Thematique The Millennium development goals, where do we stand on health ?

Introduction

For several years, France has openly declared its commitment in favour of international health. Soon there will be the opportunity to play a leading role in this field, when France takes over the Presidency of the European Union in July 2008. The period covers decisive meetings for the world fight against poverty, in particular : the OECD High-Level Forum on Aid Effectiveness (Accra, September 2008), the special session of the United Nations General Assembly on Millennium development goals (New York, September 2008) and the Follow-up International Conference on Financing for Development (Doha, December 2008). The second half of 2008 is in fact a special opportunity for France to point the way forwards in the area of global health.

Even if the United Nations claims progress on certain MDGs, the health MDGs have a long way to go. Levels of infant mortality, maternal mortality and the prevalence of AIDS continue to be alarming in certain regions, especially Sub-Saharan Africa.

This document is meant to supplement the position paper published by Global Call Against Poverty - France in 2005 during the "2005 – No excuses!" campaign. It sets out the analyses and recommendations of member organizations of GCAP-France on the main themes which concern them in the field of health, in particular :

1. Prioritize health as it does not appear as a priority sector in French development cooperation policies.

2. Remove the many obstacles to accessing healthcare : geographical, financial or discriminatory factors as regards certain more vulnerable groups (women, children, handicapped persons, ethnic minorities).

3. Overcome the human resources crisis in the health sector if we seriously wish to enable healthcare access in the countries of the South.

4. Increase health financing and improve the efficiency of aid allocated to the health sector.

5. Make greater efforts with the recent global health initiatives.

These topics do not address health MDGs in an exhaustive way but our organisations and other networks also work on the various aspects not presented in this document. Although our recommendations are directed at bilateral and multilateral donors, it is important to bear in mind that the governments of developing countries also have their share of responsibility in efforts required to meet the Millennium development goals.

Note : three out of the eight MDGs are directly linked to health

MDG 4 : Reduce under-5 child mortality

MDG 5 : Improve maternal health

MDG 6 : Curb HIV/AIDS, malaria and other diseases

The MDGs do not have the last word on health and development. They do not for instance refer to the crucial role of health systems if we are to meet all goals for health, whether as regards reproductive health or non-transmissible diseases.

We therefore have to consider the MDGs as a non-exhaustive list of the most important results to be achieved by development, namely to :

- reduce the number of women who die during or just following

childbirth

- enable more children to survive the first two years of life

- check the pandemic of HIV/AIDS

- ensure that populations have access to basic medication

- improve health in all its forms and for everybody, in order to help reduce poverty.

Make health a priority in cooperation for development

We are now midway to reaching the Millennium development goals. All of them have an impact on health and three of them specifically involve this issue as well as target 17 (MDG 8) which deals with access to medicines: If it is true that progress has been made, it remains irregular and insufficient. Those health MDGs have therefore fallen behind considerably.

Thus, over a million women still die each year as a result of complications of pregnancy and childbirth. The large majority of these women could have received care. Half the population of developing countries does not have basic health systems. Nearly 5 million people are infected by the AIDS virus each year and the number of people dying from AIDS rose to 2.9 million in 2006. MDG results at the midway point underline the alarming disparities within countries amongst certain specific categories of the population (rural communities, the poorest households, handicapped persons, children, minorities, etc).These disparities are especially flagrant in the field of access to healthcare services. Moreover, new international health alarms and the increasing burden of chronic disease (diabetes, cancer, cardiovascular diseases) are now added to the main pandemics (AIDS, tuberculosis, malaria, meningitis).

This means changing development cooperation policies and practices and giving a higher priority to health. In the European Union, health is not sufficiently in the forefront of thematic programmes and few country programmes are focused on health. The preference given to budget support mechanism raises concerns as there is no efficient system to monitor expenses.

For around ten years, the French government has shown its commitment to global health and the fight against HIV/AIDS. However, the methods of implementing these commitments do not match the declarations made : there are too many decision-making bodies and public sources of funds and France is still under-involved in developing public health strategies within international organizations.

Likewise, in the bilateral field, the priority to health declared by the ministries is not reflected in the activities of the diplomatic missions and health is included in only 10% of plans prepared at country-level. The fight against infectious disease (and particularly AIDS) takes up half of the financing allocated to health, to the detriment of other problems such as mother-child health, non-transmissible diseases and neglected tropical diseases. Support to health systems is also inadequately taken into account and requires French action to be rapidly mobilized, particularly by the bilateral channel.

