[afro-nets] Health for All or Health for Half?

[Claudio Schuftan <claudio@hcmc.netnam.vn>]

Health for All or Health for Half?
----------------------------------

The People's Goals go beyond Mediocre and Disappointing Gener-
alities.

by Wim De Ceukelaire
intal/Medical Aid for the Third World

The Millennium Development Goals (MDGs) are high on the agenda
of summits and conferences and are heavily influencing the de-
velopment discourse of multilateral agencies and NGOs. Health
figures prominently in the MDGs as almost half of them relate
directly to health and health is an important contributor to the
other goals. According to Dr. Lee Jong-Wook, the director-
general of the World Health Organization (WHO): "Improvements in
health are essential if progress is to be made with the other
Millennium Development Goals." As health is so important for the
MDGs and the goals are so intimately related with health, we
have ample reason to take a closer look at them and at their
background.

Where do the MDGs come from?

The Millennium Development Goals are the result of the United
Nation's Millennium Summit that was held in September 2000. This
summit was an attempt to put the UN back at the forefront of the
international political and economic relations in the new cen-
tury after the organization had lost much of its influence dur-
ing the 1990s. At the end of this meeting, the 147 Heads of
State and Government who were present adopted the Millennium
Declaration that is supposed to reflect their commitment to de-
velopment and poverty alleviation. This commitment was summa-
rized in eight goals related to poverty alleviation and develop-
ment that are to be attained by 2015. For each of these eight
goals, the UN has formulated targets that are made measurable by
a set of 48 indicators.

Although the MDGs are a UN project the origins of the goals are
to be found in an organization that defends the interest of the
industrialized countries. It was the Development Assistance Com-
mittee of the OECD, the club of rich countries, that pioneered
the idea of "International Development Goals" in 1996. After ap-
proval of the IMF and World Bank, they were adopted as the MDGs
in the Millennium Declaration. To a large extent, the MDGs are
the goals of the industrialized countries.

Moreover, the MDGs are a rehash and reformulation of development
goals that were originally set (and not met) for the year 2000.
For example, in 1990 primary education for every child was set
as a target for 2000 but in the MDGs, the same target is given a
new time frame and should be achieved by 2015. Sad to say, the
reality is even worse. According to the 2003 Human Development
Report, the target will not be attained before the end of the
21st century.

What is to be eradicated?

Knowing that the MDGs largely reflect the development agenda of
the industrialized world and are a watered down version of ear-
lier international goals it is not surprising that they are
criticized for lack of ambition. Indeed, a closer look at the
goals reveals they are far less ambitious than it seems. For ex-
ample, the first goal is to "eradicate poverty and hunger". Ac-
cording to the corresponding target, however, this will be
achieved by halving the proportion of people living on less than
US$ 1 a day and the number of people who suffer from hunger by
2015. Take note that the plan is to halve the proportion of the
poor and not the actual number. Because of population growth,
absolute numbers will not be cut in half. Moreover, the base
year is not the year 2000, as one would expect, but 1990, which
makes the plan even less ambitious.

Although they are supposed to be development goals, the MDGs re-
fer to hunger, poverty, child mortality etc. These are the con-
sequences of mal-development but that doesn't mean that develop-
ment will be brought about by their eradication. The absence of
poverty and hunger, even if they would be possible, doesn't nec-
essarily mean that society is developed, let alone that a sus-
tainable state of development has been brought about.

Are these development strategies?

The focus on measurable indicators reflects a certain attitude
towards development. It considers development as a 'technical'
problem that should be solved by 'technical' solutions. That is
for example the consequence of the World Bank's US$ 1 a day
threshold as a measure of poverty. In theory, poverty would be
eradicated as soon as per capita income exceeds US$ 1 and yet
many people would still be poor. In reality poverty is much more
complicated and is not only a matter of income. Being poor is
about a lack of power, assets, autonomy, participation, secu-
rity, welfare, etc. Fighting poverty is about the peasants'
struggle for land, about the workers' demand for regular con-
tracts and about the slum dwellers' rally for an own house.

It is exactly because of this erroneous focus on 'technical' ap-
proaches that the solutions that have been offered are likewise
focusing on "quick wins". In fact many efforts are wasted on
calculating how much money would be required to solve this or
that problem as if it is only a matter of money. In 2001 there
was the WHO Commission on Macroeconomics and Health that called
for US$ 27 billion in annual donor funding. In January 2005,
Jeffrey Sachs' Millennium project called for US$ 73 billion ex-
tra in 2006, rising to US$ 135 in 2015 to achieve the MDGs. Re-
cently, researchers in The Lancet estimated it will cost US $
5.1 billion to prevent 6 million child deaths, etc... Is it
really just a matter of money?

What global partnership?

