Regional Consultation on “Health, the SDGs and role of Universal Health Coverage: next steps in South East Asia", 30 March-1 April 2016, New Delhi, India
Speech of Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia Region
Distinguished Participants, Ladies and Gentlemen,
A very good morning to you, and welcome to this important meeting about what the SDGs, and within that Universal Health Coverage, are going to mean for health in the South East Asia Region.
On 25th September last year, the 193 Member States of the United Nations adopted a resolution, which begins like this:
I quote -
"We resolve, between now and 2030, to end poverty and hunger everywhere; to combat inequalities within and among countries; to build peaceful, just and inclusive societies; to protect human rights and promote gender equality and the empowerment of women and girls; and to ensure the lasting protection of the planet and its natural resources. We resolve also to create conditions for sustainable, inclusive and sustained economic growth, shared prosperity and decent work for all, taking into account different levels of national development."
You will agree that with an opening paragraph like that, no one is going to accuse the UN of undue modesty!
This, as the Declaration goes on to say, “ is a supremely ambitious and transformational vision”. Put more bluntly, it is a huge amount to achieve in 15 years.
I want to address two big questions.
First, how did we succeed in getting the heads of state and government of virtually every country on the planet to agree to commit themselves to achieving 17 ambitious goals, and 169 associated targets in the name of sustainable development?
Second, setting goals and targets is one thing. Achieving them is altogether something different. Is it really going to be possible to get even close to this level of ambition in such a short period of time?
So, question one: how did we get here?
To celebrate the beginning of a new century the UN General Assembly passed the Millennium Resolution, which made reference to a number of development goals that had been agreed at a series of UN conferences over the course of the 1990s.
We would all agree that the Millennium Development Goals - the MDGs - have been an outstanding success.
It took some time to get the ball rolling. But a combination of skillful advocacy and some powerful champions made a difference. It also helped that the MDGs were few in number - just eight - and they dealt with subjects that people understood and could relate to: decreasing hunger, increasing the number of children in school, reducing maternal and child deaths, conquering major pandemics of AIDS, TB and malaria and improved water, sanitation and environment.
There has been remarkable progress in health outcomes over the last 15 years.
Development funding for health has tripled since 2000 and domestic budgets in many parts of the world have grown rapidly. In our region, the regional MDG targets for HIV, tuberculosis and malaria have been met or are on track. Child mortality has fallen by over 60% and maternal mortality by over 40%. Even though these figures fall short of the two-thirds and three-quarters declines that were targeted, they are still cause for celebration.
In addition, and this is a key point, because the targets were quantitative the MDGs have had a huge influence on promoting measurement and monitoring systems. Without them the world would not be in a position to track progress with the degree of confidence that is now possible.
Measurement also has a political spin off. Commitments made by national leaders not only put pressure on ministries of health, but also provide a way for civil society, parliament and the media to hold health providers accountable for their performance.
As I am sure you are aware, the MDGs have not been without their critics. Let me give you a few examples. We hear that…
Their scope is too narrow - they focus on a few human development outcomes and overlook the broader determinants of poverty.
They say nothing about the role of economic growth.
They say little about the need to address inequity and inequality. They are silent on the issue of gender.
They are a top-down instrument, loved by donors but are of less consequence to national governments. They have influenced aid more than they have national budgets.
And in health …they focus on a limited set of outcomes: they overlook new priorities like noncommunicable diseases and health security; they say little about the role of health systems.
They have created silos, vertical delivery and financing systems and distorted national planning and budgeting.
And, of course, there is a huge unfinished agenda of global targets that have yet to be met, and countries that lag far behind in their achievements.
Listening to that list might tempt you to think that global goal setting has had its day. You would however be completely wrong.
As the world approached 2015, there was unequivocal support for a new generation of goals. Rather than acting as a disincentive, the critique of the MDGs merely fuelled the desire to do things better next time around.
So part of the answer to our first question (how did we get here?) is that the MDGs have been more influential and achieved wider public recognition than any other attempt at international target-setting in the field of development. Their influence in attracting financial and political support for the goals and targets included has been unprecedented.
Indeed, the legacy of the MDGs was such that succession was inevitable.
The question we now turn to is how did we end up with the current agenda and a daunting total of 17 goals and 169 targets?
The SDGs are different, and the transition from MDGs to SDGs is not just a question of a longer list of goals and targets.
The SDGs are designed to be relevant to all countries. They are about development as a shared global concern not just about developing countries.
Their scope is much greater, and a key theme is the creation of an integrated agenda, where the links between goals are as important as the goals themselves.
