Outline the processes through which discourse has concrete outcomes in global health.
To respond to this question is to keep a promise – to qualify and keep in contention the many contextual and linguistic interpretations of the terms that comprise it. ‘Processes’ are perhaps most readily defined as a series of actions or steps taken in order to achieve a particular end, and will here be associated with the case study of the Millennium Development Goals 2000-2015 (MDGs) taking the year 2000 as the main historical departure for this discussion. In the opening remarks to the MDG Summit on 20 September 2010, Secretary-General Ban Ki-moon stated that: ‘there is no global project more worthwhile. […] Let us keep the promise’ (UN, 2010b). This resonates with Jan Neverdeen Pieterse’s concurrent remark that ‘development is the management of a promise – and what if the promise does not deliver?’ (2010, p. 111). This extrapolation of fact into a field of rhetoric and inquiry is perhaps the essence of discourse which, in the social sciences following the formative work of Michel Foucault, is considered to be an institutionalized way of thinking: a socially determined field defining what can be said about a specific topic. Discursive processes can change the content of policy issues and thus open up new options or exclude others. Indeed, one must consider the representativeness of a discourse when considering it as a collection of statements which ‘provide a language for talking about – i.e. a way of representing – a particular kind of knowledge about a topic’ (Hall, 1992). As such, it can be asserted that language is closely connected with power, which in turn impacts the nature of – and feedback on – concrete outcomes. The outcomes are variously considered to be achievement of development goals through statistical analysis or by treating them as benchmarks of progress through coherency of action.
Notwithstanding critique levelled at the MDGs for not focusing on root causes, and an apparent tunnel vision on activity for low-income countries, they represent a case study of an overseas development framework. They will be considered in relation to their successors, the Sustainable Development Goals 2016-2030 (SDGs), which will shed light on the outcomes and progress of the earlier agenda. The SDGs champion an inclusive process that aims to be culturally relevant, fit for purpose and universally applicable to all nations while accounting for differences in engagement and priority. Notably, the temporal lapse between the MDGs and SDGs saw a growing data generation with many global industries capitalizing on the potential for new technology to revolutionise the way that discourse outcomes are assessed and secured. As with discourse, any outcomes must be studied as a sum of parts that interrelate to form goals. So too, they must be examined in context as non-finite, open systems susceptible to the influence of non-discursive factors such as socio-economic determinants. Hall (1992) articulates that discourses ‘go on unfolding, changing shape, as they make sense of new circumstances’ and work towards delivering a promise. Moving from ideology to policy this promise-keeping follows a precedent for ‘the ideological connection between humanitarian concerns, national security, and economic gain, and the sedimentation of these connections into the institutions of state public health and international health’ (King, 2002). The discourses considered following cover discursive, priority-setting, othering, collaborative and empowerment systems and assess the scope and success of the chains by which ideology ‘sediments’ into concrete outcomes.
Discursive discourse, or the practice of producing meaning and power through writing out concrete change, is evidenced in the study of both the MDGs and SDGs. In the UN Millennium Declaration Resolution, the General Assembly remarked that humans should celebrate ‘their diversity of belief, culture and language […]. A culture of peace and dialogue among all civilizations should be actively promoted’ (UN, 2010a). Comparably, discursive formation is defined by Foucault as the functional interaction between several statements, which share ‘a strategy…a common institutional…or political drift or pattern’ (Shortland, 1986). Discourse thus understood transcends the traditional binary drawn between language and practice, so influencing all social practices ‘not as reflections of social reality, but as constitutions of it’ (Gow, 2002). However, this assertion is troubled by the ready reversibility of discourse as noted by Andrea Cornwall: ‘for all the association of Foucault’s work with the totalizing power effects of discourse, […] even the most powerful masters of meanings can never completely secure the capture of language for their own projects. […] It is, after all, in the very ambiguity of development buzzwords that scope exists for enlarging their application to encompass more transformative agendas’ (2010, pp.480-1). This nonfinite quality of discursive discourse suggests that the production of concrete outcomes is not necessarily static and that processes can be diverted or restructured to effect different end-points. Of course, the ‘process’ must not be confused with the ‘product’, but the nature of global health is that situations change, so discursively formed policies that historically produced transformative outcomes must be revisited, reframed and newly implemented. This is the subject of current debate surrounding the neglected tropical disease, leprosy, which the World Health Organization (WHO) has classed as eliminated (defined as a prevalence rate of less than 1 case per 10 000 persons) so politicizing it as of lesser financial and humanitarian priority than other diseases (WHO, 2015). However, its linguistic association with ‘neglected’ suggests an absence of continued material outcomes or reduced prevalence (WHO, 2012).
