Statement by Mark Suzman, Managing Director, International Policy, Programs, & Advocacy
Bill & Melinda Gates Foundation
High Level Dialogue on Health in the Post-2015 Development Agenda
Gaborone, Botswana, March 5, 2013
The Millennium Development Goals (MDGs) have become a central framework to guide global development efforts. Endorsed by every UN member state, they have helped align actors and focus donors and developing countries on many of the basic ingredients needed to improve the lives of the poorest. The deadline associated with the goals, the specific targets attached to each goal to measure achievement, and the “compact” that both rich and poor nations have roles to play in achieving the MDGs, have led to a degree of public awareness and support, and a seriousness of effort on poverty reduction, that is largely unprecedented.
Given this success, the foundation is pleased to see such strong interest in the post-2015 agenda and the robust discussion about how to continue the fight against extreme poverty. The centrality of health to successful development is articulated well in the background paper for this meeting. There is no doubt that health must be a central part of this poverty and equity agenda, and I welcome this opportunity to help feed into the discussion.
The context for development has experienced significant changes since the Millennium Summit in 2000.
The financial context has changed. Many countries are successfully growing their economies, moving into or higher within middle income status, though still with large pockets of extreme poor. Domestic resource mobilization is increasing in most developing countries, though not always translating into pro-poor investments. New donors—public and private—have joined the landscape, while fiscal constraints in traditional donors pose big threats to a significant source of support for global health and development programs.
Some issues have risen to greater prominence. In the area of health, while we still face the unfinished agenda of maternal and child survival and reducing communicable diseases among low income communities, non-communicable disease is a greater share of the global disease burden. Resource constraints and environmental threats are an increased concern as global environmental negotiations have stalled and failed to catalyze significant changes in production and consumption patterns. The importance of political leadership and good governance is even more apparent as we learn both from good performers and those that are failing to turn their assets into productive investments for the well-being of all. As extreme poverty is projected to be concentrated in populous Middle Income Countries and in fragile states, the latter makes the absence of issues such as peace and security, rule of law, and strength of state institutions in the current MDG framework seem more glaring.
We need to find ways to better address these challenges. This means utilizing and re-animating the existing forums we have to address climate, biodiversity, trade, investment rules, and so on. This is challenging as the political context has also changed. The world is more multi-polar and long-standing models for forging political momentum (e.g. the G8) no longer hold as much sway. Global agreement will be more difficult to secure, particularly on issues that impose real costs. Governments will be paying keen attention to what they are endorsing.
How do we move forward?
Since the MDGs have garnered universal endorsement, there is a temptation to use the post-2015 discussion as the platform to move forward on these global concerns without critically examining: What is the purpose of agreeing to goals, and are time-bound, specific goals and targets the right tool to tackle all of these issues?
Addressing extreme poverty and the main factors that contribute to poverty reduction should be our first order of business, the global community’s top priority. The MDGs helped advance this agenda. The purpose of agreeing to successor goals after 2015 is to extend and finish this agenda, setting specific outcomes to significantly reduce extreme poverty and its contributing factors and manifestations (such as preventable death and disease), particularly among the poorest and most vulnerable populations, that the global community collectively sets its will to achieve. The overall vision for what the goals themselves will contribute to can be laid out in an overall framework or vision statement. The Millennium Declaration in 2000 helped set the overall vision for the world we want, encompassing wider issues of peace, security, human rights, and good governance that set out the wider context in which the more concrete MDGs, which sought to measure progress in specific areas of development, were to be situated.
The resulting global goals are a time-bound, limited set of most critical priorities that require (and can secure) global cooperation and for which concrete targets could be set and progress could be measured through clear interventions. Their simplicity and clarity have also resonated with the public, both making them an effective advocacy rallying cry and making it easier to track and push for governmental accountability for their achievement. We need to preserve these core principles for the next goals while also coming up with a system that allows countries, or groups of countries, to customize their own additional national or regional priorities, goals, and targets. Global goal-setting isn’t meant to preclude this, but rather to set shared global priorities that require action from many countries and actors, and for which these actors can be held accountable to deliver.
Post-2015 and Health:
Improving health is central to the post-2015 agenda, both because ill-health contributes to and is a manifestation of poverty, and because good health contributes to development. If global development goals are about a global commitment to address key factors, such as health, that contribute to the conditions of poverty, then a central question for health goal(s) ought to be what are the afflictions of the poorest and most vulnerable that prohibit their fulfillment as productive members of society. Addressing these issues and working with and reaching these populations through ambitious targets and meaningful, measurable indicators would be the first order of business.
