A. The MDGs: benefits and limitations

Transcription

1 A. The MDGs: benefits and limitations Aids Fonds operates both in the Netherlands and internationally. In its home country, Aids Fonds has been involved in prevention, treatment, care and support for people with HIV and risk groups for 25 years. The unique Dutch approach has proved successful: overcoming taboos and doing everything necessary to tackle smaller outbreaks that could potentially combine to form one huge national epidemic. As a result, we use our expertise in addressing the HIV epidemic. We can only respond to HIV and AIDS effectively if countries have adequate health care. Well-educated doctors, pharmacists, nurses and health educators are needed, as are wellequipped clinics. Aids Fonds therefore invests in projects that improve a country's health care. HIV and AIDS hit some groups harder than others often people who are already in vulnerable situations, like men who have sex with men, drug users, sex workers and ethnic minorities. People with HIV are vulnerable and frequently have to deal with stigma and discrimination. Aids Fonds fights for these people. The right to prevention, treatment, care and support is central here. 1. To what extent has the MDG framework influenced policies in the country/ies or sectors you work in/with? The MDGs had a strong impact on the global awareness of health-related poverty inequalities and their consequences. The combination of informing and mobilising the broad public and civil society through campaigning on the one hand and pointing world leaders on their responsibility on the other hand, greatly helped in putting health back on the international development agenda. Both in donor and developing countries, political support for programmes that benefit the poorest and most vulnerable groups improved and financial commitments increased. The health goals were taken up as key objectives of development cooperation within international and national policies. The MDGs combined with other international agreements allowed for goals to hold governments to account. Important national and international initiatives were set up in line with the MDGs. When the MDG framework was adopted, to take the example of MDG 6 on combating HIV/AIDS, Malaria and other diseases, there was virtually no NGO with a focus on AIDS treatment in the developing world. Malaria was a neglected disease; it was accepted that children dying of Malaria was an inevitable part of life in endemic countries. Tuberculosis control efforts were stagnant. Together, the three diseases were taking at least 6 million lives, every year. International mobilisation around the MDGs resulted in the launch of several major initiatives to address the three diseases. At global level, the Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund) was established in 2002, specifically to mobilise international financing for MDG 6. The Global Fund approved more than $22 billion in a decade and has saved more than 7.7 million lives to date. At bilateral donor level, international mobilisation led US President George W. Bush to launch the President s Emergency Plan for AIDS Relief (PEPFAR) in It was the largest commitment by any nation for an international health initiative dedicated to a single disease: a five-year, $15 billion, and multifaceted approach to combat the disease around the world. In 2008, PEPFAR was reauthorized for $48 billion over five years (from 1

