Can the millennium development goals be attained?
http://www.100md.com
《英国医生杂志》
1 London School of Hygiene and Tropical Medicine, London WC1E 7HT, 2 World Health Organization, 1211 Geneva 27, Switzerland
Correspondence to: A Haines andy.haines@lshtm.ac.uk
To achieve the UN's goals worldwide, less developed countries need to address weaknesses in health systems and policy makers need to look beyond aggregate national figures to inequalities in outcomes
Introduction
Health is central to the achievement of the millennium development goals—both in its own right (see goals 4, 5, and 6), and as a contributor to several others. For instance, the impact of poverty on ill health is well known and extensively documented. Ill health can also be an important cause of poverty through loss of income, catastrophic health expenses, and orphanhood. Thus improving health can make a substantial contribution to target 1, which aims to halve between 1990 and 2015 the proportion of people whose income is less than $1 a day. Although this article focuses on health, the millennium development goals should be considered as a mutually reinforcing framework contributing interactively to human development.
Are international goals worthwhile?
With 1990 as the base year for the millennium development goals, the score at half time is decidedly mixed. Some countries have made impressive gains and are "on track," but many more are falling behind. The situation is not encouraging for goals related to lowering child and maternal mortality and infectious diseases, especially in sub-Saharan Africa. For mortality in children under 5, for example, the developing world has managed only a 2.5% average annual rate of reduction during the 1990s, well short of the target of 4.2%.4 In 16 countries (14 of which are in Africa) levels of under 5 mortality are currently higher than those in 19905; figure 1 summarises progress by region. Although the largest number of hungry people live in Asia, food production is increasing and the number of hungry people is declining, while in Africa the number is increasing and one third of the population is under-nourished.6 With more than 500 000 women a year dying in pregnancy and childbirth, faster progress on reducing maternal mortality also remains a key challenge. Maternal death rates are 100 times higher in sub-Saharan Africa than in many high income countries. However, the good news is that, outside sub-Saharan Africa, some strong progress has been made in increasing the rate of attended deliveries: for example, the percentage of deliveries with a skilled attendant rose by two thirds in southeast Asia and north Africa between 1990 and 2000.7
Fig 1 Mortality in children under 5 years, 1990-2001, current trend (dotted line), and millennium development goals targets for 2015.6 Used by permission of Oxford University Press
Despite success in selected countries, the prospect of falling short overshadows the other health related targets, particularly as a result of the worsening global pandemic of HIV/AIDS, which has reversed life expectancy and economic gains in many parts of Africa. Malaria, tuberculosis, access to safe water and sanitation, and use of solid fuel as an indicator of indoor air pollution have similar prospects. The 2003 Human Development Report puts the situation starkly: "If global progress continues at the same pace as in the 1990s, only the millennium development goals of halving 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 poverty goals until the year 2147 and for child mortality until 2165."6
Measuring progress
Clearly, the goals do not say everything that needs to be said about health and development. It is best to think of them as a kind of shorthand for some of the most important outcomes that development should achieve: fewer women dying in childbirth, more children surviving the early years of life, dealing with the catastrophe of HIV/AIDS, making sure people have access to lifesaving drugs. The millennium development goals represent desirable ends; they are not a prescription for the means by which those ends are to be achieved. They say nothing, for example, about the importance of effective health systems, which are essential to the achievement of all of the health goals, or the importance of rural infrastructure (roads, telephones, etc) in reducing maternal mortality. Similarly, the goals focus on communicable diseases, when we know that non-communicable diseases and injuries contribute as much or more to the total burden of disease in many countries. In this regard, WHO has argued that an overall measure of mortality is included among the indicators of progress. In addition, some countries chose to broaden the range of indicators to encompass priorities not covered by the goals.
Whose goals are they anyway?
The health goals are expressed as national averages, rather than gains among poor or disadvantaged groups. This means that significant progress in non-poor groups can result in the achievement of goals even though only minor improvements in the health of the poorest have been made.11 The use of aggregate data may mask growing inequalities, but such inequalities are not inevitable, as countries such as Guatemala and Bangladesh have shown.5
What needs to be done?
Achieving the health millennium development goals represents some of the greatest challenges in international development, not least because they include the goal of reversing the global epidemic of HIV/AIDS. To this we have to add the steep declines required in child and maternal mortality, where progress lags far behind aspirations in many parts of the world. Improving health outcomes will not be possible without major improvements in healthcare delivery systems, which in turn depend on changes in public sector management, new forms of engagement with the private sector (leading, for example, to wider availability of affordable drugs, vaccines, and diagnostics), more research directed at improving health systems, as well as policies and interventions well beyond the health sector itself. Moreover, improvements in health are essential if progress is to be made with the other millennium development goals, including the reduction of absolute poverty.