The SDGs cover the three pillars of sustainable development: economic, environmental and social, with a strong focus on equity - leaving no-one behind. They therefore better reflect the full range of real-world issues that keep all politicians awake at night.
The Declaration states clearly “Each country has primary responsibility for its own economic and social development”. This means that if the SDG agenda is genuinely universal and relevant to all countries, then the close link between development goals and financing from donors will be less important.
In contrast to the MDGs, which were developed out of the glare of political debate, the SDGs are the product of extensive consultation and negotiation.
Once the starting gun was fired some four years ago, the number of global, national, regional, grass-roots, thematic, governmental, civil society, on-line, and off-line discussions, debates and consultations that took place reached almost epidemic proportions. Indeed, for many of those involved in the process, it is a minor miracle that the result was only 17 goals!
On a more serious note, though, throughout the negotiations a veritable army of interest groups lobbied intensely to ensure that their priorities found a place; sadly, with little concern for the coherence of the agenda as a whole.
So where have we arrived as we try to answer the two questions?
On one hand, the SDGs have been welcomed for their comprehensiveness, universal applicability and breadth of ambition. But equally they have been criticized for trying to do too much and proposing an unattainable utopia.
On the plus side: we have a set of goals that have been endorsed by the world’s governments, (even if the signatories will be long out of office by 2030) but which reflect a commitment to address - albeit at a level of intent - an agenda of undeniable importance to our troubled world.
But the response from the critics is that goal setting should stick to what is actually doable and forget idealism and political correctness. They say it is absurd to try “to eradicate extreme poverty for all people everywhere” in 15 years, or to “end all forms of discrimination against all women and girls everywhere” in the same time frame.
So, a house divided.
Let us therefore move on to our second challenge. We now have a new set of goals, what can we do to make sure they are achieved?
At this point in our discussion, I am going to be more parochial and focus on health.
I also want to come off the fence.
While the debate on the merits and the faults of the SDGs will continue, in the second half of this talk I want to make the case that the new agenda provides us with a great opportunity to accelerate progress in health, to make universal health coverage a reality, and to improve the lives of millions of our fellow citizens.
This is an agenda of vital importance for this country and our region.
Let me start by pulling some of the strands of the argument together.
First of all health is in a prominent place in the new agenda. Goal 3 is broadly drafted: Ensure healthy lives and promote well-being for all at all ages. It is followed by 13 more specific targets. Several of these follow on from the unfinished MDG agenda. Indeed, much of the critique about feasibility and measurement directed at the SDGs can be easily countered when it comes to the health goal, even though the agenda is now more ambitious.
At the same time, it is important we recognize the breadth of the new agenda. Where the MDGs saw health in isolation, the new agenda frames health as both a contributor to sustainable development as well as an important beneficiary.
In practical terms, this means that health is clearly linked with the goal of reducing hunger and improving nutrition; to assuring universal access to sexual and reproductive rights; to safe water and sanitation; to energy efficiency; to climate change; to sustainable production and consumption; to civil registration and legal identity; to preventing violence; and of course to the broader goal of eliminating absolute poverty.
The second point is that at first glance, the list of targets under Goal 3 is a bit of a mixed bag. However, if we go back to the Declaration that precedes the detailed description of goals and targets, it gives us a clue as to what is required. Let me quote what it says:
“To promote physical and mental health and well-being and to extend life expectancy for all, we must achieve universal health coverage and access to quality health care. No one must be left behind….”
Universal Health Coverage seen in this light is the target that underpins all the others and helps make the health agenda cohesive and less like a list of separate programmatic silos.
It is thus a means to an end. And, I must add, it is also a desirable end in and of itself.
The key idea of Universal Health Coverage is that all people have access to the services they need, without facing financial hardship when they fall ill. Obviously, each country comes at this target in its own way. UHC is not a fixed state - it needs to be seen as a journey where the range of services available increases progressively, as does the proportion of the population that is protected financially.
In this meeting we will begin by reflecting on ‘who is still being left behind?’ in terms of access to care and financial protection in our Region. Despite considerable progress on the MDGs, a recent report on Tracking Universal Health Coverage by WHO and the World Bank found that globally, 400 million people still lack access to one or more of seven essential health services. 130 million of those people are in our Region. And around 50 million people are pushed into poverty each year in our Region, because of the costs of health care.
From the perspective of the health SDGs, UHC helps to bring together three elements. First, the unfinished agenda of the MDGs - reducing maternal, newborn and child deaths; ending the epidemics of AIDS, TB and malaria as well as hepatitis and other communicable diseases; and ensuring access to sexual and reproductive health care services.
