WHAT'S NEW THIS MONDAY: TWO ON POST-2015

Sunday, 7th of April 2013

·       TWO ON POST-2015

·       HEALTH AND THE POST-2015 DEVELOPMENT AGENDA

The Lancet, Volume 381, Issue 9868, Page 699, 2 March 2013 

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60562-0/fulltext

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.

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Correspondence Can WHO survive? An organisational strategy question Sebastiano Massaro. The Lancet 2 March 2013; Volume 381, Issue 9868: Page 726

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Correspondence The route to effective coverage is through the health worker: there are no shortcuts James Campbell. The Lancet 2 March 2013; Volume 381, Issue 9868: Page 725

The Lancet Commissions The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015 Jeff Waage,Rukmini Banerji,Oona Campbell,Ephraim Chirwa,Guy Collender,Veerle Dieltiens,Andrew Dorward,Peter Godfrey-Faussett,Piya Hanvoravongchai,Geeta Kingdon,Angela Little,Anne Mills,Kim Mulholland,Alwyn Mwinga,Amy North,Walaiporn Patcharanarumol,Colin Poulton,Viroj Tangcharoensathien,Elaine Unterhalter. The Lancet 18 September 2010; Volume 376, Issue 9745: Page 991

Articles Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis Rafael Lozano,Haidong Wang,Kyle J Foreman,Julie Knoll Rajaratnam,Mohsen Naghavi,Jake R Marcus,Laura Dwyer-Lindgren,Katherine T Lofgren,David Phillips,Charles Atkinson,Alan D Lopez,Christopher JL Murray. The Lancet 24 September 2011; Volume 378, Issue 9797: Page 1139

Comment Universal health coverage: the post-2015 development agenda Jeanette Vega. The Lancet 19 January 2013; Volume 381, Issue 9862: Page 179

Articles Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions Countdown Coverage Writing Group,on behalf of the Countdown to 2015 Core Group. The Lancet 12 April 2008; Volume 371, Issue 9620: Page 1247

·       A HEALTHY PERSPECTIVE: THE POST-2015 DEVELOPMENT AGENDA

Seth Berkley a, Margaret Chan b, Mark Dybul c, Keith Hansen d, Anthony Lake e, Babatunde Osotimehin f, Michel Sidibé g

Best viewed at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960722-9/fulltext

A proliferation of complex challenges to development, such as political conflict, economic austerity, and environmental degradation, all demand attention, but should not deflect from recognising that good health is central to advancing global prosperity. Development is about improving people's lives. A population cannot progress if it is burdened with ill-health. Good health is the foundation on which communities and nations can and do flourish. A healthy, educated population is one of the major engines of development—and one of its most universally valued outcomes. Whatever framework for development is agreed upon for the post-2015 era, people must be at the centre. Ultimately, we must be able to measure our success through indicators that help us understand the difference we have made in people's lives.

Looking back to 2000, when 189 countries adopted the Millennium Declaration, which set the principles and commitments for the Millennium Development Goals (MDGs), it was not known if such a framework would work. Although the MDG framework is not perfect, its contribution to the results in global health is tangible. Fewer children are dying: the number of children younger than 5 years who die each year has been reduced by more than 40% since 1990.1 Fewer children are underweight: the percentage of underweight children under the age of 5 years in developing countries is estimated to have dropped from 25% in 1990 to 17% in 2011.2 Fewer people are contracting HIV: worldwide the number of people acquiring HIV infection in 2011 was 20% lower than in 2001, and an unprecedented 8 million people in low-income and middle-income countries are on life-saving antiretroviral treatment.3 And fewer women die in childbirth each year: maternal mortality has been reduced by almost half from 1990 to 2010.4

