With another deadline around the Millennium Development Goals (MDGs) reached, there is a renewed debate on how effectively they have helped shape the agenda and the strategies to improve health, reduce poverty and promote development across the globe.
Of the eight goals created in 2000 – which pledged member countries to reduce poverty and unacceptable global health disparities and improve the lives of poor people – there were two dedicated to maternal, reproductive, newborn and child health.
Goal four intended to reduce child mortality by two-thirds. Goal five was to reduce the maternal mortality rate by 75% by December 2015.
In absolute terms, there has certainly been a narrowing of the gap between countries. Significant progress has been made in all the MDGs.
It is widely accepted that both these goals have helped enormously in setting a clear agenda for maternal, reproductive and child health. The United Nations’ 2015 report released this week found the number of children dying before their fifth birthday has more than halved while the maternal mortality rate dropped by 45% worldwide.
But the goals are a classic case of missed opportunity for several reasons. The first is that they failed to address the disparities within countries. The national average data reported in these countries conceals these differences. The second is that there has been no focus on improving the health for sub-populations that are worse off within countries and to narrow the gap between countries.
How to fix the mistakes made last time
There is an argument that the MDGs failed to recognise the central role of existing health systems and the need to strengthen them. Instead, they placed more importance on measurable health outcomes related to vertical programmes. A vertical health programme is one that is managed, delivered and monitored outside the existing health care system. They are considered by many as parallel systems that weaken existing health systems.
The Sustainable Development Goals (SDGs) present an opportunity to correct this.
The end of the MDGs has renewed discussions on the concept of Universal Health Coverage, now firmly part of the post-2015 agenda. In 2014, UN member states asked the secretary-general to synthesise the full range of inputs into the post-MDG discussions. These were finalised by the end of the 2014 under the rubric: the road to dignity by 2030.
The proposed SDG related to health is to attain a healthy life for all at all ages. One target within this (3.6) is to achieve universal health coverage. This has the potential to reduce disparities and inequalities if implemented properly. The goal of universal health care is to make both preventative and curative health interventions accessible to the whole population – urban or rural, rich or poor.
The concept of universal health care is not new. It was discussed at the 2005 World Health Assembly. It was defined then as:
… access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost, achieving equity in access.
At the time, the discussion also emphasised the need to make access to health prevention and curative services affordable by ensuring that households did not risk financial hardship from unaffordable out-of-pocket payments. The suggested parameter was that no more than 40% of household non-food expenditure should be spent on health services.
New focus areas
While the new agenda seems to focus on strengthening health systems to take on the full responsibility of ensuring health for all, it will not specifically drive reproductive, maternal and newborn health.
It does, however, provide an opportunity to focus on specific targets within reproductive, maternal and newborn health. These focus areas include society, health providers and service delivery.
Within the society dimension is social and financial protection, under health provider dimension there is workforce quality, responsiveness and efficiency and around service delivery, there is affordability, acceptability, accessibility, efficiency and equity.
Addressing these three areas will ensure that quality reproductive, maternal and newborn health is accessible to the entire population with financial protection. Financial risk protection is the most popular but the other dimensions need to be defined to make sure it is successfully implemented.
Indicators covering all components of the three proposed areas will facilitate comprehensive coverage in the post-MDG era.
Implementing universal health care
There are several models of implementing universal health care. The most common is health insurance for the working population, starting with government employees. But this model will potentially exclude hard to reach populations.
Another increasingly popular approach is to provide free services for pregnant, lactating women and children under five years of age. But this needs to be properly funded, monitored, evaluated and has to include a wide range of quality preventive and curative services. The services must be accessible to both rich, poor and urban and rural women.
Countries that have struggled to meet the MDG targets will need a concrete framework to guide the implementation of universal health care to ensure inequalities and disparities in health care are closed fairly quickly.