Helen Clark: The Lancet Lecture

22 Nov 2010

Remarks for Helen Clark, UNDP Administrator
The Lancet Lecture - “ Human Development Reporting and Meeting the MDGs –
Taking an Evidence-Based and Cross-Sectoral Approach to Development”.

University College London,
Institute for Global Health
22 November 2010 6pm


It is a pleasure to be joining you at UCL today for this year’s Lancet Lecture. I thank Provost Malcolm Grant and Lancet Editor Richard Horton both for the invitation and for their warm welcome this evening; and my thanks also go to UCL’s Institute for Global Health for their role in organizing this lecture.

The Institute’s 2009-2010 report, “The Grand Challenge of Global Health”, reveals an impressive contribution to strengthening both the understanding and the practice of public health through interdisciplinary collaboration and partnership. The organization which I lead, UNDP, very much shares your focus on addressing the systemic development challenges which underlie poor health results – as well as your interest in seeing evidence translated into practice; both factors are reflected in my address this evening.

At the outset, I would also like to express my appreciation of the contribution of The Lancet to health policy debate. As one of the world's leading health publications, it has helped advance the health of people around the world, as was envisaged when the journal was established more than 180 years ago.

The Lancet’s many publications are an important resource for the UN in its advocacy for human development. In the lead up to the MDG Summit held in New York in September, for example, evidence published in The Lancet helped focus the attention of nations on the links between the MDGs – including on the importance of women’s education for improving health. By reporting that development assistance had a role in improving maternal, newborn, and child health from 2003 to 2008, The Lancet helped make the case for sustained support for development.

As a former Health Minister who is now leading one of the largest global development agencies, the intersection between health and development is both of keen interest to me and close to my heart.  As a young Health Minister two decades ago, I was inspired by the Alma Ata Declaration of the World Health Organisation’s 1978 International Conference on Primary Health Care.

In proclaiming that health was a state of complete physical, mental, and social well being, and that its attainment rested on socio-economic and other factors far beyond the purview of the health sector, it placed improving health status in a broader developmental context.

At UNDP, while we are clearly not a specialist health agency, we affirm the importance of improving health as both an enabler of development and as a desirable outcome in its own right.

This was inherent in the simple yet powerful proposition put forward in the first Human Development Report published by UNDP in 1990. It declared that “people are the real wealth of nations”, and made the case that a country’s success cannot be reduced to evaluating income alone.
 
The Human Development Index

To put this into practice the report offered a new measure, the Human Development Index – which combined life expectancy, education, and income measures. It helped to broaden our understanding of progress by moving beyond a simple focus on GDP growth to encompass a broader set of indicators.

The human development approach has sought to put people at the very centre of development, as both its drivers and its beneficiaries. It sees development as ultimately being about expanding people’s choices and capabilities – enabling them to have the freedom to live long, healthy, and creative lives. 

In the twenty years since the first Human Development Report was published, this approach has gained significant traction among development practitioners. Indeed the independent UN Intellectual History Project credits the human development approach with being one of the UN’s most important contributions to development thinking and practice.

The human development approach  laid the foundation for ideas and concepts which now form part of the development mainstream, such as the Millennium Development Goals.

Earlier this month, the twentieth anniversary edition of the global Human Development Report was launched. It asserts the continuing relevance of  the human development approach in understanding the varying trends and patterns of national progress, and in thinking about the future of development.

This year’s Report contains a systematic review of the human development record over the four decades. There is good news to report.

Overall, people today are on average demonstrably healthier, better educated, and wealthier than ever before. Since 1970, average life expectancy has risen from 59 to 70 years. School enrolment has grown from 55 to 70 per cent. Per capita incomes have doubled to more than $10,000 per annum in real terms. 

The Report shows that health and education outcomes between developed and developing countries have narrowed significantly over the last forty years even though the income divide has, with a few notable exceptions, worsened.

Some of the greatest gains in human development have been seen in the poorest countries. In Sub-Saharan Africa, for example, life expectancy has risen by eight years since 1970, and school enrolment has more than doubled from 26 per cent to 54.

