Helen Clark: UN progress on the global development agenda, post 2015 and NCDs
Helen Clark, Administrator UNDP
Keynote Address at
Launch of The Lancet Non-communicable Disease series
Opening plenary: UN progress on the global development agenda, post 2015 and NCDs
John Snow Lecture Theatre, London School of Hygiene and Tropical Medicine,
Keppel St., London WC1, United Kingdom.
11:30 a.m., Monday, 11 February 2013.
My thanks go to The Lancet and the organizing committee for inviting me to take part in the launch of the fourth series on Non-Communicable Diseases (NCDs), and to our hosts, the London School of Hygiene and Tropical Medicine and especially, Professor Peter Piot.
This Lancet series of articles and comments on NCDs is a very significant contribution to the debate on the post-2015 global development agenda. It positions the prevention and control of NCDs at the very heart of the global development agenda, building on the outcome of the UN General Assembly’s September 2011 High Level Meeting on NCDs.
The Political Declaration from world leaders at that meeting, acknowledged that NCDs constitute a major challenge to development and threaten the achievement of internationally agreed development goals. The leaders also recognized that NCDs are “a threat to the economies of many Member States, and may lead to increasing inequalities between countries and populations.”
At UNDP we believe that NCDs pose a significant threat to improving and sustaining human development progress in the 21st century. That is because:
o NCDs, and the illnesses and suffering associated with them, stand in the way of people’s aspirations, freedoms, and capabilities to lead lives they value – that is, they stand in the way of realizing the core objective of human development.
o At the household level, NCDs can push families into poverty when adequate social protection measures and access to affordable health care are not available. In such situations, children may have to give up their education to work or to care for parents – that makes the impacts inter-generational.
o For low-income countries, managing the growing burden of NCDs can be very expensive, and over time will put even more severe strain on already overburdened health systems. There are inexpensive and cost effective interventions, but to date they have not been widely implemented.
o At the macro level, morbidity and mortality related to NCDs sap productivity among working age populations and pose a significant economic burden. A report by the World Economic Forum and the Harvard School of Public Health suggests that over the next twenty years, NCDs will cost more than US$ 30 trillion, representing 48 per cent of global GDP in 2010, and pushing many millions of people below the poverty line.
As a former Prime Minister and Health Minister in New Zealand, and in my current role leading one of the world’s largest development agencies, I appreciate that just as health shapes development, so development shapes health. Poor health impedes lifting human development. Equally, the conditions in which people live and work impact on their health and well-being. Further, inequalities in health outcomes tend to mirror inequalities and inequities present in broader society – and indeed in our world.
UNDP is not a specialist health agency. We are a general development agency working within the human development paradigm. As such, our core mandate of supporting countries to tackle poverty and inequality, promote gender equality, support inclusive governance, and achieve sustainable human development is central to lifting health status. Our work is a natural complement to that of the World Health Organization and other specialized global health agencies.
My remarks today will focus on three areas:
First, I will look at the progress being made on the health goals and targets in the current set of MDGs.
Second, I will look at how health broadly and NCDs specifically could fit into the post-2015 development agenda.
Third, I will comment on how development actors like UNDP, in partnership with the WHO and other health actors can support multisectoral action to tackle the NCDs.
Health and the MDGs
Health targets are very prominent in the current MDGs, recognizing that health and development are inextricably linked. Three of the eight MDGs were devoted to health outcomes, and significant progress has been recorded in some areas, such as turning the tide on HIV (MDG6) and reducing infant and child mortality (MDG4). Progress on achieving the MDGs, however, has been uneven across regions and within countries.
According to WHO, as of the end of 2011, eight million people were on life-saving antiretroviral therapy for HIV in low- and middle- income countries, and UNAIDS projects that countries are on track to reach the MDG target of having fifteen million people on that treatment by 2015. The number of deaths of under-five year old children worldwide fell from more than twelve million in 1990 to 7.6 million in 2010.
