equalisation of key morbidity and premature mortality rates, these are currently characterised by massive inequalities. They have calculated, for example, that collectively, health inequalities between countries result in around 20 million lives lost each year (i.e. this is the size of the gap between outcomes in high-income and other countries), and that this has held over the last 20 years. This is roughly one third of all deaths over the period, and says nothing about the effect (known to be powerful) of inequalities within countries – where e.g. The Spirit Level presented evidence that the most unequal countries have systematically poorer health outcomes at the national level (and similarly for the most unequal states of the USA).

 

To challenge this, this growing movement proposes a framework convention that would seek to establish a set of principles to shift fundamentally the way that things develop. The umbrella group that is taking this thinking forward is JALI: the Joint Action and Learning Initiativeon National and Global Responsibilities for Health. JALI’s steering committee is comprised of Lawyers Collective from India, SECTION27 from South Africa and the O’Neill Institute for National and Global Health Law from the USA. The steering committee is broader, including among others tax justice’s own Attiya Waris from the University of Nairobi and Armando de Negri of the World Social Forum.

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The emphasis on learning is seriously meant: while the group has a powerful manifesto, to which they invite signatories, the approach is far from one of pursuing a settled path. The website is focused as much on research questions as on presenting the idea, with responses actively sought through international consultation to a set of important, wide-ranging questions. This diagram (click for full size) illustrates the ‘bottom-up, top-down continuum’ of research areas:

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Unsurprisingly, JALI see the post-2015 discussions as potentially providing the space in which to take this forward. While the full Framework remains to be developed, there is already an outline analysis of what supporters should advocate for in the post-2015 process. Broadly, it emphasises the progressive realisation of universal health coverage, with particular attention to systematic inequalities in coverage, to accountability and to inclusive participation in decision-making.

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What’s not to like, you may well ask. What perhaps remains to be developed as the next step is the type of specific proposal that could point the way to elements of content in the MDG successor framework. What indicators, for example, would best encourage accountability on, and progress towards, universal coverage?

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The fourth of ten points in the post-2015 document, in full, is this:

4. “Universal” as universal: “Universal” must be truly universal. No population should be
excluded because of legal or other status (e.g., undocumented immigrants, stateless people). Similarly, universal should entail 100% population coverage. Less than truly universal coverage as a goal may enable countries to forego the efforts required to ensure coverage for the most difficult-to-reach populations, who are often the most marginalized.

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Given the concerns that universal goals in the MDGs allowed some governments to pursue the ‘low-hanging fruit’ – i.e. in order to reach the targets that they had set for themselves, all too often they put in place interventions and policies that reached the easiest to reach, while leaving the most excluded behind – this raises important questions of approach. For example:

  • Should we propose targets that capture progress towards health coverage among the most excluded groups (whether, for example, by income, ethnicity, gender or disability) relative to the most empowered? Targets would reflect levels of convergence – e.g. reducing the differentials in India between high caste groups and Scheduled Castes, Scheduled Tribes and Muslims, or between Afrodescendant and white Brazilians, and so on.
  • Can we envisage inclusive, national processes that determine in each country the relevant dimensions of exclusion to be covered? Much of the problem of weak national ownership of the MDGs could perhaps be addressed through an initial stage in rolling out the post-2015 framework in which citizens contribute identify the key group inequalities in their societies, effectively mandating specific applications of a global outline.
  • Should every country in addition have some common targets, such as the relative progress of the poorest 10% (or 20%, or 40%) against the richest?
And notwithstanding the sense of conflicting views of global health that this post’s title refers to, USAID themselves have done some great work on the programme side in thinking about how to ensure they are challenging health inequalities at each step of their work – see, for example, this checklist.
Slavonski Brod transit camp in Croatia. Croatian Red Cross volunteers assist the arriving people who are then directed to busses heading for registration. After registration almost all refugees continue to Slovenia. Volunteers provide refugees food items and warm winter clothes.

