australian aid and international development policy workshop canberra, february 13-14, 2014

CRICOS Provider No 00025B

Framing health in the post-2015 development agenda: Multilateral development agencies in the first phase of consultation

Australian Aid and International Development Policy Workshop

Canberra, February 13-14, 2014

Peter S Hill and Claire Brolan

The University of Queensland

The context

• In 2001 a group of technocrats from UN, IMF, WB, OECD systematically analysed Millennium Declaration targets

• These were clustered to form 8 goals--the MDGs—and appended to S-G Report to UN General Assembly 2001

• MDG deadline: UN General Assembly 2015• What next?... • Sept 2012 UN S-G announced a UN process of

consultation, including 11 thematic consultations, 88 country consultations, web based individual consultations

• But Sustainable Development Support Network already established in Aug 2012 to progress the Sustainable Development Goals proposed from Rio+20 conference


The context

• The period June-July 2013 saw the public release of three key documents:– Global Thematic Consultation on Health. (2013). Health in the

Post-2015 Agenda. The World We Want – High-Level Panel of Eminent Persons on the Post-2015

Development Agenda (HLP). (2013). A New Global Partnership: Eradicate Poverty and Transform Economies Through Sustainable Development.

– Sustainable Development Solutions Network. (2013). An Action Agenda for Sustainable Development. Report for the UN SecGen.

• Our research followed these, and provides a synchronic representation of UN and related agency positions.

• However, while preserving this perspective, the analysis has developed diachronically as the discourses evolve.


The context

• The “completion” of the first phase of consultation is reflected in Report of the UN SecGen– General Assembly, UN. (2013). A life of dignity for all: accelerating

progress towards the Millennium Development Goals and advancing the United Nations development agenda beyond 2015.

• His report focused on the progress towards the MDGs: relatively little detail was provided on the post-2015 goals.

• What was clear was his expectation of a meeting of the two agendas: the poverty reduction focus reflecting the incomplete agenda of the MDGs and the sustainable development agenda articulated in Rio+20.

• But the critical shift now is towards the UN Member States, rather than the UN agencies and Secretariat.


Methodology

• Go4Health: 13 partners, EU funded, providing evidence for the development of the post-2015 development goals

• WP4: Role of the multilaterals (UN agencies, development banks, Public-Private Partnerships, linked NGOs)

• This research focuses on “The World We Want”: UN consultation phase, Sept 2012 to Sept 2013

• Documentary analysis• Key informant interviews:

– 58 interviews in New York, Washington, Paris, Geneva (June and July 2013)

– 31 institutions (18 multilateral development agencies and banks)

• Thematic and Discourse analysis• Triangulation of findings with research group


The UN Agencies and health

• Given the predictability that there would be a post-2015 process, preparation within UN agencies varied.

• WHO has been anticipating this process, with UHC being systematically positioned by Margaret Chan since 2005

• Formal structural responses within agencies most commonly linked to UN SecGen Sept 2012 announcement

• Usually a single point person nominated, in addition to current workload—in limited cases a new position created

• Usually a network of officers engaged in different aspects of the process, depending on issues

• Exceptions: agencies directly mandated around Sexual and Reproductive Health and Rights: UNFPA, UN Women


The UN “position” on Health

• Universal concession: health would only have one goal• Absolute consensus on the need for a united health lobby

if health was to maintain prominence post 2015:– At the end for us it was most important that health held together

and had a common view point– the idea of an inclusive goal was the strongest idea that came

through the consultation

• Little serious conflict between positions at present:– I think part of the reason why it’s been so well received is that

anybody with a major pet issue [has] a phrase in there

• But early division between preferred goals:– this shows…better…the shepherding of the co-leads, in terms of

the two major themes, healthy life expectancy and UHC


The unfinished MDG agenda

• Universal recognition that the MDG agenda would be the focus of the UN Sec Gen report 2013:– The report will be 80% progress on the MDGs, 20% on the post-

2015 development goals. It won’t be very prescriptive.

• Consensus that the MDGs agenda should continue:– you cannot forget that the MDGs still have not been met on

maternal mortality… the child health target– to be very clear, AIDS isn’t over and it’s an unfinished MDG

• And be extended…– The kind of dark horse coming up the inside is non-communicable

diseases. That is where the future is.– HLP: ‘Ensure universal sexual and reproductive health and rights’

• But the NTDs were again neglected in these interviews


Global Thematic Consultation on Health

• The MDGs were clearly the grounding for the Global Thematic Consultation on Health: ?the MDG+ agenda?

• The Global Thematic Consultation on Health– Over 100 submissions– 14 face to face consultations– High Level meeting Gaborone, Botswana– Report released March 2013

• Health Goal: Maximizing Healthy Lives• Three targets:

– Accelerate the MDG agenda (including Neglected Tropical Diseases and access to reproductive health services)

– Reduce the non-communicable disease (NCD) burden– Ensuring Universal Health Coverage (UHC) and access


The ‘elastic’ single health goal

• The corollary of acceptance of a single health goal was its inclusiveness – and elasticity

• Despite explicit WHO preference, UHC not accepted as a primary goal for health: ‘healthy lives’ dominated

• The elements were largely the same, though hierarchies and sequencing altered, as did position of UHC

• Strategically, single health goal now embraces:– The residual MDGs: Maternal and child mortality, HIV, malaria, TB– Neglected Tropical Diseases– ‘Priority’ or ‘selected’ Non Communicable Diseases– Sexual and Reproductive Health and Rights

• And UHC?


