TWN Info Service on Health Issues (Jul14/02)
23 July 2014
Third World Network  

Dear friends and colleagues,

On the sidelines of the recently convened 67th World Health Assembly in Geneva from 19 – 24 May 2014, there was a technical briefing which discussed progress on the goals and targets for the post-2015 development agenda, with particular regard to the role of health in these.  Please read below a report on the briefing.

With best wishes,
Third World Network

Goals and Targets for health in the post – 2015 Development Agenda
WHA Technical Briefing
22 May 2014
@ 67th WHA 19 – 24 May 2014, Geneva

The debate on the goals and targets for the post-2015 development agenda is in full swing. Health as a goal appears in a dozen or more multiple processes, such as the Open Working Group of the General Assembly (OWG) and the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda. The United Nations General Assembly (UNGA) will discuss the OWG report in September 2014.

The objective of this technical briefing was to provide an overview of the current processes and the role of health in them, and to gather views from Member States about the possible health goals, sub-goals and targets.

As Chair of the Technical Briefing, Dr Suwit, in his introduction informed that when negotiations on the Millennium Development Goals (MDGs) were first held in 1990, Universal Health Coverage was not on the agenda.   It is now included.   His comment: “Let’s not kill each other to get issues included into the post- 2015 MDGs,” was taken in good humour by participants.  He requested the DG of WHO, Dr Margaret Chen to make her introductory remarks.

Dr Margaret Chen began by commenting: “When the Rio+20 meeting outcome report emerged, it showed that health was anaemic, on a respirator, in ICU.  A group of medical students came to me and requested that we work together because we need healthy people to work together.”

She went on to explain that the World Bank and WHO joint document is the outcome of a long process of joint collaboration.   “If the post – 2015 Development agenda is about poverty elimination and inclusive growth and leaving no one behind, then UHC has all the elements for achieving this,” she added.

According to Dr Chen, catastrophic healthcare costs accounts for 100 – 150 million people being pushed into poverty every year. “The post – 2015 development agenda cannot ignore social protection within UHC,” she stressed.

She further stated that the Lancet Commission on Investing in Health confirms the importance of health because any investment in health will produce good returns.

“Health delivers results,” she stated.  “This was borne out by the following:
- From 12 million deaths yearly the figures are down to six million
- HIV, TB, malaria all made good progress
- Negelected and tropical diseases are being addressed.

In this day and age, nobody will give money if there are no results,” she asserted, giving the example of GAVI and the Global Fund.

She reminded participants that to be able to show results, effective health information systems were necessary for gathering statistical data and registration purposes.

She informed that UHC is really an euphemism for strengthening health systems so that equity for financing of health care is appropriately addressed.  She indicated that there has been a lot of misunderstanding about UHC and confusion  around which system to adopt - private market based health care systems with private insurance schemes or voluntary community based insurance schemes and  reiterated that how a country structures its health system is strictly its own prerogative.  “WHO does not lack examples of countries with good experiences and success stories for this.  The role of the WHO is of knowledge broker,” she stated.

Following Dr Chen’s introductory remarks, Dr Sumit informed the group that it might be useful for Thailand to share its learnings on UHC as well.  He posed the following question to Dr Chen: “The post – 2015 development agenda has two streams, but you have only dealt with UHC – why?”

Dr Marie Paul-Kierney began her presentation by stating she would  respond to the question posed by Dr Suwit by focusing on ‘What is the post – 2015 development agenda?’  She based her presentation on the following:  processes; MDG review; emerging agenda; and place of health in the post-2015 development agenda.

On the processes, Dr Kierney stated that the post-2015 development agenda was a MS led process which started with Rio+20 in 2013 and will be followed by the UNGA MDG Review in 2014 culminating in the UNGA post – 2015 development agenda meeting in 2015.  This led to the formation of the OWG, IG Committee of Experts on SD Financing and the High-level Panel of Eminent Persons.  Some of these have delivered products/outcomes, others are still in the process of doing so.  Some of the products that have been delivered include: the Rio+20 ‘Futures we want’ report and the ‘Realizing the Futures we want for All’ Report from the UN Task Force team.

The MDG reviews showed successes and shortcomings.  Amongst the successes were:  there is more money for health; there is more progress since 2000 from before and there has been influence on political level.  The shortcomings were: there is too little focus on equity; and the human rights aspect is missing.

She informed that the MDG Review Summit of September 2013 stressed accelerated progress from then to 2015 as there were clear indications that MSs were lagging on achieving the targets;  the most off-track MDGs would be given priority.

On the emerging agenda, addressing poverty would continue to be the focus; 16 focus areas have been proposed by the OWG in 2014.  People’s view on top priorities showed that health ranked as number 2 on the list.  It was therefore clear that health was high on emerging agenda:
- Health is very prominent in the MDGs
- Good convergence on the place of health as demonstrated at Rio+20 outcome document
- Health links poverty reduction and sustainable development
- Health is a suitable goal in its own right.

She indicated that several points were noteworthy from the Health Thematic Consultation, one of which was that UHC is a service that people need in view of catastrophic costs or financial hardship where some form of protection was absent.

Dr Kierney concluded by stating that:
1.  the discussion on the post – 2015 development agenda goals and targets is a big and complex problem, but it is progressing. 
2. There is some convergence with regards to overall goals, outcomes and some targets.
3. Setting meaningful goals and targets will resonate well; the most challenging part will be prioritising the large number of focus areas and subgoals.

As the third panelist, Dr Martin Khor, Director of the Geneva-based South Centre, was requested to comment on WHO’s presentation on the review process and the emerging agenda with particular reference to health in the goals, subgoals and targets.

Martin began by stating that he endorsed all the subgoals and reiterated the concerns of  the African MS that the MDGs should not be forgotten in the discussion of the post-2015 development agenda.

