INSPIRA 2030 - v. 2 - No-One Left Behind

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Case Study zika w w w . i s a g s - u n a s u r . o r g

NO-ONE LEFT BEHIND

Interview Jessé de Souza

Expert View Indicators

n.02 South American Institute of Government in Health Executive Director José Gomes Temporão Technical Coordinator Henri Jouval Head of Office Luana Bermudez Coordinator for Information and Knowledge Management Flávia Bueno Editor-in-Chief Manoel Giffoni comunicacao@isags-unasur.org Texts Flavia Bueno, Javier Chamorro, Karla Menezes e Manoel Giffoni Translation Marinês D. and Peter Lenny Photographs ISAGS Archive, UN Photo Library Graphic Design TUUT Design Support Alessandra Ninis, Aline Fontainha, Beatriz Nascimento, Bruno Macabú, Felippe Amarante, Laura Santana, Mônica Sutton Acknowledgements Instituto Nacional de Salud de Colombia IPEA - Instituto de Pesquisa Econômica Aplicada (Brazl) Oficina de la Asesora en Derechos Humanos de las Naciones Unidas para Paraguay Universidad de Lanús (Argentina)

What are the Sustainable Development Goals?

How will they be monitored?

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editorial

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main no-one left behind

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case study zika

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interview jessĂŠ de souza, universidade federal fluminense

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expert vision: javier chamorro Indicators: a rights-based approach

What is the role of ISAGS in this new journey?

Stay tuned at http://bit.ly/SDGandISAGS

editorial

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T

he negotiations that paved the way to establishing the 17 Sustainable Development Goals were without precedent. Instead of the traditional tables bustling with diplomats and technical reports, the process began with the largest public consultation in history, which included an online poll on development priorities, open to the whole world, plus 11 thematic “global conversations” and another 83 specifically on the situations of individual countries.

The outcome of that ample, inclusive preparation was self-reflective. What the United Nations Secretary-General called the ‘people’s agenda’ is not only ambitious as regards the areas it intends to transform over the next 15 years, but it also comes with a requirement that is to inform all its goals: no-one is left behind.

One of the failings most often signalled by experts on the Millennium Development Goals in place from 2000 to 2015 was the inability to foster real change in society overall. In what some specialists termed “a tyranny of averages”, the goals were often attained, but left aside precisely those in most critical situations – by reason of social position, gender, ethnicity and so on.

Using the perspective of social determinants of health, that is, those economic, social and environmental characteristics that produce situations favourable to people’s wellbeing, the second volume of INSPIRA 2030 magazine will take as its theme overcoming inequalities in South America.

Recognised as one of the most unequal places on Earth, but at the same time featuring veritable success stories over the past decade, the continent has know-how acquired during centuries of living at the interface between coloniser and colonised, slaveholder and slave, rich and poor, abundance and starvation.

In that context, it is no surprise that the Constitutive Treaty of the UNASUR, signed by all the region’s countries in 2008, places cultural, social, economic and political

integration at the service of socioeconomic equality, social inclusion and participatory citizenship as preconditions for strengthening democracy and reducing asymmetries among States. Nor is it surprising that one of the structures first set up in the bloc was the Health Council, one of whose fundamental concerns is not just the social determinants of health, but other entirely inclusion-based concepts, such as universal health systems and universal access to medicines.

The cover story features a conversation with a Professor of Epidemiology, Health Management and Health Policy at Lanús University, Argentina, to examine the magnitude of the cross-cutting challenge posed by Agenda 2030 for both the health sector and other areas, which will need to act with more synergy than ever before.

For an in-depth investigation of inequality and how it has reproduced on our continent down through history, we interviewed Professor Jessé de Souza, former president of Brazil’s Applied Economics Research Institute and the author of now classic books on the subject, such as “A Ralé Brasileira” [Brazil’s Rabble] and “A Construção Social da Subcidadania” [The Social Construction of Sub-citizenship].

With our feet firmly planted in current realities, we went and asked what inequality has to do with the Zika epidemic, which had its epicentre on our continent. Then to round things off, we gained a valuable contribution from Javier Chamorro, a technical expert at the UN Human Rights Office in Paraguay, who explained the importance of disaggregating the indicators that measure countries’ progress towards the SDGs so that no-one is left behind.

Good reading!