Meanwhile, the activity of structural power and adjustment through the provision of evidence-based good governance discourse effects outcomes via priority-setting policy, rationality and legislative measures in a frequently self-limiting top-down approach. In addition to identifying the nature and formation of discourse, one must question by whom and how it is controlled in relation to global health. Jeremy Shiffman suggests that: ‘in global health we see structural power at work in the existence of a cadre of individuals […] who offer advice to governments of low-income countries presumed to be in need of their input. And we see productive power at work as they create concepts for thinking about health priority setting’ (Rushton, 2015). In 2012, Fukuda-Parr, et al., remarked that global development goals set priorities in ‘a normative framework based on participatory debate and consultations among governments […] and should be treated as benchmarks for evaluating progress’. This interpretation of the MDGs moves away from the finite perspective of Shiffman, instead adopting a view of the process as discursive and remarkably prescient, foreshadowing the stance taken towards structural power by the SDG agenda. During the post-2015 development summit, conveners acknowledged the ‘essential role of national parliaments through their enactment of legislation and adoption of budgets and their role in ensuring accountability for the effective implementation of our commitments’ (UN, 2015a). In the instance of the MDGs, good governance discourse was used to create outcomes by establishing policy and implementations measured by assessing ‘current achievement levels for each indicator in relation to the defined target’ (Fukuda-Parr, et al., 2012).
Indeed, one initiative under MDG 8 (Develop a Global Partnership for Development) employed good governance discourse to decriminalize HIV positive individuals, drug users and sex workers in the Temeke District of Dar Es Salaam, Tanzania (Millennium Project, 2006). Medecins du Monde’s (MdM) ‘Harm Reduction’ programme was established in 2001 and promotes societal inclusion for these individuals through counselling, care packages, infectious disease screening and weekly group meetings (McCurdy, et. al, 2007). MdM harnessed governance discourse to: reform through decriminalization of national laws or international policies that otherwise marginalise these population groups; promote the concept and activities of harm reduction at both global and local levels; advocate for affordable HIV/AIDS care and educate impacted societies for growth and acceptance through increased funding (Médecins du Monde, 2012). Comparably, Rita Abrahamsen’s Disciplining Democracy (2000) outlines how control over discourse legitimises practice, specifically of Western intervention in Africa through the ‘good governance’ agenda, which is, however, subject to neo-colonial critique. Reacting to this, the World Bank argues for development approaches that are more closely attuned to ‘the traditions, beliefs and structures of its component societies’ (Willott, 2015) so setting up a sustainable method for delivering outcomes.
Financial commitment and security is increasingly included in discourse processes, not least because it is often essential to developing policy and mobilising change. Since the MDGs were conceived, there has been a 58% decrease in global malaria mortality rate [Graph 1] while incidence has fallen by an estimated 37% (UN, 2015b). This progress is largely associated with strengthened political commitment, a tenfold increase in international financing for malaria since 2000, and the availability of widespread diagnostic testing and artemisinin-based combination therapies. These broad and sustained efforts were channeled into ‘policies and measures, at the global level, which correspond to the needs of developing countries and economies in transition’ for a shared future (UN, 2010a).Quoting from the draft release document of the UN summit for the adoption of the post-2015 development agenda, global actors suggest that success in meeting objectives ‘depends on good governance at the international level and on transparency in the financial, monetary and trading systems. We are committed to an open, equitable, rule-based’ process (UN, 2015a).
