Chapter Two Millennium health goals paths to the future The Millennium Development Goals(MDGs) place health at the heart of development and represent commitments by gov- ernments throughout the world to do more to reduce poverty and hunger and to tackle ill-health, gender inequality, lack of education, access to clean water and environmental degra dation. Three of the eight goals are directly health-related; all of the others have important indirect effects on health. This chapter traces the origins of the Mdgs and tracks the progress so far towards achieving them. It warns that without signifi cantly strengthened commitments from both wealthy and de veloping countries, the goals will not be met globally
Millennium Health Goals: paths to the future 23 Chapter Two Millennium Health Goals: paths to the future The Millennium Development Goals (MDGs) place health at the heart of development and represent commitments by governments throughout the world to do more to reduce poverty and hunger and to tackle ill-health, gender inequality, lack of education, access to clean water and environmental degradation. Three of the eight goals are directly health-related; all of the others have important indirect effects on health. This chapter traces the origins of the MDGs and tracks the progress so far towards achieving them. It warns that without significantly strengthened commitments from both wealthy and developing countries, the goals will not be met globally
Millennium health goals paths to the future The Millennium Development Goals(MDGs)adopted by the United Nations in 2000 pro- vide an opportunity for concerted action to improve global health. They place health at the heart of development and establish a novel global compact, linking developed and develop ng countries through clear, reciprocal obligations. Seizing the opportunity offered by the MDGs will not be easy. Wealthy countries have so far failed to live up to all of their responsibilities under the compact, which include establishing fairer international trade policies, increasing official development assistance, delivering debt relief and accelerating technology transfer. Despite progress in some cases, many developing countries are not currently on track to achieve their health-related MDG objectives without significantly strengthened commitments from both developed and developing countries, the MDGs will not be met globally, and outcomes in some of the poorest countries will remain far below the hoped-for achievements. WHO and international health partners must inten- sify their cooperation with Member States to speed up progress towards the MDGs and en sure that gains are made by those most in need International commitments at the millennium summit In September 2000, representatives from 189 countries, including 147 heads of state, met at the Millennium Summit in New York to adopt the United Nations Millennium Declaration (1). The declaration set out the principles and values that should govern international rela tions in the 21st century. National leaders made specific commitments in seven areas: peace, security and disarmament; development and poverty eradication; protecting our common environment; human rights, democracy and good governance; protecting the vulnerable eeting the special needs of Africa; and strengthening the United Nations. The Road Map(2) prepared following the Summit established goals and targets to be reached by 2015 in each of these seven areas. The goals in the area of development and poverty eradi cation are now widely referred to as the Millennium Development Goals. They represent commitments by governments worldwide to do more to reduce poverty and hunger and to tackle ill-health, gender inequality, lack of education, lack of access to clean water, and envi- ronmental degradation. They also include commitments to reduce debt, increase technology transfers and build development partnership
Millennium Health Goals: paths to the future 25 2 Millennium Health Goals: paths to the future The Millennium Development Goals (MDGs) adopted by the United Nations in 2000 provide an opportunity for concerted action to improve global health. They place health at the heart of development and establish a novel global compact, linking developed and developing countries through clear, reciprocal obligations. Seizing the opportunity offered by the MDGs will not be easy. Wealthy countries have so far failed to live up to all of their responsibilities under the compact, which include establishing fairer international trade policies, increasing official development assistance, delivering debt relief and accelerating technology transfer. Despite progress in some cases, many developing countries are not currently on track to achieve their health-related MDG objectives. Without significantly strengthened commitments from both developed and developing countries, the MDGs will not be met globally, and outcomes in some of the poorest countries will remain far below the hoped-for achievements. WHO and international health partners must intensify their cooperation with Member States to speed up progress