JALI’s post-2015 outline document also shows an interesting breadth, consistent with the overall approach of seeing health outcomes as stemming from much wider causes – reflecting not only a social determinants analysis (in particular, as per the report of the Commission on the Social Determinants of Health) but also wider issues such as the damage done by illicit financial flows (e.g. to accountability and to tax revenues, undermining not only governments’ ability to finance health systems but also citizens’ ability to hold them to account for doing so).

As illicit flows are increasingly highlighted by civil society as a fundamental obstacle to progress towards internationally agreed development goals, both in broader analysis and in specific areas such as health, it’s tempting to wonder whether a post-2015 element to reflect this concern could emerge, and tap the increasing interest among policymakers also. One to think about, at least…

Reigniting global development: What development goals after 2015?

For many, the coming of the year 2000 was marked by overblown hype around a computer virus that never happened and slightly disappointing parties that did.

In the world of development it was heralded with a much more momentous occasion; the agreement of the Millennium Development Goals – global goals on international development that have provided a focus for development efforts ever since.

With all their shortcomings (ranging from the way that poverty is measured to key gaps like sustainability, infrastructure or inequality), it is hard to deny the success of the MDGs in galvanising political momentum around the fight against poverty and in helping to mobilise unprecedented levels of global aid. Since the beginning of the 2000s – partly because of these goals – we have witnessed impressive progress in improving access to primary education, reducing child mortality and combating extreme poverty.

So with a track record to be broadly proud of, the question turns to what should replace the MDGs when they expire in 2015. Next week these discussions start in earnest when the High-Level Panel on the Post-2015 Development Agenda (co-chaired by our Prime Minister) will meet for the first time.

While 2015 may sound slightly less auspicious than the turn of the millennium, there are still high hopes for what the replacement framework might achieve.

Whatever shape it takes, the new framework must start by building on the strengths of the MDGs. To that end they should be specific, time-bound and measurable – we can’t let the specific targets be watered down to bland aspirations or UN speak (‘reaffirming’, ‘aspiring to’, ‘cognisant of’ must all be banned phrases).

Secondly, while the new framework should address emerging development challenges, it should remain focused on key development priorities where an international agreement can make a difference. Trying to make the framework respond to every development challenge may tick all the lobby groups’ interests but will play no role in incentivising political action in key areas. Worse still, if we try to overload the process we could derail it entirely.

Thirdly, while there were certainly gaps, the current framework did pick many of the right issues and the replacement should finish that job. Most of the issues identified in the MDGs have remained some of the key development challenges; however, targets within the MDG framework tended to be about halving extreme poverty, or reducing under-5 mortality by two-thirds, or reducing maternal mortality by three-quarters. This is why the UN Secretary General recently recognised that When the MDGs were first articulated, we knew that achieving them would, in a sense, be only half the job.” Now is the time to finish the job we started. For the first time in history, the world is at a stage where we could make historic breakthroughs. For example it is now feasible to imagine that in the next couple of decades no child would die from preventable causes, that every child could go to school and that we could eradicate extreme poverty. This inspirational human accomplishment must be seized.

Proposals that encapsulate this idea have already been put forward, including Getting to Zero. This would include a zero target for eliminating extreme poverty, and close to zero targets for child and maternal mortality, child stunting or illiteracy.

So for us there needs to be a strong thread of continuity in the replacement framework. But we also know that some things must be different because the world has moved on.

The first change in emphasis within the goals comes from the implication of moving from fraction-goals to zero goals. Possibly, one of the greatest weaknesses of the MDGs was failing to recognise that by setting aggregate targets the poorest and hardest to reach sectors of the population would be left behind. The roadmap to get to zero by 2035 should ensure that interim targets and national targets aim at reaching the hardest to reach.

Secondly, we know that the location of poverty has changed. The growing number of people in poverty living in middle income countries means that to be successful we need to take on inequality at the national level. Relying on current growth trajectories and basic service interventions alone won’t achieve the things we want. Trends in poverty reduction show that achieving these inspirational goals will only be possible if the thorny issue of inequality is addressed so progress can be dramatically accelerated.

