Health in the post-2015 agenda: three considerations in moving forward

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Sania Nishtar ¹

¹Founder and President, Heartfile, Islamabad, Pakistan.
emhj, 2014, 20(2): 71-72

When the Millennium Development Goals (MDGs), the world’s biggest promise ever, were embraced by 189 nations in 2000 as a unifying framework towards the goal of development and poverty eradication, their true potential to shape development norms was not known to the world. Since then, the MDGs, their weaknesses notwithstanding, have transformed political agendas, shaped intersectoral action, forged global consensus and helped to catalyse partnerships between governments, development partners and civil society. They have been a tool to foster consistency within domestic policy—a key gap in developing country polity, and one that threatens reform—and contributed to making development assistance predicable. Often they have served as instruments for debt relief in poor countries. Their leverage has been unprecedented.

These strengths have co-existed with their acknowledged limitations, particularly their silo approach, list of exclusions and neglect of equity. The health MDGs have been criticized for disregarding broader determinants of health, health’s ideological rights-based underpinnings and the life-course approach. Their inattention to health systems, noncommunicable diseases (NCDs) and mental and reproductive health, as well as the insufficient linkages of health with development, have also been recognized [1].

Nevertheless, despite the shortcomings, there are important lessons to be learnt from the experience with the MDGs, which should be factored into planning as the post-2015 health goals get cast. Three points are outlined in this regard.

First, it should be recognized that the political success of the MDGs depended on certain characteristics of the “goals” themselves. The goals were measurable, time-bound and outcome-based. They were specific and unequivocal and led, in most cases, to logical action. They were aspirational yet pragmatic, universally accepted yet adaptive to specific circumstances and populations, and country-specific yet allowed for cross-country comparability. Moreover, they passed the “30-second test”, the ability to make sense to a decision-maker within that time. These characteristics of “goal-setting” should be brought to bear in the next iteration of goals.

Second, the post-2015 agenda and the imperatives it creates for country capacity should be recognized. Auspiciously, there appears to be an acceptance of the need to include universal health coverage (UHC) and NCDs as well as, to a lesser extent, reproductive and mental health in the new framework [2] Both UHC and NCDs can provide an entry point to strengthen health systems, the missing element in the MDGs. Unlike the dose–response approach, i.e. immediate effect and permanent solutions, of the donor-funded, health-system-channelled MDG programmes, both UHC and NCD demand indigenous action outside of the health system. UHC, for instance, is about social policy choices made by governments at the level of the Cabinet, with many sectors, including labour and finance in particular, deeply involved. The population-based approach to NCDs inherently necessitates action outside the health sector [3]. In both cases the pathways to make change lie outside of the health system, which is why new stewardship capacities are required for intersectoral engagement. The attention to wellbeing inherent in the frameworks that are evolving in the run up to post 2015 underscore the potential of intersectoral collaboration [4–12].

The new emphasis on systems and the “whole of government” will need to be balanced with a focus on the “unfinished business of the MDGs”, which in spite of their limitations have had success. At the same time, there are some straightforward solutions to the existing MDG weaknesses. For instance, the inattention to equity in the current iteration of the MDGs could be addressed to some extent through a focus on data disaggregation and specific targets to close the gap.

Third, the broader context in which goals are evolving must be brought to bear. The post-Cold War optimism and G8 fiscal space, a milieu in which the MDGs emerged, are a contrast to the post-financial crisis world in which the post-2015 goals are being crafted. Also, the MDGs were developed for the aid system, but the post-2015 goals are meant to be owned by governments, which exemplifies how the responsibility for development is shifting from the donors to the domestic stakeholders. This shift is already evident in the language of the Busan Partnership for Effective Development Cooperation [13]. Moreover, development thinking has moved from linear to complex, from diseases to systems, from heath to multiple sectors, and from one ministry to a whole government approach. Today an appetite has been created for democracy and accountability in the aftermath of the financial crisis, and societal political awareness has become infectious after the Arab spring, all intensified by the interconnectivity and pervasiveness of social media use by the youth. Technological tools such as cell phones and unconventional channels of communication such as soap operas are becoming game-changers in development. Global discussions are veering from the future of the people to the future of the planet. The forces shaping the future are important to take stock of or we risk making assumptions that may not be valid in the future.

For all these reasons, the post-2015 era brings challenges but also opportunities. Changing institutional behaviours requires long-term investments in systems. We will have to part with the project mentality of donors and policy vacillation of governments before success can be framed as an expectation.

References

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2. The World We Want. High Level Dialogue on Health in the Post-2015 Development Agenda Gaborone, 4-6 March 2013 (meeting report) (www.worldwewant2015.org/file/320271/download/348522, accessed 3 March 2014).
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