Extreme poverty and the Sustainable Development Goals

Written Evidence

February 2022

Action for Global Health (AfGH) is a UK-based network of more than 50 organisations working towards a world where the universal right to health is realised. AfGH acts as the coordinator between the UK government and global health civil society, convening regular meetings and sharing learning from across our network. AfGH’s focus is on global inequity - taking an intersectional approach to advocacy to support the achievement of all SDGs.

1.                  This submission will answer the following questions from the Terms of Reference: 

1. How well is UK Official Development Assistance (ODA) targeted towards tackling extreme poverty and how effectively do the FCDO policies and programmes contribute to the achievement of Target 1.1 of SDG 1?
2. How might the FCDO’s strategy, policies and programmes need to change as the number of people in extreme poverty grows due to the global pandemic or the effects of climate change?
3. How effectively do the FCDO’s strategy, policies and programmes address the needs of women and girls in extreme poverty?
4. What evidence is there to suggest the FCDO is learning and applying lessons from its policies and programmes, so they more effectively tackle extreme poverty and does the FCDO have a good evidence base for what does and does not work?
5. What effect have the cuts in UK ODA had on the FCDO’s ability to address extreme poverty? What evidence is there to suggest poverty was a key consideration in deciding where the cuts should fall?
6. How the FCDO can play a more effective part in the eradication of poverty as a convener, thought leader and investor?

2.                   Introduction

2.1              As we reach our third year of the COVID-19 global pandemic, we bear witness to the first rise in extreme poverty in a generation. UN Secretary General Antonio Guterres called the last eighteen months the “most challenging period the world has seen since the Second World War … deepening inequalities, decimating economies and plunging millions into extreme poverty.”[1] The link between global health and extreme poverty is stark – without equitable access to health, people are driven further into poverty as inequitable access to health increases barriers to education, work, family and social lives.

2.2              Prior to COVID-19, more than half a billion people were already pushed or further pushed into extreme poverty due to the financial impact of paying for healthcare.[2] Now, evidence compiled by the World Health Organization and the World Bank shows that the COVID-19 pandemic is likely to halt two decades of global progress towards Universal Health Coverage (UHC) and hinder the achievement of the Sustainable Development Goals (SDGs).[3] The World Health Organization’s Triple Billion Target works towards 1 billion more people having access to UHC, but also outlines the importance of reaching the ‘bottom billion’ – those missed from current UHC plans and targets – demonstrating the need for a focused approach on the most disadvantaged. Without full Universal Health Coverage, which seeks to ensure people can access quality health services without suffering financial hardship, achieving SDG. 1.1 is rendered unobtainable.

2.3              With global poverty levels arising for the first time in a generation due to COVID-19,[4] the pandemic, layered over the climate emergency, humanitarian crises and conflicts (that are growing in complexity and length) has exacerbated pre-existing gender and other intersecting inequalities. It has had a disproportionate impact on women and girls and exposed the complex challenges that adolescent girls face.

2.4              Poverty and extreme poverty are also likely to increase the risk of worse health outcomes, as lack of financial means results in a barrier to pay for healthcare itself, as well as travel to access health and impacts the social determinants to health. It also places people at higher geographical and social risk of disaster scenarios and ill-health affecting work due to their financial and social status. There is a myriad of health concerns related to extreme poverty – from diabetes to sickle cell – many of which are not considered under the WHO’s current 5 x 5 model. Moreover, “NCDIs account for more than a third of the disease burden among the poorest billion and are attributable to a far more diverse set of conditions and risk factors than contained in the 5 x 5 model.”[5]

3.                   Official Development Assistance (ODA) and extreme poverty

3.1              Weakened focus on poverty reduction: The UK Government has seen a decline in their focus on poverty reduction over recent years. In 2015, the UK committed to developing more of a cross-government approach in their 2015 Aid Strategy, delivering more aid outside of the historic Department for International Development (DFID), and developing a number of cross-government funds.5 This decision was contentious; the International Development Committee (IDC) 2018 inquiry found that spending ODA outside of DFID created inherent risks in terms of coherence and transparency across ODA investments, as well as the UK ODA’s poverty reduction focus.6

3.1.1              Through the merger of the DFID with the Foreign and Commonwealth Office – to create the Foreign, Commonwealth and Development Office (FCDO) – we have seen these risks come to light, as development objectives and the focus on poverty reduction have been diluted in favour of foreign policy objectives. Similarly, the implementation of DFID’s ‘Leaving No-One Behind’ strategy, which focused development efforts on groups left furthest behind - including people living in extreme poverty – has lost attention within FCDO. The upcoming International Development Strategy will be a critical opportunity to put poverty reduction and the achievement of the SDGs at the centre of FCDO’s work.

