Last month’s intergovernmental negotiations in New York put the spotlight back on the proposed sustainable development goals (SDGs) and how to measure their impact.
It kicked off a series of high-level meetings in 2015 that will focus on the nitty-gritty of the goals and their respective milestones. The 17 goals (and 169 accompanying targets) represent the international community’s response to the post-2015 development question: how to harness, and build on, the momentum established by the expiring millennium development goals (MDGs).
The SDG negotiations provide a crucial window to address some of the shortcomings of the MDGs, which had a relatively narrow focus and failed to address questions concerning equity and the inclusion of the poorest and most marginalised groups.
It is disappointing and worrying, therefore, to see some of these issues cropping up in the SDG framework. Perhaps the most striking example is goal three: the health goal.
Achieving universal healthcare has become a policy priority for many countries. Defined as “access to good quality health services for all who need them without any associated financial hardship”, in its purest form universal healthcare encompasses the three crucial pillars of any national health agenda: financial risk protection, quality service provision and 100% population coverage.
Despite widespread lobbying from international agencies and NGOs, it became obvious at the beginning of 2014 that universal healthcare was likely to be relegated within the SDG framework discussions. It is currently an individual target within the much vaguer goal of “ensuring healthy lives and promoting wellbeing at all ages”. While this sends a pretty stark message about the perceived importance of universal healthcare, it becomes even more alarming when we begin to unpack some of the minutiae around the target.
The meetings in March reinforced an uncomfortable, previously overlooked, element: the proposed indicators for the universal healthcare target – both of which focus on measuring levels of financial protection – are currently rated as BBB or below. These ratings capture the feasibility, suitability and relevance of each indicator as perceived by the international community. Put another way, the majority of countries involved in the SDG consultations think that measuring progress towards universal healthcare is feasible only with significant effort and that, at best, the suggested indicators are merely “somewhat relevant” to the overall target.
While the proposed targets are unlikely to change, the indicators are still open to negotiation. Experts from national statistical offices will come together in May to start a series of in-depth discussions around the provisional indicators. Final agreement is not expected until March next year.
Given the general lacklustre ratings for the universal healthcare target indicators, it is likely these will be near the top of the list for discussion. One of two outcomes seems probable: either the indicators for the target will be removed altogether, or they will be replaced with measures deemed easier to calculate than financial protection.
Both options would be catastrophic. As the Center for Global Development’s Charles Kenny notes, governments will only be motivated to meet targets if they can be measured. Stripping out indicators altogether would effectively render the target redundant; universal health coverage would be “nice to have” rather than a standard against which to hold governments to account. On the other hand, measuring universal healthcare by access to services alone is severely missing the point.
This might sound counterintuitive, but universal healthcare is about much more than just drugs and resources. It is about ensuring everyone is on an equal footing when it comes to receiving essential healthcare services whenever, and wherever, they need them.
Some say that protecting against financial hardship is just too difficult. We know this is not true, however. There are ways to ensure that everyone can access adequate health care services without being out of pocket, as highlighted in the World Health Organisation’s seminal report. Oxford Policy Management is working with the governments of Morocco and Ethiopia to develop finance strategies that support the move towards universal healthcare in each country, with remarkable results.
There is no one-size-fits-all solution when it comes to universal healthcare. Health finance reforms must be country-specific and based on in-depth analysis. But it is clear that universal healthcare can only be achieved when financial protection is fully accounted for, at all levels and across all sections of the population. Without adequate financial protection, only the wealthiest would be able to afford good quality healthcare, widening the gap between the richest and the poorest and thus accentuating, rather than tackling, one of the root causes of poverty.
Clarity of vision will therefore be crucial during the next rounds of negotiations. It is easy to get bogged down in the detail when discussing indicators, but it is essential that we do not lose sight of the proposed targets and why they were included in the first place. What may seem like minor tweaks to make something more palatable to overburdened policymakers could actually have lasting implications, creating winners and losers on the global stage – we need to learn from the MDGs, scale up our ambitions and face inequity head-on.
- Nouria Brikci is a health policy specialist at Oxford Policy Management