2 2009 to 2013), with the goals of preventing 12 million new infections; treating 3 million people living with HIV/AIDS and caring for 12 million people affected and infected by HIV. At national level, the MDGs have resulted in a strong sense of ownership and shared responsibility emerging in many partner countries. According to the UNAIDS report Together we will end AIDS (2012) 81 countries increased their domestic investments for HIV/AIDS by more than 50% between 2006 and Domestic public spending in sub- Saharan Africa for example (not including South Africa) increased by 97% over the last five years. South Africa already spends more than 80% from domestic sources and has quadrupled its domestic investments between 2006 and In 2012, the African Union launched the Roadmap for shared responsibility and global solidarity for AIDS, Tuberculosis and Malaria in Africa which charts a course for more diversified, balanced and sustainable financing for the HIV/AIDS response by 2015 and demonstrates Africa s new leadership and voice in the global HIV/AIDS architecture. BRICS countries (Brazil, Russia, India, China and South Africa) increased domestic public spending on HIV/AIDS by more than 120% between 2006 and Domestic sources already account for more than 80% of resources spent on HIV/AIDS in China which has pledged to fully fund its response in the coming years. India, too, has committed to increase domestic funding to more than 90% in its next phase of the AIDS response. 2. To what extent has the MDG framework been beneficial for the poor in the country/ies or sectors in/with which you work? In the last decade, substantial progress has been made on the different health-related MDGs. In many middle- and low-income countries, child and maternal mortality have dropped and significant progress has been achieved in the response to HIV/AIDS, Tuberculosis and Malaria, giving tremendous hope to millions of people. Today, more than 8 million people living with HIV in low- and middle-income countries are receiving antiretroviral therapy. HIV mortality and prevalence is falling in the highest burden countries. New infections among children have declined dramatically, with 57% of an estimated 1.5 million pregnant women living with HIV in low- and middle-income countries in 2011 having received effective antiretroviral drugs to prevent transmission of HIV to their children. The global number of new cases of Tuberculosis has been slowly declining per capita since In 2010, 8.8 million people acquired active Tuberculosis worldwide, of which 1.1 million were living with HIV. Tuberculosis mortality has fallen by more than a third between 1990 and 2009, and if efforts are sustained the MDG target could be achieved. Multi-drug resistant Tuberculosis represents a significant challenge as does HIV-related Tuberculosis. Tuberculosis remains the leading cause of death among people living with HIV. More than 80% of the people living with HIV and Tuberculosis are in sub-saharan Africa; in some countries in this region, up to 82% of people with Tuberculosis are also living with HIV. Action to tackle HIV and Tuberculosis jointly is increasing, but it needs to accelerate further. Malaria is in rapid retreat, with such dramatic mortality reductions that we can now hope for a world almost without Malaria related deaths by The massive distribution of insecticide-treated nets and indoor residual spraying has helped achieve these results. However positive, we need to make sure that in order to eliminate Malaria and prevent its resurgence, we will need to sustain and renew interventions. 2

3 At this unprecedented moment however, HIV/AIDS remains one of the great challenges of our times. More people than ever, an estimated 34.2 million, are living with HIV. In 2011 only, 2.5 million people became newly infected with HIV and 1.7 million died of AIDSrelated illnesses. Stigma is still one of the biggest problems in the response to HIV and AIDS. People do not dare to get tested and treated for fear of abuse and discrimination. Violence is also an issue. The murder of the Ugandan activist David Kato on 26 January 2011 is a horrible example. But fortunately, there is also good news and hope for the future, as we now know that with good use of all the effective measures available, we can reverse the epidemic. As long as there is sufficient money. A recent study -organized by the HIV Prevention Trials Network (HPTN)- shows that in the best case scenario, people being treated for HIV have up to 96% less chance of transmitting the virus to others. Together with concurrent use of preventive measures like Post Exposure Prophylaxis; condoms; male circumcision; and microbicides, careful treatment can have a major impact on controlling the epidemic. However, substantial investment is still needed to achieve this. Not everyone has access to treatment and many people are unaware of their HIV status. In 2011, the so-called Strategic Investment Framework was presented. This is a model showing that with smarter use of available resources we can make a bigger impact, namely by investing where the problems are greatest and interventions have proven to be effective. Examples include programmes for key populations (men who have sex with men, sex workers, drug users) and programmes that make treatment accessible to everyone who needs it. This not only benefits people with HIV, proper treatment can prevent further transmission of the virus to others. 3. What features and elements of the MDG framework have been particularly valuable in the fight against poverty? As described in the answers to the questions 1 and 2, the most valuable elements of the MDG framework are the concrete goals and clear, concise and measurable targets that create public and political awareness as they were both appealing for citizens and easy for policy makers to adopt. This combination makes it possible for development partners to launch specific initiatives to meet the MDGs and adopt international and national development policies. 4. What features and elements of the MDG framework have been problematic, in your view? As highlighted in the answer to question 2, many countries will not meet the health MDGs. And even for countries that have met or are about to meet them, the current goals mask huge inequity and inequalities in access to health care. Often, there is an uneven distribution of health services or resources between men and women, between the poor and the rich, between the general population and marginalised groups, and between urban and rural citizens. The general indicators in the current framework are not detailed enough to give a realistic view of those inequalities, something that should be addressed in the new framework. The focus of the current MDG framework is too strong on low income countries rather than on poor people. Internationally we see a shift from investing in middle-income countries (MICs) towards focussing development cooperation in low-income countries (LICs). Using country income categories as the main guidance for deciding whether or not to allocate resources to specific vulnerable populations may ultimately be counterproductive as 3