He indicated that a few more targets had been added to the development agenda and that “we can debate targets but not subgoals.”  He observed that as Non-Communicable Diseases were not dealt with in the MDGs, this needed to be reflected as an ambitious goal.  He added that the third subgoal  should also be included as an ambitious goal.  He agreed that a country should be able to exercise independence in deciding how it aimed to achieve UHC, and that this should not be ‘straight –jacketed’.   He reiterated that this was in fact a part of the WHO goal of ‘Health for All by the Year 2000’.

He observed that a positive development was the inclusion of major issues like equity into Sub goal four which had not been included in the MDGs and that this in fact addressed the roots of the problem.  He stated that: ‘I would like to add “achieve better access to medicines”,’in the subgoal  and to have targets for this.

He indicated that some issues such as antimicrobial resistance were not addressed by the review process. 

“Antimicrobial resistance is missing,” he stated.  “Antibiotics have increased life expectancy by 20 years and if there are no more effective antibiotics, life expectancy would therefore drop by 20 years.  We therefore need to address this,” he reiterated.  He suggested adding “Reverse Antimicrobial resistance by the year …..” as a fifth Sub goal.

Apart from this, rational drug use and drug consumption and practices were other aspects that needed addressing.  A missing priority was the need to mobilize resources for developing countries, he added.

Martin concluded by pointing out that there was a need to combat new and emerging diseases and to manage pandemics as they occur and that this should considered for mention as another Sub goal.

In representing the position of high income countries, Dr Ushio from Japan indicated that two trends were emerging from the discussions on the post-2015 development agenda with particular respect to the OWG on SD:
1.  Despite the progress in health and achievements on the outcomes, there has been insufficient emphasis on equity in the MDGs
2. The burden of disease has changed.

Dr Ushio’s view was that the post-2015 development agenda should address those trends.  He informed that Japan’s position was that health should be an overall goal and that a common understanding of UHC was necessary, mainly to overcome misconceptions around  ‘forced/coercive’ insurance.  He indicated that the principle of financial security that UHC promised must be appropriately communicated in order to allay any misconceptions.  His view was that UHC also addresses social determinant and therefore should be considered as another sub goal.

The experience of Japan has shown that maintaining UHC and life expectancy was a challenge even for a developed country.

In representing the position of low income countries, the panellist from Bangladesh, asserted that Bangladesh can achieve UHC with support from global partners.  He stated that UHC is not counter productive in the context of NCDs.  He conveyed that Bangladesh would achieve UHC before the year 2030, in addition to other targets. 

The panellist from Chile, representing the position of middle income countries, shared the country’s experience on UHC and informed that since 2005, the government has made explicit health guarantees aimed at addressing health problems.

He shared that Chile’s system of a mix of private and public sector financing was based on discussions around everyone’s right to health.   Health outcomes in Chile were more favourable  than other countries at the same income levels.

“We are concerned about equity in health care and this mixed system has allowed equity to be achieved,” he remarked.  The Chilean position was to continue using the ‘social determinants approach’ on health.  There was reservation on the OWG draft resolution; the Chilean view was that the objectives were weak and that in the interests of developing countries,  a Sub goal which explained UHC explicitly was needed with clear definition on coverage and equal access to health care.

The panellist from Bangladesh raised concerns about finances for health care services in tertiary hospitals in the interest of UHC and requested donor countries’ responses on this.

The representative from the World Bank commented that UHC is an instrument or tool to eliminate/reduce poverty.  Access to health services is a means to achieving the subgoals.  He added that the link between health and economic development was clear.

With regards to Subgoal 4 – Improved nutrition, the comment was that there should be bigger targets for child stunting and increased breastfeeding.

It was suggested that more discussion should occur on targets, equity, human resources, access and the  social determinants for health.  It was also clear that there must be progressive realization of UHC and that low and middle income countries must increasingly help themselves and improve on their investment in health.  Donors would play a supplementary role to countries.

In her response to the comments, Dr Kierney stated that in addition to the targets and indicators for UHC, countries must continue to monitor the effectiveness of their health systems, amongst which was access to medicines.

According to the member from South Africa, the framework to monitor UHC for BRICs will be expected to be launched in September 2014.  “How can we be sure that we don’t end up in the same situation as Alma Atta?” (where comprehensive PHC was launched as a means to ‘Health for All’ but selective PHC was adopted instead)

Dr Ilona lent her support to Dr Martin Khor’s plea for including antimicrobial resistance as a subgoal.  She wondered how agreement on these suggestions could be arrived at.  She was concerned about the place of health as a goal, in view of all the other existing goals.

The member from India commented that current measurements of equity were based on socio-economic gradients, and that it was also necessary to look at other gradients and how these could be captured and incorporated into the review.

The member from South Africa suggested the need for planning and support to governments on how to prepare and achieve UHC.

A general question was how to design a simple way of measuring progress on health, without focussing on UHC.  The concern here was that ‘well being would not be addressed, with focus on disease and disability’.

Dr Kierney informed that the OWG had agreed on 16 goals and 80 sub goals.  Within these were 400 – 800 indicators.  She added that to be credible there was a need for a framework with a manageable number of indicators.

According to Dr Kierney the World Bank is very committed to health and is working ‘hand-in-hand’ with the DG Dr Margaret Chen.  She added that MS strategies were being monitored by the working group at WHO.

“Each country must be transparent and explicit about the packaged that it offers to its people,” she stated.

In his summing up of the briefing Dr Sumit stated that there was general acceptance of the subgoals and reservations on the targets and package.  He added that the OWG at WHO must link and work together with the OWG in New York  to fully reflect MS needs.

Prepared by:  Ms Shila Kaur
              Health Consultant
              Third World Network (TWN) Penang