It is also notable that many countries have made impressive gains in health and education even where their growth in income has been modest. Conversely, some countries with strong economic performance over the decades have not made commensurate progress in life expectancy, schooling, and overall living standards.

Over the four decades analyzed, the top ten achievers in the world in advancement in the HDI relative to their starting point include those also well known for rapid advances in economic growth miracles such as China and the Republic of Korea.

But the top movers also include Laos, Nepal, and three North African countries – Algeria, Morocco, and Tunisia - which have all made advances on the health and education fronts. And Ethiopia, Botswana, and Benin are in the ranks of the top twenty movers over the past forty years. 

If we examine the last decade, five African countries - Burkina Faso, Ethiopia, Mozambique, Rwanda and Uganda - are among the top ten movers in the HDI, relative to where they were.

These findings suggest that there is much leaders can do to improve people’s lives even where growth is less impressive.
The technologies and treatments available these days appear to make it easier for poorer countries to make substantial human development gains. Improvements, however, are never automatic – they require political will, smart policies, and the continuing commitment of the international community.

Nor has human development progress been constant. Economic crises, conflict, poor governance, natural disasters, and epidemics all take their toll. Three countries - the Democratic Republic of the Congo, Zambia, and Zimbabwe - have lower HDI scores today than they did in 1970.  Both the DRC and Zambia, however, have increased their HDI over the last decade.

The latest HDR concludes that a variety of paths can lead to human development success, and that there is no “one size fits all” approach.

Basic principles, however, can drive successful strategies for human development. They need to be equitable and broad-based, to enable people to be active participants in change, and to ensure that achievements for current generations do not come at the expense of tomorrow’s.

In reviewing broad trends, the HDR reports that the past forty years have seen profound political change in many parts of the world.

There has been a particularly dramatic growth in democracy in Europe, Central Asia, and the Latin American and  Caribbean region since 1970. Africa, East Asia, and the Pacific have also registered notable advances in this area.

Over the same period the Report also finds that rising income inequality has been the norm within most countries, and that there has been a deterioration on most counts of environmental sustainability. 

Clearly one of the most urgent challenges to human development is the world’s current unsustainable production and consumption patterns, as seen, for example, in climate change, but also in poor air and water quality and diminishing biodiversity. 

This reminds us of the importance of protecting our planet and ecosystems, and pursuing lower carbon routes to development.

This year’s Report also shows how inequality limits human development progress. It introduces a refined Human Development Index and three new indices. They include an Inequality Adjusted HDI and a Gender Inequality Adjusted HDI.

On average, inequality is shown to reduce countries' scores on the HDI by 22 per cent. It is countries with lower human development which tend to be the most unequal.

We can deduce from the Gender Inequality Index that enabling girls and women to have equal educational and employment opportunities, access to health services, and political representation will boost a nation’s human development – as well as being the right thing to do.

The highest average losses on the Gender Inequality Adjusted HDI were found to be in the Arab States, Sub-Saharan Africa, and South Asia. Shortfalls in reproductive health contributed the most to these disparities.

The latest HDR also introduces the new Multidimensional Poverty Index, developed at Oxford University with UNDP support. It identifies overlapping deprivations at the household level in health, education, and living standards.  This can help policymakers to better understand the challenges their countries face and to target responses and resources more effectively.

The Millennium Development Goals (MDGs)

The Millennium Development Goals themselves flowed naturally from the human development approach. It inspired calls for more effective global action against poverty, hunger, inequalities, and disease.  That spirit culminated in the historic commitment of the UN’s Millennium Summit in 2000 and the drive to achieve the MDGs by 2015. 

The MDGs remain the world’s most comprehensive set of agreed benchmarks for development progress. They represent time-bound and specific commitments by leaders of rich and poor countries alike to make a difference for the better for those denied the basics of a decent life. They set out to: reduce poverty and hunger; empower women; increase access to education, healthcare, and clean water and sanitation; reduce the incidence of specified deadly diseases; protect the environment; and forge strong global partnerships for development.