Currently, one in six of the people living in extreme income poverty (less than $1.25 a day ) live in upper-middle income countries and more than half live in lower-middle income countries. New analysis by Andy Sumner for the Center for Global Development shows that extreme income poverty in each group of countries could be eliminated by a small redistribution of GDP: just 0.2% of GDP in upper-middle income countries, and 1.3% in lower-middle income countries.  Save the Children’s research shows that reducing inequality is also crucial to address other goals such as reducing stunting.

Thirdly, since 2000 countries such as China and Brazil have made incredible development strides, and there is also a much more complex geopolitical constellation. Whereas in 2000 low income countries were broadly seen as recipients of an agreement, this time emerging economies and many low income countries will rightly be much more vocal. Pushing for goals that only focus on the poorest countries is unlikely to get traction. Hence, the new framework will have to include goals that have obligations for all governments. Some of these will be about richer countries helping the poor (e.g. aid targets); but there is also an opportunity to go beyond this and identify global priorities that every country will strive to deliver on. These could include goals on transparency, sustainability, national poverty reduction targets, or employment targets.

Of course, this is not the type of agreement that can be brokered by a few technical experts from donor countries in the corridors of the UN. It will require strong political leadership that can forge one of the greatest global agreements in history.

Negotiating the new agreement will take real political skill and we know the biggest danger is stalemate. To avoid this we think it should be negotiated in a series of building blocks – rather than holding off on everything until everything is settled. For example, hardly anyone disagrees on the need to eradicate extreme poverty or end child mortality. These common agreements needs to be ring-fenced early, so potential in-fighting in other areas does not compromise progress on this central principle.

If we can get both the content and the negotiating strategy right, the replacement framework to the MDGs could be a truly historic document. If we mishandle either, it may end up feeling more like the millennium bug that never was.

Failure to Count

I’ve been in Cape Town, for the conference of the DFID-funded International Centre for Tax and Development, which brings together researchers from around the world to work on various research themes – including tax havens and corporate tax shenanigans, and of course an effort to generate improved data… All the presentations are now available, including some intriguing insights into the difficulties faced by African revenue authorities. Too much is uncounted, here too.

Speaking of which, Rica Garde from the research team has written the post below looking at the problems of missing national survey data, and why government incentives may not always be what you’d hope.

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Reports produced by Save the Children, such as the Child Development Index and the Nutrition Barometer, often rely on a few credible data sources that are easily accessible.  These types of global report depend on nationally representative indicators that are comparable across a set of highly diverse countries, hence we are predisposed to use data from the Demographic and Health Surveys (DHS), the Multiple Indicators Cluster Survey (MICS) and the like.  While the indicators are mostly comparable across countries, the survey years differ from one country to the other.  Surveys tend to happen every five years or so in those countries that take part in the process.

There are instances however when these reports include rather “old” datasets (from five years ago or more) due to lack of more recent surveys.  Take India’s case for example.  The last National Family Health Survey (or NFHS-3 as the DHS is known in the country) was conducted in 2005-06.  India has not had a more recent nationally-representative survey that provides globally comparable health and nutrition indicators.  Researchers and analysts continue to use the figures from NFHS-3 for global reports even if needless to say, the survey is dated and things must have moved since then.

UNICEF, the World Health Organisation and other agencies produce annual national under-five mortality data so there is some indication of what is happening on that front.  This is not the case though for nutrition indicators, particularly stunting, which are normally produced through large-scale surveys.

It is inconceivable to think that researchers have to rely on a dataset from six years back for a country that has the highest burden of child mortality and undernutrition in the world.  Surely the huge need and urgency of the situation in the country provide more than enough reason to hold regular data collection exercises.  Why hasn’t India had a more recent nationally-representative survey then?

It would be difficult to say that it is a funding issue.  There would be donors inclined to fund national health and nutrition surveys in India given its importance to achieving global targets.  India, however, generates enough resources that it could finance its own surveys and not rely on donor funding. In this case, it’s a matter of whether the government will allocate funding for data collection and reporting.

