Lead Author: Dzintars Gotham
Additional Authors: Kristine Onarheim and Melissa Barber
Organization: The 8E Task Force
Country: UK; Norway; South Africa
In this submission, we look at the Millennium Development Goals (MDG) and new Sustainable Development Goals (SDG) as a tool to improve Access to Medicines. This submission is relevant to the work of the High Level Panel on how progress to meet these overarching goals are measured and monitored. We have looked at 8.E as an example to illustrate measurement and accountability challenges when aiming to meet targets and indicators. In particular, the submission focus on accountability for SDG 3 and the sustainable development agenda. We argue that to be able to evaluate progress, better systems for measurement and accountability is needed as a baseline to evaluate progress towards the SDGs and improved access to medicines, vaccines and diagnostics. The High Level Panel should in its recommendation address the following issues:
1. The UN should affirm that increased data collection efforts will always precede abandonment of a target/indicator;
2. Decisions to change or abandon data collection for, and the reporting of, goals, targets or indicators, should undergo a robustly transparent and accountable process, including consultation of stakeholders such as member states, civil society and academia;
3. Decisions on the absolute and relative (as applicable) levels of resources allocated should be needs-based, rational, accountable, and based in a consultative decision-making process;
4. Additional funding will be needed to support better and appropriate data collection and reporting.
Background and aim of submission
The High-Level Panel on Access to Medicines (HLP) calls for input to “address the misalignment between the rights of inventors, international human rights law, trade rules and public health where it impedes the innovation of and access to health technologies,” with attention to contributions that can promote health and wellbeing, as outlined in the SDGs, and particularly for SDG 3. This submission is relevant to the work of the HLP in how these global goals are measured and monitored. We looked at Millennium Development Goal (MDG) target 8.E - the target on access to medicines - to illustrate measurement and accountability challenges when aiming to meet targets and indicators. In particular, our submission focuses on accountability for SDG 3. We argue that to be able to evaluate progress towards targets, better systems for measurement and accountability will be needed.
The 2000 Millennium Summit in New York set out an ambitious agenda for poverty reduction. Few imagined that the agenda, and later developed goals, targets, and indicators would be as crucial as we now know.
Global goals have significant influence on the agendas and financing of governments, international organizations, NGOs, the private sector, and civil society.(1) Global goals offer attention and focus, and have real implications for the opportunities and lives of people.
For several years, MDG 8.E was excluded from the yearly MDG reports. In this submission, we would like to draw the attention to shortcomings in the monitoring of the MDG target MDG on access to medicines, and the lack of accountability and transparency that accompanied these shortcomings.
The lessons learnt are highly relevant to new metrics that will be used to monitor progress towards reaching the SDGs.(2)
A comment article on the story of MDG target 8E has recently been accepted for publication in The Lancet Global Health.(3)
Target E of Millennium Development Goal 8 was: “In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries”.
Six MDG progress reports, from the 2008 report up until the 2015 report, make no mention of target 8E whatsoever. All other targets, including 8D and 8F, are mentioned and reported on in the reports. Having noticed this in early 2015, we began to make inquiries into the omission from the main MDG progress report. The 2015 MDG progress report, published later that year, once again included 8E - but only as an abrupt note that data in the area was lacking.
While the separate MDG Gap task force has reported on target 8E every year, the data has been very lacking.(4) The data reported by is based on only 26 country surveys conducted over 7 years (as of 2015).(5) For many other targets, data from over a hundred countries is available, owing to significant efforts to scale up the monitoring and reporting of respective indicators.(6)
The Friends of the Chair group recommended that 8E have “special effort [...] put into setting up data collections to provide the information”, or, alternatively, be changed or abandoned, recommending that priority should be given to “established” indicators that are “closely related to existing data collection programmes”.(7)
We find this line of argumentation taken in the 2005 Report of the Friends of the Chair concerning. The Friends of the Chair assert that a) 'established' indicators should be favoured, and that b) the metric 'proportion of the population with access to essential medicines' is not 'established'. The establishment of Goals and targets implies, by definition, that new actions need to be taken to change the status quo. It is not surprising that areas of human wellbeing in which gaps are identified (gaps that are to be filled by reaching a Goal) will also have gaps in knowledge and measurement. In our view, it is very clear that the mandate to continually create and improve relevant metrics and measurement techniques is an inalienable part of the mandate of the targets and Goals themselves. While deficiencies in data availability and measurement techniques for indicator 8.13 should have prompted “special effort [to be] put into setting up data collections to provide the information”, as the Friends of the Chair proposed, it was simply swept under the carpet: after a string of inquiries, we were eventually told by a senior employee at the UN Statistics Division that “[t]he decision not to report on the indicator for target 8E was made by the WHO representatives in the [Inter-Agency Expert Group] [...] A few years ago they decided to focus on HIV/AIDS treatment and stopped reporting on the rest” (email communication, 14 May 2015).
Put in simple terms, when it was found that data for an indicator was not already being collected by non-UN entities (such as governments) without ‘special effort’ being put into it, a small group, without broad consultation or publicly visible discussion, opted to abandon the indicator. As the mandate to strengthen indicators is a part of the mandate to strive towards the Goals, this is tantamount to a semi-clandestine abandonment of part of a mandated development agenda. While we recognise that bodies tasked with technical statistical tasks need some flexibility in order to function (the General Assembly cannot be asked to reach unanimity on every statistical calculation used), we feel that a decision to deprioritise a whole target in favour of a different target under a different Goal clearly lies outside the flexibility needed for technical work.
