Health and the post-2015 development agenda
(The Lancet) - Next week marks the culmination of a 4-month global consultation on the position of health in the next era of human development. The online consultation saw input from individuals, civil society, academia, the private sector, WHO member states, and UN partners, and was condensed into a highly accessible report that will provide the focus for discussions in Botswana on March 4—5. The consultation's aim was to summarise the achievements and shortcomings of the Millennium Development Goals (MDGs), which expire in 2015, and to devise a new set of health goals with suggestions for how they should be implemented and measured.
Around 100 papers were submitted to the consultation website, and the report is a balanced reflection of these contributions. However, the paucity of input from low-income and middle-income countries is striking. Whether 4 months was sufficient time to communicate the process and garner responses from communities beyond the “policy elite”, as one paper describes them, is perhaps open to question. Nevertheless, the process usefully consolidated previous thinking, and drew attention to some fresh new proposals that could revitalise health's role in the post-2015 development agenda.
So what can we take forward, post-2015, from the successes of the MDGs, and what have we learnt from their shortcomings? It is widely agreed that one of the greatest assets of the MDGs is their simplicity. Presented as a set of eight unambiguous goals, 18 clear targets, and 48 measurable indicators, the MDGs were adopted with rare enthusiasm by governments and civil society alike. Their simplicity, however, has proven to be a double-edged sword. In narrowing down the goals to a limited number, many elements were left out—notably the rising tide of non-communicable diseases. This narrow focus encouraged vertical programming. The target-driven nature of the MDGs has also proven problematic. Many MDG targets involve increasing or decreasing by a set proportion the population beyond a certain threshold. There has been a temptation, therefore, to channel action towards those individuals nearest the threshold. The MDGs have thus contributed to greater inequity in some areas.
Given these pros and cons, several factors have emerged during the consultation process as vital for the next stage of human development: building on the conceptual simplicity of the MDGs; taking a people-centred, not disease-centred, approach that captures the determinants of health; and returning to the notion of health as a human right, with equity at its heart. How can these themes be converted into goals?
The consultation report proposes a hierarchy of goals, with maximisation of healthy life expectancy at the top. The proposal is a surprise move away from the concept of universal health coverage (UHC), which many had seen as the clear candidate for the role of overarching health goal. However, UHC does not address the determinants of health, is difficult to measure and compare across countries, and is only an indirect indicator of health status. Conversely, as Cesar Victora and colleagues argue in their Correspondence in this issue, “How long people live for is an easily understood concept, which accounts for the multiple determinants of health and disease”. Three indicators are proposed to measure progress: improved survival (including maternal and child survival), reduced burden of disease (including diseases covered by the MDGs plus non-communicable diseases), and lower levels of risk factors (eg, smoking and lack of access to sanitation). UHC is proposed as a further goal by which healthier life expectancy could be achieved, with increased coverage of essential services (eg, immunisation, reproductive health services, essential medicines), reduced out-of-pocket expenditure, and strengthened health systems (including the health workforce) as proposed indicators for this goal.
Health is just one of 11 themes on which global consultations have taken place. The outcome of discussions in Botswana next week will be crucial in ensuring that health remains central to the post-2015 development agenda. Running concurrent to the global consultation is the intergovernmental process to create a set of Sustainable Development Goals. The outcomes of both processes will be considered by UN Secretary General Ban Ki-moon in his report to the General Assembly in September. For health to maintain its prominence throughout these processes, it must be positioned as a key contributor to sustainable development. Healthy life expectancy, with UHC as a key means to that end, epitomises the cross-cutting role of health as both a requirement for, and outcome of, human development.