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Business News/ Politics / Policy/  Swachh Bharat issue highlights the importance of sanitation: Mark Suzman
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Swachh Bharat issue highlights the importance of sanitation: Mark Suzman

Suzman on sustainable development goals and the challenges in implementing them, including funding

Suzman says there’s a need to acknowledge that progress and prosperity depend not just on focusing on the poorest, but looking at key overarching challenges, particularly climate change and the environment. Photo: Ramesh Pathania/MintPremium
Suzman says there’s a need to acknowledge that progress and prosperity depend not just on focusing on the poorest, but looking at key overarching challenges, particularly climate change and the environment. Photo: Ramesh Pathania/Mint

New Delhi: Mark Suzman is president (global policy, advocacy and country programmes) at Seattle-based Bill and Melinda Gates Foundation. In India this week for the Call to Action health conference, Suzman spoke in an interview about the 17 ambitious sustainable development goals (SDGs) that will be adopted at the 70th UN General Assembly session next month and the challenges in implementing them, including funding. Edited excerpts:

What brings you to India?

The immediate reason for my being here is to participate in the Call to Action summit that the government of India is hosting, that we are co-sponsors of. It brings together senior officials from 24 developing countries that between them, have some of the largest global health burden, but also some of the world’s most encouraging success stories in addressing child mortality and in reproductive health. And India itself has an important, strong story of progress that has been made in the last decade and a half.

How do the SDGs differ from the millennium development goals (MDGs)? Are they a continuation?

They are different in a couple of broad ways. The MDGs were broadly focused on poverty and health. They also included some goals on education, environment, sanitation and drinking water. It was very focused on the battle against extreme poverty. The new SDGs continue to have these at their heart. There were eight MDGs and there are going to be 17 SDGs. The first half a dozen SDGs can be summed up as finishing the unfinished agenda of the MDGs.

The MDGs had as their overarching targets halving extreme poverty globally, to reduce child mortality by two-thirds, maternal mortality by three-quarters, put all boys and girls in primary schools. But those left huge gaps. There are still six million children under five who are still dying from preventable diseases. There are still a billion people living on $1.25 per day or less. So how do you finish that unfinished agenda is a central element.

But then the agenda has also been broadened to say that it should be universal; we need to acknowledge that progress and prosperity depend not just on focusing on the poorest, but looking at key overarching challenges particularly climate change and the environment, which were under-represented in the MDGs.

Where is the money going to come from for these ambitious SDGs?

You need resources attached to smart policy. It wasn’t intended, but in practice the MDGs ended up being, to a large degree, a discussion about international aid and the role of international aid from rich countries to poor countries as a tool to help achieve many of the goals. What the Addis Ababa conference (on 12 August) did was to reframe the discussions. Actually, there are three broad sources of finance needed to achieve the SDGs. The first and most important will be domestic resource mobilization. This is the primary responsibility of developing countries themselves, even the very poorest developing countries, that they have more resources on hand to use these much more effectively.

The second area is the role of the private sector, knowing that much of this is going to be generated through private sector investment and economic growth broadly. Economic growth is the engine that does not necessarily lift all boats, but if you don’t have the engine driving then it is difficult to raise any boats. The third (source of funding) is international aid—a smaller proportion than absolute numbers, but still indispensable in targeted areas like health.

So if you look at an organization like Gavi (Global Vaccine Alliance that was founded by the Gates Foundation to help save children) that was founded in the year 2000—at that time it was a completely pioneering initiative. The notion was that you pooled donor financing. The private sector contributes through a project called Project RED, which goes like this—consumer goods companies will sell a brand of product called a RED product. So you could buy an iPad which is a RED iPad and a proportion of those sales will be allocated to global funds for fighting HIV/AIDS or malaria.

So the Gavi Alliance and the Global Fund to Fight HIV (AIDS) and Malaria were the two things that did multilateral financing and used that financing to radically shape procurement of vaccines or tuberculosis or HIV medication, and that massively drove down the cost. By driving down cost you allowed an increase of access, which is why today you have 10 million people on antiretrovirals. So these were the examples pioneered around the MDGs. We need to double down on those—use aid very effectively in a way that actually leverages these other forms of finances and gets you to those outcomes.

One of the key things that come through in the MDG experience and India’s own development experience is that absolute poverty is no longer the primary challenge of development policy in this country. It is now slowly shifting to inequality. And there has been enormous debate globally even in OECD and the International Monetary Fund, even the United Nations Development Fund. That somehow doesn’t figure as an obvious and clear parameter in this. Is there a logic to this?

Well, there was a discussion about inequality in the SDG process and it was one of the fiercest areas of debate in the negotiations. You can’t avoid it completely, but from our (Foundation’s) perspective, our mandate is to focus on the needs of the poorest. What is written on our building in Seattle is that every life has equal value. So even though inequality is a challenge, there is still that base line for the very poorest and that’s why child mortality is so fundamental. If you are not alive you simply can’t enjoy any of the fruits of development.

You want both to put in place tools for child survival, but also what are the ingredients that will allow the child to survive. That requires multiple interventions—basic nutrition, but also quality education and all these things connect up together. One of the things in health that is not properly understood is how important investments in health are, to creating an overall economic environment that allows for the broader growth and widening of opportunity that ultimately would reduce inequality.

