The ratification of the MDGs in 2000 was an unprecedented international agreement that inspired a generation to try and tackle the global scourges of poverty, hunger and disease. Health was mainly tackled through a commitment to combating the three big infectious diseases – HIV, TB and Malaria – as well as reducing child and maternal mortality. Between 1990 and 2002 the total global amount spent on overseas development assistance was static at around $50-$60bn per year. However, as a result of this new global commitment, funding has since rocketed upward to reach $141bn in 2011.
Net official development assistance disbursements from Development Assistance Committee donors, 1970-2009 (millions):
(From: UNCTAD 2012, UNCTAD Secretariat Calculations based on UNCTADStat, available here http://dgff.unctad.org/chapter4/4.3.html)
This increased financial and political commitment should be celebrated – the diseases mentioned in the MDGs were blights on the conscience of humanity and required urgent intervention. However, the MDGs also spawned an entirely new international development industry, alongside which came a number of unintended consequences.
If it’s a goal, it gets funding.
One result was that the system that arose to meet the targets valued some diseases more than others. While I was working in a rural South African clinic I experienced this paradox first hand. I treated one young man with anti-retroviral drugs supplied by a large NGO for his HIV infection, only to watch him die of appendicitis two weeks later through lack of access to a comprehensive health system.
Avian Park Township DOT clinic
The combined burden of non-communicable diseases (NCDs), which includes cardiovascular disease, cancer and trauma, far outstrips that of the infectious diseases. Two of every three people who die globally each year die from an NCD and 80% of these deaths are in low and middle income countries (LMICs). However, NCDs did not feature in the MDGs and thus did not receive and equitable portion of the funding. While HIV/AIDS is the world’s 5th leading cause of morbidity and mortality it received almost $6bn funding in 2012. Comparable figures are hard to come by for NCDs, but in 2008 the estimated global funding to tackle the entire burden of NCDs received less than$700m. One analysis suggests that funding proportional to disease burden is 30 times higher for HIV, TB and Malaria than for NCDs5. If that wasn’t bad enough, mental health and its devastating effect on individuals and communities around the world remains almost entirely neglected.
This disease specific focus has led to a situation where people with some diseases can access health services and others still cannot. Vast health inequalities are thus perpetuated by this fragmented and incoherent international development system. Often the decision as to which services are provided lies in the hands of the funders and due to the lack of coordination between organisations some services are even unnecessarily duplicated. As an example, in 2010 I was in South Africa running a vaccination programme in Khayelitsha Township outside Cape Town. With a group of medical students I was tasked with vaccinating schoolchildren against Measles on behalf of the South African Government. However a team from MSF also turned up to do the same thing. Despite much negotiating we ended up vaccinating half the school each to meet the needs of our respective masters. As the cold chain for our vaccines had been broken almost half were thrown away.
Vaccinating against measles in Khayeltisha Township (TCB left image, front left).
The Development Industrial Complex
As the process of deciding what will replace the MDGs gathers pace we have seen the enormous power of this new international development industry. Goals get funding and organisations need funding to meet their aims. Therefore many charities and NGOs have been wielding their influence to advocate for their particular area of interest to be included in the post-2015 agenda.
Currently the international development community do not have a robust conceptual framework for prioritising in health and the cacophony of calls for things to be included has become almost overwhelming. Theoretically the independent arbiter of global public health is the World Health Organisation, but it suffers from chronic under-funding and lack of political clout. Now 18% of the WHO’s funding comes from independent global health charities and funds. In my view that undermines its objectivity.
As a result of this situation the health goal proposed in the High Level Panel’s Report follow largely in the footsteps of the MDGs, being disease specific or demographic selective. This will only serve to continue the unacceptable cycle of global health inequality. With the process having come this far it’s likely that the final goals will be similar after some final wrangling.
Achieving Global Health
However all is not lost. The post-2015 goals define the ends, but the means remain open for debate. Herein lies a great opportunity to make concrete steps to frame an international consensus on the framework through which “global health” should be achieved. I believe that the Labour Party should be advocating for a system that is universal, promotes equality, and is applicable to all life course stages. It should be possible to develop a framework encompassing a safe birth and a healthy death. Good examples of this approach include universal access to clean water and universal health coverage.
Improving health is not just about tackling diseases, but also about influencing the wider determinants of health such as poverty, employment, housing and education. Arguably the provision of a social protection floor may do more to improve health than any medicine. A strong empirical evidence base should be used when designing and delivering interventions aimed at improving the health of the entire populations. A commitment to the independence of the World Health Organisation with national governments providing it with the resources it needs to do its job properly would be a valuable starting point.
Dr. Tim Crocker-Buque is a member of LCID