Millennium Health Goals: paths to the future more or less on track, but several countries in each region are not. Some countries of the South-East Asia Region are behind schedule and sub-Saharan Africa, as noted above, is not likely to reach the target until the second half of the next century. If overall trends continue, under-five mortality worldwide will be reduced by approximately one-quarter over the pe- riod 1990-2015, which is very far from the goal of a two-thirds reduction. Lack of progress can be attributed to mother-to-child HIV transmission in some parts of Africa, but for most countries the problem is long-standing underinvestment. This applies to efforts both to re- duce malnutrition and to achieve full coverage of interventions to reduce mortality from diarrhoea, pneumonia, vaccine-preventable diseases, malaria and perinatal causes. The maternal mortality picture shows a similar divide between, on one side, southern Asia and sub-Saharan Africa, and on the other. the rest of the world there is a hundred-fold difference in lifetime risk of dying in pregnancy between the worlds poorest and richest countries. One of the indicators of progress, the proportion of births attended by skilled personnel, is rising slowly from a very low base in parts of the South-East Asia Region, and stagnating in sub-Saharan Africa. Only a dramatic improvement in the quality and coverage of health services is likely to have a significant influence on progress in relation to this goal (see Box 2.3) The global HIVIAIDS pandemic continues to worsen, with over 70% of all infections occur ring in sub-Saharan Africa. Around 40 million people are now living with AIDS, over 5 million new infections occur each year and, in 2002, almost 3 million people died as a result of the disease. Progress is currently measured(for the purposes of tracking Goal 6) by Box 2.1 Progress towards the Millennium Development Goals -the case of Uganda B& e Many sub-Saharan African countries are struggling to make than that required to reach the MDG target(Figure A) ess towards the Millennium Devel opment Goals(MDGs). Never- Progress in reducing mortality in children under five years of age eless, some countries in WHOs African Region have registered has also been substantial. However, it is important to disaggregate the impressive gains (10, 11) inder- 5 mortality data in order to understand the impact on different Uganda, for example, cut poverty sharply in the 1990s and will socioeconomic groups. As Figure B indicates, the gap between the rich achieve the MDG poverty reduction target if present trends continue. est and poorest sections of the population widened in the mid-1990s. pecifically pro-poor economic policies may be needed, however, in or. While the richest made gains in line with the MDGs, much less progress der to distribute the fruits of economic growth more evenly was observed for the poorest households. Since the poor make up over between rich and poor, especially in rural areas. Furthermore, growth a third of Uganda's population, instituting a"bottom-up"approach that self needs to be revived through economic diversification. In control. focuses on the needs of the lowest quintiles first could achieve the MDG ling the spread of HIV, Uganda's progress has actually been more rapid under- 5 mortality target ahead of time Figure A Current and projected progress towards progress toward IDG HIV prevalence target, Uganda MDG under-5 morta e200 100 宝 00 Year
Millennium Health Goals: paths to the future 29 more or less on track, but several countries in each region are not. Some countries of the South-East Asia Region are behind schedule and sub-Saharan Africa, as noted above, is not likely to reach the target until the second half of the next century. If overall trends continue, under-five mortality worldwide will be reduced by approximately one-quarter over the period 1990–2015, which is very far from the goal of a two-thirds reduction. Lack of progress can be attributed to mother-to-child HIV transmission in some parts of Africa, but for most countries the problem is long-standing underinvestment. This applies to efforts both to reduce malnutrition and to achieve full coverage of interventions to reduce mortality from diarrhoea, pneumonia, vaccine-preventable diseases, malaria and perinatal causes. The maternal mortality picture shows a similar divide between, on one side, southern Asia and sub-Saharan Africa, and on the other, the rest of the world. There is a hundred-fold difference in lifetime risk of dying in pregnancy between the world’s poorest and richest countries. One of the indicators of progress, the proportion of births attended by skilled personnel, is rising slowly from a very low base in parts of the South-East Asia Region, and stagnating in sub-Saharan Africa. Only a dramatic improvement in the quality and coverage of health services is likely to have a significant influence on progress in relation to this goal (see Box 2.3). The global HIV/AIDS pandemic continues to worsen, with over 70% of all infections occurring in sub-Saharan Africa. Around 40 million people are now living with AIDS, over 5 million new infections occur each year and, in 2002, almost 3 million people died as a result of the disease. Progress is currently measured (for the purposes of tracking Goal 6) by Box 2.1 Progress towards the Millennium Development Goals – the case of Uganda Many sub-Saharan African countries are struggling to make progress towards the Millennium Development Goals (MDGs). Nevertheless, some countries in WHO’s African Region have registered impressive gains (10, 11). Uganda, for example, cut poverty sharply in the 1990s and will achieve the MDG poverty reduction target if present trends continue. Specifically pro-poor economic policies may be needed, however, in order to distribute the fruits of economic