Summary points
Improving health outcomes will not be possible without major improvements in healthcare delivery systems
Improvements in health are essential for progress with other millennium development goals
Without more resources and changes in policies, the goals cannot be attained—but accelerated progress is possible
In answer to the question posed in the title, if none of the changes described in this article take place then the answer is almost certainly no, the goals cannot be attained. But accelerated progress is possible, and lies within reach. It is a matter of political choice in both the developed and developing world. We also know that substantial progress, even if it were to fall short of the targets set four years ago, could dramatically transform the lives of millions of the world's poorest people. The millennium development goals are one means of exerting the leverage that can make this happen.
We thank Becky Dodd and Carla Abou Zahr, WHO, for their comments and advice.
Contributors and sources: AH has had a longstanding interest in global health issues and has written articles on a range of relevant topics. AC is director of the department within the World Health Organization concerned with coordinating WHO's work on the health related millennium development goals. In addition to quoted publications, the article draws on discussions at the High Level Forum on the Health MDGs held in Geneva in January 2004. Both authors are guarantors of the paper.
Competing interests: None declared.
References
United Nations Millennium Declaration. New York: United Nations, 2000. (United Nations General Assembly Resolution 55/2. www.un.org/milleennium/declaration/ares552e.pdf (accessed 8 Jul 2004).)
Road map toward the implementation of the United Nations Millennium Declaration. New York: United Nations, 2002. United Nations General Assembly Document A56/326. www.eclac.cl/povertystatistcs/documentos/a56326i.pdf (accessed 8 July 2004).
Report of the International Conference on Financing for Development, Monterrey, Mexico, 18-22 March 2002. New York: United Nations, 2002.
World Bank. The millennium development goals for health: rising to the challenges. Washington: World Bank, 2004.
World Health Organization. World health report 2003: shaping the future. Geneva: WHO, 2003. www.who.int/whr/2003/en/ (accessed 8 Jul 2004).
United Nations Development Programme. Human development report, 2003. The millennium development goals: a compact among nations to end human poverty. New York: Oxford University Press, 2003.
United Nations, Department of Economic and Social Affairs, Statistics Division. Progress towards the millennium development goals, 1990-2003. http://unstats.un.org/unsd/mi/mi_coverfinal.htm (accessed 8 Jul 2004).
World Health Organization, World Bank. Monitoring the health MDGs. Issue paper 3 for the high level forum on the health MDGs. December 2003. www.who.int/hdp/en/IP3-monitoring.pdf (accessed 8 Jul 2004).
Report of the International Conference on Population and Development, Cairo, 5-13 September 1994. Chapter 7. www.unfpa.org/icpd/docs/index.htm (accessed 8 Jul 2004).
H M Treasury. Statement by the chancellor of the exchequer on the 2004 spending review. 12 July 2004. www.hm-treasury.gov.uk/spending_review/spend_sr04/spend_sr04_statement.cfm (accessed 15 Jul 2004).
Gwatkin D. Who would gain most from efforts to reach the MDGs for health? An enquiry into the possibility of progress that fails to reach the poor. Washington, DC: World Bank, 2002. www1.worldbank.org/hnp/Pubs_Discussion/Gwatkin-Who%20Would%20-Whole.pdf (accessed 8 Jul 2004).
World Health Organization, World Bank. Resources, aid effectiveness and harmonisation. Issue paper 2 for the high level forum on the health MDGs. December 2003. www.who.int/hdp/en/IP2-resources.pdf (accessed 8 Jul 2004).
H M Treasury. International finance facility. 23 January 2003. www.hm-treasury.gov.uk/documents/international_issues/global_new_deal/int_gnd_iff2003.cfm (accessed 8 Jul 2004).
Lee K, Walt G, Haines A. The challenge to improve global health: financing the millennium development goals. JAMA 2004;291: 2636-8.
African Development Forum. Abuja Declaration on HIV/AIDS, tuberculosis and other related infectious diseases. 2001. www.uneca.org/adf2000/Abuja%20Declaration.htm (accessed 8 Jul 2004).
Stilwell B, Diallo K, Zurn P, Vujicic M, Adams O, Dal Poz M. Health workers and migration from low-resource countries—what can be done? Bull World Health Org (in press).