Our recommendations

France must :

1. Give more priority to health in its development policies, especially as regards bilateral aid.

2.Contribute to putting in place a development cooperation strategy based on an offer of community health services which are permanent, of good

quality and accessible to everybody, including marginalized groups. This

supposes :

- strengthening health systems as a whole, including by means of the vertical health aid instruments we have at our disposal

- taking into account transversally in our strategies the situation of marginalized population groups (women, handicapped persons, children, homosexuals, transgender persons, users of intravenous drugs, sex workers etc)

- respecting its commitment, made at Gleneagles (2005) and repeated at Saint Petersburg (2006), to achieve universal access to treatment of HIV/AIDS by 2010

- supporting the proposal from Kenya and Brazil for an international resolution defining new priorities in research and development - in particular those which are non commercially viable

- financing the fight against chronic non-transmissible diseases

- intensifying funding to promote reproductive health and the fight against mother-child mortality and morbidity.

3. Use its influence to ease restrictive macroeconomic conditionalities imposed on developing countries in the health sector and press for international financial institutions to guarantee a status of exception to this sector.

Remove the obstacles to accessing healthcare

For this vast, complex subject, we begin with the realities of the field, putting the following two questions : what are the main obstacles preventing patients from receiving appropriate preventive or curative care in time? What are the steps necessary to remove certain of these obstacles?

Because the conclusions are rather alarming at all levels of the health pyramid, from the main hospital in the capital city to the peripheral healthcare centre in a rural district. Public health is under-financed and provides healthcare which is limited and/or of uncertain quality. Health systems are in fact very deficient overall and themselves represent a basic obstacle to achieving the health MDGs. Strategies and programmes do not systematically take into account the situation of marginalized groups, who then find themselves excluded from systems of prevention and care. The most significant defects in national health systems must be identified, in order to define priority measures to improve public health infrastructure, reinforce this latter and then make plans for an overall consolidation of the system.

Our recommendations

1. An action plan to modernize/renovate and develop health systems must be set up. Multilateral and bilateral donors together with each partner country must ensure that they coordinate efficiently and draw up this joint agenda.

2. Donors and France in particular must encourage the abolition of user-fees for basic healthcare and long-term illness and also a phased development towards risk-pooling mechanisms throughout all the population. This will enable developing countries to remove the financial barriers which prevent the poorest (over 70% of the population of these developing countries) having access to this healthcare.

3. For fairer access to healthcare, we must encourage strategies which include the marginalized groups, taking into account their situation transversally and thus facilitating their taking part.

4. The Doha WTO agreement on access to generic drugs and reagents must be put into practical application. Faced with pressures from certain rich countries and pharmaceutical multinationals applied against every county trying to use this agreement, France must organize an international summit meeting to enable compulsory licenses on AIDS/tuberculosis/malaria medicines and reagents to be issued simultaneously by a large number of poor countries. Only such a simultaneous, multiple-country approach will make it possible to neutralize these pressures and unblock the situation. France, being a forerunner of the UNITAID tax, has special legitimacy to initiate such a summit.

Overcome the crisis of human resources in the health sector

57 countries are confronted with an acute shortage of health workers, equivalent to a worldwide deficit of 2.4 million doctors, nurses and midwives. According to the WHO, nearly 90% of the African population lives in areas where there are fewer than five doctors for 10,000 inhabitants. This crisis is threatening the capacity of health systems to ensure efficient services in affected countries and is seriously compromising achievement of the health Millennium development goals.

This crisis has a multitude of causes, of which we may underline several :

- The dilapidated state of health infrastructure due to lack of means (effects of structural adjustment programmes) and lack of interest by local authorities, thus bringing about a fall in commitment on the part of health workers.

- Inadequate coverage of health personnel salaries, linked to health budgets cut to a minimum and the reluctance of donors to support the recurrent costs involved in human resources.

- The migration of health agents from the country to the towns and to other countries, from the public to the private sector or to NGOs, from the health sector to other sectors, in particular the best-trained amongst them.

- Lastly, the question of the disease and death of health professionals particularly as a result of AIDS. It is estimated that Botswana for instance lost 17% of its care staff through this disease between 1999 and 2005. In an area of Zambia a study has shown that 40% of midwives were HIV-positive (UNAIDS 2006).

In such a situation, deplorable both for destitute populations and for the credibility of rich countries, it is urgent to match commitments with action. Health has to be an absolute priority, and consolidating human resources in the health sector is a crucial recommendation.

Our recommendations

1. Donor countries must make long-term predictable commitments in all aspects of health system reinforcement, taking up the 2006 WHO proposal : 50 per cent of the funds allocated must be attributed to strenghtening health systems and half of this share at least should be dedicated to reinforcing health workers.

