WORLD HEALTH ORGANIZATION FIFTY-SIXTH WORLD HEALTH ASSEMBLY Provisional agenda item 14.3 A56/11 4 April 2003
WHO’s contribution to achievement of the development goals of the United Nations Millennium Declaration Report by the Secretariat BACKGROUND 1. In September 2000, representatives from 189 countries (and 147 Heads of State) met at the Millennium Summit in New York to adopt the United Nations Millennium Declaration.1 The Declaration set out principles and values that should govern international relations in the twenty-first century, and identified seven areas in which national leaders made a series of specific commitments: 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. 2. The Millennium Development Goals relate to the section of the Declaration dealing with development and poverty eradication and follow on from some of the key commitments made at the major conferences of the United Nations system in the 1990s. Subsequently, at the International Conference on Financing for Development (Monterrey, Mexico, 2002), the international community reaffirmed its commitment to the Development Goals and developed countries pledged to increase aid levels. At the World Summit on Sustainable Development (Johannesburg, South Africa, 2002), poverty was addressed within the context of sustainable development. A new challenge is to ensure coherence between the goals set at the World Summit and those of the Millennium Declaration. 3. Three of the eight Development Goals, eight of the 18 targets, and 18 of the 48 indicators are health related. Important areas of WHO’s mandate, including reproductive health, noncommunicable diseases and health-system functions are not explicitly mentioned. A list of the Development Goals, targets and indicators which relate to health is contained in the Annex.
PROGRESS IN MEETING THE MILLENNIUM DEVELOPMENT GOALS 4. The first annual report of the United Nations Secretary-General on implementation of the Millennium Declaration to the United Nations General Assembly summarized progress made since 1990 and concluded that many of the goals will not be reached by 2015 unless international efforts are
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United Nations General Assembly Resolution 55/2.
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significantly increased.1 Across regions, progress towards the health goals and targets has been uneven. Sub-Saharan Africa has made least progress, and much of South Asia is also unlikely to achieve the targets at current rates of progress. There is also concern that, because the health goals, unlike other Development Goals are expressed in terms of national averages rather than gains among poor or disadvantaged people, they could be reached without significant improvement among those groups.2 5. Examples of progress on selected health goals are summarized below.
• Goal 4, Target 5: to reduce under-five mortality by two-thirds between 1990 and 2015. The Middle East and North Africa, Latin America and the Caribbean, and Europe and Central Asia are on track to meet this target, though in each of these regions some countries are not. South Asia is lagging behind, and sub-Saharan Africa is unlikely to reach the goal without significant changes in current trends. • Goal 5, Target 6: to reduce maternal mortality by three-quarters between 1990 and 2015. Similarly, most regions are currently on track, whereas South Asia and sub-Saharan Africa are unlikely to meet the target. However, the challenge is greater here than for Goal 4 Target 5, as the percentage of births attended by skilled personnel is rising only slowly (from a very low base) in South Asia and improving very slowly (or even falling) in sub-Saharan Africa. • Goal 6, Target 7: to have halted and begun to reverse the spread of HIV by 2015. Progress is measured by a reduction in HIV prevalence among young pregnant women aged 15 to 24 years and in the number of HIV/AIDS orphans, and an increase in condom use among women and men aged 15 to 24 years. This age group is targeted because over half of all new infections occur among young people. Many countries could reach this target, although those of sub-Saharan Africa would need a substantial improvement in current trends.
UNITED NATIONS CORE STRATEGY FOR ACHIEVING THE MILLENNIUM DEVELOPMENT GOALS 6. Support for achieving the Development Goals, coordinated by the United Nations Development Group, is provided through four activities: Millennium reports; the Millennium Project; the Millennium Campaign; and operational support at country level. • At global level monitoring of progress is coordinated by the United Nations Department of Economic and Social Affairs, in collaboration with the competent organizations of the United Nations system. Output feeds into the Secretary General’s annual progress report and comprehensive five-year report. At country level, the United Nations Country Team provides support to the host government in preparing its report, based on existing products. Easy-to-read reports are also aimed at mobilizing national audiences. A key feature of the reporting is to localize the Development Goals and establish a sense of national ownership, rather than simply to transfer global targets to country level.
