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.
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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