Nearly 10 years ago, the Simons Review of the Australian Aid Program proposed that eradicating poverty should be a major focus, that the voices of recipient countries should be heard, and that greater accountability, as well as evaluation, information sharing and research, were crucial.1

Fast forward to 2005, to a globalised world with the “war on terror” and national security at centre stage. From the Indian Ocean tsunami to Hurricane Katrina, from the Kashmir earthquakes to the silent emergencies in Darfur, Niger and Uganda, disasters disproportionately affect the poor and marginalised. There are now increasing inequalities within and between states, heightened concerns about peace, security and development, and threats to human rights and fundamental freedoms.

In September 2005, world leaders assessed the progress made towards meeting the Millennium Development Goals (MDGs), a set of globally agreed development objectives for the year 2015. Three goals — reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other diseases — have a specific health focus. For each goal, targets have been established, but are unlikely to be met (Box).2 The United Nations Development Program identifies aid, trade and security as crucial to achieving the MDGs.3

As the federal government is preparing a White Paper on its aid program, Australia has an opportunity to reshape its role as a global citizen.

The Prime Minister, John Howard, announced on 13 September 2005 that Australia’s official development assistance will be increased to $4 billion by 2010. While this commitment is welcome, Australia’s contribution will still be only 0.35% of its Gross National Income in that year, well below the UN-proposed target of 0.7% by 2015.

It is particularly important to ensure that the available funds are used to eliminate poverty and support development, the objectives of the MDGs. This will mean focusing on the core issues of poverty eradication, enhancing social justice, promoting equity, and delivering basic health and education services.

In Asia and the Pacific, five countries, including Timor-Leste and Papua New Guinea, are not expected to achieve even one of their targets for the high priority indicators — and 14 other countries are not on track for more than half of them.4

Trade and the economy influence a state’s ability to meet basic needs and redress inequalities. Eighteen countries, with a combined population of 460 million people, have shown declines in the Human Development Index (a comparative measure of poverty, life expectancy, education, literacy, and other factors) — revealing poorer health, education and wellbeing since 1990.3

Trade should be seen as a means to development and not as an end in itself. Structural inequalities in international trade must be addressed; fair trade rules should be put in place and tariff barriers inhibiting trade with developing nations removed.

Trade concerns in the health sector range from access to pharmaceuticals to establishing and retaining an adequate health workforce. A key MDG indicator is the “proportion of the population with access to affordable essential drugs” on a sustainable basis. Australia’s Department of Foreign Affairs and Trade is promoting bilateral free-trade agreements that jeopardise developing countries’ access to affordable pharmaceuticals, including antiretrovirals, by strengthening and enforcing patent monopolies globally.5 Bilateral agreements have been described as a covert form of private governance, threatening to undermine hard-won public gains in health regulation.6 Failure to ensure access to drug therapy and combat neglected diseases will lead to widening gaps in health status, and the threat of emergent disease. A valuable intervention would be to support countries to collectively procure drugs at competitive prices.

Australia benefits greatly from the immigration of skilled health workers, including those from developing countries. While AusAID spends aid monies on building human resource capacity in the health sector in developing countries, Australia’s immigration system, by design, attracts doctors, nurses and other scarce health professionals from these countries to overcome skills shortages in our own health workforce. More engagement with the countries providing personnel is needed: recruitment and migration should be accompanied by government-to-government negotiation, and commitments to strengthening the health workforce in developing nations in our region and investing in developing our own health capacity. In addition, long-term twinning and partnership agreements to build capacity, and the use of new technologies to facilitate training and bridge geographic divides, are likely to be of value.

The recent UN publication, Report on the world social situation 2005. The inequality predicament,7 highlights the significant links between poverty and conflict: social disintegration and violence increase where inequalities are extreme and competition over scarce resources is greatest. Countries with high rates of poverty and inequality generally have poorer social supports, more unequal access to health and education, and fewer opportunities for young people, contributing to heightened risks of armed conflict.

Moving from a narrow framework of national security to considering human security in its broadest sense is a fundamental challenge;8 ultimately, human security will be achieved only if there is equitable development in the region, support for governance structures, and increasing responsiveness to community needs.

In Australia, establishment of a dedicated unit within AusAID to concentrate on fragile states recognises the potential threat they pose to health and security in the region, and the need to understand and work more closely with them. Fragile states are those which are hard-pressed to govern, to deliver services, and to ensure the safety and security of their citizenry. The Solomon Islands has one of the fastest growing youth populations, lacks educational and employment opportunities and, until recently, was flooded with small arms. Papua New Guinea struggles with corruption, governance, and the difficulty of delivering basic services. Timor-Leste, while making massive strides in building a new nation, remains fragile, with the government under enormous pressure to rapidly bring the benefits of independence to the majority rural population.

While previous policy advice was to stay away from fragile states and donors withdrew to avoid “wasting” aid, it is increasingly recognised that maintaining service delivery and governance are crucial. “Strengthening weak states against failure is far easier than reviving them after they have definitively failed or collapsed.”9

For the health sector, supporting the resilience of health professionals and peripheral services, and assuring the delivery of essential care, must be a priority. This better positions the sector to move forward from a more secure base when violence and instability recede. In the longer term, this may position the health sector to lead in promoting quality, responsiveness and good governance in these fragile states.

By articulating more equitable, whole-of-government responses that take account of national and regional interests, Australian engagement can make a difference. Meeting the MDGs and tackling poverty remain central.10 Identifying and mitigating the adverse effects of globalisation — the widening gaps between those with and without access to resources — and strengthening the economies of marginalised countries, deserve attention. Australia can be innovative, progressive, strategic and ethical at the same time. Doing so requires more explicit support for the MDGs, as well as:

• A long-term view which places constructive global citizenship at the core;

• Appreciation that national security rests on human security and more equitable arrangements within and between states;

• A commitment to linking aid, trade and security and adopting whole-of-government approaches;

• A commitment to building system capacity in public health, supporting human resources and securing health in fragile states; and

• An investment in development-related research — monitoring trends, evaluating interventions, and learning and sharing lessons from aid delivery and its effects.