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Document A/57/270 (31 July 2002).
Gwatkin, D.R., Who would gain most from efforts to reach the Millennium Development Goals for Health? World Bank, December 2002.
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• The Millennium Campaign aims at raising public awareness of, and political commitment to, the Development Goals in both developed and developing countries. • The Millennium Project involves research on, and analysis of, the best strategies to achieve the Development Goals. Over a period of three years, its 10 task forces will work on identifying the operational priorities, organizational means of implementation, and financing structures necessary to reach the Goals. Preliminary work of the task forces will feed into UNDP’s Human development report 2003, focused on the Development Goals. • At country level operational support for achieving the Development Goals is provided by United Nations country teams, among other means by incorporating them into the processes of the Common Country Assessment and the United Nations Development Assistance Framework, and joint planning and programming exercises. Their active involvement in the preparation of the national reports also helps to strengthen links between the Development Goals and national priorities and provides support for the creation of national millennium campaigns.
WHO’S CONTRIBUTION Support to countries 7. The Development Goals are assuming increasing strategic importance in many development agencies. They are being used to focus and reorient the work of individuals and programmes, and as a benchmark against which to assess development impact and organizational performance. WHO’s commitment to the Millennium Declaration was reaffirmed at the Fifty-fifth World Health Assembly by resolution WHA55.19. The four strategic directions outlined in WHO’s corporate strategy link closely with the Development Goals.1 The Director-General has also taken them into account in preparation of the Proposed programme budget for 2004-2005.2 8. WHO’s work extends beyond areas covered in the Development Goals. It is therefore important to bear in mind the intent of the Goals to improve peoples’ health and livelihoods overall, rather than to focus on those aspects that are reflected in the specific goals, targets and indicators. Recognition of the growing problems attributable to noncommunicable diseases and their determinants, for example, needs to receive attention. 9. The significance of the Development Goals is that they provide a new lens through which to assess existing programmes, and thus have the potential to provide the basis for new forms of accountability – both for governments and for international organizations. They offer WHO a benchmark to help prioritize its support to countries as part of the process of drawing up country cooperation strategies. 10. WHO supports national efforts to achieve the Goals through an extensive body of normative and technical work in the areas of maternal health, control of communicable diseases, HIV/AIDS, water and sanitation, access to medicines, and environmental health. In addition, all countries can benefit from actions which strengthen national capacity to track progress and monitor outcomes in ways that avoid duplication of effort and ensure consistency and quality of data. Common to all these efforts is 1 2
Document EB105/3. Document PB/2004-2005.
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the need to address the systemic and institutional issues that limit progress in most low-income countries (some of which are reflected in Goal 8). 11. A concerted effort to tackle these constraints on a scale commensurate with the extent of the problem, is central to achieving the health (and other) Goals. The issues to be addressed are well known – with those affecting the supply and distribution of human resources in health professions high on the list. Examples of others include financial, physical and social barriers to accessible health services; safe and predictable supplies of affordable drugs and vaccines; mechanisms for increasing health coverage; a policy and institutional framework that allows the state to act as an effective steward of the health system; modalities for working across, and learning from other sectors. The relationship between the Development Goals and health systems will be explored in greater detail in The world health report 2003.
Tracking progress and measuring achievements 12. WHO has worked with other organizations of the United Nations system to identify indicators associated with each health-related Development Goal and target, and is now collaborating closely to establish complementary and coherent reporting procedures. The United Nations Population Division, UNDP, and the World Bank are using WHO, UNICEF and UNAIDS databases as their main sources of health information in relation to the Goals. 13. WHO’s work on reporting complements efforts to improve access to, and reliability of, country health data. A framework to ensure the quality of health statistics has been developed on the basis of five criteria: validity, reliability, cross-population comparability, data audit-trail and consultation with countries. The sources, methods and full development cycle of each published figure have been made more transparent, and explicit data audit-trails are now publicly available and open to peer review. In addition, a consultation process has been established which allows governments to work with WHO on verifying their national figures prior to publication. 14. Of the Goals’ 18 health indicators The world health report 2003 will provide country results for the 17 that are monitored by WHO, in addition to the core health indicators routinely published in previous reports. All will have been submitted to the validation process described above. WHO is also monitoring indicators for major domains of public health not captured by the Goals, but which can help explain progress (or lack thereof) toward achievement of the Goals at country level. These include immunization coverage for new antigens, prevalence of noncommunicable diseases, effectiveness of interventions against these diseases, and impoverishment of households through health payments.