Progress on MDG 5 on reducing maternal mortality and ensuring universal access to reproductive health, however, has been less impressive. The obstacles in the way to achieving the targets extend beyond shortcomings in the health sector to gender inequality and disempowerment, poverty and poor nutrition, and inadequate infrastructure – including in the transport sector. This gives us insights into why multisectoral action to achieve health goals is so important.
Overall, the MDGs with their time-bound, and measurable targets have galvanized unprecedented global attention around a common agenda, and have succeeded in mobilizing action and directing resources to lift human development.
The Lancet’s recent coverage of the 2010 Global Burden of Disease study tends to confirm this, with the paper by Chris Murray and co-authors on Disability-Adjusted Life Years suggesting that the 32 per cent decline in the burden from MDG-related disorders between 1990 and 2010 is largely due to the increased global attention they received.
The post-2015 development agenda debate and the shape of health goals and targets
The question now is: can the time bound, measurable, and easily communicated approach of the MDGs be brought to bear in the post-2015 development agenda on the threat posed to global health by the NCDs?
The Lancet’s Editor, Richard Horton, notes in his commentary on the series of articles being launched today that their objective is to “present the case for including NCDs as part of the post-2015 framework being developed now and over the next two years by governments and the UN system.” This issue is also the topic of the paper in this series by Sir George Alleyne and colleagues.
The series is timely, as major consultations on the post-2015 development agenda are currently underway, supported by UNDP and its sister organisations in the UN Development Group. Already:
o national consultations have been scheduled for 73 countries, and the number could rise to 100;
o eleven thematic consultations are being held on areas ranging from health to inequalities, environmental sustainability, and governance. The thematic consultations on health are being led by WHO and UNICEF, and will culminate in a high level meeting in Botswana next month. I understand that the background paper for the event is now available for comment.
o global consultations are being conducted through virtual platforms and social media, so that the voices of audiences far beyond official and expert circles can be heard. I encourage you all to participate in this process and, better still, ensure that widespread discussion takes place on these issues in your countries.
The information gathered in the various consultations is available to inform the UN system’s advice to the Secretary General, the High Level Panel on Post-2015 appointed by the Secretary General, and the Open Working Group appointed by the UN General Assembly to work on the design of Sustainable Development Goals, as called for by the outcome document from Rio+20.
Sustainable development calls for integrated policy-making across the economic, social, and environmental spheres – an approach highly consistent with the multisectoral approach required to address NCDs. One of the challenges in this approach, and in designing sustainable development goals, is to ensure that economic and social development and environment actors work together.
So: what could the unifying concepts for a global health goal be?
There is strong advocacy for a focus on universal health coverage, and also some opposition. The UN General Assembly passed a resolution last December, recommending that: “consideration be given to including universal health coverage in the discussions on the post-2015 development agenda in the context of global health challenges”, and asserting that “ the provision of universal health coverage is mutually reinforcing with the implementation of the Political Declaration on the Prevention and Control of Non-communicable Diseases”.
The concept of universal health coverage should be seen as covering preventive and long term care services as well as acute illness services. The concept is a departure from the element of verticality inherent in the current health-related MDGs, and, to some extent it addresses concerns of equity and inclusion, particularly for those who are financially excluded from accessing healthcare. Given the persistent, and likely growing, inequities in NCD burdens within countries, as articulated in this Lancet series by Majid Ezzati and colleagues, universal health coverage could offer a means of ensuring that everyone affected by them has access to the services they need, especially to essential medicines for NCDs ( see the paper in this series by Hogerzeil and colleagues) - and is not impoverished as a result.
Universal health coverage, however, desirable as it is, will not in itself deliver higher health status. Action on a much broader front is needed, including on tackling the socio-economic determinants of health. That is because various forms of stigma, discrimination, and marginalization, rooted in laws, policies, and economic, social, cultural, and other factors, have profound impacts on health status, and on whether people will access health services even when they are readily available.
At UNDP we know this well from our work with the Global Commission on HIV and the Law. Its report shows how discriminatory laws and stigma can prevent people seeking HIV services – even where the services are available. Indeed such discrimination can also be a constraint on MDG progress in general.
