SIXTY-FIRST WORLD HEALTH ASSEMBLY Provisional agenda item 11.12
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Monitoring achievement of the health-related Millennium Development Goals Report by the Secretariat 1. At the mid-point in the countdown to 2015, the target date set by the United Nations Millennium Declaration, there are several examples of success. However, great inequalities still exist within and between countries, and current trends suggest that many low-income countries will not reach the Millennium Development Goal targets. This report sets out current progress towards the health-related Goals and targets. It outlines WHO’s role in monitoring progress, and in supporting national and international efforts to overcome key policy and operational constraints. 2. An earlier version of this report was considered by the Executive Board at its 122nd session in January 2008. The Board agreed that the report should be debated fully by the Health Assembly.1
CURRENT STATUS AND ACHIEVEMENTS Millennium Development Goal 1: Eradicate extreme poverty and hunger 3. Much of childhood mortality is attributable to undernutrition, which exacerbates the impact of diseases such as malaria, diarrhoea and acute respiratory infections. While the global prevalence of underweight (low weight for age) has declined since 1990 from 43% to 27%, 143 million children under five years old remain affected. Most of these children live in south Asia, where two out of every five children are underweight. Prevalence is lower in sub-Saharan Africa, at around 28%, but progress in reducing this figure has been particularly slow. 4. Stunting (low height for age, chronic undernutrition) and wasting (low weight for height, acute undernutrition) are more precise measures of poor nutrition than underweight. WHO estimates that, in 2005, 178 million children in developing countries were stunted and 55 million wasted. The prevalence of stunting is highest in south Asia and sub-Saharan Africa.
Millennium Development Goal 4: Reduce child mortality 5. Major progress has been made towards achieving Goal 4, a two-thirds reduction in the mortality rate among children under five by 2015, in all regions except for sub-Saharan Africa, which now accounts for around half of the 9.7 million deaths that occur among children under five every year.
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See document EB122/2008/REC/2, summary record of the ninth meeting, section one.
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The under-five mortality rate in sub-Saharan Africa is estimated at 160 per 1000 live births compared with 83 in south Asia, 29 in east Asia, and 27 in Latin America in 2006. Just four of 46 sub-Saharan African countries are on track to achieve Goal 4. However, lessons can be learnt from several countries including Bangladesh, Eritrea, Ethiopia, Madagascar, Malawi, Mozambique, Nepal, Niger, and United Republic of Tanzania, where striking declines in the under-five mortality rate have been observed in recent years. 6. The slowest progress in reducing child mortality continues to be in countries with high prevalence of HIV or those affected by conflicts. The coverage of services that can be delivered by outreach, such as immunization, vitamin A and insecticide-treated bednets, has shown encouraging trends. In addition, trends for early and exclusive breastfeeding are positive. According to estimates based on the latest data, measles vaccination coverage has reached 80% globally and 72% in sub-Saharan Africa; between 2000 and 2006, measles-specific mortality declined by 68% globally and by 91% in sub-Saharan Africa. However, those interventions requiring a functional health system (prevention and treatment of neonatal disorders, diarrhoea, pneumonia, malaria and malnutrition) are having less impact. Pneumonia, for example, continues to kill more children worldwide than AIDS, malaria and measles combined. Although about half of all children with pneumonia are taken to appropriate health-care providers, this proportion has hardly changed since 2000 so that many children do not receive effective treatment. Diarrhoeal diseases cause a further 1.6 million child deaths each year but only about half of children with diarrhoea receive the recommended oral rehydration therapy with continued feeding.
Millennium Development Goal 5: Improve maternal health 7. Slower progress has been made towards Goal 5, the reduction in the maternal mortality ratio by three quarters by 2015. More than 500 000 women died of causes related to maternity in 2005, with around half the deaths occurring in sub-Saharan Africa and one third in south Asia. Maternal mortality ratios for countries in sub-Saharan Africa are the highest in the world at 920 per 100 000 live births compared with 8 per 100 000 in industrialized countries. This ratio translates into a woman’s lifetime risk of maternal death of 1 in 22 in Africa. The single leading cause of maternal death is haemorrhage, which causes one maternal death in three in Africa. 8. Progress in reducing this preventable cause of death has been slow. While middle-income countries have achieved decreases in maternal mortality since 1990, declines in sub-Saharan Africa have been negligible. No region has achieved the necessary 5.5% annual decline needed to meet the Goal target, although east Asia came close with a 4.2% annual decline. 9. A well-functioning health system is a prerequisite for significant improvements in maternal health. Globally, coverage of skilled delivery attendance has increased over the past decade and around 60% of births in the developing world are attended by a doctor, nurse or midwife, but progress has been especially slow in sub-Saharan Africa and, in both the African and South-East Asia regions, under half of deliveries take place with a skilled attendant present.