towards the MDGs and ensure that gains are made by those most in need. International commitments at the Millennium Summit In September 2000, representatives from 189 countries, including 147 heads of state, met at the Millennium Summit in New York to adopt the United Nations Millennium Declaration (1). The declaration set out the principles and values that should govern international relations in the 21st century. National leaders made specific commitments in seven areas: peace, security and disarmament; development and poverty eradication; protecting our common environment; human rights, democracy and good governance; protecting the vulnerable; meeting the special needs of Africa; and strengthening the United Nations. The Road Map (2) prepared following the Summit established goals and targets to be reached by 2015 in each of these seven areas. The goals in the area of development and poverty eradication are now widely referred to as the Millennium Development Goals. They represent commitments by governments worldwide to do more to reduce poverty and hunger and to tackle ill-health, gender inequality, lack of education, lack of access to clean water, and environmental degradation. They also include commitments to reduce debt, increase technology transfers and build development partnerships
The World Health Report 2003 A compact to end poverty The idea of the MDgs as a compact, in which both rich and poor countries have responsibili ties, was further developed in early 2002 at the International Conference on Financing for Development, in Monterrey, Mexico. The resultant Monterrey Consensus(3)reaffirms the importance of the MDGs and provides a framework for building the partnerships that will be needed to achieve them. A few months later, in September 2002, the World Summit on Sustainable Development, held in Johannesburg, South Africa, took the process a step fur ther by recognizing that poverty reduction and the achievement of the mdgs were central to the overall sustainable development agenda(4). Both the World development report 2003 and the Human development report 2003 have further developed the concept of a compact, with a view to informing policy The MDGs summarize some of the key commitments made at the major United Nations conferences of the 1990s. They also build on the international development targets prepared by the Organisation for Economic Co-operation and Development(OECD) in 1996(5) However, it is the two-way nature of the compact that sets the MDGs apart from their predecessors. Developing countries are committed to achieving Goals 1-7. Goal 8 concerns developed countries and the actions that they can take in order to create a more enabling environment in the areas of trade, development assistance, debt, essential medicines and tech nology transfer. Without progress on Goal 8, it is unlikely that the poorest countries will be able to tackle the structural constraints that keep them in poverty, or sustain the levels of nvestment requ uired to achieve the other goals New concepts of poverty and development Since the early 1990s, the concepts of poverty and development have evolved away from ar exclusive emphasis on income towards a fuller notion of human well-being, as found in the United Nations Development Programmes Human Development Index(HDI) and other multifactorial indices, which provide alternatives to per capita gross national income(GNi as a measure of development(6) In this new understanding, poverty means not just low income but the undermining of a whole range of key human capabilities, including health. The term human poverty refers to deprivation of the means to achieve capabilities(for example, physical access to health care) and of basic"conversion" factors that facilitate this achievement(such as social access to health care)(7). Human development refers to processes that enlarge people's choices to en able them to achieve capabilities (for example, the freedom to choose a healthy lifestyle)(8) The interaction of health and development This more complex concept of poverty and development takes account of the interactive processes that are crucial to the social dynamics of health improvement. For example, economic capabilities affect health, as low income constrains access to health care and health promoting opportunities Equally significantly, ill-health limits people's ability to earn higher comes, and contributes to povert The two-way causal relationship between economic development and health has been high lighted by the Commission on Macroeconomics and Health, in order to underline the crucial role of health in economic growth(9). The importance of health within a multidimensional del of sustainable human development is also a key message of the MDGs
