Healthy Dialogues: October, 2010
October 12, 2010
This month, CSIS Global Health Policy Center (GHPC) is happy to announce the launch of our new monthly blog – Healthy Dialogues. The Healthy Dialogues blog strives to create a dynamic space for conversations about current topics in health. We pick experts, from both inside and outside CSIS, to provide a range of views on a single topic. We hope that by stringing our experts’ responses together, an interesting and complex picture of the topic will be created. An integral component of this blog is you! If you have a topic you'd like us to address in the future, tell us. If you have a question you'd like us to answer next, ask it. We want to hear what's on your mind.
As the Millennium Development Goals Summit recently concluded, we thought this would be a fitting place to start. This month, GHPC experts - J. Stephen Morrison, Lisa Carty, Katherine Bliss, and Phillip Nieburg will answer questions related to the outcome of the summit.
Question: How do we sustain progress on the MDGs beyond 2015?
J. Stephen Morrison
Arguably the single most important, and perhaps the most complex and challenging factor will not be what we do. It will be whether low and middle income countries themselves make a strategic commitment, over a very extended period, to own the MDGs as national priorities. That commitment will rest on high-level political leadership; aligning higher budgetary commitments against those goals that are most lagging (such as 4 and 5, maternal and child health, respectively); training and employing the critical personnel; guaranteeing the delivery of the services that will in the end alter mortality and morbidity figures. That commitment will rest on improved controls over corruption and waste, sustaining economic growth, allowing space for civil organizations to flourish, and proving performance through better measurement.
The United States as a partner donor – the “we” in the above question – has much to contribute to sustaining progress by actively supporting governments that move in the directions outlined above. And one vital dimension of that will be whether there is success in rebuilding the U.S. Agency for International Development, the major agency responsible for administering U.S. development programs. USAID in its almost 60 years has struggled with successive development fashions; the cross-currents of competing objectives, intrusive oversight and earmarking imposed by Congress; and severe swings in budgets and staffing levels. Across different administrations, interest from the White House and State Department has varied considerably. Public understanding and support of USAID’s mission have often been fickle.
There have been many successive reform efforts of USAID. A new effort is now unfolding. There is reason to be hopeful as well as cautious. Hope springs from the fact that President Obama has issued a development policy, after an internal foreign aid review that absorbed more than a year; that Secretary of State Clinton has embraced the role of protecting the agency and moving it forward; and that the USAID Administrator Raj Shah, charged with implementing a range of internal reforms, is a dynamic leader joined by a newly arrived talented senior team. An important consensus has taken root that USAID has a special role in several key areas: health, agriculture, governance, and emergency humanitarian programs.
But achieving success will be tough. Foreign assistance budgets are likely to decline, not grow, in the balance of this Obama administration. Recruitment of talent may prove difficult, just as sustaining enthusiasm for USAID, its mission and its future, will be difficult if Congress tilts in an isolationist direction and foreign assistance gets caught in a divide between Democrats and Republicans. Rebuilding USAID is a decade long project that will require patience and determination, and a coherent plan that remains consistent over the years.
What’s most necessary to accelerate progress towards the MDG goals by 2015? There is no one answer, but I would offer that there is one single constituency without whom the goals will never be achieved. That is an active and vibrant civil society movement. If one fact has become clear over the decades-long U.S. engagement in development, it is that among our most indispensable partners are the very communities and households whose lives we hope to better. Yet all too often the voice of those communities is the last to be heard as we set long-term goals and build programs.
No doubt we have gotten better at genuinely valuing the contributions of community groups. We’ve learned important lessons, particularly in the context of HIV/AIDS programs, where we have seen that the active participation of HIV positive persons in program planning and implementation is among the most important ingredients for programmatic success. Equally important, we have seen that civil society has a key role to play in changing broader policies and societal norms that have made it too easy for the AIDS epidemic to grow. We need to take some of the lessons learned from civil society’s role in spurring the response to HIV and apply them to the MDG goals for maternal and child health and other sectors where progress is still lagging.
Let’s not underestimate the challenges. Working in a meaningful way with diverse civil society constituencies can be time consuming and labor intensive. It means a commitment to listening carefully and hearing what others are saying even when those views challenge commonly held approaches. There are organizational and operational challenges, as well as the reality that civil society groups themselves often lack a common position and are sometimes highly competitive with one another. Finally, as we move to ever more rigorous measurement of outcomes and impacts, we need to recognize that civil society’s contributions may be harder to quantify, more qualitative in nature, but no less essential to long-term success.
For U.S. global health policy, sustaining genuine, long-term engagement with civil society poses a significant challenge, yet it is a challenge worth embracing if we want to move more quickly to the MDG finish line.
Over the past two weeks I have focused on persistent challenges in reaching the MDG target to reduce by half the proportion of people without access to improved sanitation by 2015. Last time I discussed some of the actions the international community is taking to raise awareness about sanitation challenges and solutions, to raise political will in the countries where sanitation efforts are lagging, and to encourage investments in sanitation by a wide range of actors. But while considerable energy is focused on mobilizing state action where sanitation is concerned, the research community also has a significant role to play in extending – and maintaining -- sanitation coverage over the long term.