UHC: yes, but…

• UHC seen as “necessary but not sufficient”– It’s a very attractive concept that I don’t think anyone really in

health has any problem with– It’s got to go beyond health services; there’s health service

coverage but there’s also many other cross sectoral issues we’ve got to pick up, which I guess life expectancy does bring in…

– UHC is not enough…to stop kids dying. A lot of things are not in UHC. Maternal education is not part of UHC. Nobody will say that ensuring that young women finish school is part of universal health coverage and yet we know how essential that is to stop kids dying. A lot of the preventive policies, the water and sanitation, the early child development, you know, it’s not part of UHC

– “[UHC] tells you nothing about major preventive interventions that can have a big impact on health like tobacco taxes and legislation. It’s very sectoral.


And anyway, what is UHC?

• Problems with definitions, marketability and metrics:– Nobody knows what UHC is– What does it mean and where are resources coming? And what

are the processes to build the system?– Do you tell your aunty—in the suburbs of Sydney: “Oh, yeah.

We’ve got a campaign for universal health coverage”? Or do you say, “we’re trying to maximise healthy lives”

• And it certainly didn’t convince the High Level Panel:– Literally two days before it [the HLP report] was published… it

didn’t have really anything on universal health coverage at all, which is a major problem… to me that just was not the focus of the people who were drafting that report, and so they just did not give enough thought to what the global health community was saying. And then at the last minute when they realised that they were going to get quite a bit of backlash


High-Level Panel of Eminent Persons• The High-Level Panel of Eminent Persons on the Post-

2015 Development Agenda (30 May 2013)– Informed by 11 thematic consultations, 88 country consultations– The World We Want internet consultation

• Health Goal: Ensure Healthy Lives– a) End preventable infant and under-5 deaths – b) Increase by x% the proportion of children, adolescents, at-risk

adults and older people that are fully vaccinated – c) Decrease the maternal mortality ratio– d) Ensure universal sexual and reproductive health and rights – e) Reduce the burden of disease from HIV/AIDS, tuberculosis,

malaria, NTDs and priority non-communicable diseases

• And UHC is a means to achieve this (in two references)


And all you wanted to ask about sex…• If the volatility around UHC was unexpected, what of the

current apparent unequivocal support for SRHR?• Clear that the MDG experience was critical for SRHR:

– [there is] a definite push with the post-2015 framework to come up with things that correct the past

– SRH will be the first thing to fall off at local and country levels– I think this will be a very difficult discussion… [for] Muslim

countries, and even the Vatican– The other factor, that we don’t know how it will play, is the new

Pope. So he has been saying interesting perspectives on poverty which is great but we have not seen or we have not heard anything about sexual and reproductive health or women’s rights

• Implicit in this is the recognition that the consultation is not where “the action is”: with the SDGs and member states


Now for the real action…

• Consensus that the UN Consultation phase has been comprehensive, inclusive, self-congratulatory

• Despite differences, conflict currently limited:– people are still going to push their particular issue…[but] right

now…[no one] feels threatened by other people’s issues

• But increasingly there is a recognition that the agenda is not going to be set by the UN, but by member states

• These interviews retained a focus on sectoral perspectives: little explicit engagement with the SDGs

• But the UHC/healthy lives dichotomy may be a proxy:– there’s health service coverage but there’s also many other cross

sectoral issues we’ve got to pick up, which I guess life expectancy does bring in


But what will the SDG focus be?

• Critics argue that health is still talking to itself, and failing to engage with the SDGs.

• UHC remains a contender: – there is a group of countries that are very committed to UHC…

countries that have already… made some progress– So you have the foreign policy in global health, the BRICS

countries who made a statement this year in Geneva at the Assembly, and they said, “We want to work with WHO to ensure that the agency is able to monitor and measure universal health coverage,”

– I feel fairly optimistic that in the next 12 months, the SD group… the Sustainable Development Solutions Network… will strongly focus on universal health coverage, so we feel pretty optimistic.

• The SDSN report and their health theme reinstates UHC


Sustainable Development Solutions Network• Sustainable Development Solutions Network. An Action

Agenda for Sustainable Development. • Report released 6 June 2013.• Four dimensions, 10 sustainable development priorities:• Health Goal: Achieve Health and Wellbeing at All Ages

– Ensure UHC, including the prevention and treatment of communicable and NCD, SRH, family planning, routine immunization, and mental health, prioritising PHC.

– End preventable deaths by reducing child mortality, maternal mortality, non communicable diseases.

– Promote and monitor healthy diets, physical activity and subjective wellbeing; reduce unhealthy behaviors such as tobacco use and harmful use of alcohol


With two years still to come…

• There is a strong consistency still for UHC:– it’s quite natural for the WHO to come up quite strong on universal

health coverage… for a variety of reasons that are sort of about their own existential issues… and just what they do, that [UHC], is what the WHO is about

– UHC supporters are a very organised… constituency… [whose] voices are very powerful and influential

• Yet the case still needs to be made:– When I saw the HLP report and they were talking about

eradicating poverty… when most people around the world say poor health and catastrophic illnesses are a major factor in driving them into poverty, liquidating assets et cetera, it would seem quite natural to me that universal health coverage with its aspect of financial protection would be naturally integrated to that, naturally linked to that. But it hasn’t been made. It’s a little bizarre to me


australian aid and international development policy workshop canberra, february 13-14, 2014

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