26 The World Health Report 2003 A compact to end poverty The idea of the MDGs as a compact, in which both rich and poor countries have responsibilities, was further developed in early 2002 at the International Conference on Financing for Development, in Monterrey, Mexico. The resultant Monterrey Consensus (3) reaffirms the importance of the MDGs and provides a framework for building the partnerships that will be needed to achieve them. A few months later, in September 2002, the World Summit on Sustainable Development, held in Johannesburg, South Africa, took the process a step further by recognizing that poverty reduction and the achievement of the MDGs were central to the overall sustainable development agenda (4). Both the World development report 2003 and the Human development report 2003 have further developed the concept of a compact, with a view to informing policy. The MDGs summarize some of the key commitments made at the major United Nations conferences of the 1990s. They also build on the international development targets prepared by the Organisation for Economic Co-operation and Development (OECD) in 1996 (5). However, it is the two-way nature of the compact that sets the MDGs apart from their predecessors. Developing countries are committed to achieving Goals 1–7. Goal 8 concerns developed countries and the actions that they can take in order to create a more enabling environment in the areas of trade, development assistance, debt, essential medicines and technology transfer. Without progress on Goal 8, it is unlikely that the poorest countries will be able to tackle the structural constraints that keep them in poverty, or sustain the levels of investment required to achieve the other goals. New concepts of poverty and development Since the early 1990s, the concepts of poverty and development have evolved away from an exclusive emphasis on income towards a fuller notion of human well-being, as found in the United Nations Development Programme’s Human Development Index (HDI) and other multifactorial indices, which provide alternatives to per capita gross national income (GNI) as a measure of development (6). In this new understanding, poverty means not just low income but the undermining of a whole range of key human capabilities, including health. The term human poverty refers to deprivation of the means to achieve capabilities (for example, physical access to health care) and of basic “conversion” factors that facilitate this achievement (such as social access to health care) (7). Human development refers to processes that enlarge people’s choices to enable them to achieve capabilities (for example, the freedom to choose a healthy lifestyle) (8). The interaction of health and development This more complex concept of poverty and development takes account of the interactive processes that are crucial to the social dynamics of health improvement. For example, economic capabilities affect health, as low income constrains access to health care and healthpromoting opportunities. Equally significantly, ill-health limits people’s ability to earn higher incomes, and contributes to poverty. The two-way causal relationship between economic development and health has been highlighted by the Commission on Macroeconomics and Health, in order to underline the crucial role of health in economic growth (9). The importance of health within a multidimensional model of sustainable human development is also a key message of the MDGs
Millennium Health Goals: paths to the future Improvements in health are important in their own right, but better health is also a prerequi site and a major contributor to economic growth and social cohesion. Conversely, improve- ment in people's access to health technology is a good indicator of the success of other development processes. All of these relationships are evident in the MDGs. Thus, three of the eight goals, eight of the 18 targets required to achieve them, and 18 of the 48 indicators of progress are health-related (see Table 2.1). The MDGs are interrelated and interdependent. In many countries, it will be impossible to achieve a 50% reduction in income poverty(Goal 1, Target 1)without taking steps to ensure a healthier population. Similarly, eliminating gender disparities( Goal 3)and increasing en- rolment rates for primary education( Goal 2)are prerequisites for success in improving health outcomes. Population health can no longer be considered in isolation from questions of the stewardship of natural resources and environmental sustainability(Goal 7). It is therefore mportant that the health-related MDGs are not seen in isolation-as discrete programmes but as the result, or desired outcome, of a development agenda with several parts working One of the most challenging goals, to achieve a two-thirds reduction in child mortality(goa 4, Target 5), requires technical interventions that tackle the major causes of child deaths, such as malnutrition, infections and parasitic diseases. But the effectiveness of these interventions ll be mediated through a network of public and private delivery systems, and will depend on adequate levels of financing. Their effect will be reinforced by actions such as those that ensure greater food security and access to education, essential medicines and clean water, and by improved public expenditure management. The ability of governments to finance these fforts will be influenced by both the domestic and international policy and trade environ ments, and, in poorer