“Leave No One Behind”

Health as a Prerequisite for Sustainable Development

Health is a commodity that should be acces­sible to everyone, no matter their socioeconomic status, ethnicity, gender, or geographical location. The founding fathers of the United Nations came to this conclusion as early as 1948 when they included the corresponding passage in Article 25 of their Universal Declaration of Human Rights. The same year saw the founding of the World Health Organization (­WHO), an institution with the goal of enabling “the attainment by all peoples of the highest possible level of health” and whose strategic priorities also reflect the idea that health and sustainable development are inextricably linked. Accordingly, the activities in the current work programme are also subordinate to the health-related objectives of the 2030 Agenda.

The nexus between health and sustainable development was also addressed in the United Nations Millennium Development Goals (­MDGs), which, from 2000 to 2015, formed the overarching global framework for tackling numerous development-inhibiting challenges and served as the template for today’s Sustainable Development Goals (­SDGs). In both development visions, improving the health of all people plays a central role as “a precondition, an indicator, and an outcome of sustainable development”.

The final United Nations report on the Millennium Development Goals documents the fact that considerable progress had already been made in many health-relevant areas by 2015: For instance, the proportion of malnourished people in developing regions has fallen from 23.3 per cent (1990 to 1992) to 12.9 per cent (2014 to 2016). The mortality rate for children under the age of five has been reduced by more than half worldwide, between 1990 and 2015. In addition, the global maternal mortality rate has also fallen by 45 per cent during that period. Nevertheless, these developments, which appear to be positive at first glance, must not be allowed to obscure the fact that most of the ­MDGs were not reached, and that progress was unevenly distributed, both between world regions and between urban and rural areas. The great call for the “Post-2015 Development Agenda”, adopted by the UN General Assembly in September 2015 as the Agenda 2030, was also a call for efforts to continue to be made in order to improve health care for people around the world.

The extent to which health is anchored in the 2030 Agenda is particularly evident in ­SDG 3– “Ensure healthy lives and promote well-being for all at all ages”. It has 13 sub-goals, including reducing global maternal and child mortality, combatting communicable diseases, and ensuring access to universal health care. Health-­related goals and indicators can also be found in many other ­SDGs.

­Specific Challenges in Fragile Contexts and Conflict Situations

In ­SDG 3, which is central to health concerns, sub-goal 3.8, “achieve universal health coverage (­UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all”, is considered an important lever for reaching health-related goals. However, fragile and conflict-ridden countries, in particular, are far from achieving this goal, as their capacity to provide even basic health services is often severely limited.

Illustrative of this is the fact that 50 per cent of the as of yet unachieved health-related goals, such as those regarding maternal and child mortality, relate to fragile contexts. If fragile situations are also characterised by conflict, it is not only the number of deaths and injuries caused by conflict actions that rises. The destruction of infrastructure and housing associated with conflict also leads to a deterioration of general living conditions, impedes access to food, clean water, and sanitation, and thus creates much greater health risks for the affected populations. Only a fraction of deaths in conflict situations is caused by direct combat; the majority of cases of deaths are due to disease and malnutrition– deaths which could often be avoided by access to health services. Health systems in fragile contexts and conflict situations are, however, often greatly limited in their functions due to the deliberate or collateral destruction of facilities, the flight of health personnel, and the insufficient availability of medication. In many cases, private providers take the place of collapsed public health systems. However, financial cost means that only a small, privileged social class has access to these private services. Women, children, the chronically ill, and refugees, including internally displaced persons (IDPs), are amongst the most vulnerable groups in fragile contexts.

In these contexts, the provision of health services is therefore often limited to emergency treatment due to severely limited capacity. Preventative treatments, vaccinations, and the treatment of chronically ill patients are the first to be abandoned due to insufficient finances and operational capacity. In many cases, this leads to new outbreaks of diseases that had once been thought eradicated, and to the rapid spread of epidemics. Thus, more than 80 per cent of outbreaks of major epidemics occur in fragile contexts– often with cross-border effects because of migration flows. Nor do negative effects end with the end of the conflict. Experts estimate that the impacts on public health persist for up to ten years after the end of a conflict.

Such setbacks in fragile and conflict-ridden states therefore present a risk to the achievement of the health goals worldwide that should not be underestimated since in the worst case, they can set entire regions back years in their development.

Fig. 1: SDG 3, Its Sub-Goals and Other Health-Related SDGs

Fragile Health: Venezuela and Yemen

Below, these challenges will be illustrated by two case studies. Venezuela is a fragile state, which, due to its economic and political situation, is unable to maintain or increase its population’s health level at the moment; instead, it is falling below the standards it had already achieved with regard to the 2030 Agenda’s health-related goals. Yemen’s starting position with respect to health indicators was poor, and years of conflict have exacerbated existing weaknesses, fostered the emergence of new threats, and thrown the country far back in its progress towards achieving the goals.

