As the deadline for the achievement of the Millennium Development Goals (MDGs) approaches, the UN is driving a global consultation around a new global development agenda post 2015. The People’s Health Movement (PHM) welcomes the prospect of a global compact which commits to sustainable and equitable development. However, the negotiators will need to go beyond the mere palliation of symptoms to confront the dynamics that are driving widening inequality, avoidable suffering and accelerated destabilization of the biosphere including global warming. The UN documents on a post 2015 development agenda are neither addressing the looming crisis of capitalism, accelerated by the ascendant ideology of neoliberalism nor the unequal global power relations which both reflect and deepen the crisis.
The MDGs, and the concomitant expansion of international assistance, were direct responses to a global revulsion at the continued transfer of resources from South to North through ‘debt’ repayment, unfair trade and investment regimes and the role of ‘intellectual property’ protection in the denial of access to medicines at the height of the AIDS epidemic.
Increased international assistance for health has helped to extend access to treatment for people living with HIV although 7m people who need treatment access are still waiting. However, the MDGs have not addressed the structural barriers to sustainable and equitable development – nor were they designed to do so.
PHM calls for activists in people’s movements across sectors and countries to redouble our efforts to hold governments to account and to channel the aspirations and energies of communities and social movements towards redirecting humanity’s development from its current disastrous path.
Key messages
Our messages for the political leaders who will formulate the next set of ‘development goals’ are:
· Development must not be construed solely as economic growth and industrialisation; it must include cultural and institutional development; and include the rich world as well as low and middle income countries (LMICs). The right to health will not be achieved without commensurate social, cultural, institutional as well as economic development. The determinants of health arise in social practice across all sectors including work, agriculture, trade, education and culture among others. ‘Development goals’ that speak of health but do not aim for broadly based equitable and sustainable development would be a hoax.
· Addressing the global health crisis requires that we confront the social, economic, political and environmental determination of health, as well as the prevention and treatment of specific diseases. As a tool for shoring up the existing distribution of privilege, in the face of the looming crisis of globalised capitalism, the ideology of neoliberalism is promoting exclusion, exploitation, inequality and environmental degradation; it is transferring the functions of governance to the anarchy of the market. A new economic order and new forms of global regulation are critical pre-requisites to address the challenges of today and the post-2015 period.
· Unless reform of the global economic and political architecture is put on the table, there is no point in discussing a post-2015 'development agenda' for health or any other purpose. The current drive for global economic integration through ‘free trade’ agreements is designed to protect the prerogatives of transnational corporations and global elites, but makes it increasingly difficult for nation states to achieve sustainable development and universal social protection.
· The post 2015 development agenda must work towards new approaches to national and global decision making, based on popular participation, direct democracy, solidarity, equity and security. The MDGs presumed that development could be achieved solely through international aid; this is an illusion which has served to divert attention from the deeper political issues of governance. The prevailing ‘charity’ model needs to be replaced by a human rights-based approach with clearly delineated responsibilities and strong accountability to civil society.
· Sustainable and equitable development - including governance reform and the restructuring of economic and political relationships – will be achieved only if people’s movements unite across sectors, cultures and national boundaries and articulate a coherent set of goals and strategies for change. There will be fierce opposition from the corporate sector and from those nations and classes whose privilege depends on continuing economic integration globally notwithstanding the instabilities of this regime. Carrying out these struggles will require solidarity, determination and political organisation. We call for leadership across civil society worldwide and from progressive governments in the global south.
Lessons learned from the MDGs
The UN Task Team on the Post-2015 UN Development Agenda concluded that “the central challenge is to ensure that globalization becomes a positive force for all the world’s peoples of present and future generations. Globalization offers great opportunities, but its benefits are at present very unevenly shared”(1).
This sentence is taken directly from Article 5 of the Millennium Declaration and there are other similarities between the two documents. Have we learned nothing over 12 years, that the central message remains unchanged? Instead of jumping into new goals we need to analyze why, behind the chattering statistics of progress, the situation has not fundamentally improved.
We have previously criticized the MDGs for focusing on ends while being silent on the means to achieve them. As recognized by the UN Task Team: “this has been a lost opportunity to provide guidance on how to address the root causes of poverty and unmet basic needs”. The values and principles expressed in the Millennium Declaration were lost in implementation and we were left with a set of quick wins in which progress was measured in terms of country averages that have left much suffering unrecorded. The MDGs were conceived, defined and implemented in a top-down process, structured around international financial assistance; issues of governance, participation and empowerment were insufficiently addressed.