Moreover, social determinants shape not only access to and the use of services, but also the pattern of the underlying risks themselves. Risk factors for NCDs – such as tobacco and harmful alcohol use, and consumption of foods high in salt, saturated fats, and processed sugars – are influenced by underlying policy choices which span the areas of, for example, agriculture, trade, intellectual property and trade law, tax policies, and attitudes to regulation as highlighted in the paper in this series by Rob Moodie and colleagues. Similarly, preventive behaviours, such as physical activity, can be impacted by public policy in areas as wide ranging as sport and recreation, transport, and urban planning.
A broader chapeau for a health goal could therefore be envisaged – possibly around “universal health” – as in the Almaty Declaration’s “Health for All” – or maximizing “healthy life”, beneath which specific targets could be set; for example, for progress towards universal health coverage and on tackling the drivers of ill health. Such a goal could encourage multisectoral action on social determinants of health, embrace the WHO’s agreed goal of a 25 per cent reduction in premature mortality from NCDs by 2025, and adopt targets for tackling major drivers of NCDs as agreed by the WHO Executive Board last month. A key lesson from the experience of working with the MDGs is the need for focus on a small set of clear targets.
Collaboration between health and development actors in advancing positive health outcomes
Global leadership on health lies with the World Health Organization, but development actors like UNDP can offer important support for building capacities in-country for stronger health systems and for multisectoral approaches to addressing major health challenges. This includes action on preventing and combating NCDs.
In an example of such collaboration, WHO Director General Margaret Chan and I wrote jointly to all the UN’s Resident Co-ordinators in developing countries in March last year, encouraging them and their teams of UN agencies to support the integration of NCDs into their country partnership agreements and to work on multisectoral responses to the NCD challenge.
Around the world we do see countries acting on the NCDs as part of their efforts to achieve the MDGs. Rwanda, for example, has paid close attention to mental health within its MDG-based planning. Tonga has placed NCDs at the heart of its strategies to accelerate progress on the MDGs, drawing links between the NCD epidemic and poverty, hunger, and gender.
WHO and UNDP are collaborating at the regional level in the South Pacific to hold a workshop this month in Fiji on trade, trade agreements, and NCDs for Pacific Island policy officials. The aim is to identify strategies to align trade agreements with public health concerns, particularly those relating to NCDs. The workshop draws on WHO’s extensive work on prevention and control of NCDs, on UNDPs work on intellectual property rights and access to medicines, and on human rights impact assessments of trade agreements.
At the global level, the UN Interagency Task Force on NCDs, chaired by WHO, is developing a joint UN programme framework for NCD prevention and control, to promote better cohesion and co-ordination among different UN actors, as well as an accountability mechanism for UN actions at the global and country level. I would note that independent accountability mechanisms can also play a critical role, as described in one of the comments in this series.
Priorities in the Framework are likely to include the integration of NCDs into development planning, strengthening the capacity of governments to respond, the creation of health-promoting environments and improving surveillance. It will be important for new efforts to be aligned with existing ones, such as those being made to implement the WHO Framework Convention of Tobacco Control.
The role of research is important – as we understand more about the impact which policies outside the health sector can have on reducing NCDs, and on the negative consequences of NCDs on development progress, more multi-sectoral action can be encouraged.
In conclusion, let me congratulate The Lancet again on publishing this timely series on the NCDs.
The record of responses to the HIV challenge suggests that firm and early action – as seen in countries like Thailand and Senegal – can change an epidemic’s trajectory, saving lives in the short term, and significant resources in the long-term. This can be true for action on NCDs as well. The paper by Ruth Bonita and colleagues highlights the steps countries can take to make rapid progress towards the global NCD mortality goal of a 25 per cent reduction in death rates by 2025.
Failure to curb the growing NCD epidemic now will lead to a significant toll on human life and well-being, and to great strain on health systems and family and public budgets.
By placing NCDs permanently on the global development agenda, people’s lives, opportunities, and future prospects will improve – thereby advancing sustainable human development overall.
I hope that all attending this important event will return home knowing that with a determined effort now, we can, working on a multisectoral basis, make huge strides on facilitating NCDs within the framework of a reinvigorated global development agenda.