Venezuela– A State of Emergency

Venezuela, the world’s most oil-rich country, with a population of 32 million as of 2018, is currently in a political, economic, social, and humanitarian crisis. This has prompted more than 2.7 million people to leave the country since 2015. Over the same period, ­GDP has fallen by about 50 per cent, and inflation for 2019 is estimated at seven-digit rates. The country is greatly dependent on imports, and the 54 per cent drop in its oil extraction since 1998, along with the international decline in crude oil prices last year, have meant an 18 per cent drop in Venezuelan ­GDP.

The consequences of this economic crisis are felt primarily by the country’s population, which is suffering from a widespread supply crisis. Since the crisis began, there has been a shortage of food, clean drinking water, and medical services throughout the country. This runs counter to the central objectives of the 2030 Agenda, which the Nicolás Maduro government has committed itself to implement. These conditions impair the function of health-related infrastructures. Insufficient supply weakens people, especially vulnerable groups such as children, women, and the sick, and makes them more susceptible to disease. Hyperinflation raised the price of an average shopping basket by 283,880 per cent in 2018. The majority of the population can no longer afford the basic food and medicine they need, especially since the state-set minimum wage is insufficient and rapidly depreciating in value due to inflation.

The economic and political crisis in Venezuela has led to a deterioration of many of the country’s health-related indicators. These include food security (­SDGs 2.1 and 2.2), infant mortality (­SDG 3.2), maternal mortality (­SDG 3.1), basic health services (­SDG 3.8), the spread of infectious diseases (­SDG 3.3), access to safe drinking water, sanitation, and energy (­SDGs 6.1, 6.2, and 7.1), as well as the number of victims of intentional killing and conflict-related deaths (­SDG 16.1). This is primarily due to the acute economic and medical supply crisis. Another cause is the rise in violence and criminality, some of which is itself caused by the supply crisis.

As a consequence of governmental mismanagement, Venezuela has become strongly dependent on imports of food and consumer goods. Constantly falling agricultural production means that current levels of production cover only 25 per cent of the national demand. At the same time, imports of staple foods fell by 67 per cent between 2016 and 2017. Despite state distribution of food by means of the so-called Comité Local de Abastecimiento y Producción (Local Supply and Production Committee), or ­CLAP boxes, 80 per cent of households suffered food shortages in 2018, making malnutrition increasingly widespread. While only 3.6 per cent of Venezuelans were malnourished in 2013, this number rose to 11.7 per cent by 2017. About 280,000 children under the age of five suffered from acute, life-threatening malnutrition in 2017.

Basic health care for the population, as aimed for in ­SDG 3.8, has not been possible since the political and economic crisis in the country worsened because medicine, medical tools and devices, such as hypodermic syringes and scalpels, are no longer available in sufficient quantities. According to official Venezuelan government reports, the infant mortality rate rose by 30 per cent between 2015 and 2016, and the maternal mortality rose by as much as 65 per cent– a devastating development in view of the targets of the 2030 Agenda.

Those with chronic illnesses are hit especially hard by the medical supply crisis. For instance, 87 per cent of registered ­AIDS patients were cut off from medication, which led to the deaths of over 5,000 people. Illegal drug trafficking on the black market poses additional health risks. Moreover, medical facilities are also limited in their ability to function properly. In a national hospital study conducted in March 2018, 70 per cent of the facilities surveyed stated that they had only irregular supplies of power and drinking water. In addition, because of low pay, 22,000 doctors left the country between 2012 and 2017, further exacerbating the medical supply crisis. One lever for counteracting this development would be the measures described under sub-goals 3.c and 3.d of the 2030 Agenda: recruiting, training, and retaining the health workforce and calling for a strengthening of “the capacity of all countries… for early warning, risk reduction, and management of national and global health risks.” If these goals were to be sustainably pursued and implemented, fragile and conflict-ridden countries would also be better equipped to deal with health crises.

The shortage of medication, medical care, and clean drinking water has resulted in a renewed spread of preventable infectious diseases as well as of previously eradicated diseases. For instance, between June 2017 and September 2018, there were 5,500 cases of measles, 64 of which were fatal. Between 2008 and 2015, there had been only a single case. In 2017, cases of tuberculosis rose to their highest levels in 40 years. Cases of diphtheria and malaria have also risen dramatically over the course of the crisis. The latter disease had been considered eradicated in Venezuela since 1961, but between 2010 and 2015, the number of cases rose by 359 per cent. Because of reduced efforts at combatting the malaria-carrying mosquito and bottlenecks in the supply of malaria medication, this figure rose again by 71 per cent to 411,586 cases, between 2016 and 2017.