REPRODUCTIVE HEALTH 15. Several key dimensions of reproductive health feature prominently in the Development Goals, including maternal health, child health (including the newborn) and HIV/AIDS. Reproductive health also contributes to goals of poverty reduction, gender equality and women’s empowerment. Access to reproductive health information and services enables people to regulate their fertility, which is associated with improved child survival and expanded choices in life, particularly for women. The management of reproductive-tract infections, which are major risk factors for HIV transmission, requires accessible, high quality sexual- and reproductive-health services. Such services are also essential for prevention of mother-to-child transmission of HIV. Through reproductive health, the Development Goals are strongly linked to the goals and targets set at the International Conference on
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Population and Development (Cairo, 1994), which were reaffirmed at the twenty-first special session of the United Nations General Assembly (ICPD+5) in 1999.1 16. In response to resolution WHA55.19, a proposed strategy for accelerating progress towards attainment of international development goals and targets related to reproductive health is currently being drawn up for submission to the Board and the Health Assembly, in close consultation with WHO regional and country offices, and other key stakeholders. 17. The strategy will examine the conceptual basis and operational issues at country level related to provision of high quality reproductive-health services. It will examine the systemic and institutional requirements of comprehensive reproductive-health programmes and reassert the underlying principles of national leadership and ownership, community involvement, equity, including gender equity, and human rights. 18. Key elements of the strategy will be: • generating strategic information at global and country levels, including better ways of measuring reproductive ill-health and stimulating research to produce data, using the five quality criteria for data validation outlined above; • establishing links between reproductive health and poverty, and exploring the cross-sectoral impact of health-sector reform on the ability of countries to respect the commitments made at ICPD; • addressing risk factors such as unsafe sex and lack of access to contraception that may cause maternal mortality and other adverse health outcomes, in particular HIV/AIDS, and identifying and disseminating information on protective factors, in particular for young people; • strengthening partnerships at global, regional and country levels to mobilize resources and ensure sound technical support to programmes.
REVIEW BY THE EXECUTIVE BOARD 19. The Executive Board at its 111th session in January 2003 reviewed an earlier version of this report.2 Comments by Board members focused on placing the Development Goals in a broader development context, for example, by demonstrating links with the Fourth WTO Ministerial Conference (Doha, 2001), the International Conference on Financing for Development, and the World Summit on Sustainable Development. 20. With regard to monitoring, it was stressed that the Development Goals should not increase the burden of reporting. Rather, there was a need to ensure complementarity with other reporting processes. It sought further information on WHO’s practical support for achievement of the targets,
All countries should strive to make accessible, through the primary health care system, reproductive health to all individuals of appropriate ages as soon as possible and no later than the year 2015. International Conference on Population and Development, Programme of Action, paragraph 7.6. 2
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Document EB111/3 and Corr.1.
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and requested that due attention should be given to the global partnership needed to support the efforts of developing countries, as reflected in Goal 8. 21. A focus on the Development Goals should not result in other health priorities being neglected. For instance, it was noted that although there was no specific goal or target for reproductive health, it was central to the achievement of those related to maternal health, child health and HIV/AIDS. It was important to show that work on reproductive health could contribute not solely to the health goals, but also to those concerned with poverty reduction and gender equality. WHO played a leading role in this area, and should stress the critical human rights and gender dimensions of reproductive health that go beyond specific public health interventions. 22. The current report reflects the above comments.