The verdict on the Millennium Development Goals to date is not dissimilar to that reached by the Human Development Report on human development progress overall. Considerable progress has been made, although it varies across and within countries and regions.

On a global level, the goal on poverty is likely to be reached, and gains have been made on getting all children into school, reducing infant and child mortality rates, increasing access to clean water, and turning back the tide on HIV/AIDS and malaria.

But less is being achieved on tackling chronic hunger, providing universal access to sexual and reproductive health and on reducing high maternal mortality rates, on gender empowerment, on improving sanitation, and on reducing biodiversity loss

At the MDG Plus Ten Summit held two months ago in New York, Heads of State and Government again committed themselves to achieving the MDGs. The Summit Outcome Document – adopted by consensus by all 192 member states – set out an agenda for action over the next five years on the Goals. It called for an holistic approach, prioritising interventions which would multiply progress across the MDGs and address the underlying systemic challenges which continue to impede progress.

To inform the MDG Summit, UNDP produced a peer-reviewed and well received International Assessment of what it will take to achieve the Goals – which fed into the Outcome document.  We identified eight cross-cutting drivers of MDG progress, and they are reflected in the Summit’s Outcome Document:

  • The need for strong national ownership of development plans, underpinned by leadership, vision, institutions, and capacity;
  • building inclusive growth which can contribute to poverty reduction and job creation;
  •  widening access to affordable energy;
  • underpinning sustained development with effective social protection;
  • investing heavily in opportunities for women and girls as  a good thing in its own right and because of the multiplier effects across generations and communities; 
  • continued targeted investments in health and education;
  • supporting countries to grow their own funding base,
    and 
  • building strong partnerships for development.

The constructive outcome of the Summit owes much to the fact that so many developing countries came to the Summit with concrete evidence of what had worked for them, and clear ideas of what it would take to accelerate progress on the MDGs.

The task now before developing countries and development partners is to focus our too often dispersed efforts on the concrete actions which have been proven to accelerate MDG progress, and to be guided by the principles which the Human Development Report has shown to be essential for  success – those of inclusion, equity, and sustainability.

A Cross-Sectoral Approach

In this context, addressing the socio-economic determinants of health remains as critical as ever. The importance of that was learned long ago. In England during the Industrial Revolution, one in four deaths was from “consumption”. The setting was conducive to a sustained epidemic - overcrowding, poor nutrition, and an absence of workplace health and safety regulations. It was not until those conditions improved that the tide turned. Two-thirds of the decline in TB mortality occurred well before the introduction of effective treatments.

The same was broadly true of the fight against malaria. Only a hundred years ago, the disease was endemic to Europe and North America. I understand that it was largely eliminated long before people realized that it was carried by a mosquito-borne parasite and before the advent of quinine in the twentieth century. Economic development, changing agricultural practices, and better sanitation, irrigation, and housing broke malaria’s grim hold.

These are familiar lessons for many in this audience. Indeed it is many of you, your colleagues, and your predecessors, who have gathered the evidence which allows us to describe the socio-economic determinants of health.

It is urgent to apply this knowledge widely – that is critical for accelerating progress on all of the MDGs. Now is the time for bold and innovative partnerships between health and other development actors to achieve that.

If we can reduce child mortality, improve maternal health, and turn the tide on HIV/AIDS, malaria, and tuberculosis, that will, over time, reduce poverty and help to empower women. That, in turn, would further reduce mortality rates and curb the spread of disease. 

But tackling the complex public health challenges of our time effectively will require collaboration between health and other sectors, as it always has. Whether we are talking about maternal and child health, HIV, TB, or malaria, we need to do a better job of working across sectors and disciplines. Doing so will not only help us tackle the socio-economic determinants of health - it will simultaneously advance progress across multiple MDGs.

We can be encouraged by the evidence which does exist of health and development professionals working together to deliver innovative and multi-sectoral responses to public health challenges.