Having good data about existing coverage and where investments are being made is essential. The WHO/UNICEF Joint Monitoring Program tracks progress in improving access to water and sanitation at the country level, and contains information gathered through household surveys since the mid-1990s. More recently, UN-Water mandated the publication of the Global Annual Assessment of Sanitation and Drinking Water (GLAAS) to deepen understanding of what works and what doesn’t in terms of policies, donor assistance, and program design, among other issues. Carried out by international organizations, the JMP and GLAAS both provide important information about water, sanitation, and hygiene programs to national level decision-makers and donor agencies, alike.
University researchers also contribute to global sanitation goals by carrying out basic scientific investigation, by conducting training programs and capacity-building exercises, and by sharing their scientific expertise in developing monitoring and evaluation schemes to assess program effectiveness. University-based research has already contributed to understanding what works in terms of program scale-up and how to make sanitation projects sustainable in the long run
On October 24, during a networking session, at the University of North Carolina Water Institute’s inaugural conference on “Water and Health: Where Science Meets Policy,” the recently formed University/WASH Consortium met to discuss ways to strengthen U.S. universities’ contributions to international policymaking on WASH issues. Beyond encouraging greater communication between scientists and policymakers, the Consortium is focused on promoting international WASH-focused scientific collaborations. Noting that there are already existing partnerships between individual universities in the U.S. and in world regions where sanitation challenges loom large, such as Asia and sub-Saharan Africa, the group’s discussion focused on ways to enhance exchanges between U.S.-based researchers and international research partners to share scientific expertise and learn about needs and successful approaches at the community level.
Of course, research – whether carried out by international organizations or university researchers – is only part of the solution. Financing to ensure program implementation and sustainability is also important. And the local private sector has a strong role to play in producing and marketing sanitation interventions that can be maintained over the long term. In the end, governments, international organizations, researchers, investors, entrepreneurs and community members must all contribute to the effort to deliver sanitation services to the more than 2 billion who are still waiting.
Question: In your opinion, to achieve the MDGs, what can be done in the next five years that is different from what was done in the previous five years?
J. Stephen Morrison
One intriguing proposition for doing business differently over the next five years, vis-à-vis achieving the Millennium Development Goals (MDGs) by 2015, has come from UNICEF and its new executive director Anthony Lake.
Based on a four month study, ‘Narrowing the Gaps to Meet the Goals,’ released in early September, UNICEF proposes that major gains in child (MDG-4) and maternal (MDG-5) health can be achieved through an “equity focus” – concentrating in a new and disciplined way on the lowest quintile (20%) of women and children living principally in low income, high mortality countries. This is a refreshing new idea.
The report argues that since 1990 disparities in poverty and child development persist or have worsened, despite a significant reduction in under-five mortality in low income countries. These improved averages conceal persistent, nagging gaps that should now be the priority focus of UNICEF and others’ efforts.
UNICEF acknowledges that reaching these populations can be costly and difficult: owing to remoteness, poor transport access, and weak infrastructure. Nonetheless, it argues that an equity focus can accelerate progress in MDG 4 and 5, reduce disparities, be cost effective, and reduce the out-of-pocket expenditure for the poor if a strategy concentrates on a few key steps...
**Anthony Lake was at CSIS on Wednesday October 20 and presented this proposition to a gathering of experts. Please watch the event here**
Last week I wrote about the persistent challenge of sanitation, noting that the world is not on track to reduce by half the proportion of the population without sustainable access to sanitation, one of the targets of MDG 7 focused on ensuring environmental sustainability. At least 2.6 billion people worldwide lack access to basic facilities. Even if current efforts to put in new systems remain constant, that number is projected to rise, thanks to population growth and the need to maintain existing infrastructure.
Beyond its deleterious effects on the environment, the lack of sanitation has negative implications for health. Diarrheal diseases are the second leading cause of childhood mortality in the developing world; nearly two million people, 90% of whom are children, die from diarrhea each year. But safe disposal of feces is estimated to reduce diarrheal disease by up to 40% in some areas, while drinking water interventions alone have been shown to reduce diarrhea by 25%. And the economic benefits of sanitation are impressive. The Geneva-based World Water Supply and Sanitation Collaborative Council (WSSCC) reports that every dollar spent on sanitation in developing countries leads to a nine dollar economic return over time.
Both at the September MDG Summit -- and since then -- there have been positive signs that the international community intends to accelerate efforts to improve access to sanitation over the next five years. Sanitation activities were mentioned several times in the Summit’s outcomes document, and high-level side events raised high-level awareness of the challenges that remain...
As the resident curmudgeon in CSIS’ Global Health Policy Center, and as a pediatrician with extensive developing country field experience, I see efforts to improve health in any country or region as a long distance hike rather than as a sprint. This view has given me a different perspective on how and when we should expect to achieve the MDGs.