4 income alone is not indicative of countries ability to pay for the cost of their disease responses. Moreover, this approach ignores a few other factors among which: - Poverty and inequity in MICs remain high and 2/3 of the world s poor live in those countries. - The situation is similar when it comes to disease burden: MICs have a higher burden of HIV and Tuberculosis than LICs. MICs carry 2/3 of the disease burden for Tuberculosis, and 3 of the top 5 countries with the highest HIV burden are MICs. - The capacity of MICs to pay for health and their disease responses varies. Where there is capacity and willingness among countries to provide more public funds for their HIV and health responses, the money is often targeted at building health systems and paying for ARVs rather than for often controversial or unpopular interventions such as those for key populations at higher risk (men who have sex with men, drug users, sex workers, etc). Therefore, it is important that we keep the focus on poor people instead of country income categories when deciding where and how to invest in development cooperation. Moreover, the current MDGs lack sustainability. No indicators were accompanied with a clear process on how to reach them and what support is provided to governments. The lack of binding commitments also blocks sustainability. Despite gains, the health MDGs are not on track to be achieved by 2015, and nobody is being held responsible for that. Although the MDGs have been used by civil society to hold leaders to account, this has only been done from a naming and shaming perspective. A human rights based approach is clearly missing in the MDGs. Instead of focusing on minimum standards, international development goals should promote a strong human rightsbased response. Excluding one part of a population also means that the poorest and most vulnerable stay behind and these are the people that are most in need of better health care. For instance, in the HIV field, all communities should have the right to equal access to high quality prevention, treatment and care services, including those communities most marginalised, such as men who have sex with men, sex workers, drug users, and women and children. Placing human rights at the core of addressing HIV ensures meaningful participation by all and results in positive public health outcomes. Respecting, promoting and protecting human rights, including the right to life; the right to health; the right to freedom of association; the right to privacy; and the right to self-determination, need to be at the centre of the response to HIV. Human rights programmes need to be part of national HIV and AIDS strategies and need to be adequately resourced and regularly monitored to guarantee progress. Southern governments and civil society organisations were not enough involved in the process of setting up the MDGs, which consequentially, led to lack of ownership. The process was donor-driven, lacked involvement and did not build on national plans. The next framework should therefore be more in line with national needs and existing programmes, as this will increase political will and accountability. If not, there is a possibility that no agreement will be reached. To have full southern ownership, governments and civil society need to be involved in the whole process and they will need financial and capacity support for that. An invitation for a UN consultation of civil society in 50 countries will not be enough. 4

5 5. In your view, what are the main gaps, if any, in the MDG framework? See answer to question 4. B. Feasibility of a future framework 6. In your view, in what way, if at all, could a future framework have an impact at global level in terms of global governance, consensus building, cooperation, etc.? To have global sustainable impact, the future framework should take into account the lessons learned from the MDG framework (see answer to question 4), and be aligned with the aid effectiveness principles as decided in Busan in The new framework should also promote development as a matter of shared responsibility between all stakeholders and build on already existing commitments such as the African Union s 2012 Roadmap for shared responsibility and global solidarity for AIDS, tuberculosis and malaria in Africa. A future framework should also look very closely at the issues of donor coordination and policy coherence for development. A new framework should propose concrete measures to increase policy coherence across trade, external action, and development and human rights policies to support the realisation of the right to health and to ensure that trade agreements do not undermine progress towards this right for people living with HIV and others in need of essential medicines. Although national governments should bear the prime responsibility for the development, implementation and monitoring of a new framework, it is important that all relevant stakeholders are involved in the process. Civil society organisations are key actors and should participate in the definition of any new framework to ensure that the needs of the most vulnerable are taken into account. They should also have strong responsibility in monitoring progress of a new framework and national strategies based on it. Civil society participation and involvement will enhance the political will and accountability and the sustainability in case a new framework will be more responsive to the people s needs. 7. To what extent is a global development framework approach necessary or useful to improve accountability with regard to poverty reduction policies in developing countries? A global development framework will only be really meaningful when it contains a strong accountability component. Accountability is crucial to ensure that corruption and misconduct do not go unpunished and good governance and human rights principles are respected. Accountability improves policy making and ensures that those whose rights are infringed upon in the development process are able to seek redress. Thus, a global development framework should try to strengthen existing accountability mechanisms or follow best practices, but where needed new mechanisms should be put in place. New indicators should promote greater harmonization between different frameworks where possible. Civil society participation should be supported so that citizens are empowered to advocate and demand accountability from their governments. A new framework should be universal and not only directed towards developing countries in order to avoid a lack of ownership. A new framework should be transparent in order to strengthen the monitoring 5