countries, by the availability of external financial assistance. The MDGs are consequently a way of assessing and tracking progress in development on a number of critical fronts. They are a shorthand for the ends, or outcomes, that governments have com mitted themselves to achieving, rather than a prescription for the means by which those ends are to be achieved Progress and prospects Despite political consensus and the avowed commitment of countries throughout the world, the MDGs will not be achieved at current rates of progress. The Human development report 2003 notes that if global progress continues at the same pace as in the 1990s, only the Millennium Development Goals of halving income poverty and halving the proportion of people without access to safe water stand a realistic chance of being met, thanks mainly to China and India. Sub-Saharan Africa would not reach the goals for poverty until the year 2147 and for child mortality until 2165. And for HIVIAIDS and hun ger, trends in the region are worsening". There are some areas where optimism is justified, but the general outlook, in particular for sub-Saharan Africa, is bleak. Even in countries that making overall progress, gaps in health status between rich and poor may be widening(see Box 2.1) It is generally agreed that reducing child mortality by two-thirds before 2015 is the fur of all the health-related goals from being realized. Infant and child mortality is the complex development indicator, as it is considered to include systemic as well as socioeco nomic and cultural factors(see Box 2.2). Overall, the Caribbean, central Asia, Europe, Latin America, some countries of the Eastern Mediterranean Region and northern Africa may be
Millennium Health Goals: paths to the future 27 Improvements in health are important in their own right, but better health is also a prerequisite and a major contributor to economic growth and social cohesion. Conversely, improvement in people’s access to health technology is a good indicator of the success of other development processes. All of these relationships are evident in the MDGs. Thus, three of the eight goals, eight of the 18 targets required to achieve them, and 18 of the 48 indicators of progress are health-related (see Table 2.1). The MDGs are interrelated and interdependent. In many countries, it will be impossible to achieve a 50% reduction in income poverty (Goal 1, Target 1) without taking steps to ensure a healthier population. Similarly, eliminating gender disparities (Goal 3) and increasing enrolment rates for primary education (Goal 2) are prerequisites for success in improving health outcomes. Population health can no longer be considered in isolation from questions of the stewardship of natural resources and environmental sustainability (Goal 7). It is therefore important that the health-related MDGs are not seen in isolation – as discrete programmes – but as the result, or desired outcome, of a development agenda with several parts working together. One of the most challenging goals, to achieve a two-thirds reduction in child mortality (Goal 4, Target 5), requires technical interventions that tackle the major causes of child deaths, such as malnutrition, infections and parasitic diseases. But the effectiveness of these interventions will be mediated through a network of public and private delivery systems, and will depend on adequate levels of financing. Their effect will be reinforced by actions such as those that ensure greater food security and access to education, essential medicines and clean water, and by improved public expenditure management. The ability of governments to finance these efforts will be influenced by both the domestic and international policy and trade environments, and, in poorer countries, by the availability of external financial assistance. The MDGs are consequently a way of assessing and tracking progress in development on a number of critical fronts. They are a shorthand for the ends, or outcomes, that governments have committed themselves to achieving, rather than a prescription for the means by which those ends are to be achieved. Progress and prospects Despite political consensus and the avowed commitment of countries throughout the world, the MDGs will not be achieved at current rates of progress. The Human development report 2003 notes that “if global progress continues at the same pace as in the 1990s, only the Millennium Development Goals of halving income poverty and halving the proportion of people without access to safe water stand a realistic chance of being met, thanks mainly to China and India. Sub-Saharan Africa would not reach the goals for poverty until the year 2147 and for child mortality until 2165. And for HIV/AIDS and hunger, trends in the region are worsening”. There are some areas where optimism is justified, but the general outlook, in particular for sub-Saharan Africa, is bleak. Even in countries that are making overall progress, gaps in health status between rich and poor may be widening (see Box 2.1). It is generally agreed that reducing child mortality by two-thirds before 2015 is the furthest of all the health-related goals from being realized. Infant and child mortality is the most complex development indicator, as it is considered to include systemic as well as socioeconomic and cultural factors (see Box 2.2). Overall, the Caribbean, central Asia, Europe, Latin America, some countries of the Eastern Mediterranean Region and northern Africa may be