NO-ONE LEFT BEHIND

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outh America is a continent conspicuous for its diversity, most obviously in its geography. The societies that flourished here, in a gamut of environments as diverse as the Andes and the Atlantic Forest, the Amazon and the Pampas, have been marked by a history of culture shocks and economic models based on exploiting their wealth of labour and natural resources, which came to constitute a classic recipe for inequities and under-development.

During most part of the 20th century, this mixture resulted both in social calamities including hunger, extreme poverty and violence and in environmental disruption ranging from desertification and pollution of water sources to disorderly urban growth. The latest report by ECLAC places some 170 million people now living below the poverty line in Latin America, 71 million of them at the subsistence threshold of only two dollars a day. It is a global consensus that all these characteristics – which feature in the lives of 30 percent of South America’s peoples – have very material effects on health.

“Poor conditions of life lead to poor health indicators – even in developed countries”, notes Marcio Alazraqui, Professor of Epidemiology, Health Management and Health Policy at Lanús University in Argentina. It was on that view that, starting in 2005, the World Health Organisation (WHO) adopted a concept designed to address the impact of socioeconomic factors on the wellbeing of populations, which took in broader considerations than those generally contemplated by countries’ health ministries, to include education, basic sanitation, working conditions and so on – what are known as the “social determinants of health” (SDHs). “Processes of health and disease are driven by structural power relations that form part of the ‘social determination of health’, a concept that is more than common in South American studies of health inequalities”.

On that approach, in addition to one of the 17 Sustainable Development Goals’ focussing exclusively on more

traditional health concerns, such as reducing maternal and infant mortality and improving access to medicines, the inter-sector call to “leave no-one behind” has brought health care and the concept of social determinants to the heart of the new global development agenda.

The first ten years of the 21st century saw South America experience one of its most successful economic periods, with not only a rather shallow GDP growth, but also bold social gains that proved their worth in efforts to achieve the Millennium Development Goals.

In the health field, the figures are beyond question.

Between 1990 and 2013, deaths among the under-fives decreased by two thirds (from 54 to 18 per thousand live births), measles was almost completely eliminated, preventable contagious diseases (tuberculosis and malaria, for example) were brought under greater control, there was progress in family planning and antenatal care and specialist care at childbirth, in addition to South America’s establishing itself as the region with the fullest coverage in antiretroviral treatment for HIV/AIDS – not to mention the reductions in extreme poverty and hunger.

As seen in the graphs, Argentina displayed improvements in indicators concerning inequalities in the past decade, which was followed by improvements in health indicators as well.

However, with the concept of sustainability featuring strongly on the new agenda, these endeavours must necessarily overflow into other areas with direct impacts on health, posing challenges of governance for which most of the countries’ political systems are not prepared.

The latest report by ECLAC places some 170 million people now living below the poverty line in Latin America, 71 million of them at the subsistence threshold.

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“the reduction of these inequities demands coherent policy responses across sectors and across countries, with firm political commitment by all parties.”

This issue was already being raised in discussions at the World Conference on Social Determinants of Health, in Rio de Janeiro in October 2011, where UNASUR countries played a major leading role. “Poor progress in the implementation of a social determinants approach reflects in part the inadequacy of governance at the local, national, and global levels to address the key problems of the 21st century”, observes a meeting’s discussion paper, warning that the issue of inequities challenges the traditional division of governments into sectors, such as Ministries of Health, Social Development, Infrastructure and so on, whereas “…the reduction of these inequities demands coherent policy responses across sectors and across countries, with firm political commitment by all parties”.

One of the conference participants, Brazil’s national coordinator on the South American Health Council, Paulo Buss, was invited by the Pan-American Health Organisation (PAHO) to form part of a High-level Commission on Equity and Health Inequalities. At its launch on 11 May, Dr Buss underlined the role of health in the SDGs, but alerted to the need to formulate development plans with a strong emphasis on real, balanced inter-sector collaboration: “What must be avoided is a certain health imperialism, as if health was more important than the other sectors”.

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Countries do in fact face the challenge of horizontalising traditionally vertical public administrations and much the same can be said of regional cooperation in South America, particularly at the UNASUR, whose key structures were set up around Ministerial Councils. Recent efforts at ISAGS, however, suggest that this difficulty may be surmounted through flexibilities embodied, from the outset, in the bloc’s Constitutive Treaty, such as the incentive to work jointly with peer organisations or institutions.