3.2              ODA cuts: Despite being a strategic priority, global health has still seen dramatic and devastating cuts of up to 40% overall. In addition, as global health inequality is a structural driver of a range of other development concerns – such as reducing access to education, diminishing gender equity and increasing poverty – these cuts to health will have direct impacts on all other government priorities and deepen poverty for many around the world (and, in turn, the impacts on these other issues will have an impact on health inequality). For example, cuts to health will directly inhibit the UK Government’s goal of improving girls’ education, as lack of access to health services increases poverty and results in more girls leaving school.

3.2.1              COVID-19 and climate change have underscored how good health is the foundation for every aspect of human and societal wellbeing – including poverty reduction. Without sustained global collaboration and sustainable financing in health systems globally, it will be impossible to achieve SDG 1.1. Through its recent cuts to ODA spending, the UK ignores this hard-learned lesson of the pandemic at the world’s peril and at the risk of its own reputation.  

3.2.2              As COVID-19 continues to weaken fragile health systems, exacerbates barriers in access to care and results in the first rise in extreme poverty for a generation, now is not the time to be stepping away. These cuts will lead to a decades-long rollback on progress towards improving health and lead to the severe rollback in progress to the SDGs and render the achievement of the most pressing global challenges unattainable. The severe nature, abrupt implementation and lack of transparency of the cuts, deepen their negative impact and provide the future return to 0.7% facing additional compounding and unnecessary challenges in the reinstatement of programmes.

3.2.3              This sudden nature of the cuts, and the confusion on the new budget allocations, has led to abrupt closures and/or severe cutbacks to programmes; meaning many people have been left suddenly unable to access a myriad of healthcare (including emergency healthcare, polio vaccines and family planning services). This lack of transparency and sudden nature of the cuts will further deepen the rollbacks to global health and leave so many more disadvantaged people facing health inequity and its corresponding issues, such as poverty and lack of education.

3.2.4              The lack of transparency around multilateral and bilateral spending, and how this fits into the wider global health spending, has led to confusion on the continuation of various programmes, the connection with the COVID-19 response, and how this spend contributes to achieving the FCDO’s strategic priorities, the manifesto commitment on ending preventable deaths and the SDGs.

3.2.5              Analysis developed by Action for Global Health indicates that the reduction in UK global health spending represents a cut of up to 40% overall. We are already witnessing the impacts of the cuts on health services around the world – from the sudden closure of ambulance services, leaving people unable to reach emergency healthcare, to cuts of 80% to UNAIDS, jeopardising the effective delivery of the 2021-2026 Global Aids Strategy which the UK endorsed only two months ago. Startlingly, many health projects that were on the cusp of success now face devastating setbacks. For example, a 95% cut to the Global Polio Eradication Initiative that was so close to achieving its goal will no doubt result in a resurgence of polio. 

3.3              Financial risk protection for health services: A critical component of UHC is ensuring no one suffers financial hardship as a result of seeking health services. The UN HLM Political Declaration on UHC commits member states to ‘eliminate impoverishment due to health-related expenses by 2030’ and achieve financial risk protection.

3.3.1              AfGH’s ‘Stocktake Review’ (2020) reviewed health ODA project documents and indicated that the UK’s contributions towards increasing financial risk protection and eliminating out-of-pocket payments present a mixed picture. While ‘Supporting a Resilient Health System in Zimbabwe’ documents stressed that user fees have now been almost universally removed for antenatal care, and the Saving Lives in Sierra Leone 2016 programme sought to ensure availability of essential medicines for the government’s free healthcare initiative, the DFID-BRAC Strategic Partnership II made clear the project was testing charging fees for health services and products in hard-to-reach areas.[6] DFID’s annual review of the BRAC programme states that ‘while the cost recovery model appears to be working well in terms of reach and demand for services, BRAC should demonstrate that the demand from people unable to pay service fees is consistently accommodated’.[7] Furthermore, one element of the Sustaining and Accelerating Primary Healthcare in Ethiopia programme sought to enrol 1 million new households in community-based health insurance (CBHI) schemes. Yet the evidence is complex on CBHI, with some pointing to the weakness of such schemes’ voluntary nature, making it hard to progress towards UHC and leaving many vulnerable to continued out-of-pocket payments.[8]
 