6 process. And finally, there also needs to be increased focus on measuring impact and value for money of development programmes. 8. What could be the advantages and disadvantages of a global development framework for your organisation/sector, including how you work effectively with your partners? A global development framework has the advantage that it can put pressure on governments that would not otherwise prioritise human and social development. Common commitments under a global development framework can lead to a system of peer pressure and constitute a powerful advocacy tool for civil society to hold governments to account. C. The potential scope of a future framework 9. In your view, what should be the primary purpose of a future framework? The primary purpose of a future framework should be to eradicate poverty, mobilise resources for that purpose and hold governments to account for their actions and policies in this sense. Therefore, the framework should consist of a set of concrete and binding objectives, with clear indicators, agreed upon through a participatory process. It is important that the search for better ways to define development and measurement of its progress does not lead to a rejection of the current goals, and does not undermine progress in a critically important aspect of human development and poverty reduction. The new framework should be time-bound and universal to gather global support, while being adapted to national and local needs with common indicators for transparency and accountability. 10. In your view, should its scope be global, relevant for all countries? The new framework should face global challenges and thus needs to be universal and apply to all countries, including middle-income countries. As highlighted in response to question 4, using country income categories as the main guidance for deciding whether or not to allocate resources may ultimately be counterproductive, notably because as income alone is not indicative of countries ability to pay for the cost of their disease responses. Moreover, this approach ignores a few other factors among which the fact that many countries will evolve from LIC to MIC status over the next few years. According to UNAIDS and IMF estimates, the vast majority of people living with HIV will be in middle income countries by Whereas in 2010, 37% of people living with HIV were living in low income countries. In 2020, their number will be 13% in low income countries against 87% in middle and high income countries. These statistics show why the new framework should focus on poor people instead of country income categories. It should promote and protect human rights, especially for the poorest and most vulnerable, including those communities most marginalised (such as men who have sex with men, sex workers, drug users, and women and children To what extent should a future framework focus on the poorest and most fragile countries, or also address development objectives relevant in other countries? See response to question 10. 6

7 12. How could a new development agenda involve new actors, including the private sector and emerging donors? It is important that a new development agenda engages a variety of stakeholders, such as civil society organisations, the private sector, as well as emerging donors, to uphold its claim for universality in terms of acceptance and legitimacy. It is essential for the success of the new development agenda that all actors are bound to the overarching goal of poverty eradication and reducing inequalities in a human right based approach. The private sector has an important role to play in a new development agenda as demonstrated for instance in That year, the Medicines Patent Pool announced its first licence with a pharmaceutical company, permitting the generic manufacture of compounds produced by Gilead Sciences. The Medicines Patent Pool (established in 2010) works in collaboration with a number of pharmaceutical companies to expand global access to quality, low-cost antiretroviral therapy through the licensing of patents. Companies interested in producing generic versions of Gilead medicines for developing countries will be able to approach the Medicines Patent Pool to negotiate licensing terms. However, even with the tools to stem the tide of the HIV epidemic within reach we need to make sure that the world can organise to get medicines in the hands of people who need them most. Therefore, the private sector should be pushed by governments to go beyond the concept of corporate social responsibility and develop programmes or projects in line with the new development agenda. New incentives are needed to counter balance the profit-maximizing orientation of private capital. Especially for health problems which mainly affect poor people in developing countries, private sector companies might be reluctant to develop technologies because the return on investment will be low. The development of necessary health technologies should be encouraged by using so called push and pull mechanisms, as it leads to a win-win situation between profit maximisation and development goals. When involving new actors, clear measures should be taken concerning the responsibilities of the variety of stakeholders acting at different levels. 13. How could a future framework support improved policy coherence for development (PCD), at global, EU and country levels? People in developing countries are continually being asked to pay the price for global crises, as these have tremendous impact on development. The globalisation of these problems results in an increasing importance of PCD, thus comprehensive approaches are needed, with clear linkages between different development sectors. One example that shows the overlap between different policy sectors in relation to health is the tension between protection of trade related intellectual property rights (TRIPs) and the availability of affordable medicines. Actors at all levels should work towards strengthening drug regulatory systems; ensuring that countries acquire essential health-related technologies and commodities. Intensified efforts are needed to establish robust capacity in emerging economies and in developing countries, especially in sub-saharan Africa, for the domestic manufacture of pharmaceuticals. As free trade agreements are negotiated, care should be taken by all parties to avoid the imposition of measures that limit the flexibilities now permitted under the TRIPs Agreement. 7