One example were the activities undertaken with the support and/or participation of the Social Development Council, including a course on “Inter-sector Public Policies and Social Determination of Health”, the meeting on “Dialogue among Income Transfer Policies” and the “Mapping of Income Transfer Policies and their Social Oversight and Participation Mechanisms”. “As the social inequalities are multiple, it is a matter that hinges not just on effective social policies, but above all on multidimensional action”, explains Alessandra Ninis, ISAGS technical consultant on Social Determinants of Health and coordinator of the three projects. “The path forward for Agenda 2030 depends on a structural change towards a more inclusive model of development with, for example, education, social protection, quality employment and women’s empowerment, but more than anything requires new ways of thinking and about income concentration with a view to tackling exclusion and inequality”.

OVERCOMING INEQUALITY AND POVERTY IN ARGENTINA 20

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Indicators from Argentina between 2000 and 2015 show that, after a period of deterioration, the country managed to reverse the trend. The GINI index, which measures income inequality, fell consistently, as well as child mortality and desnutrition

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case study

and the situation was quickly declared a Public Health Emergency of International Concern (PHEIC).

ZIKA

In the heat of the epidemic and its repercussions in the media, which even prompted a visit by World Health Organisation (WHO) Director-General Margaret Chan to Brazil, the countries’ emergency responses have centred on surveillance. On the one hand, an implacable hunt was launched for the mosquito’s breeding grounds, with awareness-building campaigns and even brigades formed to combat the mosquito; on the other, diagnostic and research capabilities relating to zika-related complications were reinforced. “After carrying out a risk analysis, the Colombian health authorities made adjustments to the action plan, to intensify epidemiological surveillance of microcephaly and GBS and conduct research jointly with international institutions”, reports Dr Martha Lucia Ospina Martínez, Director-General of Colombia’s National School of Public Health.

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arnival and a hot climate are not the only things the cities of Barranquilla in Colombia and Recife in Brazil have in common. The zika epidemic that has exploded in South American countries since 2015 had epicentres in both, revealing a cascade of other important shared features. In both cities, for instance, economic vibrancy coexists with poverty levels of the order of 40% of the population and with urban conditions tailored to cultivate vectors such as the Aedes aegypti mosquito, which transmits not only zika, but dengue and chikungunya fevers.

People’s circumstances – the conditions they are born, grow up, live, work and get old in – explain most health inequities. Accordingly, efforts to combat zika must address a range of factors from health service access to access to drinking water, and including urbanisation conditions. “Where sanitation, sewerage and refuse collection are lacking, there will be more foci of the mosquito”, declared ISAGS Executive Director José Gomes Temporão, showing that central to the issue is a model of urban development that condemns the poorest to being most vulnerable to diseases of various kinds.

It is no surprise, then, that in Recife the neighbourhood with the highest risk of infestation by Aedes aegypti is Alto José Bonifácio, whose population is essentially lowincome and whose infrastructure suffers from a number of problems. “We need to work on water distribution and refuse collection”, said the city’s health surveillance officer, Cristiane Penaforte, in an interview for the Jornal do Comércio, revealing that in these cases the health authorities are extending the scope of their activities beyond simple health surveillance.

In a globalised world, a threat of this kind soon ceases to be local. In just a few months, the alarming association of an expanding zika epidemic with its confirmed link to neurological disorders such as microcephaly and GuillainBarré Syndrome (SGB) opened the eyes of the world

One of Colombia’s most successful strategies was implemented in Barranquilla. Every day, caminantes (community health ‘walkers’) go about the communities, using their proximity to the local people to identify ad hoc health promotion measures to tackle vector-borne diseases. Going from house to house, they build up a body of data identifying risk areas and patients in need of medical care, so as to direct them to health posts distributed across the city.

Long before zika became an epidemic, the city was investing in building a network of health centres with an interesting configuration: outpatient care facilities are located at most 800 metres from the family homes of society’s most vulnerable strata, while 24-hour medical care centres are sited at most two kilometres from those homes.

As Dr Martínez explains, this highly capillary network has made the ‘walkers’ “the backbone for interventions into any vector-borne disease”, because they are working in health promotion, prevention, diagnosis and follow-up of suspected cases. In addition, it has turned Barranquilla into a research laboratory on the disease. “We are conducting a follow-up study of one thousand pregnant women in order to ascertain the incidence of vertical transmission of zika, the incidence of new-born babies with congenital disorders and how this varies with the month of infection”, she adds.

