After years of prioritising diseases of poverty such as HIV and malaria, the United Nations has finally realised that “non-communicable diseases” such as cancer, diabetes and heart disease are now the biggest health problem facing developing countries. This will be the topic of a major UN summit in New York on September 19 and 20, where governments will agree to a global plan for tackling these diseases. Up for discussion are new targets and funding.
This is not the first time the UN has proposed a grand initiative to tackle disease. Although they are fading from public consciousness, in 2000 the UN created the Millennium Development Goals, a series of global targets to reduce disease and poverty. Over a decade on, what lessons do the MDGs hold for this new generation of summiteers?
Those trying to influence the New York summit are convinced of the utility of measurable targets. “Without global goals or targets, this is not going to fly. What gets measured gets done,” Margaret Chan, Director-General of the World Health Organisation, told a pre-summit meeting in April. The WHO wants the UN to agree to a target of 25 per cent fewer preventable deaths by 2025, and detailed targets covering everything from salt consumption to breast cancer screening.
The MDGs show the need for caution, particularly when applying targets to developing countries. In most of such countries, the quality of health data is patchy in the extreme. Causes of death are rarely registered, and the incidence of diseases such as malaria is only vaguely understood.
This paucity of data made the MDGs meaningless from the outset, and almost useless as a mechanism to track progress. Unfortunately, the same gaps in data exist for non-communicable diseases, forcing public health specialists to rely on forecasts and models, which give only a vague indication of the reality on the ground – hardly a sound basis from which to mobilise hundreds of millions of dollars.
Second, politicians too often succumb to the temptation to sign up to targets that sound good in the conference hall, but have little chance of actually being achieved. The MDGs fall into that category, with 48 of the world’s poorest countries totally off-track as the 2015 deadline approaches.
Other failed health plans include the Roll Back Malaria target of reducing malaria deaths by 50 per cent by 2010, and the WHO ‘3 by 5’ target of putting 3 million people on AIDS treatment by 2005.
These kind of catchy targets offer no real accountability, as there are no sanctions for failure – the health agencies simply move on, setting up a new target for a new problem. But continually missed targets can breed cynicism, undermining public support for global efforts to tackle poverty and disease. Money is not necessarily the issue, either. Foreign aid for health has more than tripled over the last decade, rising from $7.6bn in 2001 to $26.4bn in 2008.
Sadly, much has been wasted. A 2009 study by the WHO attempted to gauge the impact of the last 20 years of aid spending. While it listed some successes, such as increased diagnosis of tuberculosis and higher vaccination rates, it also found some U.N. programmes were counterproductive because they undermined basic services and resulted in falls in domestic health spending.
Corruption remains a major problem: The Global Fund for Aids recently announced it will stop funding for Nigeria and Djibouti over apparent fraud worth $474.6m and $20m million respectively. Even now, less than 50 per cent of people have access to basic medicines in many parts of Africa, as public health systems creak under the combined weight of corruption, mismanagement and brain drain of medical personnel.
The USA and its European allies are facing a massive debt crisis. As such, is it feasible to continue the old way of handing money to health ministries in developing countries in the hope that public health infrastructure will improve enough to deliver the treatments and interventions necessary to tackle diabetes, heart disease and cancer?
Instead of re-treading the old path of attempting to fund increases in capacity in local public sector health provision, why not try to harness the private sector, which already provides the majority of healthcare throughout Africa and Asia? Experiments have long been taking place using public money to provide access to quality private sector healthcare for the poor, via methods such as contracting and franchising.
Framed correctly, these partnerships can improve both the quality and capacity of health services, something that will be vital as the numbers of people suffering from non-communicable diseases grow. Without such bold thinking, the UN summit risks becoming yet another historical footnote.
* Thompson Ayodele, Director of Initiative for Public Policy Analysis, Lagos, Nigeria. Philip Stevens, Senior Fellow, Centre for Medicine in the Public Interest, New York. Email: thompson@ippanigeria.org