If we have made so much progress on the MDGs, then why is the central message after twelve years still the same? We are still facing a world with hunger, widening inequalities and continuous destruction of our planet. Instead of jumping into the process of defining new goals we need to analyze why, behind the numbers and statistics of progress, the situation has not changed.
MDGs focus on ends while being silent on the means. The values and principles expressed in the Millennium Declaration were lost in translation and we were left with a set of quick wins in which progress was measured in terms of country averages. The MDGs were defined and implemented in a top-down process and issues of governance, participation and empowerment were insufficiently addressed. This all has been said many times over.
World leaders have tried to solve our problems by simply doing more of what caused these problems in the first place. We cannot realistically expect more of this to get us out of it. If we want the next set of goals to change the situation we need to have the courage to make a radical turn in our approach.
A principled approach, tackling the causes of the causes
We therefore support the Task Team’s call for transformative change and a holistic approach with a focus on the core values of human rights, equity and sustainability. We call upon the UN to add empowerment to the list of core principles. Instead of translating the core values and principles of the Millennium Declaration we should put them at the centre of the agenda. This is also being said many times over.
We welcome the suggestion to define a set of “development enablers” to guide countries on how to achieve the desired end(s). However, one size does not fit all. Policy choices need to be discussed at country level in a democratic and participatory way. Overarching principles and values agreed at the global level can guide policy choices, but countries should be given space to move on different paths with different speeds.
Looking into the proposed “enablers” to achieve inclusive social development, we welcome the concept of Universal Health Coverage (UHC) –-since the underlying causes of malnutrition pertain to food, care and health. UHC can potentially promote equity and health systems strengthening overall, instead of the current disease-focused approach which leaves nutrition at the fringes. If defined correctly, realizing UHC is a means to achieving the progressive realisation of the Right to Health and of nutrition. However, the concept is broad and there is no consensus to date on its precise meaning. We oppose the promotion of a minimalistic insurance model that would offer “basic packages of care” (often excluding nutrition) and would operate within a market-based system of healthcare. UHC must be achieved through organized and accountable systems of high quality public provision of comprehensive primary health care that includes nutrition services and of a fully functional referral system governed by need of care.
In addition, we are worried that the focus on “service delivery” will divert attention from action on the structural determinants of malnutrition and tackling the root causes of preventable ill-health, malnutrition and premature deaths. Equal access to health care and nutrition services address an underlying social determinant of malnutrition, but just one of them. Striving for UHC should be part of a comprehensive strategy focusing on the social determinants of health and of nutrition in general. Although the UN and WHO define health services as including “prevention, promotion, treatment and rehabilitation”; we are concerned that the promotional services for nutrition will encompass action only on some of the determinants of health, e.g. water and sanitation, but leaving out others, e.g., trade and power relations. If one really wants to use nutrition as a benchmark for progress in other fields of development and to promote a health-and-nutrition-in-all-policies approach, a more pro-active attitude will be needed. The holistic approach advocated for by the UN Task Team means going beyond health and and nutrition and looking at the other fields to ensure policy coherence and synergies between the different goals. Human rights, including the right to health, the right to nutrition, equity and sustainability should be put at the center of all policies. We call on WHO and on FAO to take this approach a step further and to engage with all the other sectors that affect health and nutrition, including global trade.
Engaging with other sectors is crucial. We look at the global crisis as a consequence of the failure to go beyond the individual sectors (health, food, education) to address the social, political and environmental determination of their shortcomings --that additionally result in an erosion of people’s food sovereignty, in higher levels of poverty, as well as in a lack of fair and equitable access to water, housing, sanitation, education, employment and universal and comprehensive social services. The new sectoral goal(s) should not be solely about service delivery, even if broadly interpreted; we need to address the causes of the causes.
In our view, the UN has, so far, not gone far enough in suggesting an alternative course for the development paradigm. The global food, fuel and financial crises have exposed systemic failures in the workings of financial and commodity markets and major weaknesses in the mechanisms of global governance. We have argued, in the PHMs Global Health Watch 3, that the multiple crises not only show the failure of the current institutional framework of the global economy, but also of the currently dominant neoliberal paradigm of economics itself. It demonstrates the non-viability of capitalism in its current form, characterised by perpetuating extreme inequalities traceable to poorly extreme inequality and poorly regulated markets, and dominated by the interests of a small rich minority embedded in the corporate and financial sectors.