growth more evenly between rich and poor, especially in rural areas. Furthermore, growth itself needs to be revived through economic diversification. In controlling the spread of HIV, Uganda’s progress has actually been more rapid than that required to reach the MDG target (Figure A). Progress in reducing mortality in children under five years of age has also been substantial. However, it is important to disaggregate the under-5 mortality data in order to understand the impact on different socioeconomic groups. As Figure B indicates, the gap between the richest and poorest sections of the population widened in the mid-1990s. While the richest made gains in line with the MDGs, much less progress was observed for the poorest households. Since the poor make up over a third of Uganda’s population, instituting a “bottom-up” approach that focuses on the needs of the lowest quintiles first could achieve the MDG under-5 mortality target ahead of time. Figure B Rich and poor – unequal progress towards MDG under-5 mortality targets, Uganda 250 200 150 100 50 0 Under-5 mortality rate Year 1988 1995 2015 Target Figure A Current and projected progress towards MDG HIV prevalence target, Uganda Year 1990 2000 2006 20 18 16 14 12 10 8 6 4 2 0 HIV prevalence rate, adults aged 15–49 Target Poorest quintile Richest quintile
The World Health Report 2003 Box 2.2 Child survival -turning knowledge into action Despite progress in recent decades, globally more than 10 million chil- meta-analysis has shown that children in Brazil, Pakistan and the Philip- en still die every year. The number of children and adolescents who pines who were not breastfed were 5.8 times more likely to die by the died in 2002 was twice the total of adult deaths from AIDS, tuberculosis age of one month than children who received at least some breast milk and malaria combined. All but about 1% of these child deaths occur in (12). There should be a skilled attendant at every birth, infection control developing countries, and more than half are caused by malnutrition, for the newborn, support for exdusive breastfeeding, and identification pneumonia, diarrhoea, measles, malaria, and HIV/AIDS. Effective low- of complications. If necessary, the infant should be referred urgently to cost interventions are available that could prevent at least two-thirds of higher levels of health care these deaths. Some interventions are preventive, for example Child health programmes need to move beyond tackling single breastfeeding, insectioide-treated materials, complementary feeding, zinc, diseases and instead deal with the child' s overall health and well-being vitamin A supplements, improved delivery procedures and immunize- Based on the experiences of Integrated Management of Childhood tion. Others involve treatment, such as oral rehydration therapy, antibi- lness(IMCI), WHO, together with partners, is developing a simple but otics for sepsis and pneumonia, antimalarials and newborn resuscitation. comprehensive framework that will guide countries on implementation The challenge is to deliver these life-saving interventions to the children and scaling-up of effective child health interventions. The framework who need them most. has five components Scaling up effective child health interventions will require increased A situation analysis to assess variables specific to country or context attention to newborn health and the application of an integrated, com. such as burden of child diseases, socioeconomic status, infrastructure, prehensive approach to child health at country level health system capacity, available resources, political stability and Although significant progress has been achieved during the past predictability for investments. 10 years in reducing mortality in childhood, there has been little progress Development and formulation of a concise national child health policy in reducing deaths among newborns. Almost 4 million infants every year with outcome-oriented strategic directions do not survive their first month of life. Most newborn deaths are a con- . ldentification of a set of proven cost-effective child health interven- sequence of poor health and nutritional status in the mother, absent or tions. low-quality care during pregnancy and delivery, and inadequate basic Scaling-up of interventions through a two-pronged approach: increas- care of the healthy baby and management of the sick ing health system efficiency to serve more children, and engaging fami infant Action to improve the health and survival of newborns and their lies and communities more closely in disease prevention and care for mothers is urgently needed. High-quality maternity services, including sick children skilled attendants at delivery, can save both newborns and their moth..Ongoing monitoring designed to inform decision-making at opera- ers. Early and exclusive breastfeeding protects newborn lives. A recent tional level and support countries and partners in measuring progress. reductions in HIV prevalence among pregnant women aged 15-24 years(where in some African cities it is beginning to decline), by the number of HIviaIdS orphans(which is forecast to double by 2010), and by increases in condom use in the 15-24-year age group Some countries could reach the target of reversing the spread of AidS by 2015, but again,not without an unprecedented increase in the level of effort in the worst affected regions Similar prospects overshadow the other health-related targets and indicators-those related to tuberculosis and malaria, improved water sources, improved sanitation, and solid fuel an indicator of indoor air pollution. While limited progress has been made in some coun tries,major differences in achievement exist between and within regions and countries. There are major variations in the provision of essential medicines: WHO estimates that 15%of the world's population consumes 91% of the world,s production of pharmaceuticals(by value Overall progress depends on what happens in the world's largest countries, such as China and India. Above all, success in achieving the health-related MDGs requires much more com mitment and effort between now and 2015 than has been evident since the countdown started The other side of the compact: Goal 8 Most discussion of the MDGs focuses on Goals 1-7. However, a comprehensive assessment of progress requires an examination of both sides of the compact. Defining indicators for oal 8 has been difficult. Indeed, there has been a reluctance on the part of some developed