The Financing for Development work plan that was agreed in 2015 at the Third International Conference held in Addis Ababa, Ethiopia considered mobilisation concerns. As Amina Mohammed commented at a lecture titled ‘The new universal Sustainable Development Goals for 2030: from vision to action’, if the SDGs are to produce concrete outcomes, government expenditure that goes into leveraging the capital economy must be supported by complementary monetary flows. The financing framework of Addis Ababa is, according to Mohammed, operational and ‘doable’ provided smart investments are made that go beyond social corporate responsibility (MattersduMonde, 2015). In the case of the post-2015 development framework, this governance discourse supported by financial processes, gained currency through priority-setting and promoting evidence-based policy. Meanwhile, the legislative authority of The Washington Consensus writes out a prescriptive economic package intended to reform outcomes in the developing world through the united efforts of actors including the World Bank and the International Monetary Fund (Burki and Perry, 1998). However, good governance discourse is not standalone, and many critics have suggested that it does not mobilise the necessary participants but merely guises bureaucratic inertia. Notably, Ursula Read (2009) writes that ‘national legislation may echo the best of the international human rights discourse with its language of freedom, […] however many of those whom it seeks to protect would struggle to understand it, if they were even aware of its existence’. Furthermore, if this form of evidence-based governance is deconstructed its concepts and ideas are seen as being contingent upon historical, linguistic, social and political discourses. ‘In the words of Michel Foucault, these discourses represent an awesome, but oftentimes cryptic, political power that work[s] to incite, reinforce, control, monitor, optimize, and organize the forces under it. Unmasking the hidden politics of evidence-based discourse is paramount’ to seeing products from it (Holmes et al., 2006).
Perhaps one of the least readily acknowledged processes by which global health discourse gains a purchase on development outcomes is through the activity of drawing difference. Hall (1992) identifies the characteristic activities of: drawing hierarchies (such as of the “West and Rest”); marking binaries, and othering or splitting. He suggests that a discourse ‘produces knowledge that shapes perceptions and practice. It is part of the way in which power operates. Therefore, it has consequences for both those who employ it and those who are “subjected” to it’. Historically, the discourse and activity of the West and the Rest has produced outcomes through processes that place countries on a continuum from the most ‘developed’ to the most ‘underdeveloped’ based on pre-defined criteria, which creates a conversation around how countries progress from a state of ‘under-’. Within this lexicon, developing countries are conceptualised in terms of their lack of things the West possess. As Escobar (2012) remarked in 1995: ‘development was – and continues to be for the most part – a top-down, ethnocentric, and technocratic approach, which treated people and cultures as abstract concepts, statistical figures to be moved up and down in charts of “progress”’. While Escobar identifies technocratic concerns surrounding this mode of discourse, in the data revolution that has marked the transition between the MDGs and SDGs, these statistics are crucial to assessing outcomes as well as mobilising donor support. However, these operational binaries establish a series of oppositions between implicitly value-based characteristics such as: development/underdevelopment and tradition/modernity and, as a result, our conceptualisations of what “development” means can be rather narrow, reflecting the dominance of a particular paradigm, which is socially and culturally specific (‘Western’). Similarly, Foucault and Edward Said’s Orientalism have challenged this development discourse which works via ‘othering’ from linguistic levels with pronouns of ‘they’ and ‘us’ (Said, 2003). Such critics highlight the cultural imperialism of this approach which discursively controls power through objectification while also assuming the “West” and “Rest” are cohesive entities (Mosse, 2005).