The recent Global Burden of Disease study is one tool that helps illuminate the health burdens of the poor. While the data show progress in MDG areas, including a 32% decline in the MDG DALY burden between 1990 and 2010, they also show that the burden of disease for the poorest is still heavily concentrated in the health areas outlined in the MDGs. In Sub-Saharan Africa, approximately 70 percent of DALYs is still attributable to nutritional, communicable, maternal, and neonatal disorders. These are priorities in the current MDG framework through goals 1, 4, 5, and 6, and should therefore remain a first-order focus post-2015, particularly when considering the equity gaps in achievement to date.
Regardless of the final architecture of post-2015 goals, there needs to be a prominent space retained for an updated set of targets related to the current outcome-focused health goals, given their relevance as major causes and drivers of premature deaths and illness of hundreds of millions of the world’s extreme poor.
What might these targets look like?
Targets should be ambitious, but technically feasible, as with the current MDGs. While ambitious, to varying degrees the current targets were set within reach at the global level. This made the MDGs different: they are not pie-in-the-sky aspirational targets of the kind the UN was too often prone to embrace in the past with little hope of achievement, but are concrete and at the global level, largely achievable.
Governments feel accountable for achieving the MDGs. That is what has led to many developing countries actively allocating resources against “MDG priorities” in their budgets, adopting target acceleration frameworks to try to achieve the goals, and sometimes even adding their own additional goals. Purely visionary targets without a chance of achievement would have been much easier for governments to ignore – and indeed have routinely ignored over the decades. This is something we should keep in mind as we assess proposals to end preventable deaths by 2030, for example.
For child mortality, an ambitious but achievable target might be closer to a two-thirds reduction in deaths by 2030, based on a baseline as close to 2015 as possible. Analysis of historical change and projections of future coverage and under-five mortality in 75 countries shows that under best case scenarios -- i.e. scaling up of treatment and interventions around birth, reaching high vaccine coverage, and for some countries in Sub-Saharan Africa, reaching high coverage of prevention and treatment of malaria -- that target for under-five mortality would be plausible, especially if countries analyze and determine their own best case scenarios and set country specific target levels. More ambitious targets, such as reaching a common level of 20 deaths per 1000 live births in all countries (representing the eradication of preventable child deaths), would require a more than doubling of current annual rates of reduction. This seems excessively challenging and would require all countries to reach the level of the very best performers.
Analysis by the Institute for Health Metrics and Evaluation indicates that reapplying the current maternal mortality rate reduction target of 75% to 2030 would require that countries perform to the 95th percentile of those developing countries that achieved the greatest success in the past decade – a goal that is likely impossible for countries, such as high-HIV burden Sub-Saharan African countries, that have the most challenging initial conditions. Sustaining current rates of reduction would lead to a figure closer to 50% reduction. Scale-up strategies based on local causes of maternal deaths and contextual factors with focus on high impact interventions (i.e., family planning, quality care around birth, prevention and treatment of obstetric complications), could help countries accelerate their annual rate of reduction, perhaps suggesting a target in the range of two-thirds reduction. On reproductive health, an interim target for access to modern contraceptives might be added as a stock-taking measure toward the overall goal of universal access.
All these figures are illustrative and clearly require much deeper technical analysis, but present a starting point for what meaningful updates might be. Hopefully as more new innovations become available and ways of delivering services to the poorest improve, we will be able to boost reduction rates, and bumping up targets would be technically sound. If target dates are set for 2035 or 2040, we can push for more ambitious targets.
To update MDG 6, we must reflect the progress that has been made with diagnosis and treatment and be much more ambitious than halting and reversing disease. One possible approach is to make reductions in mortality from HIV/AIDS, malaria, and tuberculosis direct targets. Using data from the Global Burden of Disease study, if we were to model progress made by the 90th to 99th percentile most successful developing countries, mortality rate reductions for HIV might range from 60% to close to 90%, and TB from over 50% to almost 70%. Malaria rates are even bolder, with the range from 90% up. Incidence rates could also replace prevalence rates and be the basis for potential targets.
These ranges are significant and highlight the need to have a robust set of technically-based conversations about the best basis for setting global and national targets, as well as the assumptions made about future rates of progress. There is also a risk that mortality-based targets for HIV would disproportionately focus resources on treatment rather than prevention when a more balanced approach is needed, so alternative indicators might be considered. What is most critical is that targets are ambitious but plausible, and provide a clear benchmark of success or failure.
Given the rising toll of non-communicable diseases (NCDs) in the global burden of disease, an updated MDG 6 could also include non-communicable diseases. For example, we might agree on mortality rate reductions for a few NCDs of greatest global relevance with indicators built around a reduction of risk factors such as tobacco use.
Though not outlined in MDGs 4, 5, and 6, we should not lose sight of the importance of nutrition, an additional health-related issue that will be taken up in a subsequent thematic consultation on food, hunger and nutrition security. A new target to reduce stunting, for example, might be added as part of a hunger goal.