8 Countries must be empowered to make effective use of flexibilities available under international intellectual property rules. The 2001 Doha Declaration on TRIPs and Public Health recognized the right of countries to take public health considerations into account to promote patients access to priority medicines. A number of countries have already used TRIPs flexibilities to promote access to essential medicines, but even greater action will be needed, as many countries have yet to exercise the full array of access-promoting options available under international rules. 14. How could a new framework improve development financing? To set up a framework that improves development financing it should take into account the aid effective principles. The biggest challenges are complex and include insufficient funding, weak links between investments and development outcomes, and a lack of political will to invest in social sectors, notably health, by Ministries of Finance in aid recipient countries. These challenges have been compounded by increasing complexity in the number of external actors in the health sector and a proliferation of different financing mechanisms, resulting in high transaction costs for Ministries of Health. Insufficient attention to equity and financial sustainability are also persistent problems in the sector. Ownership and Participation All too often, ownership is narrowly interpreted as government ownership driven by Ministries of Finance, which may have limited appreciation of the needs and priorities in the health sector. Civil society organisations (CSOs), parliamentarians, and academia are often excluded from health policy decision-making. In many cases, CSOs are not even aware of the major policy processes and mechanisms that have been put in place to enable their participation. Where mechanisms to include CSOs are in place, governments tend to handpick a select group to engage with, and often fail to engage with local CSOs that represent marginalised and vulnerable groups. Lack of transparency undermines CSOs participation, and contributes to CSOs being unable to monitor funding intended to benefit the communities they represent. Another important group is the one consisting out of parliamentarians. They play a key role in advancing the development agenda, particularly in mobilising the necessary support and holding government leaders accountable for their commitments. As representatives of the people, parliamentarians play a crucial role as part of a global co-operation mechanism. Therefore, there is an urgent need to strengthen parliamentary technical expertise and capacity to ensure involvement, ownership, commitment and responsibility in the formulation of state budgets, with particular attention to health budgets. Donor coordination and alignment The health sector provides a compelling example of the need for greater donor coordination. Over the past two decades, the number of donors, financing and delivery mechanisms in global health has grown exponentially. There are now more than 100 global partnerships in the health sector alone, with 80% of donors providing just 10% of total assistance. Each of these donors has its own method of aid delivery, monitoring and evaluation framework and timeframe. The result is sometimes chaotic and expensive for the intended beneficiaries, with Ministries of Health being overwhelmed by the weight of administration required to manage 8