We support the Task Team’s call for transformative change and a holistic approach with a focus on the core values of human rights, equity and sustainability, and call upon the UN to include empowerment in the list of core principles. However, we believe the Task Team failed to properly delineate the problems humanity is facing. “Today’s Global Challenges” presents the surface symptoms of the underlying problems; there is no mention of the skewed global power relations or the hegemonic prescription of particular models of ‘development’ by a few countries. World leaders have tried to solve our problems by simply doing more of what caused them in the first place. It is necessary to rethink what we mean by development and to challenge economic globalisation, neoliberalism and the entrenched global power imbalances.
On development
The dominant view identifies ‘development’ with economic growth and positions it as solely a problem for LMICs. This ignores the challenges of planetary sustainability and the need to move to a steady state economy. The current model privileges economic over social, cultural and institutional development and diverts attention away what needs to be done in the rich countries (HICs).
Environmental sustainability is clearly one of the key issues that must be addressed in any set of upcoming development goals. This calls for a dialogue regarding the causes of the current destabilisation of the human environment, including the growth fetish of dominant economic thinking. Changing economic relationships, including capital accumulation without net global growth, is the big challenge of economic development. Global development goals must be directed to both the rich world and the LMICs; to both the global economy and the ecology of the biosphere.
We need to think in terms of social, cultural and institutional as well as economic development. Failures in national and global decision making around climate change, tax justice and regulating the financial sector illustrate the need to put the institutions of policy making on the development agenda. Critical challenges to sustainable and equitable development such as racism, patriarchy, gender-based violence, inequality and exclusion, individualism and consumerism are insufficiently addressed in current development thinking.
The concept of ‘development’ needs to be delinked from international financial assistance. The term has become synonymous with international aid, including the ‘development assistance’ industry and ‘development partnerships’ between donors and governments. In fact, the power of donors to dictate national policy to recipient countries reflects the global power imbalances and the political and economic relations through which they are sustained. These grossly unequal power relations are barriers to real development. International aid could be useful, though often it is not. Real development has to recognise local histories, the role of communities, power relations and ideology.
On Capitalism, neoliberalism and globalisation
The global health crisis reflects the failure to address the social, political and environmental determination of health. Any new health goal(s) must not be solely about health service delivery, even if broadly interpreted; we need to address the causes of the causes as the Commission on the Social Determinants of Health called for.
In this regard, the Task Team has come to some important conclusions, but does not go far enough in its suggestions for a new development paradigm. Their report rightly notes that the global food, fuel and financial crises have “exposed systemic failures in the workings of financial and commodity markets and major weaknesses in the mechanisms of global governance”. We have argued, in Global Health Watch 3(2), that the multiple crises not only show the failure of the current institutional framework of the global economy, but also of the neoclassical conceptualization of economics itself. Capitalism in its current form, with widening inequality and poorly regulated markets, and dominated by the interests of a small rich minority is a major barrier to achieving equitable, sustainable development.
It is capitalism and the ideology of neoliberalism (small government, ‘free’ markets, global economic integration) that promote exclusion, exploitation, inequality, waste and environmental degradation. New economic relations and new forms of regulation are critical pre-requisites for addressing the challenges of today and the post-2015 period.
None of the circulating proposals and documents from UN-institutions challenge the prevailing paradigm of economic growth. The UN Task Team calls for “stable, equitable and inclusive economic growth, based on sustainable patterns of production and consumption”; but, despite the finding of the Commission on the Social Determinants of Health that “income redistribution, via taxes and transfers, is more efficient for poverty reduction than economic growth per se”(3), the word “redistribution” does not appear once in the entire Task Team report. Redistribution, however, is only one step towards disparity reduction. Other mechanisms to change the prevailing system are also needed. In a carbon-constrained world, a strategy of continuing net global material growth does not make sense.
Any discussion of post-2015 priorities that ignores the constraints imposed by capitalism, globalisation and neoliberalism is unlikely to come up with workable solutions to the substantive issues at stake. PHM calls upon civil society organisations around the world to insist on these issues being discussed. PHM calls upon the countries of the global south to provide strong leadership in containing and regulating capitalism and moving towards an equitable and sustainable global economy, capable of creating decent living conditions for all. Revisiting the New International Economic Order called for by the UN General Assembly 1974(4) would be a good start.
On global governance and power imbalance
We strongly welcome the emphasis placed on issues of governance in the report by the UN Task Team. We agree that “better governance of the economic and financial sector will be key to maintaining regulatory frameworks that respect human rights and protect the environment”. The current global trade and investment regime is seriously undermining universal social entitlements and human rights, as well as the power of states to regulate the activities of corporations and private financial institutions. Rich countries ‘spheres of influence’ encumber the rights of the citizens in less powerful countries to determine their own development pathways. Improving governance, nationally and globally, should be central to the post-2015 development agenda.