CONCLUSIONS 23. There are early indications that the Development Goals are fostering greater collaboration and policy coherence between development partners through the initiatives and strategies of the United Nations system described above. These processes will require careful monitoring to ensure that they stay on track, and are coordinated with efforts to promote ownership of the Development Goals at country level. Many countries are making good progress towards achieving the goals, although concern remains that gains will not be evenly distributed, either globally or within countries. 24. There is growing recognition that achieving the Development Goals will require a significant increase in resources for health. WHO continues to be a strong and vocal advocate of additional resources for the health sector, and to provide estimates of the resource needs.
ACTION BY THE HEALTH ASSEMBLY 25. The Health Assembly is invited to note the above report.
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ANNEX HEALTH IN THE MILLENNIUM DEVELOPMENT GOALS Goals, targets and indicators in the Millennium Development Goals directly related to health GOAL 1: Target 1: Target 2: ERADICATE EXTREME POVERTY AND HUNGER Halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day Halve, between 1990 and 2015, the proportion of 4. Prevalence of underweight children (under five years of age) people who suffer from hunger 5. Proportion of population below minimum level of dietary energy consumption ACHIEVE UNIVERSAL PRIMARY EDUCATION Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling PROMOTE GENDER EQUALITY AND EMPOWER WOMEN Eliminate gender disparity in primary and secondary education, preferably by 2005, and to all levels of education no later than 2015 REDUCE CHILD MORTALITY Reduce by two-thirds, between 1990 and 2015, the 13. Under-five mortality rate under-five mortality rate 14. Infant mortality rate 15. Proportion of 1-year-old children immunized against measles IMPROVE MATERNAL HEALTH 16. Maternal mortality ratio 17. Proportion of births attended by skilled health personnel COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES 18. HIV prevalence among 15-to-24-year-old pregnant women Have halted by 2015, and begun to reverse, the spread of HIV/AIDS 19. Condom use rate of the contraceptive prevalence rate 20. Number of children orphaned by HIV/AIDS 21. Prevalence and death rates associated with malaria Have halted by 2015, and begun to reverse the incidence of malaria and other major diseases 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 Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio
GOAL 2: Target 3: GOAL 3: Target 4: GOAL 4: Target 5:
GOAL 5: Target 6: GOAL 6: Target 7:
Target 8:
GOAL 7: Target 9:
ENSURE ENVIRONMENTAL SUSTAINABILITY Integrate the principles of sustainable 29. Proportion of population using solid fuels development into country policies and programmes and reverse the loss of environmental resources Target 101: Halve, by 2015, the proportion of people without 30. Proportion of population with sustainable access to an improved water source, urban and rural sustainable access to safe drinking water 31. Proportion of urban population with access to improved Target 11: By 2020 to have achieved a significant sanitation improvement in the lives of at least 100 million slum dwellers GOAL 8: DEVELOP A GLOBAL PARTNERSHIP FOR DEVELOPMENT Target 12: Develop further an open, rule-based, predictable, non-discriminatory trading and financial system Target 13: Address the special needs of the least developed countries Target 14: Address the special needs of landlocked countries and small island developing States Target 15: Deal comprehensively with the debt problems of developing countries through national and international measures in order to make debt sustainable in the long term Target 16: In cooperation with developing countries, develop and implement strategies for decent and productive work for youth 46. Proportion of population with access to affordable essential Target 17: In cooperation with pharmaceutical companies drugs on a sustainable basis provide access to affordable, essential drugs in developing countries Target 18: In cooperation with the private sector, make available the benefits of new technologies, especially information and communications 1 At the World Summit on Sustainable Development, Member States adopted an equivalent target for sanitation: “to halve, by the year 2015, the proportion of people who do not have access to basic sanitation.” Note: For WHO’s operational activities in monitoring and reporting, Development Goal health indicators representing more than one measure (i.e. for tuberculosis and malaria) have been broken down into their single measures. Additionally, HIV-related indicators have been reformulated to incorporate the corresponding footnotes of the initial indicator list. Sources: Implementation of the United Nations Millennium Declaration, Report of the Secretary-General, document A/57/270 (31 July 2002). First annual report based on the “Road map towards the implementation of the United Nations Millennium Declaration”, document A/56/326 (6 September 2001); World Summit on Sustainable Development: Plan of Implementation, September 2002.
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