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Thursday, 31 January 2013

Post-2015 development agenda: whither health?

We are only two years away from the target year set by the UN Millenium Declaration to achieve the MDGs. It is now evident that few if any of the MDGs will be met by 2015, especially by the low-income countries. Where it is on target, inequity within countries is too obvious. While the role of the MDGs in raising the ‘profile of poverty and development issues’ is commendable, the setting of narrowly focused goals and targets has received much criticism.

The process itself was criticized since it was not done through ‘an open, honest, accountable and ultimately democratic debate’ and with the participation and voices of those for whom these were meant. It based its poverty eradication agenda on neoliberal policies which instead of lessening, increased inequalities and pauperization. It ignored or bypassed the complex and comprehensive nature of development and the interlinkages of its different components e.g., education, health and poverty alleviation, including prioritization of the problems. Others reiterate that the goals and targets should have been ‘tailored to national circumstances and priorities’. A consensus is emerging for a paradigm shift in how to approach the post-2015 development agenda beyond setting narrow goals and targets towards a comprehensive, thematic approach.

Globally, achievements in health related MDGs present a mixed picture. Whereas some progress has been made in improving child and maternal survival, progress in other health MDGs is not encouraging especially in the SSA and SA countries. Whatever progress has been made, again, is fraught with inequities with respect to SES, gender, and region.
Bangladesh has progressed well in achieving MDGs 4 and 5, though inequitably. Since 1990, there has been an estimated reduction of 57% in child mortality and 66% in maternal mortality. Both the Government and the NGOs (e.g., BRAC with its focused MNCH interventions in rural and urban slum areas) worked together to achieve this remarkable success. This is all the more commendable because these achievements have taken place within a health system that is frequently characterized as weak and low performing. However, progress in other areas such as reducing neonatal mortality (accounting for 60% of deaths in children younger than five years), under nutrition, skilled attendance at birth or unmet need for family planning or use of sanitary latrine is lacking far behind.

While consolidating the above gains beyond 2015 itself presents a challenge, new issues are also cropping up. The population is ageing, so is the burden of NCDs such as diabetes, hypertension, COPDs, cancers etc. But the current health system infrastructure is not aligned to address these new challenges. Added to this is the health fallbacks from the consequences of climate change. Beside the direct effects of heat such as heat stress and heat strokes, health impact of such changes in Bangladesh include increase in certain vector borne diseases (e.g., malaria, dengue, kala-azar etc.), diarrhea, skin diseases, and malnutrition (from threatened food security). As the climate change worsens, natural disasters like flood, tidal waves etc. will increase with catastrophic effects on health and wellbeing. Managing health effects of climate change will pose a major challenge to the post-2015 development agenda

Thus, health system needs radical realignment to address health issues beyond 2015, with more emphasis on public health aspects of the emerging problems. A comprehensive tackling of the problem should be based on influencing social determinants of health and strengthening the heath system with respect to human resources, infrastructure, drugs and other supplies. Health consumers should be shielded off from the ‘income erosion effect of illness’ and sliding back into poverty from ‘catastrophic health expenditure’. Universal Health Coverage through risk sharing and resource pooling (insurance or tax revenue) may be one approach, but is not the panacea for all problems (‘better health requires much more than UHC’). ‘Good health at low cost’ with equitable health outcomes, should be the ultimate goal in a post-2015 world.

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