For the SDGs, we thus recommend that
The UN should affirm that increased data collection efforts will always precede abandonment of a target/indicator;
Decisions to change or abandon data collection for, and the reporting of, indicators, should undergo a robustly transparent and accountable process, including consultation of stakeholders such as member states, civil society, and academia;
Decisions on the absolute and relative (as applicable) levels of investment should be needs-based, rational, accountable, and based in a democratic decision-making process.
From 8E to the proposed SDG indicators
Indicators analogous to the MDGs’ indicator on access to affordable medicines have been proposed as SDG indicators.
SDG targets and indicators on access to affordable medicines will demand sufficient political investment for robust measurement. In the MDGs, monitoring of access to medicines was done in collaboration between Health Action International - a non-governmental organisation (NGO) -and the WHO. NGOs have historically been key in both reporting and advocating for policy changes in the area of access to medicines. However, it is worth noting that 8E, debatably, is the only target of the MDGs’ 21 targets for which data collection was done chiefly by an NGO. While it is not clear how large a part this fact played in what we argue was the deprioritisation of the target, it comes to our attention that this may reflect an element of lower resource allocation.
We note that progress on other MDG goals and targets such as child and maternal health has received attention. These indicators have been monitored by the UN itself through the WHO, but also by external actors such as the Institute of Health Metrics and Evaluation .(8-9) Further, initiatives such as “Countdown to 2015” has monitored country progress on the MDG targets and indicators as well as coverage levels for maternal, newborn and child health interventions.(10)
For the MDG indicator (8.13) on access to medicines, data reported in 2015 was based on survey data from 26 countries conducted over 7 years - enough data for a global median of very limited representativeness, but nowhere near the amount of data that would be necessary for true country-level comparisons and progress-tracking.(5) Compared to the data that has been collected and analyzed for other health MDGs - such as maternal and child health - the data used for monitoring of 8.13 illustrate that access to medicines needs further attention.
While many of the suggested SDG indicators are relevant for access to medicines, some are of particular relevance. In our view targets 3.8 and 3.b are the targets most directly relevant to access to medicines. The suggested indicators for these targets are:
3.8.1 Coverage of tracer interventions (e.g. child full immunization, antiretroviral therapy, tuberculosis treatment, hypertension treatment, skilled attendant at birth, etc.)
3.8.2 Fraction of the population protected against catastrophic/impoverishing out-of-pocket health expenditure
3.b.1 Proportion of the population with access to affordable medicines and vaccines on a sustainable basis
3.b.2 Total net official development assistance to the medical research and basic health sectors
For indicators 3.8.1 and 3.8.2, it is suggested that data can be based on data already collected by WHO and World Bank. Details are provided on how these can be collected and analyzed, including information numerators to be used and disaggregated data to be collected. We are however concerned regarding the proposed indicators 3.b.1 and 3.b.2. Compared to other indicators for SDG 3, these indicators include noticeably little information on how data should be collected or monitored, and who will held accountable and responsible to collect the data.(11) Considering that the SDGs include 167 targets, as opposed to the MDGs’ 21, we are concerned that this lack of detail early in the SDG process is reflective of the area receiving little attention, and may be a harbinger for future neglect.
Importantly, adequate financing will be needed to support better data to monitor these indicators. From the lessons learnt from tracing the story of target 8E and its indicator 8.13, it is obvious to us the in order to be adequate, financing will need to be significantly increased.
Decisions regarding target 8.E were made without consultation with relevant stakeholders and without broader acknowledgement. In our view, this undermines the inclusion of access to medicines as a genuine and crucial part of the development agenda. The HLP can highlight the challenges in measurement of globally agreed targets for access to medicines. Better processes in ensuring accountability, and financing of monitoring processes, is key to meeting the SDGs and fulfilling the human right to health.
Bibliography and References
1. Waage J, Banerji R, Campbell O, et al. The millennium development goals: A cross-sectoral analysis and principles for goal setting after 2015: Lancet and London international development centre commission. Lancet 2010; 376: 991– 1023.
2. United Nations Economic and Social Council. Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators. 2015. http://undocs.org/E/CN.3/2016/2 (accessed Feb 18, 2016).
3. Gotham D, Onarheim KH, Barber MJ. How the Millennium Development Goals gave up on measuring access to medicines. Lancet Global Health (in press, 2016)
4. United Nations Department of Economic and Social Affairs Development Policy and Analysis Division. MDG Gap Task Force Reports. http://www.un.org/en/development/desa/policy/mdg_gap/mdg_gap_archive.shtml (accessed Feb 18, 2016).
5. United Nations. Millennium Development Goals Reports. http://www.un.org/millenniumgoals/reports.shtml (accessed Feb 18, 2016).
6. United Nations Statistics Division. Data Availability by Series. http://mdgs.un.org/unsd/mdg/DataAvailability.aspx (accessed Feb 18, 2016).
7. United Nations Economic and Social Council. Report of the Friends of the Chair on Millennium Development Goals indicators. 2005. http://undocs.org/E/CN.3/2006/15 (accessed Feb 18, 2016).
8. Kassebaum NJ et al (2014). "Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013." The Lancet.
9. Wang H et al (2014). "Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013." Lancet 384(9947): 957-979.
10 Victora CG, Requejo JH, Barros AJD, et al. Countdown to 2015: a decade of tracking progress for maternal, newborn, and child survival. Lancet (London, England) 2015; 6736: 1–11.
11. Inter-agency Expert Group on SDG Indicators. Compilation of Metadata for the Proposed Global Indicators for the Review of the 2030 Agenda for Sustainable Development:
Goal 3 Ensure healthy lives and promote well-being for all at all ages. http://unstats.un.org/sdgs/files/metadata-compilation/Metadata-Goal-3.pdf (accessed Feb 18, 2016).