The Countdown to 2015 for Maternal, Newborn and Child Survival monitors coverage of priority interventions to achieve the child mortality and maternal health Millennium Development Goals (MDGs). A June 2010 Lancet article summarizing the report offered welcome news to those of us concerned with the rights and health of children. It noted the need to go beyond the MDGs to truly impact newborn, child and maternal survival, and emphasized work underway to develop measures that "include elements that are indicative of social determinants of health" (pg 2036). It is promising to see the donor community beginning to reengage with concepts related to equity and rights. It remains unclear, however, if relevant measures can actually be married to the MDGs, and alongside this whether current discussion of these measures in political for a are actually going to take us where we need to go in terms of public health policy, research and practice - or at least any time soon.
Despite their importance on the global stage and their good intentions, the recent spate of political declarations with a focus on health do not offer any conceptual, let alone procedural, clarity as to how relevant measures will be developed or used. The Rio Political Declaration on Social Determinants of Health
, for example, brought together heads of government, ministers, government representatives, UN officials, and civil society representatives (though civil society was not part of the negotiations) in October of this year to move forward concerns with health equity through action on the social determinants of health. Interestingly, the Rio Declaration pays formal tribute to the Millennium Declaration
, but refers only obliquely to the MDGs.
Its focus is achieving health and social equity, and it brings explicit attention to the relevance of human rights principles to achieving its goals. It accompanies this with a detailed call for the development and implementation of reliable measures of societal well-being, but with no explicit time frame attached. The Rio Declaration came on the heels of the September Political Declaration on the Prevention and Control of Non-communicable Diseases
(the NCD Declaration), which included 34 heads of state in the negotiations. The NCD Declaration names the human right to health as relevant to the prevention and control of non-communicable disease, references a range of global and regional strategies and declarations, and also does not put the MDGs front and center. It notes, instead, on two occasions “internationally agreed development goals, including the Millennium Development Goals.” [emphasis added para 31 and 65].
The NCD Declaration also includes a call for a comprehensive global monitoring framework and for a set of indicators capable of application across regional and country settings to be completed before the end of 2012, but explicit attention to health inequities was sufficiently vague that it was good to see the Rio Declaration specifically noting the need to ensure a focus on reducing health inequities in taking it forward. Alongside their implicit sidelining of the MDGs, and their explicit language around the need for monitoring, accountability and follow-up, it is of concern, therefore, that these new equity and rights-oriented declarations, even as they do not have Programmes of Action attached, do not find any well-defined equity sensitive measures to propose or support.
Why does this matter? It is worth recalling that the Millennium Declaration included strong attention to human rights but by the time the MDGs had been drafted this had all disappeared. The lack of attention to explicit measures is not a picayune issue. The international community has long recognized that to achieve meaningful progress, rhetorical commitment is not enough. Concrete measures and accountability mechanisms at global and national levels are required. The exclusion of relevant concepts and language in these documents are the result of active political negotiation. Every word of what is, and is not, in these documents matters because what is named is what, if all goes according to plan, is measured. What matters most, in other words, is what is counted not, unfortunately, what is said.
To be fair, determining appropriate measures sensitive to equity and human rights concerns, and with global application, is not an easy task. Even as all agree on general principles, the devil is of course in the details. All too often what has been counted falls back into a traditional paradigm of economic inequity - measuring poorest and richest quintiles - not for lack of interest but for lack of agreement on an appropriate measure, let alone what priority measures should be. While we all recognize the need to go further, tested and validated measures bringing attention to geographic, ethnic, age and gender disparities are few, let alone those which truly measure inequities and inequalities in health and the related availability, accessibility, acceptability and quality of services as mandated under the right to health. But this must be the goal, with important implications for the health and well-being of children.
Building off these recent political commitments, it is incumbent on us all to bring to light relevant measures and data sources, ensure sufficient funding for the development of robust measures where they do not yet exist, and do all we can to ensure that equity and rights measures are fully integrated into global accountability frameworks going forward. This will require political support and international cooperation to allow us to develop the necessary research, and eventually policy and programmatic interventions. This, in turn, will give a firm basis for work to ensure that poor, marginalized, and vulnerable groups are given access to the health and other services to which they are entitled and, ultimately, achieve better health.
(i) Bhutta et al., Countdown to 2015 decade report (2000-2010): taking stock of maternal, newborn and child survival, The Lancet, Vol 375, 2032-2044, June 5, 2010