A long-term solution will require that South American countries review their whole model of urban development, including land use policies, continuous access to drinking water and refuse collection, lack of which currently provides the ideal macrostructure for the disease to spread.

review their whole model of urban development, including land use policies, continuous access to drinking water and refuse collection, lack of which currently provides the ideal macrostructure for the disease to spread. “It is very difficult to maintain a high level of mobilisation for a long time, so it is fundamentally important to act on the structural dimension of the zika epidemic and of vector-borne diseases in generalâ€?, stresses TemporĂŁo.

Nonetheless, it is important not to lose sight of the fact that underlying all epidemics (and shared also by numerous neglected diseases) is inequality. A long-term solution will require that South American countries

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interview

JESSÉ DE SOUZA. Inequality – over and above its determination by income differences between poor and wealthy – is a social construct imprinted on each one of us from the very earliest age.

That is the thinking set out by Jessé de Souza, Brazilian researcher at Fluminense Federal University and former president of the Institute for Applied Economic Research (IPEA).

i2030 What is there that is structural about levels of inequality in South America?

JESSÉ In a nutshell, inequality is produced by neglecting and forgetting considerable fractions of society, the ‘excluded’ of what are known as the ‘popular classes’. In South America, these popular classes comprise not only the – largely precarious – working class, but also these people who are excluded and have no more to sell than their muscle power. It is important to think about this, because people generally think about class structure in terms of income-based divisions, which is just too superficial.

After several decades of the opposing trend, inequality decreased in South America, essentially for two reasons.

The first was political will, because – in this case, as has been seen at other times – economic conditions are not enough. In Brazil at least, what has made the difference in recent years has been a policy of minimum wage revaluation and income transfer programmes. To lesser extent, in Brazil I would cite education and employment generation measures, such as the ‘My Home, My Life’

housing programme. The same trend can be seen on the rest of the continent and is elevating large numbers of people into the formal competitive market and thus affording them access to rights. i2030 How should you think about class structure then, if not in terms of income?

JESSÉ Inequality is produced from the cradle, in a process that is invisible to the general public and leads people to develop that mistaken way of thinking that income defines class. In fact, classes are constituted in the family by a process of stimulus. For example, in the middle class, children are stimulated towards discipline, concentration, abstract thinking, imagination and fantasy, which are essential tools for forming citizens.

In that way, the middle-class child enters school at five already a champion. With children from the poorer classes, those stimuli are much scarcer. They receive fewer stimuli towards reading and concentration and so arrive at school at an enormous disadvantage – and that is not to mention other factors, such as health. That is how classes are formed and, as a result, inequality too.

Those who cannot see inequality being formed in this way think they occupy their place in society from merit, which is a big mistake. Inequality comes from the cradle and is a flagrant injustice, because no-one chooses the cradle where they are born.

i2030 In a scenario of economic crisis, how can South America advance so as to continue reducing inequality?

JESSÉ Poverty reduction based on increasing economic capital – that is, by consumption – has brought about a substantial revolution on the continent. Nonetheless, it needs to be taken further by incentivising resources that are less susceptible to turbulence, such as cultural capital, which is also strongly concentrated in about 20% of the middle class. In countries like Germany and France (two capitalist societies), inequalities were reduced in the twentieth century largely by democratising cultural capital. In those countries, between 70 and 80 percent of the population has access to leading-edge knowledge, which reflects in prestige and income – that is, better living.

It is important to stress the role of the State in this process. On the one hand, it involves maintaining income transfer programmes and raising the minimum wage and, on the other, better schools, cultural policies and more plural media.

i2030 What losses does inequality cause to society and democracy?

JESSÉ In profoundly conservative and unequal societies like ours there is an elite with an interest in maintaining the social structure that funds election campaigns for politicians who defend its interests. Through the media conglomerates, they sell the middle class the idea that income is a zero-sum game, that is, that affording opportunities to the excluded means giving up their own wellbeing. This really narrows down the room for manoeuver available to democratically-elected governments wanting break the vicious circle of the reproduction of inequality, because there is a structure built up over the centuries that is determined to keep society in this class – and, in some cases, racist – dispute.

A harmonious society in solidarity is an essential factor for any democracy.