It goes without saying that only poor countries are being moni-
tored scrupulously for their progress with regards to the MDGs.
Multilateral institutions like the World Bank and the IMF are
using the MDGs already as a yardstick and condition for loans
and aid. Still, one of the MDGs, number 8, also refers to the
rich countries. They are supposed to join a 'global partnership'
to attain the other MDGs. This goal does not have any concrete
targets, however, but only vague promises. There is no promise
of 'eradicating' debt, for example, or even halving it. The rich
countries are only supposed to "deal comprehensively with the
debt problem to make debt sustainable in the long term"--a for-
mulation that means different things to different people.

The 'global partnership' is touted as the linchpin of the MDGs
but it might be its Achilles heel instead. The governments of
the Rich and the Poor countries are supposed to work hand in
hand with the multinationals in order to bring about a better
world. It sounds like a fairy tale and it might as well be one.
Is it really realistic to expect the plunderers to repent and
help their victims?

This kind of reasoning is only possible because the MDGs are fo-
cusing on the consequences instead of the causes. The whole Mil-
lennium Declaration does not make any reference to the causes of
poverty and hunger. It is not surprising therefore that the MDGs
fail to provide any hint of a solution. In reality, the poor and
the hungry are the products of historical processes of margin-
alization, mal-development and exploitation. Addressing poverty
and hunger requires addressing these forces and processes that
are at the roots of inequity and marginalization.

As the root causes of poverty and hunger are not addressed, the
forces of globalization have only intensified during the past
decade. Consequently, progress for most development indicators
has been minimal during the 1990s and definitely not fast enough
to attain the targets. Child mortality decreased much faster in
the period 1960-1990 than in the 1990s when the average annual
improvement of 2.5% slowed down to a mere 1.1%. The same goes
for maternal mortality, and access to potable water and sanita-
tion. For AIDS, malaria and other diseases, the situation even
deteriorated.

The People's Goals for health

In the field of health, there are already millennium goals for
more than 25 years. In 1978, at the Alma Ata Conference, minis-
ters from 134 countries in association with WHO and UNICEF
called for 'Health for All by the Year 2000.' The Alma Ata Dec-
laration reaffirmed the WHO's holistic definition of health as
"a state of complete physical, mental and social wellbeing, and
not merely the absence of disease or infirmity." Moreover, it
went on to signal that the "existing gross inequality in health"
was unacceptable, that people have a right to participate in the
organization and implementation of health care, and that primary
care should be universally available. Finally, signaling the re-
sponsibility of governments for health, the declaration launched
the ambitious goal of "health for all" by the year 2000.

At the turn of the century it became clear that the world was
farther from this goal than ever and that governments and world
leaders had not delivered on their promises. For them it was a
reason to rehash them and integrate them into the Millennium De-
velopment Goals. Apparently they wanted to forget Alma Ata as
soon as possible and burry the promises in the general MDGs. For
the people's movement, however, the year 2000 was an occasion to
come up with the People's Charter for Health that reaffirms the
principles of the Alma Ata declaration.

A comparison between both approaches reveals why the Alma Ata
declaration could also be called the people's millennium goals
for health:


Alma Ata
Millennium Declaration

Goals
Health for All
Progress on a number of indicators

Targets
The attainment by all peoples of the world by the year 2000 of a
level of health that will permit them to lead a socially and
economically productive life.
To halve by the year 2015 the proportion of people who suffer
from hunger.

To reduce maternal mortality by 1/2 and U5MR by 2/3.
To halt the spread of HIV/AIDS, the scourge of malaria and other
major diseases.

Moral framework
Health is a fundamental human right
Freedom, equality, solidarity, tolerance, respect for nature,
shared responsibilities.; promote democracy and strengthen the
rule of law.

Strategy
Comprehensive primary health care
"Quick wins" to attain selected indicators.

General objective
Equity and economic justice
Ensure globalization becomes a positive force

Economic context
Economic and social development, based on a New International
Economic Order
Develop further an open, rule-based, predictable, nondiscrimina-
tory trading and financial system.

International context
A genuine policy of independence, peace, détente and disarme-
ment.
A global partnership with the private sector and civil society
organizations.

Peace
Make better use of the world's resources, through the re-
allocation of spending on armaments and military conflicts.
The world needs a broad vision of collective security because it
is under threat by international war and conflict, as well as
terrorism, weapons of mass destruction, organized crime and
civil violence.


With all the hullabaloo about the MDGs, we have to keep our pri-
orities right. Of course the promises of the Millennium Declara-
tion are welcome but they are also too little too late. More-
over, the MDGs should not make us forget that the people are not
contented with health for half when 'health for all' is possi-
ble. The Alma Ata Declaration and the People's Charter for
Health are leading the way.