The key issue to long term and sustainable improvement in the health of entire populations is creating and maintaining adequate public health infrastructures in countries. Let’s think about several examples of what that might mean in real terms.
Strengthening Public Health Systems: While training more nurses and doctors, or building more clinics and hospitals, or providing more anti-retroviral drugs to AIDS patients are each important short-term goals for taking care of individuals who need assistance, they will not be enough. What is also needed is a workforce that makes public health systems effective, e.g., people who know how to create and maintain disease surveillance systems, carry out population based surveys, investigate disease outbreaks, and run public health laboratories, to name just a few skill sets. Others will be needed to run data systems that keep track of disease rates as well as which vaccines have been ordered and/or shipped out to clinics and hospitals. People who have the skills to evaluate the effectiveness of disease control programs (e.g., malaria control) will be needed. In the U.S., we have people in our public health system to carry out all of these tasks. Most developing countries don’t have them. We need have a long term plan to help countries train and maintain this kind of expertise...
Question: In your opinion, what was the greatest achievement or disappointment to result from the MDG Summit?
J. Stephen Morrison
One stark impression from the MDG summit was the profound dampening impact that the long-running global recession continues to have on donor activism, including the United States. Absent altogether was any major big initiative backed by major new commitments of resources. That was sad and frustrating, but also a powerful indicator of the heavy realism that has settled into international deliberations. A similar thread of austerity and constraint ran through the prior G8 and G20 summits held this past summer in Canada. President Obama delivered an eloquent and very insightful set of remarks at the MDG summit on the US evolving approach to development, but that statement made no new commitments and did not contain a single number. That is a reflection not just of the upcoming U.S. November 2 elections, in the midst of nearly 10 per cent national unemployment. It is also a reflection of the uncertainty and angst of what lies ahead for U.S. budgets.
The President’s speech said some things that needed voice. Development is about strategic interests and economics, as well as a moral imperative. We need and will have a new national policy on global development. We need to give high priority to helping developing countries achieve broad-based economic growth and put into force greater controls over corrupt officials stealing resources. And we need to be more selective and focused in our choice of partners. In combination, these are somewhat edgy and tough-minded sentiments. But welcome.
Certainly one of the most promising opportunities to emerge from the MDG Summit is the chance to refocus the world’s attention on maternal and child health. The need to make greater progress on MDGs 4 and 5 resonated throughout both the formal interventions made at the Summit as well as at the dozens of side events convened throughout the week.
But, how do we start to untangle the complicated mix of interventions that will be required to bring success? Where do we begin to focus our efforts so that we are building the best long-term prospects for real and sustained progress in reducing maternal and infant deaths? When I reflect on this challenge, I am quickly reminded of the wise words of a neonatologist I worked with in the Middle East a number of years ago. His mantra was “Count every birth, and make every birth count”. Simpler and truer words were never spoken. At that time, we were engaged in an effort to reduce unacceptably high neonatal death rates. His point was that until we could identify and monitor every pregnancy and birth we would never be successful. He was, of course, absolutely correct. And, as straight forward as this task might sound, it was much more complicated than one might imagine. Strong surveillance systems are probably the most critical, but under-recognized and oft-neglected component of a country’s public health system. If we are to make real progress towards MDGs 4 and 5 by 2015 those systems, and the networks of people who support them, need to be strengthened. This is particularly true if we want to put a dent in the still shockingly high levels of neonatal deaths (i.e. deaths in the first 28 days of life). More than four million infants die in the first month of life, nearly ¾ of those deaths from preventable causes. If we could better identify those moms and infants – before birth – and then keep track of them we would have a much better chance of ensuring their healthy futures.
So my greatest hope from the MDG Summit is that we take all the energy generated on maternal and child health, and that we translate it into some practical, concrete steps that will help strengthen critical surveillance systems so we can count every birth and make every birth count. In your view, what is the most important “first step” in accelerating progress on maternal and child health?
From the backseat of a taxi stalled in mid-town Manhattan, idling as motorcade after motorcade carrying high-level officials sped by, it might have been difficult to believe that developing world environmental health challenges would get much play at last month’s MDG Summit. However, the high-profile focus on the need to reinforce global efforts on sanitation and the launch of the Global Alliance for Clean Cookstoves offered a cause for optimism, even as the challenges loom large.
Heading into the summit, there was good news that the world is on track to meet the target of reducing by half the proportion of people without sustainable access to safe drinking water by 2015 compared to the baseline year of 1990, contained in Goal 7 to Ensure Environmental Sustainability. Within 5 years the United Nations estimates that 86% of the population in developing regions will have access to an improved source of drinking water. That’s up from 71% in 1990, a fairly impressive achievement when one takes population growth into account, even if significant urban-rural disparities remain.
But progress on the effort to reduce by half the proportion of people without access to basic sanitation by 2015 is a different story. Right now 2.6 billion people lack access to improved sanitation, such as a toilet or a latrine. The UN warns that even at present levels of effort, that number could be even higher by 2015, making it unlikely the world will reach the sanitation target without new energy and fresh resolve...