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Health in the post-MDG era: what “paradigm shift” are we talking about exactly?

By Lara Gautier
on April 3, 2015

Two weeks ago Kent Buse and Sarah Hawkes, a couple sharing the pursuit of “understanding and social justice” published a commentary on the upcoming SDGs. We find the article very useful in that it provides a good review of how health will be positioned in the post-2015 development era, and more specifically on how a single health goal and related targets could be implemented. They argue that success in realizing the agenda requires a paradigm shift and wonder whether the global health community and the broader international community fully understand the extent of the shift required.

Although we agree with many things said by the authors, a more practical message could have contrasted significantly with the overly enthusiastic rhetoric of the SDGs. Like most in the development field, the authors tend to use phrases or “woolly jargon” referring to “politically-smart approaches” that are “fit for purpose”, advance “human dignity”, and “leav[e] no one behind” without defining these expressions and without, more importantly, providing clear insights “on what [they are] supposed to look like” (see Hickel).

The focus of their piece, i.e., asking whether the world is “ready for a paradigm shift” is not really itself elaborated – if a paradigm shift refers to “a change in the basic assumptions…within the ruling theory of science” (Kuhn, 1962) this would require (we agree) not only a shift in framing – from poverty eradication to more holistic and sustainable pathways to development but also changes in the way power is allocated within global governance for development. Essentially, this would mean a departure from the way development is currently envisioned. From a top-down/North-South and often paternalistic enterprise (in which philantrocapitalists play a growing and controversial role) based on a post WWII geo-political order, we could move toward a new balance of power that is inclusive with changed infrastructure for decision-making.

In the authors’ narrative, there is no indication that development will be “done” differently, and thus no paradigm shift.  Their analysis omits issues of equity and any allusion to SDG 10 (reduce inequality between and among countries) in dealing with the political economy of health (or at best only hints at these key political and global governance questions in a rather diplomatic way).  As regards to health we sense a bit of Western righteousness when the authors say that “[t]he achievement of many health targets will require leadership from ministries other than health, which will require reforms in the health governance architecture for many countries” without actually providing any kind of tangible framework or guidelines. So much for enabling the shaping of Foucault’s biopolitics (i.e., creating a welfare state), which aim at strengthening the state’s legitimacy. While Foucault’s arguments have been developed in the French context (and mostly focus on domestic policy), other authors (such as M.G.E Kelly) have sought to apply his concepts in the context of globalization and development assistance. For Kelly, the neoliberal ideology behind foreign aid undermines the foundations of biopower (i.e., the “development of a government and social system”) in developing countries, because it reflects an obvious “lack of appreciation of the importance of the state” (Kelly, p.21).

In our opinion, a true paradigm shift would instead mean accompanying the countries in the establishment of decent social safety protection that would be tailored to their contexts, with well-defined guidelines. Universal health coverage – if articulated clearly with measurable indicators – could lead the way. Even in 2013 this was not thought to be politically viable in the report of the High Level Panel (HLP) of Eminent Persons on the Post-2015 Development Agenda but the deadly Ebola outbreak in the last year has highlighted the importance of resilient health systems in addition to disease control. Although UHC is now a key target in the SDG health goal, and many influential global health actors can’t stop talking about it, one still has the feeling that that the global health community wants to do UHC and resilient health systems “on a shoestring”.

As for the goals themselves, we do feel that the MDGs’ measurable targets and indicators were helpful in providing a realistic framework for progress in development. While there were some obvious flaws (think dubious methods of measurement, particularly for poverty) these told us a story about the effectiveness and outreach of programs with very focused aims for human development that involved only a few sectors.  In contrast, the SDGs are an articulation of very different fields with limited congruence, though one useful visualization is offered by Waage et al. (in the Lancet Global Health) where they separate 16 goals into three categories – well-being, infrastructure, and natural environment – all under the overarching goal of a global partnership for sustainable development. And of course there are the cross-cutting issues across the SDGs, and Buse and Hawkes have very neatly isolated what they see as health-related targets under other SDG goals. Still, multiple sectors are called upon for action on climate change and human and economic development, and the goals themselves read awkwardly – with the exception of the 6 goals around human well-being, all others are two- or three-fold commitments.

We wonder if this well-intentioned but overzealous approach results from the sheer magnitude of the post-2015 consultations, which were far-reaching. With an open consultation online and country consultations in 88 countries yielding responses from over 7 million people, it is fair to say that the UN has made sincere and laudable efforts at inclusiveness instead of setting new goals arbitrarily (by “experts” only). Civil society, the general public, governments, and academics all responded to this call with enthusiasm at this unprecedented willingness to let people have their say in how they prioritize global goals. It is doubtful, however, that marginalized communities faced the same opportunities to participate; their needs do not appear to be addressed in the SDGs.

Which finally brings us to the sheer size of the SDGs – 17 goals with 169 targets – did the MDGs go so wrong that a full-blown search to add eggs to the basket became necessary? As far as we know, the MDGs, albeit based on a framework of poverty and disease that was very quantitatively and questionably measured, did result in change for some countries. In order to achieve any concrete step toward state-led social protection, human and environmental well-being must be addressed at a structural level, that is, there must be a willingness to take advantage of the current policy window (for instance, are we ready to raise the international poverty line to $5/day, as UNCTAD proposes?) of the SDGs.

Perhaps underlying the SDGs is the belief that one cannot have too much of a good thing. If the SDGs are adopted as they are now, however, we can only imagine a future proliferation of government and NGO development programs and projects gone out of control. Anyone willing to take a bet on the number of indicators?

About Lara Gautier

Lara Gautier is an assistant professor at University of Montreal’s School of Public Health (ESPUM). With a training background in public health, political science and socioeconomics, she is also an adjunct professor at McGill University in Montreal, and an associate researcher at the Centre Population et Développement in Paris. Her research interests lie at the intersection of implementation science, health policy and systems research (HPSR), and migrant health.

About Sameera Hussain

Senior Advisor, Strategic Policy and Development, Canadian Society for International Health & IHP correspondent for Canada
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