We take strong exception with the fact that none of the currently circulating proposals and documents from UN-institutions challenges the prevailing paradigm of economic growth. The UN Task Team calls for “stable, equitable and inclusive economic growth, based on sustainable patterns of production and consumption”, but the word ‘redistribution’ does not appear once in the entire document. For us, it is not about poverty reduction by all efforts going to uplift the poor; it is about disparity reduction. The Commission on the Social Determinants of Health stated rightly that “income redistribution, via taxes and transfers – the latter of which are key to social protection – are more efficient for poverty reduction than economic growth per se.” Moreover, in a carbon-constrained world, a strategy of growth does not make sense. A paradigm break is needed post-2015.
We strongly welcome emphasising issues of governance. We agree with the UN that better governance of the economic and financial sector will be key to maintaining regulatory frameworks that respect human rights and protect the environment. The current global trade and investment regime is seriously undermining universal social entitlements and rights, as well as the power of states to regulate the activities of corporations and of private financial institutions.
We need to redesign our political culture and our institutions, both nationally and globally; to create relations based on solidarity; and to put in place the mechanisms of accountability needed to run the global political, economic and social structures in a manner that is just, equitable and sustainable. Genuine equality of influence should be at the heart of all decision-making.
We are further adamant about the need to divert from the prevalent ‘charity’ model in global relations to a rights-based approach with clearly delineated responsibilities and related accountability-mechanisms. One of the major shortcomings of the current MDGs has been the imprecise definition of the global partnership for development. Many of the commitments made by the international community have remained unfulfilled because of the absence of accountability frameworks and undemocratic global governance. To be achievable and sustainable, the new development goals will have to be embedded in an agreement that allocates new responsibilities, both national (states towards their inhabitants) and international (the international community towards states needing assistance). We cannot ignore issues of governance and finance: there need to be clear agreements on how to pay and who will pay. In this respect, we call for fair and progressive taxation regimes within and between countries that will enable a transformative and equitable redistribution of resources and power instead of relying on charity.
Governance not only requires allocation of responsibilities, but also organisations and mechanisms to ensure accountability. Uneven progress towards the health and nutrition MDGs may be due, at least in part, to the uneven creation of organisations, institutions and regimes for supporting the achievement of the MDGs. There are simply too many global health actors and initiatives – better coordination and a truly country-driven approach to health improvement will require a radical rationalisation and shrinkage of the global health and nutrition architecture. In addition, there is inadequate monitoring of the policies and actions of donors --they are largely immune from scrutiny or censure. PHM calls upon WHO and FAO to play a significantly more active role in this call for more global democratic governance and to seek a more coherent and accountable system of global health governance. PHM will support WHO and FAO in such an endeavor.
Finally, and most importantly, the implementation of a post-2015 development agenda will depend critically on the legal and economic empowerment of people, especially those most excluded, and of their civil society organizations, to participate effectively in national and local decision-making. People should be at the centre of the new development agenda and be engaged at every stage of the process; defining, implementing and monitoring of the new development framework. This links with accountability; the ability of people to hold institutions accountable for the delivery of quality services; it calls for responsiveness, recourse and transparency; and for setting and adjusting priorities and targets --and people’s empowerment is key for this.
Empowerment should be one of the core values of the new development framework. We cannot achieve equality in health and nutrition without addressing power imbalances at local, national and global level. There is promising work ongoing using community monitoring for accountability and social action in both the health and the food and nutrition areas. Such processes have to play an increasingly important role in measuring and monitoring progress. The national and global surveys currently used give a very distorted picture about people’s lived reality. Community monitoring does not only provide richer data, but also enables people to claim their human rights.
In terms of community participation and empowerment, the UN consultation process is largely falling short. The country consultations are supposed to target the poor and marginalized, but the guidelines suggest to include only representatives of various groups in the consultations (e.g., NGOs, community-based organizations (CBOs), universities and research institutions, private sector entities). These consultations shouldn’t be simply about extracting information to help define global goals that will then be implemented in a top-down approach. They should be used to put in place mechanisms of continuous community engagement. We must set up a constant feedback loop that will enable people to effectively engage in the entire process and hold their governments accountable for their promises. We call for community consultations, not as a one-time information collection effort, but as a first step towards democratic global governance.
PEOPLE’S HEALTH MOVEMENT
This thematic discussion was led by FAO and WFP in collaboration with “The World We Want”.
The consultation was facilitated by the Global Forum on Food Security and Nutrition (FSN Forum)