The launch of the Sustainable Development Goals (SDGs), the successor to the MDGs, last week in New York, marks yet another milestone in committing global leadership to the development agenda. I attended and participated in various events linked to the Equitable Access Initiative(EAI), with Global Fund and EAI partners, UNFPA, Gates Foundation, UN Foundation, Civil society, and the private sector.
Quantity vs quality
There are a few things to note. Goals grew more ambitious while means remained vague at best. There were 10 MDGs to be implemented in the last 15 years; now we have 17 SDGs! But more does not necessarily mean better: the number of these goals has increased, as have targets, but this has not been matched with clarity of means nor outcomes. While one should commend the UN for a more consultative process with developing regions, compared to the MDG process more than 15 years ago, this may not warrant the congratulatory mood around the announcement of the SDGs in the long-run.
I want to raise three (3) points, namely process, target clarity and monitoring and financing of the targets.
Private sector missing in action
Firstly, in the adoption of SDGs, there was a worldwide consultative process, especially with the developing world which is the main target of the SDGs. I remember participating in the training and preparation sessions, with African Ambassadors to the UN, in getting them engaged with the development issues. It was understood that the ambassadors may not be technically equipped to negotiate on development issues, given their background as political actors. Various high level panels and forums, including the World Economic Forum Global Agenda councils, focussed on being consultative in their approach to contributing to the shaping of the SDGs. I engaged on SDGs through the WEF GAC on Sustainable Development to which I belong, and we produced various papers, including one on financing SDGs. The financing conference in Addis Ababa, equally, had a consultative character to it.
The consultative process, in general, was highly commended for engaging leaders more closely with development goals. However, for all the effort placed on the beneficiaries, a key solution provider, the private sector, does not seem to have been consulted substantially. The private sector is critical to providing drugs and vaccine development, private health facilities and equipment as well as providing and managing health insurance products and managing procurement processes that impact pricing of commodities, among other things. The private sector needs to be on board. The case of Turing Pharmaceuticals in US, who raised the price of the HIV drug, Deltaprim, by 5000% two weeks ago, and the backlash it generated, even from Hilary Clinton, is a reminder of why the private sector is a vital partner in the fight against HIV. Biotech stocks even dropped 6-10% on the Nasdaq, compared to only a 0.5% drop in the Nasdaq index, itself last week. Needless to say, the company has since reversed the price hike, in response to global outrage.
If you can’t measure it, it doesn’t exist
Secondly, SGDs have many more targets, compared to MDG targets, many of which lack clarity. The multiplicity of targets may make the implementation and tracking by already under-resourced countries more cumbersome.
Take health development, as captured by SDG 3. It reads: ‘Ensure healthy lives and promote well-being for all at all ages’. That’s hard to argue with. But look at the targets and your head starts to spin.
Wow! Good luck with monitoring that.
Let’s just focus on target 3, regarding HIV, which aims to ”end the HIV epidemic by 2030”. At the end of 2013, 35 million people were living with HIV. That same year, some 2.1 million people became newly infected. Close to 12 million people in low and middle-income countries were receiving antiretroviral therapy, at the end of 2013. More than two-thirds of new HIV infections are in sub-Saharan Africa. While 15 million people are currently on treatment worldwide, less than half those eligible to receive drugs are not accessing them. Most are in sub-Saharan Africa. There is no currently funded plan to address the massive scale-up required, let alone boost prevention efforts for an epidemic which still has no vaccine. As funding transitions from donors to affected countries, there are no clear plans on how to keep at-risk populations on treatment programmes, etc.
And Finally…. Who will pay for all this?
Let us just stick to HIV as an example. The disease has mutated from a mere emergency to a long-term financial liability for high prevalence countries, from both treatment and prevention perspective. As a chronic disease, the cost of keeping people currently on treatment alive for the duration of their life in sub-Saharan Africa alone is over US$ 300 billion. This is daunting and remains unaddressed. RethinkHIV research by Collier, Sterck, and Manning (2015), shows that this hidden liability is about 13% of GDP in Kenya, for example, if one projects 35 years into the future, beyond 2030. This is a substantial hidden cost that would need to be funded by both affected countries and the international community. There is currently no mechanism to do this and the HIV response lurches from replenishment cycle to replenishment cycle without a sustainable strategy. And while the disease still kills thousands daily, especially in Africa, it has disappeared from the headlines…and from distinct SDG priorities! How will the financial commitments required to break the back of the epidemic compete with so many other development priorities?
The Conference in Ethiopia on financing sustainable development, just prior to the adoption of SDGs, did not quite clarify this question. ODA is flattening, as developed countries face fiscal challenges, and commitment to 0.7% of GNI in ODA by OECD countries, will increasing become a challenge. Some of the countries in Africa, that were hopeful of tapping into revenues from natural resources, have experienced a collapse in commodity prices, especially oil copper and nickel. It is not surprising that Nigeria and Zambia are experiencing major macroeconomic challenges with rising budget deficits, falling currency reserves, exchange rate volatility, and rising debt levels. The domestic environment for financing health needs, and SDG targets in general, is proving to be difficult for some countries. There is still room to innovate, especially in areas such as introducing National Health Insurance schemes, mobile telephony usage charges debt guarantees from international financial institutions, and plain-vanilla taxation effort, inter alia.
But where the money will come from to finance so many, sometimes complementary, but often competing priorities, remains the key challenge for the SDGs.
Written by Prof Mthuli Ncube, Leader of RethinkHIV
30 September 2015
RethinkHIV is a consortium of senior researchers from London School of Hygiene & Tropical Medicine, Imperial College London, Harvard School of Public Health, Centre for the Study of African Economies and Blavatnik School of Government at Oxford University.
The consortium will evaluate new evidence related to the costs, benefits, effects, fiscal implications, and developmental impacts of HIV interventions in sub-Saharan Africa, in order to maximise contributions to the fight against HIV there.
The aim of RethinkHIV is to find ways of creating, optimising, and sustaining fiscal space for domestic HIV investment, as well as exploring long-term, sustainable national and international financing mechanisms. RethinkHIV is funded by RUSH Foundation.