9 donor relationships and meet donor requirements. More efforts are needed to address these challenges through improved donor coordination and stronger alignment. Managing for Results Aid should have a significant impact on country progress towards the health MDGs, universal access to primary healthcare and the right to health. Results-based financing programmes have the potential to ensure that aid brings better results, but their success depends heavily on program design and implementation. It is important to identify results indicators that reflect the specific needs, rights and social realities of intended beneficiaries. Reductions in aid, due to poor performance or problems with data, should not exacerbate inequities. One of the main risks of focusing on results is a de-prioritisation of interventions that bring changes over longer periods of time, such as health and community systems strengthening, behavioural change, preventative medicine, research and access to healthcare for stigmatised and marginalised populations. In the field of health, the Global Fund to fight AIDS, Tuberculosis and Malaria has for instance demonstrated to deliver great value for money. The new framework should build on the work done by the Global Fund over the past decade, recognising it as a highly effective mechanism for performance-based financing and include civil society and strengthen health systems. D. The potential shape of a future framework 15. What do you consider to be the "top 3" most important features or elements which should be included in or ensured by any future development agenda? HIV and other health issues need to figure prominently in the formulation of any future development agenda. One of the central elements of the new framework should be to realise the right to health as defined by the WHO, which places human rights as an integral dimension of the design, implementation, monitoring and evaluation of health-related policies and programmes in all spheres, including political, economic and social. 1. HIV/AIDS and related health goals and progress indicators of the future development framework should be equally ambitious as in the MDGs. The HIV/AIDS and related global health post-mdgs goals should be based on the principles of equity, social determinants of health, universality and measurability. Progress measurements should be the balance of health outcomes and health systems indicators. 2. One of the central elements of the new framework should be to realise the right to health, particularly for the poorest and most vulnerable groups. 3. Communities and community system strengthening should be at the core of the sustainable development agenda. To achieve this, the new framework should strongly promote the achievement of Universal health coverage (UHC). It means that all people have access to health services (promotion, prevention, treatments and rehabilitation), without fear of falling into poverty. Health coverage is determined not only by the direct cost of health services to the patient, but also by the financing mechanism that is used to pay for it. For example through user fees or progressive public financing from tax income - including specific taxes for health financing. 9

10 The availability of health services, the quality of care and predictability of costs that will be incurred also influence health care coverage. The WHO has proposed a set of indicators to measure UHC that should form the basis of the health components of the post-2015 framework 1 : - Health service coverage indicators (including access to antiretroviral drugs (ARVs), attended births, contraceptive prevalence, insecticide-treated bed nets, access to affordable drugs and others); - Health outcomes indicators (including prevalence of underweight children, child mortality, maternal mortality, HIV/AIDS, Malaria prevalence and others); - Selected health system determinants of health service coverage (including health workers, hospital beds and others). Here, one should note recent scientific evidence on the effectiveness of antiretroviral drugs in HIV prevention in broadening the options for prevention and enhancing the response against AIDS. The new framework should commit towards universal access to ARV treatment, care and support for people living with HIV, while highlighting the importance of national ownership and investments. But, in order to truly make an impact, the new framework needs to go beyond the concept of UHC, and promote equality in access to services and a rights based approach, building on the UNAIDS Strategic Investment Framework for the HIV Response, designed to promote efficiency while maximizing results. The Strategic Investment Framework encourages focused funding for six basic programmatic activities: (a) programmes for key populations at higher risk of HIV infection recognized in the 2011 Political Declaration on HIV and AIDS: men who have sex with men, sex workers and people who inject drugs; (b) elimination of new infections in children; (c) programmes for sexual risk reduction; (d) condom programming; (e) care, treatment and support for people living with HIV; and (f) voluntary medical male circumcision in priority countries. These basic programmatic activities need to be supported by critical enablers and by well-resourced efforts to capture synergies between the HIVspecific and broader health and development initiatives. According to modelling exercises, improving the strategic use of resources according to the principles of the investment framework would avert 12.2 million new infections and 7.4 million AIDS-related deaths by 2020, with optimized investment leading to rapid declines in new HIV infections globally. Such an approach would improve equality in access to healthcare and non-discriminatory health services as key principles for realising the right to health, as it would empower traditionally marginalised and stigmatised groups to better accessing health care and thus realise their right to health. In that perspective, the new framework should include commitments for all countries to undertake an immediate, comprehensive review of national legal and policy frameworks to remove obstacles to equality in access to health care and to effective and rights-based AIDS responses. Laws prohibiting HIV-based discrimination should be in place in all settings and should receive implementation support and include concrete mechanisms and services to increase access to justice for all people affected by the epidemic. Countries and donors should work together to focus substantial new funding on community-based programming to overcome HIV-related stigma and promote norms of gender equality