The World Health Report 2003 Table 2.1 Health-related Millennium Development Goals, targets and indicators Goal: 1. Eradicate extreme poverty and hunger Target: 2. Halve, between 1990 and 2015, the proportion of people who suffer from hunger Indicator: 4. Prevalence of underweight children under five years of age 5. Proportion of population below minimum level of dietary energy consumption Goal: 4. Reduce child mortality Target: 5. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Indicator: 13. Under-five mortality rate 14. Infant mortality rate 15. Proportion of 1-year-old children immunized against measles Target: 6. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio 17. Proportion of births attended by skilled health personnel Goal: 6. Combat HIVIAIDS. malaria and other diseases Target: 7 Have halted by 2015 and begun to reverse the spread of HIVIAIDS Indicator: 18. HIV prevalence among young people aged 15 to 24 years 19. Condom use rate of the contraceptive prevalence rate 20. Number of children orphaned by HIv/AID Target: 8 Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Indicator: 21. Prevalence and death rates associated with malaria 22. Proportion of population in malaria-risk areas using effective 23. Prevalence and death rates associated with tuberculosis 24. Proportion of tuberculosis cases detected and cured under rectly Observed Treatr Goal: 7. Ensure environmental sustainability Target: 9. Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources ator: 29. Proportion of population using solid fuel Target: 10. Halve by 2015 the proportion of people without sustainable access to safe drinking-wat Indicator: 30. Proportion of population with sustainable access to an improved water source urban and rural Target: 11. By 2020 to have achieved a significant improvement in the lives of at least 100 million slum dwellers Indicator: 31. Proportion of urban population with access to improved sanitation Goal: 8. Develop a global partnership for development Target: 17. In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries Indicator: 46. Proportion of population with access to affordable essential drugs on a sustainable basis b Indicators from the mbg list reformulat and United Nations General Assembly Special Session on HIV/AIDS
28 The World Health Report 2003 Table 2.1 Health-related Millennium Development Goals, targets and indicators Goal: 1. Eradicate extreme poverty and hunger Target: 2. Halve, between 1990 and 2015, the proportion of people who suffer from hunger Indicator: 4. Prevalence of underweight children under five years of age 5. Proportion of population below minimum level of dietary energy consumptiona Goal: 4. Reduce child mortality Target: 5. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Indicator: 13. Under-five mortality rate 14. Infant mortality rate 15. Proportion of 1-year-old children immunized against measles Goal: 5. Improve maternal health Target: 6. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio Indicator: 16. Maternal mortality ratio 17. Proportion of births attended by skilled health personnel Goal: 6. Combat HIV/AIDS, malaria and other diseases Target: 7. Have halted by 2015 and begun to reverse the spread of HIV/AIDS Indicator: 18. HIV prevalence among young people aged 15 to 24 yearsb 19. Condom use rate of the contraceptive prevalence rate 20. Number of children orphaned by HIV/AIDS Target: 8. Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Indicator: 21. Prevalence and death rates associated with malaria 22. Proportion of population in malaria-risk areas using effective malaria prevention and treatment measures 23. Prevalence and death rates associated with tuberculosis 24. Proportion of tuberculosis cases detected and cured under Directly Observed Treatment, Short-course (DOTS) Goal: 7. Ensure environmental sustainability Target: 9. Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources Indicator: 29. Proportion of population using solid fuel Target: 10. Halve by 2015 the proportion of people without sustainable access to safe drinking-water Indicator: 30. Proportion of population with sustainable access to an improved water source, urban and rural Target: 11. By 2020 to have achieved a significant improvement in the lives of at least 100 million slum dwellers Indicator: 31. Proportion of urban population with access to improved sanitation Goal: 8. Develop a global partnership for development Target: 17. In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries Indicator: 46. Proportion of population with access to affordable essential drugs on a sustainable basis a Health-related indicator reported by FAO only. b Indicators from the MDG list reformulated by WHO and United Nations General Assembly Special Session on HIV/AIDS