The agenda for global health is changing in a number of important ways which have a bearing on how priorities for development are defined in the future and how they should be measured.
Epidemiological and demographic transitions impose a complex burden of infectious diseases alongside non-communicable diseases, mental health, injuries and the consequences of violence. Whereas the current set of health-related MDGs focus on priorities for developing countries, the rapid spread of risk factors, such as tobacco use and Physical inactivity, along with ageing populations and unplanned urbanization, have a Profound influence on health and wellbeing globally.
The cost of inaction in relation to no communicable diseases – estimated in trillions of dollars - is now recognized as a global risk requiring action in all countries that extends well beyond the health sector alone.
Similarly, emerging infectious disease outbreaks and epidemics constitute a universal threat to the “just-in-time” global economy. In 2003, the SARS outbreak halted travel and trade in Southeast Asia and cost an estimated $50 billion in that region alone. In 2010, the H1N1 outbreak highlighted the inequity in global access to vaccines, and illustrated that a lack of domestic detection and response capability in any one country is a threat to all.
In many countries, the net effect of the increasing costs of technology, ageing populations and rising public expectations is to threaten the financial sustainability of health systems. In contrast, the future in other countries will be one in which current challenges continue, with inadequate levels of unpredictable funding, limited access to life-saving technologies, lack of financial coverage and a continuing daily toll of unnecessary death and disability from preventable causes. The common thread for the global agenda is the need to change the focus from developing health systems that deal with selected diseases and conditions.
Instead the focus becomes ensuring access to services, using innovation to foster efficiency, preventing exclusion (particularly of poor women and girls) and protecting people against catastrophic expenditure when they fall ill through extending universal health coverage. It is not just content issues that need to be reflected in the new global health agenda – it also needs to reflect more than is the case with the current MDGs – how health issues can be addressed more effectively.
In this regard, a human rights-based approach to health is essential. The right of everyone to enjoy the highest attainable standard of physical and mental health is recognized in numerous global, regional and national treaties and constitutions. It underpins action and provides part of the rationale for including health in the post-2015 development agenda.
The progressive realization of civil, cultural and political as well as economic and social rights is a prerequisite for sustainable growth and human development. Irrespective of where one lives, gender, age or socio-economic status being healthy and having access to quality and effective health care services is of fundamental importance for all people, while at the same time healthy populations are essential for the advancement of human development, well-being and economic growth.
A frequent criticism of the current MDGs is their preoccupation with aggregate achievement in the face of a growing body of evidence of the importance of the multidimensional aspects of increasing equity (in terms of opportunity, access and outcome). With about three fourths of the world’s poorest people now living in middle income countries, the issue is no longer confined to a debate about development aid (although aid will remain important for some countries). Rather it is about social justice and its realization in all countries rich and poor. Social policy developments in major emerging economies such as Brazil, Mexico, India, China and South Africa increasingly highlight the importance of universal health coverage as a means of linking equitable social and economic development.
A third element of the approach to the global health agenda concerns the need to address the social, economic and environmental determinants of health, not just the proximal causes of illness and disease. Clearly, all these elements are linked. Addressing social determinants has been shown to be an effective way of increasing equity of access and outcome. Similarly, tackling the burden on non-communicable diseases requires action in multiple sectors. A number of different conclusions can be drawn from this analysis. On one hand, it can be argued that the health agenda has broadened and that “new” issues such as noncommunicable diseases, health systems and health security need to be reflected in goals or targets. It is equally evident, however, given the context in which we are working, that a long list of health goals is unlikely to be acceptable. An alternative interpretation is that health is genuinely an issue of global concern, and that it is affected by a broad range of policies across a wide range of sectors. The challenge then becomes one of deciding how “health” in this broad sense can be characterized in a way that is measurable and ensures political traction and public understanding. We return to this issue in the final section of the paper.
Lastly it is evident that the “how” of health and development is as important as the “what”. The challenge here is to decide whether approaches based on human rights, equity, social determinants need to be reflected in the way health-specific goals or targets are framed, or whether they are equally applicable across all development sectors. For instance, the global AIDS response has demonstrated that placing people, particularly those most affected, as a central driver of policy promotes dignity and respect for all, and ultimately leads to better outcomes. But it could be easily argued that a people-centred approach is just as important in dealing with food security, educational policy or any other aspect of development.
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