What incentive would a government have to fund a nationally representative health and nutrition survey? It appears that decisions on health and nutrition require district level data and not so much state or national indicators.  Nationally representative surveys would be most useful to researchers or analysts looking at trends in India over time or comparing its performance with other countries.  Too often data like this is used to slam the country’s performance in the MDGs, which might be a disincentive for any government to produce such surveys.

Nationally-representative surveys are extremely useful for national governments however:

  • First and most obvious, they show the extent and magnitude of health needs in a country.  This can be very useful when allocating the national budget. Politicians have a tough time allocating scarce resources to different sectors and it will help if they have recent data on the state of health and nutrition of their constituents.
  • Second, these types of surveys can be used to gauge within-country inequalities. Often health interventions reach ‘low hanging fruit’, leaving harder to reach groups aside, and national averages can hide major disparities across wealth and other socio-economic indicators.  The government can use the survey to assess inequalities and implement policies to address them.
  • Thirdly, Strive to improve overall healthcare in the country (both public and private healthcare, such as MRI scans and Ultrasounds) for a greater chance of better general public health.
  • Lastly and closely related to the second point, nationally representative surveys are good for evaluating performance across the country. Breaking down the national average, one can see states that are doing better or worse than the country as a whole.  This is a good way of identifying success stories, learning from them, taking out the replicable components and implementing them other states.

Fieldwork for NHS-4 is due to start in 2013. Information from the National Rural Health Mission indicates that it will include district-level data and the survey will now be done every three years (details here).  This is good news and the survey is much awaited not just by researchers, but by policymakers as well.

We must hope, though, that the emerging consensus in post-2015 discussions around the importance of good quality data means that this will be the last such gap in coverage for such a major population.

AID is GREAT Britain

 

The last couple of weeks have seen a flurry of articles from diverse media outlets, pointing out that a share of aid is going to for-profit consultancy firms in the UK and to big British multinationals; yet aid plays a crucial role in reducing poverty and in supporting development processes, as shown in a recent Save the Children and ODI report.

For this reason, a constructive dialogue about aid needs to put the spotlight on how we can make aid deliver more, and to a higher standard – to ensure that aid delivers the best value for the needs of people living in poverty.

aid

As to how to do this, there is a wealth of expertise that can be tapped at DfID and at the OECD DAC. In addition, here are two proposals that could help :

1.       Value for money revisited. Current aid debates, warmly embraced by DfID, suggest – and rightly so – that we as taxpayers and the beneficiaries of aid should be getting the best value for money. Technical assistance services are sometimes needed to transfer knowledge and exchange experiences. However, using international consultants from donor countries is not always the cheapest option. According to an OECD study, goods and services bought in developed countries can be 15% to 40% more expensive than those bought in developing countries. This is due to limited competition, which allows providers to charge monopoly prices, or due to high transportation costs, compared to goods and services purchased locally in poorer countries.

 

In order to get more value for money, goods and services paid with aid should be bought – when and where possible – in developing countries. There is a wealth of expertise in these countries that aid-funded technical assistance could be tapping.

2.       Double impact of aid. In addition, by setting targets for aid funds to buy goods and services produced in developing countries, we could not only get better value for our money, but trigger a double impact of aid. Aid provides a good or a service directly, while indirectly it also contributes by creating the job of the person who delivers this good or service. Companies and consultants in developing countries increase their access to markets and business opportunities which, in turn, has the potential to boost local entrepreneurship and created sustained growth and jobs in these countries. In India, the Karnataka Government decided to buy the textiles required for government programmes from local weavers ensuring business opportunities for local producers. There is no reason why aid agencies should not do the same (when and where possible).

DfID has been at the forefront of international debates and practice on how to make aid more effective. We are now faced with the historic opportunity to make our aid both bigger and better, so that in 2013 the GREAT campaign can add an extra line to its great slogan: AID is GREAT Britain.