PHM-Exch> PHM position ppr: Health in the Post-2015 Development Agenda

[Claudio Schuftan]

People’s Health Movement[1] <#_ftn1>
Health in the Post-2015 Development Agenda



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*<../../../../AppData/Local/Temp/PHM_Post-2015DevAgenda(121230).docx#_ENREF_1#_ENREF_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<http://www.ghwatch.org/sites/www.ghwatch.org/files/global%20health%20watch%203.pdf>
(2<../../../../AppData/Local/Temp/PHM_Post-2015DevAgenda(121230).docx#_ENREF_2#_ENREF_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<../../../../AppData/Local/Temp/PHM_Post-2015DevAgenda(121230).docx#_ENREF_3#_ENREF_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 <http://www.un-documents.net/s6r3201.htm> called for by the UN
General Assembly
1974(4<../../../../AppData/Local/Temp/PHM_Post-2015DevAgenda(121230).docx#_ENREF_4#_ENREF_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.           UN System Task Team on the Post-2015 UN Development Agenda.
Realizing the future we want for all – Report to the Secretary-General2012.

2.         People's Health Movement, Medact, Health Action International,
Medico International, Third World Network, editors. Global Health Watch 3.
London: Zed Books; 2011.

3.         Commission on Social Determinants of Health. Closing the gap in
a generation: health equity through action on the social determinants of
health. Geneva: WHO; 2008.

4.         UN General Assembly. Declaration on the establishment of a new
international economic order1974 1 May 1974. Report No.: A/RES/S-6/3201.







------------------------------

[1] <#_ftnref1>. Paper submitted to the *Health in the Post 2015
Development Agenda* call for papers by the People’s Health
Movement<http://www.phmovement.org/en/about>
.  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<http://www.phmovement.org/en/resources/charters/peopleshealth?destination=home>
).  This paper was developed by a team led by Natalie Eggermont and adopted
by the Steering Council of PHM in December 2012.
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