Access to electricity and clean drinking water, which have deteriorated severely over the course of the crisis, are also key indicators for achieving ­SDG 3. For instance, in March this year, almost the entire country suffered from extended power outages, and an associated collapse of the drinking water supply. Only 18 per cent of the population currently have regular access to clean water. The weaknesses in power and water supply, which are primarily due to government failures, have been exacerbated by climate-related incidents.

In view of the ongoing political crisis, no improvement in health-related indicators is in sight for Venezuela. A small ray of light here is the fact that, since mid-April, Red Cross has had permission to supply the suffering population in Venezuela with drinking water, food, and the most necessary medications.

Yemen– Humanitarian Crisis on the Arabian Peninsula

Having been called “Arabia Felix”, the happy Arabia, by the Romans due to its riches, the name hardly fits Yemen today. After more than four years of war, the country is suffering one of the most severe humanitarian crises in the world. According to UN estimates, 24.1 million people, or 80 per cent of the population, are reliant on humanitarian aid. Food insecurity and acute malnutrition endanger large parts of the population; around 18 million people have no access to safe water or sanitation services, and more than four million have been forced to leave their homes. Since 2017, preventable diseases such as cholera and diphtheria have been spreading.

Even before the conflict began, high levels of poverty and insufficient access to health care, sanitation, and drinking water kept Yemen far from achieving international health-related goals. The conflict and resulting destruction have turned this already difficult situation into a humanitarian crisis.

One important factor in the current crisis is the destruction of an already weak health infrastructure. As a result of air raids and fighting, as well as of limited medical supplies and staff shortages, – with federal pay having been stopped since 2016– only half the country’s health facilities remain operational. Thus, 19.7 million Yemenis no longer have adequate access to health services.In this situation, basic health services, as envisaged in SDG 3.8, are nowhere close to being provided. Moreover, 120 attacks on health facilities have been registered since 2015, leading to further closures and flight of health personnel. The private health service providers, some of which are still operating, are inaccessible to most of the population because of their high cost.

In the context of insufficient access to health services, the almost complete cessation of vaccinations, and the rising numbers of people with inadequate access to safe drinking water and sanitation (now almost 18 million), preventable diseases and previously eradicated diseases have been spreading since 2016. For instance, since 2017, the country has experienced the worst cholera outbreak in its history. This has so far resulted in 1.3 million outbreaks of the disease, almost 2,800 of them fatal. Diphtheria has also spread since the end of 2017, with 3,200 suspected cases so far. The seasonal outbreaks of malaria and dengue fever have worsened significantly since the conflict began. The majority of these cases could be treated by rapid access to medical care, but under current conditions are often fatal. With regard to combatting water-borne and neglected tropical diseases (­SDG 3.3) and increasing vaccinations among the population (­SDG 3.b), the country has thus been clearly moving further away from achieving ­SDG targets.

After four years of conflict, more than 20 million people– 67 per cent of the population– are affected by food insecurity, and almost 10 million of them suffer from extreme hunger. Around two million children are acutely malnourished. Because Yemen is 90 per cent dependent on food imports, conflict-related interruptions and obstacles to imports hit the population especially hard. With regard to combatting hunger and food insecurity (­SDGs 2.1 and 2.2), Yemen is thus increasingly falling short of achieving the Sustainable Development Goals. The economic collapse, currency depreciation, and massive rise in food and fuel prices have pushed 81 per cent of the population below the poverty line. Even in places where food is available, many Yemenis can simply no longer afford it. The eradication of poverty postulated in ­SDG 1 thus seems to have moved into the far distant future.

Even before 2015, Yemen was characterised by poor water and sanitation service provision– only 52 per cent of the population had access to safe drinking water, and 46 per cent to safe sanitation. The conflict-related destruction of the water systems has noticeably exacerbated this situation, and thus prevents any improvement that might allow the corresponding ­SDGs (6.1 and 6.2) to be achieved. For instance, 17.8 million people have no access to clean drinking water or sanitary facilities. This makes the population more susceptible to diseases and epidemic outbreaks, and moves the country farther away from ­SDGs 3.3 and 3.9.2, which aim to reduce the spread of diseases caused by contaminated water, and related deaths.

