Addressing gaps in national vision of "Health for All"

Can we, or can’t we? Can the world really end poverty, hunger and gender discrimination and ensure “health for all” by 2030? These questions have fuelled several discussions on development among the 193 member-states of the United Nations, in their bid to arrive at a consensus for a joint framework of action for the next 15 years.

Now that the Millennium Development Goals (MDGs) are nearing their end, the governments are confronting the “unfinished” agenda of development. This will be tackled by a new set of goals, the Sustainable Development Goals (SDGs), to be launched by the UN secretary general at the United Nations General Assembly later this month.

At this time, Prime Minister Narendra Modi will present the national strategy to meet the SDG goals and targets – a five-pronged action plan focused on financing, accountability, community engagement, advocacy, and research and innovation- from 2016 to 2030.

But here’s the glitch: the SDGs are far more ambitious than their predecessors. While there were just eight MDGs, there are now 17 SDGs. These new universal goals are grandiose, and include “ending poverty”, “ending hunger”, and so on. They aim to “leave no one behind.” The question of how, really, they will be implemented in a country the size of India, riddled by large economic and social disparities, remains largely unanswered.

Some answers to these questions arose during a recent two-day Global Call to Action Summit 2015 in New Delhi, which focused on ending preventable child and maternal deaths. Representatives from24 priority countries that contribute nearly 70 per cent of the preventable maternal and child deaths gathered at the meeting, to discuss progress on MDG4 and 5 – the goals focused on improving maternal, infant and child health.

India’s achievements on the maternal and child front were highlighted by health ministry officials: indeed, the MDGs have been catalytic in improving the health of mothers, and children. Apart from the eradication of polio, new-born and maternal tetanus are also history today. Under-five mortality rate has dropped from 126 per 1,000 live births in 1990, to 49 in 2013. The maternal mortality rate stands at 167 per 1,00,000 live births today, against the figure of 560 in 1990. About 75 per cent of deliveries take place in health facilities today, as opposed to 40 per cent, 15 years ago.

Still, several factors stall the progress. Glorification of figures doesn’t mitigate the failure of the public health system to deliver quality care to millions of women, infants and children. Crumbling hospitals minus infrastructure, requisite staff and essential life-saving drugs are the norm in many areas. No concrete solutions have emerged when it comes to the matter of doctors’ shortage in rural areas.

Progress has stalled on every single move made to remedy this; both the idea of providing short term courses to MBBS doctors that equip them to handle emergency procedures, and the new “rural” MBBS degree, have made no headway.

Though the PM announced that India had marked 184 districts that are most in need, no detailed strategy on how the health needs of the 10 per cent that slips between the gaps of health systems, the “hardest to reach” groups, was shared at the summit. But we need concrete answers to this question, to meet the SDG targets - bringing the under-5 mortality rate down from 49 to 25 per 1,000 births by 2030; and the maternal mortality rate from 167 per 1,00,000 births, to 70.

Teenage pregnancies

Another gap in the summit discussions was the absence of debate on family planning, despite the crucial role this plays in improving women and children’s health. Provision of access to contraception is imperative to prevent teenage pregnancies (to avert maternal and new-born deaths) and enable women to delay and space their children. Yet, there was no mention either of the paucity of contraceptive choices in the national programme, or the other factors hindering the uptake of contraceptives.

Other lacunae in the proposed national agenda are also a cause for concern. These include the absence of a clear implementation plan and accountability mechanisms. The declining role of the state vis-a-vis the private sector is worrying too. Civil society representatives remark that the new framework doesn’t address the obligation of the state actors, imperative to addressing systemic and deep rooted developmental challenges in the country. 

Certain public services – like delivery of healthcare, education, water and sanitation - should be the primary responsibility of the states. Making headway on the massive SDG agenda will require state governments to take the lead, and the establishment of mechanisms to ensure that targets are being met by all actors. Regulatory factors must also be put into place to ensure the inclusion of marginalised groups.

Then, there’s the matter of money. Implementing the SDGs will be an expensive business: According to the UN estimates, implementing the goals will cost $3.5 trillion to $5 trillion every year. In July this year, stakeholders in development came together at the third Financing for Development (FfD) conference in Addis Ababa, Ethiopia, to make financial pledges to support the proposed SDGs.

Though various suggestions for “innovative” financing mechanisms emerged at the FfD, the disappointing part was that India made no concrete financial commitments. The resulting lack of clarity on “who will pay for what”, and for what period, blurs the national agenda.

Lastly, experience so far shows that the comprehension and uptake of “development” goals is limited- many state players and communities still don’t have any idea of what the MDGs are about, limiting their contributions. Improving community understanding of goals and ensuring that these are aligned with policies and resources is important to achieving them. Indeed, the only way to meet the 17 goals and 169 targets of the SDGs is to prioritise on the basis of the urgent needs of the most marginalised.

(The author is a microbiologist who writes on health issues)