Second, it brings in new priorities: NCDs and mental health; prevention and treatment of substance abuse; road traffic accidents and deaths from hazardous chemicals, air, water and soil pollution.
The third element emphasizes the means for achieving these targets: ensuring access to medicines and vaccines; increasing health financing and strengthening the health workforce; strengthening capacity for early warning, risk reduction and management of health risks; and implementing the framework convention on tobacco control.
My third point is that when the SDG text was published the health professionals scoured it to see what was missing. The answer is that the targets under Goal 3 actually cover a great deal of ground. In addition, as we have already noted many health issues such as sexual and reproductive rights, water and sanitation or the health impacts of climate change are found under other goals.
Two points that should, in my view, have been given more prominence are anti-microbial resistance (AMR) and the impacts of population ageing on health systems and health financing. Anti-microbial resistance, which as you know, is one of the greatest threats facing modern health care, managed to find a place in the preamble of the declaration, but is absent from the goals and targets.
Ageing gets a mention under nutrition and healthy cities, but as a factor that will seriously impact the way we think about health care over the next two or three decades, it is noticeable by its omission.
These missing issues take me on to my fourth point about health and the SDGs: they prompt us to think about new ways of doing business. What the missing issues have in common is that neither population ageing nor AMR fit neatly into sectoral boxes. They require high-level political support and coordinated responses across government and society. The strength of the new agenda is that it provides unprecedented legitimacy for those in the health community to work across conventional boundaries. However, the fact that two of the most important challenges in global health are missing from the new agenda should give us pause for thought.
Understanding that achieving good health outcomes can never depend on the health sector alone is not exactly new. We have known this for ages. But the SDG agenda should, if nothing else, provide new impetus and energy for putting ideas into action.
Breaking down the institutional barriers that too often exist between medical and social care are essential elements in helping prepare for a society in which those over 60 will soon make up 20% of the population.
New ways of working that establish coordinated regulatory regimes and responses between the agricultural and health sector to combat AMR require action on the part of each and every government.
As we have learnt to our cost when it comes to the detection and response to disease outbreaks, it is the weakest link in the chain that determines the effectiveness of global and regional systems.
The health SDGs therefore will influence not just how health services work in each country, but have major implications for the broader role of our governments in relation to their own people and to the global community as a whole.
Ladies and gentlemen,
I have pointed to some of the key challenges implicit in the new SDG agenda. I strongly believe we can meet these challenges. But there will still be those who will ask: are the SDGs affordable?
Critics point to the UN’s estimate that the SDGs will cost between $3.3 and $4.5 trillion a year to achieve as evidence of their unaffordability.
My sense is that the anxiety generated by figures like this is misplaced. Firstly, like any normative framework the aim is for progressive realization. Countries will proceed at their own pace given the availability of resources; a point that is reinforced by the emphasis on national target setting.
Second, even though estimating the costs of some of the more aspirational targets will remain highly imprecise, some goals including Goal 3 can and will be costed more accurately.
The affordability and rate of progress in implementing the SDGs is a question - in the majority of countries - for the national government, far more than it is for their development partners.
Which brings me to my last point on the health SDGs.
Yes, it is a new agenda, and yes, it will require new ways of working, but at the same time we must not forget the basics. Good health creates wealth. But good health requires adequate financial and human resources.
In our Region, economic growth is expected to continue. We stand well placed to pull millions more out of poverty, though the inclusiveness of that growth will be a common challenge.
As you know, much health care expenditure in our Region is still out-of-pocket, though it varies across countries from as low as 10% to a high 70%. This is a tremendous financial burden for individuals and their families often resulting in financial ruin.
But let me not belabour these issues: the fundamental point I want to make is that the SDG health agenda is relevant to all countries. And part of that agenda is attending to the basic issues of resources, management, measurement and accountability.
As we conclude, it seems clear to me that the success of the MDGs has created a global environment in which there remains a voracious appetite for setting goals and targets.
Whether the SDG agenda, in its entirety, is over-ambitious with the risk that the momentum created by its predecessor may be lost, is uncertain. My sense is that it is not - with at least one proviso.
That is that we must keep our focus on the big picture - are we really getting to grips with the big challenges of our day? Accountability is key, but monitoring must not get drowned in the detail of every single target and indicator. Let’s keep our eye on the prize.
In the field of health, I am convinced we are in a good place.
We have a solid and comprehensive agenda, and the idea of universal health coverage helps pull what might otherwise be a rather disparate list of programmes, into a powerful concept that promotes both equity and rights.
We need new ways of working that will require governments to think hard about the issues that do not fit neatly into sectoral boxes. And we must not, ever, forget the basics and the people we serve.