Millennium Development Goal 6: Combat HIV/AIDS, malaria and other diseases 10. HIV/AIDS. Progress in access to antiretroviral treatment in low- and middle-income countries has been dramatic in recent years: from about 240 000 recipients in 2001 to 2.1 million in 2006. But coverage is still inadequate: in sub-Saharan Africa, about one quarter of the 4.8 million people who need antiretroviral treatment currently have access to it. The proportion of children who need and receive antiretroviral treatment has also increased rapidly, but coverage is even lower (15%) than for
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adults. In low- and middle-income countries, the proportion of HIV-positive pregnant women receiving antiretroviral treatment for prevention of mother-to-child transmission of HIV was still as low as 11%. There have been some declines in the incidence of HIV infection which can be attributed to behavioural change and may indicate the growing impact of preventive interventions. However, there are still an estimated 1.7 million new infections per year in Africa and there remains an urgent need to rethink and expand evidence-informed prevention work. 11. For malaria, use of insecticide-treated bednets has progressed from a low baseline. In 20 African countries with data for 2000 and 2005, their use increased from 2% to 13% among children under five, and in 16 countries their use tripled. Although the policy shift to more effective antimalarials (including artemisinin-based combination therapies) has been swift, only one third of children under five with fever in Africa receive any antimalarial treatment. Recent high-level initiatives are now attempting to redress the low coverage of effective interventions. 12. For tuberculosis, since 2005 the number of new cases per capita has been falling, albeit slowly, in all regions including Africa – thus meeting Goal 6, target 8. While other regions are on track to halve prevalence and death rates by 2015, and while rates have stabilized in Africa since 2003, the rate of decline in Africa is insufficient to reach the 50% target set by the Health Assembly. In Africa, rapid increases in treatment success (74% in 2004) and case detection (50% in 2005) are urgently required.
Millennium Development Goal 7: Ensure environmental sustainability 13. The health, economic and social repercussions of open defecation, poor hygiene and lack of safe drinking-water are well documented. Together they contribute to about 88% of the deaths due to diarrhoeal diseases – more than 1.5 million – in children under five years old. Infestation with intestinal worms caused by open defecation affects hundreds of millions of predominantly school-aged children, resulting in reduced physical growth, weakened physical fitness and impaired cognitive functions. Poor nutrition contributes to these effects. Currently, an estimated 1.6 billion people will need access to improved sanitation over the period 2005–2015 to meet Goal 7, target 10. Yet if trends since 1990 continue, the world is likely to fall short of the target by almost 600 million people. In sub-Saharan Africa, the number of people without access to sanitation actually increased from 335 million in 1990 to 440 million at the end of 2004. This number may increase even further if trends do not improve.
Millennium Development Goal 8: Develop a global partnership for development 14. While there have been improvements in some areas such as antiretroviral drugs, assessments of health service delivery in many countries show that a significant proportion of the population still have inadequate access to essential drugs on a sustainable basis. This is due either to physical, economic or sociocultural barriers, or to weaknesses in the health system in terms of ensuring a continuous supply of essential drugs, problems which must be addressed in order to achieve Goal 8, target 17.