Narasimhan V, Brown H, Pablos-Mendez P, Adams O, Dussault G, Elzinga G, et al. Responding to the global human resource crisis. Lancet 2004:363: 1469-72.(Andy Haines, dean1, Andre)
Correspondence to: A Haines andy.haines@lshtm.ac.uk
To achieve the UN's goals worldwide, less developed countries need to address weaknesses in health systems and policy makers need to look beyond aggregate national figures to inequalities in outcomes
Introduction
Health is central to the achievement of the millennium development goals—both in its own right (see goals 4, 5, and 6), and as a contributor to several others. For instance, the impact of poverty on ill health is well known and extensively documented. Ill health can also be an important cause of poverty through loss of income, catastrophic health expenses, and orphanhood. Thus improving health can make a substantial contribution to target 1, which aims to halve between 1990 and 2015 the proportion of people whose income is less than $1 a day. Although this article focuses on health, the millennium development goals should be considered as a mutually reinforcing framework contributing interactively to human development.
Are international goals worthwhile?
With 1990 as the base year for the millennium development goals, the score at half time is decidedly mixed. Some countries have made impressive gains and are "on track," but many more are falling behind. The situation is not encouraging for goals related to lowering child and maternal mortality and infectious diseases, especially in sub-Saharan Africa. For mortality in children under 5, for example, the developing world has managed only a 2.5% average annual rate of reduction during the 1990s, well short of the target of 4.2%.4 In 16 countries (14 of which are in Africa) levels of under 5 mortality are currently higher than those in 19905; figure 1 summarises progress by region. Although the largest number of hungry people live in Asia, food production is increasing and the number of hungry people is declining, while in Africa the number is increasing and one third of the population is under-nourished.6 With more than 500 000 women a year dying in pregnancy and childbirth, faster progress on reducing maternal mortality also remains a key challenge. Maternal death rates are 100 times higher in sub-Saharan Africa than in many high income countries. However, the good news is that, outside sub-Saharan Africa, some strong progress has been made in increasing the rate of attended deliveries: for example, the percentage of deliveries with a skilled attendant rose by two thirds in southeast Asia and north Africa between 1990 and 2000.7
Fig 1 Mortality in children under 5 years, 1990-2001, current trend (dotted line), and millennium development goals targets for 2015.6 Used by permission of Oxford University Press
Despite success in selected countries, the prospect of falling short overshadows the other health related targets, particularly as a result of the worsening global pandemic of HIV/AIDS, which has reversed life expectancy and economic gains in many parts of Africa. Malaria, tuberculosis, access to safe water and sanitation, and use of solid fuel as an indicator of indoor air pollution have similar prospects. The 2003 Human Development Report puts the situation starkly: "If global progress continues at the same pace as in the 1990s, only the millennium development goals of halving 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 poverty goals until the year 2147 and for child mortality until 2165."6
Measuring progress
Clearly, the goals do not say everything that needs to be said about health and development. It is best to think of them as a kind of shorthand for some of the most important outcomes that development should achieve: fewer women dying in childbirth, more children surviving the early years of life, dealing with the catastrophe of HIV/AIDS, making sure people have access to lifesaving drugs. The millennium development goals represent desirable ends; they are not a prescription for the means by which those ends are to be achieved. They say nothing, for example, about the importance of effective health systems, which are essential to the achievement of all of the health goals, or the importance of rural infrastructure (roads, telephones, etc) in reducing maternal mortality. Similarly, the goals focus on communicable diseases, when we know that non-communicable diseases and injuries contribute as much or more to the total burden of disease in many countries. In this regard, WHO has argued that an overall measure of mortality is included among the indicators of progress. In addition, some countries chose to broaden the range of indicators to encompass priorities not covered by the goals.
Whose goals are they anyway?
The health goals are expressed as national averages, rather than gains among poor or disadvantaged groups. This means that significant progress in non-poor groups can result in the achievement of goals even though only minor improvements in the health of the poorest have been made.11 The use of aggregate data may mask growing inequalities, but such inequalities are not inevitable, as countries such as Guatemala and Bangladesh have shown.5
What needs to be done?
Achieving the health millennium development goals represents some of the greatest challenges in international development, not least because they include the goal of reversing the global epidemic of HIV/AIDS. To this we have to add the steep declines required in child and maternal mortality, where progress lags far behind aspirations in many parts of the world. Improving health outcomes will not be possible without major improvements in healthcare delivery systems, which in turn depend on changes in public sector management, new forms of engagement with the private sector (leading, for example, to wider availability of affordable drugs, vaccines, and diagnostics), more research directed at improving health systems, as well as policies and interventions well beyond the health sector itself. Moreover, improvements in health are essential if progress is to be made with the other millennium development goals, including the reduction of absolute poverty.
