A week ago, I was writing about rights—in this particular instance, the right to safe water, having personally experienced the city of Santiago without water during my stay in Chile. It seemed to me, as the city waited for water companies, and not hospitals, to oblige, that many solutions to fundamental public health problems lie outside formal health systems.
Now I am back in Boston, in cooler climes. Despite the fact that I walk around looking like the Michelin Man (a million layers, padded coat, furry hood that just stops short of totally covering my head, gloves fit for a heavyweight finalist), at least here I can unabashedly waste the abundant outflows of the Quabbin and Wachusetts reservoirs.
Millennium Development Goal target 7c is to halve the proportion of the population without sustainable access to safe drinking water and basic sanitation, by 2015. The Millennium Development Goals (MDGs) are eight international development goals established under the auspices of the United Nations (UN) in 2000, to be met by 2015.
How timely, then, that today (Thursday 31st January) I should be lucky enough to attend a Q&A with Helen Clark, former Prime Minister of New Zealand and administrator of the United Nations Development Programme, which is “the world’s development agency” and scorekeeper of the MDGs.
Winners, losers, and in-betweeners
When asked how the MDGs were going, with a look suggesting an acute awareness of the controversies and sensibilities surrounding these development targets, Clark replied, “not so badly.”
What has been achieved thus far? There have been clear successes and clear failures, but mostly, as in life, various nuanced mixtures of the two. Ghana is described as one of the successes. A former British colony—the first to gain independence in Africa—it was a relatively late entrant to the “extractive resource industry.” Ghana has oil but it has also learned lessons from its neighbours and has taken care to avoid falling prey to the “resource curse” that has afflicted nations such as Nigeria. In contrast, those countries still mired in conflict, such as Afghanistan, the Democratic Republic of Congo, and Mali, have fared badly.
It is easy to consider the MDGs as set in stone. But MDG target data need to be interpreted in context. For example, the goal to halve the proportion of people living on less than 1USD a day has been achieved, but as Clark points out, this is largely due to successes in China. Regional disparities remain. Similarly, targets for the number of children entering education may differ from those actually remaining there. Yet, in Burkina Faso, for example, whilst the percentage of children in school may be regarded as low (68%), given that adult literacy is less than 25%, this represents a significant achievement. Furthermore, many countries have developed their own goals to reflect local circumstances.
What next for health in the post 2015 agenda? In response to various questions about this, Clark offered some thoughts. Moving beyond the health sector, to address non communicable diseases (NCDs) and the drivers of chronic disease, such as tobacco use, are key, as are sustainable development and environmental health.
In particular, the need for collaboration between health, development, and environmental agencies was made apparent. Clark is personally enthusiastic about an “environmental sustainability adjusted Human Development Index,” as a next step after the Human Development Index, which was a pioneering alternative to GDP as a measure of countries’ progress.
The difficulty, however, is that we all know people need to talk to each other. Silos are good for storing grain, but little else. Yet—particularly in times of financial constraint—institutions contract and become insular. So how and where will the dialogue happen? As well as countrywide consultations and high level expert panels, the UN is crowdsourcing ideas for the future through social media platforms and innovations such as the Rio +20 dialogues.
Universal coverage is another important goal, and social protection, “a line below which no one will fall,” is deemed key to consolidating development gains made by countries.
Recognising the increasing role of non-state actors, including private corporations, in the global health arena, the UNDP is promoting “inclusive business” models that try to reach beyond traditional notions of corporate social responsibility. Maybe they should send copies to the tax people at Starbucks and Amazon.
There wasn’t much discussion about health systems strengthening, which is widely recognised as a necessary “horizontal” addition to existing “vertical” disease specific targets and interventions. Whether it will feature in specific targets post-2015, or happen vicariously through other outcome measures, or at all, is unclear.
Those who broaden agendas to foster inclusivity and legitimacy face the ultimate conundrum: how to do so without compromising effectiveness or diluting impact. Decisions need to be made and things need to get done. Whilst United Nations agencies and policies are not short of critics, today, at least, I came away with a sense of sincere, frank, and realistic commitment to improving global health and development beyond mere lip service. 2015 isn’t far away. Let’s see what transpires.
The interpretation and views represented here are my own. Many thanks to The Forum at Harvard School of Public Health for the opportunity to hear Helen Clark.
Suchita Shah is a general practitioner in Oxford, UK. She is currently living in Boston and is a student at the Harvard School of Public Health, Boston.