In South Africa, for example, a UNDP official was a co-investigator on the IMAGE project – which paired a microfinance initiative with gender and HIV training. It aimed to encourage the poorest women in rural communities to start small businesses, while also mobilizing their communities to address domestic violence and HIV. After two years, it was found that, compared to a control group, the participating women had more economic assets, were more likely to use condoms and to go for HIV testing, and were fifty per cent less likely to experience domestic violence.

In an initiative in mountainous regions of Nepal, where high levels of neonatal and maternal mortality remain a serious problem, women’s groups were empowered to talk about perinatal health issues. The women participating were later found to be more likely to receive antenatal care, and to give birth with a skilled birth attendant. Compared to those who had not participated, they experienced a thirty per cent reduction in neonatal mortality and an eighty per cent reduction in the maternal mortality ratio.

It seems clear that programmes which bring partners together in multi-sectoral interventions can be very effective in achieving multiple goals. They are not in competition with traditional health sector interventions; they work in synergy with them.

Going Forward

Whether we are talking about urban England or rural Nepal; whether we are looking back to the 19th Century or forward into the 21st; tackling public health challenges and advancing human development involves addressing the socio-economic determinants of health. 

Making progress requires much more than isolated interventions. It requires a concerted commitment to take  interventions to scale. That requires leadership, vision, and prioritization within countries. It also needs strong partnerships between health and development actors to increase the impact of our collective efforts to achieve the MDGs.

For example, gender equality or lack of it is a key determinant for meeting all the MDGs, not least the health ones. UNDP can help by working with partners to expand women’s economic opportunities, strengthen the legal status and rights of women, and ensure that women enjoy meaningful participation in decision-making. That would undoubtedly have a beneficial impact on maternal health.

Wider factors are at play in meeting the HIV/AIDS MDG targets too. Recently UNDP launched a Global Commission on HIV and the Law to examine what changes should be made to laws which put marginalized populations at greater risk of HIV and impede effective public health responses.

In UN Country Teams around the world, UNDP can support its partner UN agencies to achieve their health specific mandates, including by strengthening local capacities to address barriers to public health.

Our country offices in Morocco and Tunisia, for example, are working with UN partners to support multi-sectoral strategies on maternal health. UNDP’s role can be the “behind the scenes” capacity building which could help ensure that systems are in place to pay health workers, get electricity to health centres, and to enable a Ministry of Health to function effectively.

UNDP’s focus now is on how to accelerate progress across the MDGs by working across stakeholders and sectors.  This year we have implemented a new approach with governments, UN Country Teams, and other partners through a formal MDG Acceleration Framework. It supports governments and their development partners to identify systematically the range of bottlenecks and constraints standing in the way of MDG progress, and then to devise ways to overcome them.  

The results of a ten-country trial suggest that this approach
 is helping to break down silos between sectors, MDGs, and disciplines, in favour of a pragmatic, cross-sectoral, problem-solving approach.

Uganda, for example, has used the Framework to identify what was blocking its efforts to reduce maternal mortality. Practitioners and experts from the Finance, Planning, and Health Ministries were brought together with their partners from civil society, the multilateral organizations, and development partners to consider the evidence of what wasn’t working, and agree on solutions which cut across the normal divisions. For example, they agreed to prioritize road connections and water supplies to critical health centres in existing sectoral plans, and establish incentives for retaining health workers in remote areas.

Where the Framework has been piloted, it has brought greater focus to existing national strategies and plans to address off-track MDGs, by building upon the evidence of what works, and what does not. We have also seen increased engagement by  development partners.

Conclusion

The MDGs are everyone’s business. In this interconnected world we are all neighbours. What happens far away to others impacts on us one way or another, sooner or later. In this broader sense, if our neighbours are poor and struggling, our prospects are affected too.

Whether we are in academia, government, NGOs, Foundations, the private sector, or at the UN, we can all be allies in the effort to advance sustainable human development.

Particularly in these challenging times, we need to collaborate more around the evidence of what works.  The challenges which confront us in meeting the MDGs and advancing human development are beyond the capacity of single actors and sectors to resolve alone.