Summary points
Improving health outcomes will not be possible without major improvements in healthcare delivery systems
Improvements in health are essential for progress with other millennium development goals
Without more resources and changes in policies, the goals cannot be attained—but accelerated progress is possible
In answer to the question posed in the title, if none of the changes described in this article take place then the answer is almost certainly no, the goals cannot be attained. But accelerated progress is possible, and lies within reach. It is a matter of political choice in both the developed and developing world. We also know that substantial progress, even if it were to fall short of the targets set four years ago, could dramatically transform the lives of millions of the world's poorest people. The millennium development goals are one means of exerting the leverage that can make this happen.
We thank Becky Dodd and Carla Abou Zahr, WHO, for their comments and advice.
Contributors and sources: AH has had a longstanding interest in global health issues and has written articles on a range of relevant topics. AC is director of the department within the World Health Organization concerned with coordinating WHO's work on the health related millennium development goals. In addition to quoted publications, the article draws on discussions at the High Level Forum on the Health MDGs held in Geneva in January 2004. Both authors are guarantors of the paper.
Competing interests: None declared.
References
United Nations Millennium Declaration. New York: United Nations, 2000. (United Nations General Assembly Resolution 55/2. www.un.org/milleennium/declaration/ares552e.pdf (accessed 8 Jul 2004).)
Road map toward the implementation of the United Nations Millennium Declaration. New York: United Nations, 2002. United Nations General Assembly Document A56/326. www.eclac.cl/povertystatistcs/documentos/a56326i.pdf (accessed 8 July 2004).
Report of the International Conference on Financing for Development, Monterrey, Mexico, 18-22 March 2002. New York: United Nations, 2002.
World Bank. The millennium development goals for health: rising to the challenges. Washington: World Bank, 2004.
World Health Organization. World health report 2003: shaping the future. Geneva: WHO, 2003. www.who.int/whr/2003/en/ (accessed 8 Jul 2004).
United Nations Development Programme. Human development report, 2003. The millennium development goals: a compact among nations to end human poverty. New York: Oxford University Press, 2003.
United Nations, Department of Economic and Social Affairs, Statistics Division. Progress towards the millennium development goals, 1990-2003. http://unstats.un.org/unsd/mi/mi_coverfinal.htm (accessed 8 Jul 2004).
World Health Organization, World Bank. Monitoring the health MDGs. Issue paper 3 for the high level forum on the health MDGs. December 2003. www.who.int/hdp/en/IP3-monitoring.pdf (accessed 8 Jul 2004).
Report of the International Conference on Population and Development, Cairo, 5-13 September 1994. Chapter 7. www.unfpa.org/icpd/docs/index.htm (accessed 8 Jul 2004).
H M Treasury. Statement by the chancellor of the exchequer on the 2004 spending review. 12 July 2004. www.hm-treasury.gov.uk/spending_review/spend_sr04/spend_sr04_statement.cfm (accessed 15 Jul 2004).
Gwatkin D. Who would gain most from efforts to reach the MDGs for health? An enquiry into the possibility of progress that fails to reach the poor. Washington, DC: World Bank, 2002. www1.worldbank.org/hnp/Pubs_Discussion/Gwatkin-Who%20Would%20-Whole.pdf (accessed 8 Jul 2004).
World Health Organization, World Bank. Resources, aid effectiveness and harmonisation. Issue paper 2 for the high level forum on the health MDGs. December 2003. www.who.int/hdp/en/IP2-resources.pdf (accessed 8 Jul 2004).
H M Treasury. International finance facility. 23 January 2003. www.hm-treasury.gov.uk/documents/international_issues/global_new_deal/int_gnd_iff2003.cfm (accessed 8 Jul 2004).
Lee K, Walt G, Haines A. The challenge to improve global health: financing the millennium development goals. JAMA 2004;291: 2636-8.
African Development Forum. Abuja Declaration on HIV/AIDS, tuberculosis and other related infectious diseases. 2001. www.uneca.org/adf2000/Abuja%20Declaration.htm (accessed 8 Jul 2004).
Stilwell B, Diallo K, Zurn P, Vujicic M, Adams O, Dal Poz M. Health workers and migration from low-resource countries—what can be done? Bull World Health Org (in press).
Narasimhan V, Brown H, Pablos-Mendez P, Adams O, Dussault G, Elzinga G, et al. Responding to the global human resource crisis. Lancet 2004:363: 1469-72.(Andy Haines, dean1, Andre)