2. In their cooperation policies, donor countries must encourage aid to Training and Research, to allow developing countries to retain the medical skills necessary to the needs of their populations, in spite of emigration by a certain number of these healthcare workers ; it is essential that support to improving salaries and working conditions of health staff is provided alongside this aid to training.

3. A compensation mechanism has to be envisaged to composante those countries where certain nationals work abroad as qualified health personnel. To ensure that active head-hunting practices cease, this compensation should be equivalent to the cost of a training course in Europe.

4. Member-countries of the International Health Partnership, including France, must issue an international call for tenders on technical support to developing countries for preparation of a national strategy to fight against the human resources for health crisis before 1st January 2009.

Increase and improve the efficiency of health financing

Despite commitments in 2000 and at G8 summit meetings, the low level of funding allocated to health by the rich countries helps intensify inequalities in health between the developed and the developing countries. The WHO General Director, Margaret Chan, recently declared, "The Millennium goals for health are those with the least chance of being reached. Results must not be assessed in relation to national averages, but rather by answering the following question; do the poorest and most marginalized populations have real access to basic healthcare ?"

According to the WHO Commission on Macroeconomics and Health (2001), the total international aid necessary to achieve the MDGs for health would amount to 20 billion euros per year in 2007 and 28 billion euros in 2015. Sums so far collected are well below this figure: 9 billion euros in international aid allocated to health in 2004. Today, amounts of public aid allocated to health by the European Union are insufficient (in 2005, the European Commission devoted only 4.7% of its ODA) and the donor countries are not keeping their promises. As regards France, recent official government declarations have called into question the commitment – repeated at the highest levels of the state in 2003 – to allocate 0.7% of its GDP to ODA in 2012. This decision risks compromising financial commitments crucial to meeting the health MDGs.

Faced with challenges of this sort, efforts must be doubled. 2008 will be an important year. Events will take place which are of major significance for the financing of development in general and health in particular : the OECD High-Level Forum on Aid Effectiveness (Accra, September 2008) and the United Nations summit on Financing for Development (Doha, December 2008).

Our recommendations

1. Mobilize additional resources for the health sector. These have to come both from the international community (global funds and bilateral aid) and from annual budgets from countries in the South (in application of the Abuja agreement to allocate 15% of the annual budget to health). It is especially important that the international community respects its commitments on development assistance in the health sector.

2. Guarantee the effectiveness of development assistance, particularly by improving predictability

In particular, France must :

3. Adopt a budget schedule by means of which it gives concrete form to its agreement to devote 0.7% of its GDP to Overseas Development Assistance (ODA) in a "real" sense, i.e. through types of budgetary credit granted as a priority to the poorest countries and the basic social sectors and associate all stakeholders concerned (government, parliament, civil society organizations in the North and South) with this initiative.

4. Catch up, between now and 2012, the average figure of 11% achieved by OECD countries as the portion of their ODA devoted to health, by allocating, before 2012, at least 1.8 billion euros per year to health.

Eight years to take up the challenge of the health MDGs

Concerned by the low level of progress made in the fight against poverty, the international community has recently increased its efforts and initiatives in favour of global health: the Paris Conference on Health risk Coverage in developing countries (March 2007), the MDG Africa Steering Group set up by the United Nations (September 2007) and the International Health

Partnership (September 2007) are the latest examples.

All these initiatives stress the need to increase cooperation between the various players in the field of development, the donors and international institutions. Through better coordination and good governance, it is essential that resources at all levels of the health sector be put to more effective and efficient use. But will these initiatives really make it possible to reach the MDGs in health in eight years' time, and especially in the most fragile countries? A large number of measures still have to be taken to meet the challenge.

Our recommendations

1. The G8 countries must immediately implement the Heiligendamm commitment to mobilize 60 billion dollars for reinforcement of health systems and the fight against the three major pandemics. France must propose opening inter-G8 negotiations on a method of sharing this sum of 60 billion between the eight nations.

2. The member-countries of the International Health Partnership must specify the portion of national health plans they intend to finance and agree together on a method of apportionment of this financial cost between

themselves.

3. International donors must support developing countries in their efforts to increase their own financing in health, starting by supporting measures against tax avoidance in these countries, and particularly by imposing sanctions on tax havens refusing full judicial and fiscal cooperation.

4. France and the G8 must ask for half-yearly reports from the IMF on policies put in place to facilitate increased public investment in health and health resources (including staff costs for health).

5. Fragile states must be able to benefit from recent health initiatives aiming to raise the effectiveness of aid, such as MDG contracts and the International Health Partnership.