Monitoring progress 15. Monitoring progress in terms of the health-related Goals’ indicators is a well-established process coordinated by the United Nations Statistics Division. WHO participates in the Inter-Agency and Expert Group on MDG Indicators. Each year an annual progress report is produced based on the statistics provided by organizations in the United Nations system and countries. The coordination between all relevant United Nations bodies avoids unnecessary duplication of requests to countries for data and ensures harmonization of statistics. In close collaboration with UNICEF and UNAIDS, WHO
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provides health statistics on HIV/AIDS, tuberculosis, malaria, child mortality and child nutrition, water and sanitation, and indoor air pollution. 16. In addition, WHO reports the most recent estimates for statistics related to the Goals in its annual publication World health statistics which is issued in May each year and includes all relevant health indicators and additional indicators including causes of death, coverage of interventions, risk factors, and health systems. Hitherto, further analyses and detailed reporting on progress towards the health-related Millennium Development Goals have been limited to occasional publications or sections of reports. 17. In addition to supporting the United Nations reporting system, WHO plans to strengthen its core function of monitoring the health situation and trends in the world by establishing a global health observatory. The observatory will build on existing data and work on information within WHO, collaborate closely with partners, and issue analytical reports on high-priority topics, such as women and health and health in Africa, through special publications and an integrated web portal. 18. A major function of the observatory will be to monitor progress towards attaining the healthrelated Goals. Its analytical work will go beyond the joint United Nations monitoring process. Equity will receive special attention, including analyses of the extent to which the poorest countries are making progress, gender-specific trends and geographical differences within countries. It will also pay more attention to cause-specific mortality trends. In addition, it will monitor global health initiatives focusing on the Goals and evaluate the impact of various initiatives that aim to expand health services. The global health observatory’s work elements will be introduced step-wise and work on monitoring progress towards attaining the Millennium Development Goals is expected to expand gradually during 2008.
OVERCOMING CHALLENGES AND CONSTRAINTS: AN OVERVIEW OF THE CURRENT LANDSCAPE 19. Recent initiatives recognize that expanding health services requires a far more coherent approach: objectives cannot be achieved without adequate investment in the systems that deliver better health, and health should be embedded in broader social and economic development planning and a multisectoral response; countries need long-term predictable aid from external donors; domestic and international contributors need to see a clear link between financing and results; and mechanisms are badly needed that will hold all partners accountable for their performance against international agreements. 20. Practical expressions of this growing consensus include: agreement on key technical strategies such as the WHO, UNICEF and World Bank framework for achieving the health-related Millennium Development Goals in Africa prepared at the invitation of the African Union; WHO’s framework for action on strengthening health systems to improve health outcomes;1 the work to follow up the High-Level Forum on the Health Millennium Development Goals; the GAVI Alliance’s expansion of support for health systems; the new agreement at the recent board meeting of the Global Fund to Fight AIDS, Tuberculosis and Malaria on modalities for health systems support and conditions for more programmatic funding (national strategy applications); the 2007 commitment of the G8 countries at Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, World Health Organization, 2007. 1
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the G8 Summit (Heiligendamm, Germany, June 2007) to scaling up of health interventions in Africa; and, most recently, several closely related bilaterally-championed initiatives – the International Health Partnership and the global campaign for the achievement of Goals 4, 5 and 6 and the recently announced Catalytic Initiative to Save One Million Lives. 21. Official development assistance for health globally has doubled in recent years from US$ 6000 million in 2000 to US$ 12 000 million in 2005. Major new resources have been committed – mostly towards the achievement of the health-related Goals, focusing on particular diseases (notably AIDS, tuberculosis and malaria) and interventions such as immunization. The Global Fund to Fight AIDS, Tuberculosis and Malaria and the GAVI Alliance have attracted much of these new resources. The organizations in the United Nations system and World Bank are also committing significant investments to health. However, recent analysis by WHO shows that levels of flexible financing under the direct control of national governments have risen much more slowly. 22. As many donor governments and development banks have shifted towards budget or sector support, decreasing their involvement in specific sectors, new partners have emerged in the health sector. The foundations (particularly the Bill & Melinda Gates Foundation), global funds (particularly the Global Fund to Fight AIDS, Tuberculosis and Malaria) and categorical bilateral programmes (particularly the United States of America’s President’s Emergency Plan for AIDS Relief) can now play a dominant role in external health sector funding in some countries. Innovative sources of finance (e.g. the International Finance Facility for Immunization and UNITAID) are tapping new sources of finance. Plans for advance market commitments promise new resources and a stimulus for research and development. Although these increases are welcome, significant gaps still exist and the current pattern of external assistance can be unpredictable at country level, making it difficult for governments to finance vital recurrent costs and make long-term plans for expanding the reach of some vital health interventions. 23. Global partnerships have been successful in raising the profile of critical issues, promoting interagency work and involving civil society and the private sector. However, there are now between 75 and 100 global health partnerships and initiatives; the global health environment has become increasingly fragmented and transaction costs faced by governments have increased. In addition, the capacity for supporting governments to expand programmes has not kept pace with the increases in resources and political attention for global health. In the field of AIDS, efforts have been made to promote a single framework – the “Three Ones” principle – in order to capture issues of governance, technical strategies and a single framework for monitoring and evaluation, which provides valuable lessons in general. The need for a common framework for monitoring performance and evaluation for the scaling up of health interventions has been recognized and international partners and countries are working together to develop and operationalize such a framework.