A healthy population is a prerequisite for development. 1 extra year's increase in average life expectancy can increase gross domestic product by 4%.5 Some of the best buys in improving global welfare are through investments in health, such as expanding access to immunisation. Healthy individuals are more productive, earn more, save more, invest more, and work longer. Unhealthy people carry a high cost for themselves and for their countries. For example, malaria, which greatly contributes to the disease burden in many African countries, is estimated by the World Bank to cost Africa about $US12 billion a year.6 This cost results from, among other things, absenteeism, reduced efficiency, families paying high health costs, and reduced interest from foreign investors. Yet malaria can be prevented and cured by fairly simple means. The coverage of insecticide-treated bednets to protect families from malaria has increased from 3% in 2000 to 53% in 2012 in Africa, while 50 countries are on track to reduce malaria incidence by 75% by 2015 in line with the MDGs.7

A child who is borderline nourished will tip into malnutrition if he or she contracts an infectious disease such as measles. Children who are already malnourished are more susceptible to infections. Protecting children from diarrhoea—eg, through exclusive breastfeeding for the first 6 months of life, handwashing with soap, better water and sanitation, and vaccination—helps them better absorb the nutrients in the food they receive.

Development also has a direct bearing on health. About 25% of the global disease burden is due to modifiable environmental factors.8 Outdoor and indoor air pollution, by-products of unsustainable development, lead to respiratory infections, heart disease, and lung cancer. Climate change and environmental degradation are increasing the risk of extreme weather events, compromising food and water security, and exacerbating susceptibility to communicable and non-communicable diseases. The greatest burden falls on the poorest population, especially women and children. Over 220 million women would like to avoid pregnancy but are not using contraceptives and lack access to family planning services.9 New challenges arise as we struggle to reach pockets of poverty in middle-income countries where about three quarters of the world's poorest people now live.

The consultative meeting of the UN High-Level Panel of Eminent Persons on the Post-2015 Development Agenda in Bali, Indonesia, on March 25—27, 2013, will produce recommendations for the post-2015 development agenda, which will be discussed at the UN General Assembly in September, 2013. Sustainable development is fundamentally a question of people's opportunity to influence their future, claim their rights, and voice their concerns. This is all the easier if a population is in good health. The post-2015 development agenda must recognise this and give due prominence to advancing global health. People are at the centre of development, but better still, let's make that healthy people.

SB is Chief Executive Officer of the GAVI Alliance. MC is Director-General of WHO. MD is Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. KH is Acting Vice President for the Human Development Network at the World Bank. AL is Executive Director of UNICEF. BO is Executive Director of UNFPA. MS is Executive Director of UNAIDS. We declare that we have no conflicts of interest.

References

1 UNICEF, WHO, World Bank, UN. Levels and trends in child mortality: report 2012. New York: UNICEF, 2012.

2 WHO. Millennium Development Goals fact sheet no 290. http://www.who.int/mediacentre/factsheets/fs290/en/index.html. (accessed March 22, 2013).

3 UNAIDS. Global report: UNAIDS report on the global AIDS epidemic 2012. Geneva: UNAIDS, 2012.

4 WHO. Maternal mortality fact sheet no 348. http://www.who.int/mediacentre/factsheets/fs348/en/index.html. (accessed March 22, 2013).

5 Bloom DE, Canning D, Sevilla J. The effect of health on economic growth: a production function approach. World Dev 2004; 32: 1-13. PubMed

6 The World Bank. Malaria in Africa. Sept, 2012. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTMALARIA/0,,contentMDK:20912730∼menuPK:377606∼pagePK:148956∼piPK:216618∼theSitePK:377598,00.html or tinyurl http://tinyurl.com/l7xyum (accessed March 22, 2013).

7 WHO. World malaria report 2012. Geneva: World Health Organization, 2012.

8 WHOPrüss-Üstün A, Corvalán C. Preventing disease through healthy environments: towards an estimate of the environmental burden of disease. Geneva: World Health Organization, 2006.

9 Singh S, Darroch JE. Adding it up: costs and benefits of contraceptive services—estimates for 2012. New York: Guttmacher Institute/United Nations Population Fund, 2012.

a GAVI Alliance, 1202 Geneva, Switzerland

b WHO, Geneva, Switzerland

c Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland

d World Bank, Washington DC, USA

e UNICEF, New York, NY, USA

f UNFPA, New York, NY, USA

g UNAIDS, Geneva, Switzerland