Fine-tuning post-2015 goals: customization, disaggregation, and indicators
Customization: New global targets that aggregate progress at the national level are needed to rally the global community. However, learning from the current MDGs, where global targets were de facto applied to all countries regardless of starting points, there should be more explicit customization and tailoring for national contexts. This could be done through a transparent process at the country level. The UN and other development actors could provide technical help and for example, work with countries to assess and learn from the high-performing countries that started from similar rates, or had similar income, spending, or capacity levels, to help fine-tune ambitious but realistic national targets.
The need to customize and move away from “one size fits all” targets also raises challenges with visionary absolute targets that represent “ceilings” for child and maternal deaths that all countries would be expected to achieve. For worse-off countries, the targets are not realistic and if interpreted to apply to them, will set them up as failures, even if they make dramatic absolute or relative improvement from their starting point. Niger, for example, reduced its under-five mortality from 304 to 176 (per 1,000 live births) between 1990 and 2007, but because of this high initial condition, it achieved “only” a 42% reduction, compared to the global target of 2/3 reduction. Indeed, the top 20 best performers in terms of absolute progress on the MDGs include 10 sub-Saharan Africa countries, while just three make the top 20 relative performers list.
Similarly, while HIV, malaria, and TB should be highlighted at the global level given their high disease burden and disproportionately devastating impact on the poor, particular countries may want to customize tracking to include neglected tropical diseases, for example. In other regions, NCDs are a greater threat, and action to combat the biggest NCD threats to health and well-being should be incorporated in health target-setting.
Disaggregation: As others have noted, MDG progress is based on averages, and much valuable research has shown that vulnerable and excluded groups (this includes rural communities, ethnic minorities, the poorest quintiles, farming families) have typically not experienced progress in the current MDG period. In the next development goals’ time frame, the global community needs to find ways of ensuring that the most vulnerable benefit. This might be done, for example, by greater disaggregated reporting by income quintile, gender, rural-urban, region, and/or setting specific targets for the bottom quintiles. This also makes the updated MDGs relevant for many Middle Income Countries, which have significant pockets of poverty, particularly for excluded and vulnerable groups.
At the level of indicators, there is also fine tuning that can be done once the overall goal and target architecture is agreed. The foundation’s program teams look forward to informing that discussion when it moves forward. As an early input, some guiding parameters might include:
- Flexibility and customization. The tools and tactics we use to address health outcomes will change as we learn what works and as new tools become available. They may also be country-specific.
- Focus. Focus on those indicators for which we have and can get good data, and that best reflect the output and outcome we seek to achieve. Recognize that a long list of indicators can put enormous monitoring burdens on countries, so they should focus effort on the most illuminating indicators.
- Smart proxies. Include measurable indicators that are good proxies for the status of health systems, such as routine immunization and access to skilled attendance at birth.
- For disease, incidence, death and cure rates are key to track and measure. To do this well, attention to and investments in improving the reach and depth of vital registration systems is essential.
The MDGs succeeded in part because they did not pretend to be the “sum total” of development. They are a set of specific goals with bold targets that the global community set its mind and will to collectively address. They are deliberately ends rather than means, and as such are not the blueprint for development. Nor do they fully represent the set of issues critical for sustainable development. This distinction is critical as we look to agree on a successor framework to the MDGs. There is a danger that in trying to create the perfect framework that fully encapsulates global development challenges, we lose the power of the goals as a global collective agreement to address some of the most egregious contributions to and manifestations of extreme poverty in the world, including preventable disease and death.
I welcome this opportunity to offer these views on the post-2015 framework and the critical space for health in it. The foundation looks forward to working with all of you to ensure that health keeps its deserved space on the global development agenda and to crafting health goals and targets that will accelerate our momentum to combat preventable disease and illness.
 This statement does not represent a policy position of the Bill & Melinda Gates Foundation.
 Maternal mortality being one clear outlier that was further complicated by the extensive reliance on modeling for maternal mortality rates.
 Historical coverage change and projections of future coverage and under-five and neonatal mortality in the 75 countdown priority countries, N. Walker, G. Yenokyan, I. Friberg, J Bryce (Feb 2013)
 Millennium Development Goals Report Card: Measuring Progress Across Countries, Overseas Development Institute, 2010. This work received support from the foundation.
 See for example “Post 2015: The Road Ahead”, Claire Melamed, Oversease Development Institute, October 2012. The table on page 7 shows the results of MDG progress disaggregated by income level, rural-urban, education level, occupation, ethnic minority. The poorest, least educated, more isolated, and minorities were health, education, and nutrition poor.