It’s partly because it happens over the long term, so it does not feel intuitively obvious to policymakers to prioritize health. But there is this interesting commission that we helped support 18 months ago called the Commission on Investing in Health—it was co-chaired by Larry Summers, the former treasury secretary—which concludes that investing in health gives you conservatively a 9x to 10x economic return, so it’s an economically savvy investment. And this is an argument from finance ministers, Larry Summers is a former finance minister himself. You are investing in the lives and livelihoods of people who are ultimately going to become much more productive members of society than they would otherwise.

You mentioned that the debate on inequality was one of the fiercest debates. What were the broad contours of the debate? Why was it so contentious?

Broadly, it goes in two ways. One is—does the focus on inequality risk being, to some degree, a distraction from the core business of ensuring that absolute poverty goes away. It’s not an either or, but while poverty exists we need to focus on that. The SDG document makes it very clear that the unfinished agenda and focusing on poverty and eradicating poverty over the next 15 years needs to be a shared top priority.

The other area is what are the interventions that help address it. This is a thread that runs through all SDGs. Part of what works is that you need to be operating in areas where we know what the interventions are to achieve success. So we come back to the child and maternal mortality. There are enough success indicators—you know it’s about training, you know it’s about education of the women, you know it’s about providing essential commodity supplies.

When you are into areas of broader inequality—the other one that is incredibly contentious is going to be the subject of climate change. There is broad agreement on the challenge and what is to be done, but its intersection back with development and what the reciprocal and respective obligations of developing countries versus developed countries are, that’s where you start getting into very contentious areas.

How has Prime Minister Narendra Modi’s cleanliness drive helped increase awareness about sanitation and its benefits for health?

I think the Swachh Bharat issue highlights the importance of sanitation. We have to give enormous credit to the Prime Minister. We have worked on this for a long time and one of the challenges is that politicians don’t like to talk about toilets. Giving it the prominence that the Prime Minister has has been tremendously important. In India, this is a challenge because of the cases of open defecation.

Aren’t the SDGs very ambitious considering there are 17 goals and 169 measurable targets compared with seven or eight MDGs and 21 measurable targets?

That is going to be one of the challenges. How do you focus and how do you prioritize? The great strengths of the MDGs was that it allowed for the first time a shared global prioritization and shared metrics of success and while it may not sound revolutionary in practice, that is the first time since World War II and the wave of independence of developing countries that actually there was a broad alliance between national country objectives, big multinational agencies like the United Nations and the World Bank and private organizations like ours, that have come together over shared goals around child and maternal mortality, reducing the spread of HIV/AIDS, how can we come together and pool our resources?

That had not happened before and I think we want to try and preserve that. We absolutely want to continue with that focus and for us the biggest risk would be that looking at all these other targets you suddenly end up as an unintended consequence seeing a net reduction of resources to these core areas where we have unfinished business, but where we have had tremendous success. India I think has an important voice in this because at the simplest level if India does not succeed in meeting the SDGs, the world doesn’t.

India seems to have got a grip on major communicable diseases that used to claim many hundred lives. The problem that seems to be burdening India is the increasing incidence of lifestyle diseases—like diabetes, obesity, etc. How does your foundation seek to address this new disease matrix in India?

There is a reference to non- communicable diseases (NCDs) in the SDGs and what will be the new health goals. From the perspective of our foundation, (it) focuses on the needs of the poorest. The fact is that in the poorest countries and in the parts of the middle-income countries like India, it still is the infectious disease burden that has a disproportionate mortality rate there. This may not be true of urban India and middle-income India, but when you are out in rural India in Uttar Pradesh, Bihar or Madhya Pradesh that is still the case. If you take neo-natal mortality, for example, that’s an area where India is still a fifth of the world’s birth cohort now—that is 27% of neonatal mortality, so more than one in four.

So there is a big disconnect and in fact many of the improvements that have been made in under 5 mortality have not been made in neonatal mortality or the first month of birth due to malnutrition and it is diseases like pneumonia which affect newborn children. The disease burden is very large and so our focus as a foundation is still going to be very much on those infectious diseases—both because that is where the need is, but also because this is also philosophical because our founders believe that we exist primarily to address so called market failures, that there is a global market for research into NCDs that is very significant because these are diseases that affect rich countries in scale.

Nobody is investing seriously in Kala-Azar (black fever), so we are. That’s a major initiative of ours. That is a market failure because there is no global push into that, there is no global push into a malaria vaccine because those who suffer from endemic Malaria are still very poor people, so it is not incentive enough for a deep-pocket pharmaceutical company. So we will use our resources to create those markets. So it’s that the NCDs are not critically important, but we as a foundation, even a comparatively healthy one, need to be careful how we allocate our own scarce capital.

Our priority areas will be family planning because the single- most important factor to reducing child mortality would be successful expansion of access to family planning and better birth spacing and so family planning, vaccination and immunization, a range of other maternal and child health interventions around birth and healthy growth and nutrition, and sanitation.

We also work in agriculture and financial services. That is another new thing in the SDGs. The MDGs had a goal of reducing hunger by half which is broadly met, but they did not talk about agriculture, which is important. Improving agricultural productivity, doubling agricultural productivity is part of the new goals. In rural areas, agricultural dependent households depend on agriculture for their primary income and if you get much of that income to women, they are more likely to invest that income on their children, to get better health outcomes. That’s another reason why the SDGs have a much stronger and more explicit call-out than the MDGs did about focusing on gender issues in order to meet development outcomes.

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Published: 29 Aug 2015, 12:09 AM IST
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