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Integrating Health into the Post-2015 Agenda
Improving health was core to the Millennium Development Goals (MDGs) with specific targets for combating infectious diseases and reducing maternal and infant mortality. While important global health issues, this disease specific and demographic selective approach has skewed funding, resources and the global health narrative to the exclusion of other important causes of global morbidity and mortality.
While volunteering as a clinician in rural South Africa I remember treating a patient with NGO supplied anti-retroviral drugs for their HIV infection, only to watch them die of appendicitis due to the lack of access to a comprehensive health system. When I asked one of my Zimbabwean colleagues why he had chosen to focus on infectious diseases, he enthusiastically described the opportunities to access research funding and international training courses. This effect has seen many African trained clinicians focusing on projects tied to an MDG target to the detriment of other areas of practice and often leaving their country of origin, further contributing to the global health workforce crisis. His hospital had not had a trained surgical specialist for a number of years and much of the radiology equipment lay abandoned. This picture is replicated across many low and middle-income countries and point to one of the greatest failings of the MDGs.
Ultimately there is more to global health than HIV, Malaria and TB. Yet we have created a system whereby some diseases matter more than others. This is not true in the eyes of sufferers, but in the reports of the funders. Although the decline in child mortality and reduction in new HIV infections are to be celebrated as an unprecedented success, there remains a missed opportunity to provide comprehensive healthcare to those most in need.
Health in the High Level Panel Report
The High Level Panel Report “A New Global Partnership” had the unenviable task of trying to meet the expectations of a disparate and demanding international development community. To the panellists’ credit the report was broadly welcomed, including by those working in global health. Richard Horton, Editor of the Lancet, praised the report as “progressive, inclusive and internationalist” and noted the overall commitment to improving global health within the 12 proposed goals.
However, the report again focuses on the ends and not the means, resulting in another set of disease and demographic specific targets. What the report lacks is a coherent narrative with which to approach the extraordinarily complex task of improving global health. I think this presents another missed opportunity to change the global health paradigm to concentrate on the needs of the people in receipt of international efforts to improve health.
A Conceptual Framework for Global Health
Integrating health into the post-2015 framework should be considered through a human rights lens, while following a life course model and tackled using a public health approach. Using this framework will promote universality, tackle inequalities and enable rational prioritisation
1. Human Rights and Health
The human rights approach provides the moral and legal imperative to meet the right to the highest attainable standard of health. This is enshrined in international law and stands independently of the post-2015 framework. It should be used as a powerful tool to empower people to hold governments and international organisations to account, while protecting against discriminatory practices. It does not, however, help unravel the political and social complexities of designing, prioritising and delivering health-improving interventions.
2. Life Course Model
Both the MDGs and the proposed post-2015 goals single out mothers and children as areas of priority. This must be welcomed, as work in this area has highlighted the vital importance of the early years as predictors of future health and wellbeing. However, this excludes huge sections of any population. Older people are hardly mentioned in either set of goals, despite the rapidly expanding global population of over 65s.
A wider view of health across the whole life course is essential, as different sets of environmental, social and biological risk factors accumulate over the course of a lifetime to alter a person’s risk of ill health. Demographic specific goals should be discarded in preference of taking a whole life course approach to identify the most important targets for improving health. It should not be impossible to advocate for a system encompassing healthy childhood and healthy ageing.
3. Public Health Approach
For a truly integrated approach to improving health the four key areas of public health practice need to be met within an international context.
i) Wider determinants of health: this includes poverty reduction, provision of a social protection floor, food security and access to clean water and these are largely covered within the proposed goals. However there is a noticeable lack of emphasis on reducing inequalities in the socioeconomic determinants of health, despite the evidence of their importance. Committed international efforts to tackle climate change should also be at the forefront, and the interaction between the MDGs and the SDG agenda needs to be better defined.
ii) Health promotion: efforts to educate and encourage people to reduce their modifiable risk factors to prevent ill health doesn’t feature features within the MDG framework, despite the growing epidemic of non-communicable diseases. Tackling smoking and reducing obesity, for example, are key to reducing future global disease burden.
iii) Health protection: while great improvements have been made in reducing new HIV infection rates, focus on the big three infectious diseases has drawn attention away from the neglected tropical diseases. Other environmental risk factors, including occupational injury, smoke inhalation and vehicle trauma hardly feature on the global agenda at all. With ever increasing urbanization these will cause a greater part of the global burden of disease across the life of the next goals.
iv) Healthcare: the movement advocating for universal health coverage (shown here in the Lancet and the WHO) has every right to be furious at its absence in the HLP Report. Health systems strengthening was shamefully lacking from the MDGs and the global health movement has been suffering from fragmentation and duplication ever since. No serious effort can be made to improve global health without resources for hospitals, clinics, drugs, equipment, staff and training.
Prioritising Health – Data, Governance and Finance.
Deciding how to prioritise global health interventions should rely on high quality data of disease burden and good research evidence of effectiveness. However, much of what goes on within the international development arena lacks this kind of information, mainly because data-collecting systems in low and middle income countries is so poor. As an example – the decision to deliver HPV vaccine in low and middle-income countries has largely been justified by poor quality data from unreliable cancer registries in sub-Saharan Africa, while at the same time it is staggering that mental health is not even touched on, despite the significant global disease burden and interaction with poverty.
Global health governance is weak and uncoordinated. Institutions such as the WHO, World Bank, UNICEF, Bill and Melinda Gates Foundation, GAVI Alliance, PEPFAR, Oxfam all work in silos with their own priorities. This has resulted an incoherent approach to improving health, with random allocation of resources to haphazardly implemented programmes in countries around the world. Ultimately those who fund global health have the power to determine priorities and, after all, if you ask cardiologist what the most important health issue is, they’ll tell you it’s cardiovascular disease. The lack of coordination of effort and absence of an evidence-based consensus is an unethical way to continue to deliver international development initiatives. When the recipients of international development aid and interventions finally hold the purse strings, then we’ll have won the battle for global health.
The Art of the Impossible
Setting the post-2015 agenda has been described as “the art of the impossible” and nowhere is this more true than in global health. It is unlikely that all of the things required to seriously improve global health could be captured within a set of highly focused, internationally agreeable, time limited development goals. Yet, sticking to a rigid system of disease specific and demographic selective targets will leave millions without the healthcare they desperately need. A much more comprehensive and integrated approach is required to tackle the synergistic relationship between poverty and ill health.