30 The World Health Report 2003 reductions in HIV prevalence among pregnant women aged 15–24 years (where in some African cities it is beginning to decline), by the number of HIV/AIDS orphans (which is forecast to double by 2010), and by increases in condom use in the 15–24-year age group. Some countries could reach the target of reversing the spread of AIDS by 2015, but again, not without an unprecedented increase in the level of effort in the worst affected regions. Similar prospects overshadow the other health-related targets and indicators – those related to tuberculosis and malaria, improved water sources, improved sanitation, and solid fuel as an indicator of indoor air pollution. While limited progress has been made in some countries, major differences in achievement exist between and within regions and countries. There are major variations in the provision of essential medicines: WHO estimates that 15% of the world’s population consumes 91% of the world’s production of pharmaceuticals (by value). Overall progress depends on what happens in the world’s largest countries, such as China and India. Above all, success in achieving the health-related MDGs requires much more commitment and effort between now and 2015 than has been evident since the countdown started in 1990. The other side of the compact: Goal 8 Most discussion of the MDGs focuses on Goals 1–7. However, a comprehensive assessment of progress requires an examination of both sides of the compact. Defining indicators for Goal 8 has been difficult. Indeed, there has been a reluctance on the part of some developed Box 2.2 Child survival – turning knowledge into action Despite progress in recent decades, globally more than 10 million children still die every year. The number of children and adolescents who died in 2002 was twice the total of adult deaths from AIDS, tuberculosis and malaria combined. All but about 1% of these child deaths occur in developing countries, and more than half are caused by malnutrition, pneumonia, diarrhoea, measles, malaria, and HIV/AIDS. Effective lowcost interventions are available that could prevent at least two-thirds of these deaths. Some interventions are preventive, for example breastfeeding, insecticide-treated materials, complementary feeding, zinc, vitamin A supplements, improved delivery procedures and immunization. Others involve treatment, such as oral rehydration therapy, antibiotics for sepsis and pneumonia, antimalarials and newborn resuscitation. The challenge is to deliver these life-saving interventions to the children who need them most. Scaling up effective child health interventions will require increased attention to newborn health and the application of an integrated, comprehensive approach to child health at country level. Although significant progress has been achieved during the past 10 years in reducing mortality in childhood, there has been little progress in reducing deaths among newborns. Almost 4 million infants every year do not survive their first month of life. Most newborn deaths are a consequence of poor health and nutritional status in the mother, absent or low-quality care during pregnancy and delivery, and inadequate basic care of the healthy baby and management of the sick infant. Action to improve the health and survival of newborns and their mothers is urgently needed. High-quality maternity services, including skilled attendants at delivery, can save both newborns and their mothers. Early and exclusive breastfeeding protects newborn lives. A recent meta-analysis has shown that children in Brazil, Pakistan and the Philippines who were not breastfed were 5.8 times more likely to die by the age of one month than children who received at least some breast milk (12). There should be a skilled attendant at every birth, infection control for the newborn, support for exclusive breastfeeding, and identification of complications. If necessary, the infant should be referred urgently to higher levels of health care. Child health programmes need to move beyond tackling single diseases and instead deal with the child’s overall health and well-being. Based on the experiences of Integrated Management of Childhood Illness (IMCI), WHO, together with partners, is developing a simple but comprehensive framework that will guide countries on implementation and scaling-up of effective child health interventions. The framework has five components: • A situation analysis to assess variables specific to country or context such as burden of child diseases, socioeconomic status, infrastructure, health system capacity, available resources, political stability and predictability for investments. • Development and formulation of a concise national child health policy with outcome-oriented strategic directions. • Identification of a set of proven cost-effective child health interventions. • Scaling-up of interventions through a two-pronged approach: increasing health system efficiency to serve more children, and engaging families and communities more closely in disease prevention and care for sick children. • Ongoing monitoring designed to inform decision-making at operational level and support countries and partners in measuring progress