As in other fragile and conflict-ridden contexts, children, women, the chronically ill, and refugees, including IDPs, are especially vulnerable in Yemen. For instance, for the around 4.3 million IDPs, access to water, sanitation, and food is even more restricted than for the rest of the population. Insufficient prenatal examinations and the rising number of births without qualified health personnel present contribute to an increase in maternal and neonatal mortality, which constitutes a setback in previous progress towards improving these indicators for ­SDGs 3.1 and 3.2. The chronically and the critically ill also suffer greatly from this situation. Since the beginning of the conflict, 25 per cent of Yemeni dialysis patients have died each year, since the vital sessions have not been available. The proportion of deaths due to non-communicable diseases (including cardiovascular diseases, cancer, etc.) has risen from 23.1 per cent in 2015 to 57 per cent in 2018 due to insufficient treatment options. This presents a clear setback for the achievement of ­SDG 3.4. Children are particularly at risk because of the combination of malnutrition, insufficient access to safe drinking water and health services, and great psychological strain. This has entailed a negative development for the indicators of the number of children with appropriate development for their age with respect to health, learning, and psychosocial well-being (­SDG 4.2.1). Save the Children estimates that 85,000 children under the age of five have died from illness and malnutrition since the conflict began.

The Armed Conflict Location & Event Data Project (­ACLED) registered more than 60,000 conflict-related deaths between January 2016 and November 2018. UN figures indicate at least 17,640 civilian deaths, including 6,872 between March 2015 and November 2018. These figures represent a drastic setback on the path to achieving the goal of reducing all forms of violence-related mortality (­SDG 16.1).

As part of the UN-mediated peace talks in December 2018, President Hadi’s government and the Houthis agreed on a cease-fire, inter alia. However, the success of the agreement remains uncertain, and a rapid stabilisation of the country as a prerequisite for significant improvement in the humanitarian situation of the population, is currently not in sight.

Conclusion

As the many interconnections in the ­SDGs indicate, health is a cross-cutting issue, the achievement of which is influenced by many factors, and in turn contributes to the achievement of other goals. While this creates positive synergy effects in stable, sufficiently funded contexts, fragile and conflict-ridden countries often experience a sort of downward spiral in which the effects of insufficient health, sanitation, food, and energy all reinforce each other. This leads to stagnation or even setbacks on the way to achieving health-related goals. Instead of moving towards universal, high-quality, affordable health care, fragile states are moving further away from this goal, as the examples of Venezuela and Yemen show. Despite the fundamental commitment of these countries’ governments and of other states involved in the conflict to implement the 2030 Agenda, the worsening of health-related indicators in both cases suggests that pursuing these goals will not be a priority in either crisis situation. The reasons for this vary from case to case, but tend to be based on insufficient capacity, lack of political will and conflicting interests.

The forecasted rise in the proportion of people who live in fragile contexts around the world will continue to widen the gap between populations with access to suitable health care, and those in countries that have only partial access or none at all. This would be in clear contrast to the guiding principle of the global sustainable development goals: leave no one behind.

The international community should resolutely oppose such a development and advocate health as a public good and a human right. The 2030 Agenda, which was signed by more than 190 countries around the world, provides an important opportunity to address the complex challenges in fragile contexts.

The 2030 Agenda postulates universal access to health as a basic human right; achieving universal health care is thus established as a central goal in its own right so as to provide a better life for all. At the same time, the networked character of the Agenda places the cross-cutting issue of health in the nexus of security, humanitarian aid, sustainable development, and peacekeeping– thus giving health a central role as “a prerequisite, an indicator and a result of sustainable development”, as was mentioned at the beginning of this article.

By emphasising global partnerships, the Agenda also points the way to achieving the goals. Only a coordinated, networked approach, by all actors involved, derived from the needs of the respective populations, can successfully address the complex challenges of achieving health-related goals in fragile contexts. The financing priorities of international donors must also be adjusted accordingly. The World Health Organization estimates that the cost of achieving the 2030 Agenda’s Global Health-related goals by the year 2030 will be between 134 and 371 billion dollars per year. In poor, and especially in fragile and conflict-ridden countries, the gap in funding for achieving the goals stands at 54 billion US dollars annually; there is, thus, a great need for financial support. Ultimately, it is important for international efforts to also focus on increasing the relevance of the 2030 Agenda in the respective countries, and on enabling them to sustainably improve their health infrastructures and to make them more resilient.

However, it is also crucial that all those involved– states, parties to conflict, and other actors– are willing to acknowledge the importance of the 2030 Agenda with its universal character as an instrument of prevention and containment of conflicts and crises.

Veronika Ertl is Desk Officer for Development Policy at the Konrad-Adenauer-Stiftung.