Scaling up: the way forward 24. Accelerating progress requires not only significant increases in the level of investment and political commitment to health, but also attention to fundamental issues of implementation.
Building the systems that create better health is important both within and beyond the health sector 25. Progress towards the health-related Millennium Development Goals cannot be sustained without adequate investment in health systems (in financing, human resources, information, procurement and logistics, governance and service delivery).
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26. The Goals are interdependent and progress towards attainment of the health-related Goals relies on achievements in relation to the others. More rapid progress – particularly in relation to prevention of HIV/AIDS, but equally with regard to other infectious and noncommunicable diseases – requires a multisectoral response.
Weak national capacity remains an obstacle to progress: there are clear priorities for capacity-building 27. A shortage of well-trained health workers is a constraint in most African countries. Strategies are needed to increase their numbers; to adjust the mix of skills to changing circumstances and tasks (task shifting); to increase retention of health personnel through better incentives and improvements in the work environment; and to tackle the issue of migration of such workers. Capacity is also needed for data collection and analysis in order to enable countries to track progress accurately. 28. In order to achieve the health-related Millennium Development Goals in Africa greater attention will need to be paid to populations living in circumstances where the State, for a wide variety of reasons, is unable to respond fully to the health needs of its people. Work in such fragile States will in turn require the United Nations to have the capacity to support governments and other development partners. 29. Capacity-building cannot focus or rely on the public sector alone. Greater cooperation between the State and civil society is essential to success. In order to make progress in areas such as service delivery, effective networks of public, private, voluntary, community and faith-based civil organizations will need to be created.
If financing commitments made by national governments and their development partners were fully honoured, many of the resource gaps in the sector could be filled 30. Donors’ aid for health in Africa has increased significantly but still lags behind stated intentions. Moreover, the volume of resources that can be used flexibly by governments to build health-delivery systems has risen far less rapidly than have the resources available for specific diseases and technical cooperation. 31. National leaders should also be urged to meet agreed commitments with regard to spending on health (as set out, for example, in the Abuja Declaration by Heads of State and Government of African countries, 2000). Domestic policies for health financing should aim to decrease reliance on out-of-pocket payments and, using pooling of risk (either through tax-based or social insurance systems), help people to avoid catastrophic levels of expense when they fall ill.
Progress in achieving the health-related Millennium Development Goals in Africa is constrained by fragmentation and inefficiencies in the international response: putting the Paris Declaration on Aid Effectiveness (2005) into practice 32. While resource gaps remain, there is no need for new mechanisms, initiatives or channels of funding. Rather, support is needed for existing coordination mechanisms. These mechanisms include those at global and regional levels in which eight global health agencies are involved as part of their support for the International Health Partnership and related initiatives including the Harmonization for Health in Africa action framework.
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33. Coordination at country level is essential. The idea of the “Three Ones” principle, that is, one national plan, one coordination mechanism and one monitoring and evaluation plan, which was developed for HIV/AIDS, is equally applicable in other areas of health. Work has begun to prepare criteria for determining what constitutes a sound health sector strategy and plan, and to agree a common approach to monitoring and evaluation. Among other things, ways will be explored of creating more effective links between the responses to HIV/AIDS and those in other areas of health. 34. Lessons learnt in strengthening coordination in the health sector will inform the third High-Level Forum on Aid Effectiveness, to be held in Accra from 2 to 4 September 2008.
Volatility in external resources makes it difficult to plan and manage the scaling up of health services: measures to increase predictability of aid at the country level are therefore critical 35. Much needs to be done to increase the predictability of health-sector financing so that finance ministries can budget with greater confidence for recurrent costs – particularly those for medicines and salaries. More robust compacts between governments and their development partners, agreements that align external financing around national results-based strategic plans that focus on the Millennium Development Goals, can provide the basis for mutual accountability and for securing long-term predictable financing from multiple sources. Mechanisms that promote a link between funding and performance while enhancing predictability, such as the “MDG contracts” proposed by the European Commission and others, merit support.
ACTION BY THE HEALTH ASSEMBLY 36. The Health Assembly is invited to note the report.
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