Although this discussion has sought to avoid subjective qualifications, one discourse that appears to offer the most sustainable outcomes is based on learnings from the MDGs, with discourse surrounding the new development agenda prioritising progressive ideas, collaborative cross-sectoral action and community level engagement. So considered, rather than as finite frames of success, the MDGs are ‘benchmarks of progress, where performance is evaluated by asking whether the pace of progress has improved since the 2000 commitments, and whether it is adequate’ (Fukuda-Parr et al., 2012). By 2015, the narratives surrounding the SDGs acknowledge that: ‘the challenges and commitments identified at these major conferences and summits [referring to the post-2000 development agenda] are interrelated and call for integrated solutions. To address them effectively, a new approach is needed. Sustainable development recognizes that eradicating poverty in all its forms and dimensions, combating inequality within and among countries, preserving the planet, creating sustained, inclusive and sustainable economic growth and fostering social inclusion are linked to each other and are interdependent’ (UN, 2015a).
As was identified through the voices of Foucault, Said and, more recently, Escobar, development discourse has experienced both failures and successes in crystallising words into outcome, but its overall power is inescapable, as Jonathan Crush (1995) noted: ‘this is the power of development: the power to transform old worlds, the power to imagine new ones’. By promoting participation and (community level) empowerment, outcomes have been witnessed, particularly those that prioritise an anthropological viewpoint which underscores much contemporary discourse – ‘an obsession with participation and empowerment’ (Gow, 2002). The SDGs diverge from the MDGs in terms of aspiration, content and scope. A country-level example from the C3 health organisation shows how this collaborative cross-sectoral approach to politics can be highly successful. They established a community engagement programme to help shape and formulate concrete outcomes through actual discourse (i.e. conversation) and donor mobilisation (the Morgan Stanley Banking group) to support disadvantaged children and young mothers in East London (C3Health, 2015). However, even this prescient process of health promotion, with ‘its grounding in science and scientific rationality, […] is not a value-free enterprise. It is enmeshed in power relations, and has profound implications for the self and for the nature of the relationship between selves’ (Petersen, 1996).
If a discourse is a process of understanding subject to power and politics, then its most recent form which prioritises personal accountability, technologisation (‘self management’) and empowerment will continue to gain favour in the global health sphere, as identified in the post-2015 development agenda which supports ‘the implementation of relevant strategies and programmes of action’ (UN, 2015a). There is scope for self-management within a community-based approach to propagate concrete outcomes that are truly polyglot in nature. Read (2009) says ‘there remains a gap between the global discourse on health (one conducted largely in English, the language of power), which is echoed within the corridors and conference rooms of ministries of health […] low-income countries, and the conversations and decisions around health care which take place at community level’. The segue from the MDGs to the SDGs is marked by a question of ownership. No longer is this agenda the elitist property of the government. This time it is owned by the people, with targets of health for all everyone’s very personal business. These goals increasingly apply to developed countries, prioritising inclusivity of all UN member states and accessing hard to reach populations from the goal-setting process onwards. The transformative agenda of the SDGs looks at how to reach those most often neglected while nurturing a growing economy. Mohammed (MattersduMonde, 2015) suggests: ‘we are not subject to the budget; we are the budget’, and as such we must be agents that simultaneously propel concrete action while protecting human rights.
Fifteen years on from the inception of the MDGs, a sustainable approach is seeking to progress both the language and processes of anthropocentric, community-based governance, legislative, and priority-focused discourses to create visible and tangible global change. As Foucault (1982) identifies, ‘what makes the domination of a group, a caste, or a class, together with the resistance and revolts which that domination comes up against, a central phenomenon in the history of societies is that they manifest in a massive and universalizing form, at the level of the whole social body, the locking together of power relations with relations of strategy and the results proceeding from their interaction’. Discourses must recognise their interconnectedness, in which their real applicability sees their differences ‘shade imperceptibly into each other’, across peoples and borders (Hall, 1992). Rather than highlighting otherness, the global health community must unite their voices and processes to create ethical and appropriate impact to ensure that no one is left behind. Aiming to keep this promise, the MDG General Assembly recognize that, ‘in addition to our separate responsibilities to our individual societies, we have a collective responsibility to uphold the principles of human dignity, equality and equity at the global level. As leaders we have a duty therefore to all the world’s people, […] in particular, the children of the world, to whom the future belongs’ (UN, 2010a).
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