11 16. What do you consider to be the "top 3" features or elements which must be avoided in any future development agenda? The MDGs which have not yet been met must not be dropped - we need to build on the momentum and progress that has been achieved to date. Whichever new health indicator/s are chosen, we must ensure that we set the bar for global health ever higher and strive ever harder to reach it. The indicators which measure the progress on HIV and AIDS should not be weakened. Any future development agenda, specially in the health sector, should go beyond the traditional opposition between horizontal and vertical interventions. It should be recognised that effective health systems need both vertical and horizontal components and the future development agenda should commit to redouble efforts to strengthen health systems through measures such as allocating national and international resources; appropriate decentralization and integration of HIV and AIDS programmes to improve access for communities; integration of HIV and AIDS programmes into primary health care, sexual and reproductive health-care services and specialized infectious disease services; improving planning for institutional infrastructure and human resource needs; improving supply chain management within health systems and; increasing human resource capacity consistent with the WHO voluntary Global Code of Practice on the International Recruitment of Health Personnel. 17. Should it be based on goals, targets and indicators? If any, should goals have an outcome or sector focus? Please give reasons for your answer. The concrete, measurable and time-bound goals, targets and indicators of the MDGs are crucial in creating a broad support among the public, civil society but also among governments and the private sector. They are clear and easy to communicate, realistic and achievable. If we wish to reach the same kind of support for the new framework we should keep this in mind. However, we need to go beyond the current goals and adapted them to the current development agenda. (See the answer to question 15 for more specific details for health.) To make this happen, the process is as important as the framework itself. It needs to be a participative process that involves all stakeholders: governments, civil society as well as the private sector. The goals should have an outcome as well as a sector focus. As all goals are interlinked: health and education, health and gender, health and population, health and environment, etc., it is important to look broader than a simple sector focus. Some of the targets should be sectorcrossing. For example when realising sexual and reproductive health and rights the access to information and sexual education as crucial as people need to have knowledge of different contraceptives, how and why to use it. This is a clear overlap between two sectors namely health and education. Another example is that people living with HIV that are on antiretroviral therapy are obliged to have good food conditions to make the medicine work, a clear overlap between nutrition and health. 11

12 18. How should implementation of the new framework be resourced? Resources for implementation of the new framework will have to include efforts from all, but with a fair application of the principle of common-but-differentiated responsibility. It implies a redistribution of wealth and resources. Specific policy interventions are required to combat both extreme poverty and unfair redistribution of resources if inequality is to be reduced. Different additional financing mechanisms can help to fulfil the need: 1. At the Monterrey conference on financing for development in 2002 industrialized countries confirmed the commitment to invest 0.7 percent of GNI in development cooperation by 2015, to realise the MDGs and make progress in the fight against poverty. For health there is a need for 0.1% of GNI as recommended by the Commission on Macroeconomics and Health. Unfortunately, recent figures show worrying trends. 2. In the Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases (2001), African governments committed to allocating 15% of their national budgets to health. However, only a handful of countries have met the target. As a result, gaps in funding programmes arise and public health problems persist. Governments should be held accountable for their promises and supported to invest their fair share based on ability and prior commitments, as a matter of shared responsibility. Countries should be encouraged to develop financially viable national plans with clear targets. In that regard, taking into account the weakness of tax systems in developing countries, regulatory means should be put in place at international level to support developing countries in domestic revenue mobilisation. That would make it possible for governments to develop a progressive and fair tax system. The African Union Roadmap for shared responsibility and global solidarity for AIDS, tuberculosis and malaria in Africa, if supported by international partners, should be able to contribute to those objectives. 3. Any innovative financing mechanism for health should be seen as a means to generate funds that are additional to ODA. A broadly supported tax at 0.05% on stocks, bonds, commodities, derivates and other financial instruments, also known as the Financial Transaction Tax, could raise approximately $650 billion a year for poverty alleviation. But other mechanisms are as important, for example the Global Fund to Fight AIDS Tuberculosis and Malaria; GAVI; Aviation Solidarity Levy; UNITAID; MASSIVE- GOOD; Advance Market Commitments; and Debt2Health. 12