4.               FCDO’s strategy, policies and programmes

4.1              Global health strategy: The UK government does not have a dedicated, public strategy – or any current comprehensive document – guiding its work in global health. If the 2015 UK aid strategy is now outdated, then the last strategies issued by the UK Government focused on global health are even more so. ‘Health Is Global – A UK Government Strategy 2008-13’ is the last complete strategy document which covered the UK’s global health work and was widely considered to be an innovative model of cross-departmental collaboration. Since this strategy expired in 2013, the UK government (including DFID) have stated repeatedly that they do not plan to publish a new global health strategy, despite calls from the International Development Committee for the government to develop a global health strategy as long ago as 2014.[9] The call for a global health strategy is supported by other notable individuals, such as the former Chief Medical Officer Sally Davies in her final report, where her first recommendation to the UK government was that they ‘publish a set of shared global health objectives as soon as possible and publish a renewed shared global health strategy by the end of 2019’.[10]

4.1.1              A global health strategy is essential because it outlines and delivers synergies that will increase the impact of the UK Government’s work across global health – including aligning initiatives to improve health equity alongside other SDGs, such as tackling extreme poverty and improving education outcomes.

4.2              Financial commitments to UHC and financial risk protection: Whilst the government’s ambitions are a step towards addressing these most pressing global development challenges, the recent cuts to ODA will render the achievement of these goals impossible. Furthermore, these cuts will lead to a decades-long rollback in progress towards the Sustainable Development Goals, hinder the global recovery from COVID-19 and leave the world more vulnerable to the impacts of climate change. These cuts also stand in stark contrast to other G7 nations’ approaches – for example, the US has increased its funding to global health by 66% over the past year2 despite its economy contracting at its deepest pace since World War II.

4.2.1              At a time when COVID-19, future pandemics and climate change pose the greatest threat to the health of people in the UK and around the world, these cuts are short-sighted and will undoubtedly increase the UK’s vulnerability. Whilst we recognise there have been fiscal restraints caused by COVID-19, cutting global health spending as a result of the pandemic will hinder the progress of global health, as well as all of the most-pressing global development challenges.

4.2.2              In order to tackle extreme poverty, the UK must instead increase support to national strategies advancing UHC, such as free healthcare initiatives and initiatives reducing out-of-pocket payments, ensuring that they are reaching the furthest behind, first. The UK should ensure all health programmes make clear how these investments reach people living in extreme poverty, and guarantee financial risk protection in all health outputs. 

4.3.              FCDO learning and applying lessons: In order to achieve the international and UK targets in improving global health it is critical that defining priorities for funding is dictated by global public health needs and not by diplomatic or political factors. The COVID-19 crisis poses challenges to increasing the financing of resilient health systems that can deal with COVID-19 and other potential infections, as well as dealing with other health issues.

4.3.1              Bilateral aid enables governments to invest in sustainable and resilient health systems, and multilateral aid is essential in setting norms and guidelines as well as directly support or fund specific programmes (such as the WHO, UNAIDS and the Global Fund) or to finance and encourage innovation and access (such as UNITAID). The UK funding for these, and other organisations, has been vital for their continual functioning.  In the midst of the current pandemic and its terrible impact of rolling back HIV programmes, cuts in UNAIDS and UNITAID will have a terrible impact on access to prevention and treatment not only for HIV but also for TB, malaria and Hepatitis C. 

4.3.2              The lack of transparency and detail around massive cuts to multilateral bodies leaves hugely important questions unanswered, particularly whether the UK government is content with critical programmes being rolled back. It is also unclear how the UK split its funding towards the global COVID-19 response and the broader global health objectives via multilateral or bilateral channels.
 

5.              How the FCDO can play a more effective part in the eradication of poverty

5.1              In order to tackle the global inequities facing individuals and achieve SDG 1.1. the FCDO must deliberately focus its ODA on poverty reduction and tackling inequalities in all their forms – including through targeted and deliberate measures to respond to the needs of the most disadvantaged. This includes prioritising countries and communities with the greatest needs, rather than those that are geo-politically strategic for the UK, and upholding aid effectiveness principles.

5.2              This should include the adoption of a cross-cutting gender-transformative approach, detailed through the forthcoming refresh of the Strategic Vision for Gender Equality, across all of the UK’s development and humanitarian policy, programming and related multilateral engagement and foreign policy. This should commit the FCDO to tackle the root causes of gender inequality and discrimination and reshape unequal power relations as a central means to achieving gender equality and the SDGs.