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EXPERT VISION: JAVIER CHAMORRO

INDICATORS: A RIGHTSBASED APPROACH Leaving no-one behind also challenges statistics. Read the opinion of the Indicators expert of the UN Office of the High Commissioner for Human Rights in Paraguay.

The new Sustainable Development Goals (SDGs) agenda marks a change for the better over the previous Millennium Development Goals (MDGs). The SDGs are inspired in the purposes and principles of the United Nations Charter, the Universal Declaration of Human Rights and other instruments, including the Declaration on the Right to Development, as enumerated in paragraphs 10 and 19 of the Resolution (A70/1) adopting the SDGs, which emphasises that it is the responsibility of all States to respect, protect and promote human rights.

In the earlier MDGs, development seemed to go one way and human rights, another. The new agenda now takes that as a lesson not to separate them again, but to construct “one universal and transformative agenda for

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sustainable development, underpinned by rights, and with people and the planet at the centre” (A/69/700).

The new goals have been formulated on an integrated approach that also includes goals connected with civil and political rights, such as participation and access to justice, bringing a comprehensive approach to building the kind of world we want.

This change constitutes a historic opportunity for all States to pursue a “a plan of action for people, planet and prosperity. It also seeks to strengthen universal peace in larger freedom”, as asserted in the preamble to the SDGs (A70/1). As a result, this represents a far-reaching change in goals, with implications particularly for related indicators. These changes will be reflected by constructing indicators focussed on rights, to enable monitoring so that “no-one is left behind”.

From the outset, we have to understand that there are limitations to be surmounted in view of the SDGs. At the Office of the United Nations High Commissioner for Human Rights (OHCHR), we feel that official statistics have traditionally focussed on national averages in various different fields, such as the economy and public policymaking for health, education and social services.

By their very nature, however, these averages conceal inequalities and, as a result, are unsuitable as the sole measure of progress.

In order to establish “no-one gets left behind” as a crosscutting purpose and to measure progress towards the SDGs will demand a high level of data disaggregation,

which will make it possible to identify existing gaps and take proper account of people in all their diversity, particularly individuals or groups living in situations of vulnerability and exclusion.

Other points to bear in mind have to do with applying a human rights approach to the SDG indicators.

The OHCHR recently published a guidance note for policymakers, statisticians or data specialists, development practitioners and human rights advocates.

It recommends considering disaggregated data on people and groups of people in order to measure possible inequalities and gaps in fulfilment of the SDGs; providing for participation by stakeholder groups in collecting data and defining indicators; applying the principle of selfidentification to assigning identities and membership of indigenous nations, for instance; respecting privacy in data handling; fostering transparency and information access on indicators; and lastly, assuring periodic accountability reporting in order to evaluate advances and challenges.

All these elements are crucial to applying the rights approach to indicators for the SDGs.

commitment in order to collect and publish indicators with the agreed data disaggregation and aligned with the SDGs. The SDG indicators have to be contextualised specifically for each different State, which will require transparent, participatory, inter-sector methodologies that comply with the rights approach to indicators throughout the whole survey process.

Javier Chamorro is a specialist in indicators for the Office of the United Nations High Commissioner for Human Rights in Paraguay.

DISAGGREGATION CATEGORIES FOR THE SDGS The Report by the United Nations Interagency and Expert Group on Sustainable Development Goal Indicators recommended disaggregation by the following categories:

INCOME

While the subject of indicators for the SDGs does pose important challenges, particularly as regards data disaggregation, at the same time it sounds a call to creativity and scientific and technological development.

SEX

In the countries of our region there are some endeavours aligned with the challenges, which are proposing to measure the SDGs. In Paraguay, for example, with technical assistance from the OHCHR, efforts are underway to apply human rights indicators to areas such as the right to health (with the Ministry of Public Health and Social Wellbeing), the right to education (with the Ministry of Education) and the right to fair trial (with the Supreme Corte of Justice). Other ventures currently ongoing are connected with measuring economic, social and cultural rights in poverty reduction programmes (with the Social Action Secretariat) and also on the right to fair trial (with the Public Attorney’s Office).

ETHNICITY

AGE RACE MIGRATORY STATUS DISABILITY GEOGRAPHIC LOCATION

Also noteworthy in Latin America are the initiatives in Mexico, which are similar to those of Paraguay and are being assisted by the OHCHR. These endeavours have taken the first step and it now remains to sustain the

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