Governance reform in the health sector must include attention to the chaotic regime of global health initiatives (GHIs) created over the past 15 years to channel donor funds to particular diseases and interventions. These GHIs were created to fill a space which was created by the refusal of the rich countries to properly fund the World Health Organization. WHO, adequately funded and defended against big power bullying, is the proper intergovernmental organisation to provide global health leadership, including health systems, social determinants and diseases and interventions.
The proliferation of global health initiatives dependent on a charity model of ‘development’ has contributed to the fragmentation of health systems and of global governance for health. A radical rationalisation of global health architecture is needed with WHO regaining the preeminent role of coordination and leadership including monitoring and holding accountable the donors and GHIs. WHO must be empowered to play a more active role in a more coherent and more accountable system of global health governance. The restoration of WHO to a leadership role in global health governance will require that the member states commit to this outcome. PHM calls on civil society organisations concerned for health to ensure that all member states are fully accountable for their carriage of this responsibility.
Gross power imbalances in political and economic decision making must be addressed. These imbalances include the formal structures of intergovernmental organisations and treaties, the daily practice of foreign affairs, the undue power of transnational corporations and the structures and ideologies embraced by those who control the media. If the global political and economic architecture with its prevailing power imbalances is still in place in 2015, it is hardly of any use to discuss a post-2015 'development agenda' for health. Finding pathways to sustainable development calls for exposing and redressing these power imbalances because they are integrally part of the problem.
On participation
A fundamental tenet of human rights is that people have a right to participate in the decisions that will affect their lives, including health-related policies at local, national and international levels. The accountability of governments and corporations depends upon the active and informed participation of individuals, civil society organisations and social movements. People must be at the centre of the new development agenda and be engaged at every stage of the process; defining, implementing and monitoring of the new development framework.
In terms of community participation, the UN consultation process around the post-2015 development agenda is falling short. The country consultations are supposed to target the poor and marginalized but the guidelines suggest inviting only representatives of various groups to the consultations. These consultations shouldn’t simply be about extracting information to help define global goals that will then be implemented in a top-down manner. They must be used to put in place mechanisms of continuous community engagement. A constant feedback loop is what needs to be set up; to enable people to effectively engage in the entire process, including holding their governments accountable for their obligations. We call for community consultations, not as a one-time information collection effort, but as a first step towards setting up democratic national and global governance structures.
On Universal Health Coverage
We are concerned about the proposal that Universal Health Coverage be adopted as the sole post-2015 health goal. On the positive side, UHC will involve health systems strengthening, replacing the current disease-focused approach and giving greater weight to equity. However, the concept is broad and there is no consensus to date on its precise meaning. We oppose the promotion of a minimalistic insurance model that would offer “basic packages of care” and would operate within a market-based system of healthcare. UHC must be achieved through organized and accountable systems of high quality public provision of comprehensive primary health care and a fully functional referral system governed by need.
We are concerned that the focus on “service delivery” associated with UHC will divert attention from action on the structural determinants of health and tackling the root causes of ill-health and disability. Equal access to health care is an underlying social determinant of health, but just one of many. Striving for UHC should be part of a comprehensive strategy including a focus on the SDH. Although the UN and WHO define health services as including “prevention, promotion, treatment and rehabilitation”; we are concerned that the promotional services will only encompass action on some of the determinants, targeting individual behaviour, while leaving out the more contested ones such as trade and power relations. In the September briefing on the post-2015 process, it is mentioned that WHO is working with UN Water and the UN Secretary-General’s Advisory Group on Water and Sanitation on framing a water-related goal. We call on WHO to take this process a step further and to engage with all the other sectors that affect health, including global trade.
If population health is to be used as a benchmark for progress in other fields of development a more pro-active health-in-all-policies approach will be needed. However, contemporary health status is not an index of intergenerational equity and given the ecological crisis, intergenerational equity is looming as one of the key parameters to be measured. The holistic approach advocated by the UN Task Team has to be understood as going beyond health and looking at the other fields to ensure policy coherence and synergies between the different goals. Human rights, including the right to health, equity, sustainability and empowerment must be put at the center of all policies. This will require a broader view of development, a more democratic and participatory regime of global and national governance and a configuration of economic relations that supports equity, decent living conditions and ecological sustainability.
References
[1]. Paper submitted to the Health in the Post 2015 Development Agenda call for papers by the People’s Health Movement. PHM is a global network of grassroots health activists, civil society organizations and academic institutions from around the world, particularly from low and middle income countries. "Equity, ecologically-sustainable development and peace are at the heart of our vision of a better world - a world in which a healthy life for all is a reality; a world that respects, appreciates and celebrates all life and diversity; a world that enables the flowering of people's talents and abilities to enrich each other; a world in which people's voices guide the decisions that shape our lives...." (from the People’s Charter for Health). This paper was developed by a team led by Natalie Eggermont and adopted by the Steering Council of PHM in December 2012.
