EXECUTIVE BOARD 124th Session Provisional agenda item 4.7
EB124/10 27 November 2008
Monitoring of the achievement of the health-related Millennium Development Goals Report by the Secretariat
1. Health is at the heart of the Millennium Development Goals. Goals 4, 5 and 6 specifically focus on health, but all the others have health-related aspects; achieving them will not be possible without progress on food security, gender equality, the empowerment of women, wider access to education, and better stewardship of the environment. Looking to 2015 and beyond, the challenges presented by weak health systems, the epidemiological transition and emerging health threats will become increasingly prominent.
CURRENT STATUS AND TRENDS 2. Overall, the proportion of children under five years of age suffering from undernutrition (according to the WHO Child Growth Standards) declined from 27% in 1990 to 20% in 2005. However, progress has been uneven and an estimated 112 million children are underweight. Undernutrition is an underlying cause in more than one third of child deaths. 3. In 2006, there were 9.5 million child deaths, significantly fewer than the 12.4 million recorded in 1990, with a 27% decline in the under-five mortality rate over that period to 71 per 1000 live births in 2006. Reducing child mortality increasingly depends on tackling neonatal mortality; globally, an estimated 37% of deaths among children under five occurs in the first month of life, most in the first week. Countries making the least progress are generally those affected by high levels of HIV/AIDS, economic hardship or conflict. 4. Much of the progress in reducing child mortality can be attributed to increased immunization coverage, use of insecticide-treated mosquito nets, access to artemisinin-based combination therapies, and efforts to eliminate disease due to Haemophilus influenzae type b infection. However, because the availability and use of proven interventions at community level remain low, pneumonia and diarrhoea still kill 3.8 million children under five each year. 5. Every year some 536 000 women die of complications during pregnancy or childbirth, 99% of them in developing countries. The global maternal mortality ratio of 400 maternal deaths per 100 000 live births in 2005 has barely changed since 1990. Most maternal deaths occur in the African Region, where the maternal mortality ratio is 900 per 100 000 live births, with no measureable improvement between 1990 and 2005.
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6. Progress in reducing maternal mortality and morbidity depends on better access to, and use of, good maternal and reproductive health services. The proportion of pregnant women in the developing world who had at least one antenatal care visit increased from slightly more than half at the beginning of the 1990s to almost three quarters a decade later. Over the period 2000–2006, 65% of births globally were attended by skilled health personnel, 4% more than in 1990–1999. 7. Globally, the contraceptive prevalence rate increased from 59% in 1990–1995 to 63% in 2000–2006. Nonetheless, in some regions it remains very difficult to reduce the considerable unmet need for family planning and the high rates of adolescent fertility. Globally, there were 48 births for every 1000 women aged 15–19 years in 2006, only a small decline from 51 per 1000 in 2000. 8. In 2006, an estimated 3300 million people were at risk of malaria. Of these, some 1200 million were in the high-risk category (living in areas with more than one reported case of malaria per 1000 population per year). Although it is still too early to register global changes in impact, 27 countries (including five in Africa) have reduced reported cases of the disease and/or deaths resulting from it by up to 50% between 1990 and 2006. Coverage of interventions for the prevention and treatment of malaria has increased. There has been a significant growth in the production and use of insecticide-treated mosquito nets, although global targets are still not being met. By June 2008, all but four countries and territories with a high burden of the disease had adopted artemisinin-based combination therapy as the first-line treatment for falciparum malaria, and use of combination therapies is being scaled up. 9. The Millennium Development Goal target in respect of halting and reversing the incidence of tuberculosis was met globally in 2004. Since then the rate has been falling slowly.1 Tuberculosis prevalence and death rates per 100 000 population declined from 294 in 1990 to 219 in 2006 for the former, and from 28 in 1990 to 25 in 2006 for the latter. Globally, the tuberculosis case-detection rate under the DOTS approach increased from an estimated 11% in 1995 to 61% in 2006. The rate of improvement in case detection slowed after 2004, largely as a result of earlier successes in the countries with the largest number of cases. Data on treatment success rates under the DOTS approach indicate consistent improvement, with rates rising from 79% in 1990 to 85% in 2006. Multidrugresistant tuberculosis and HIV-associated tuberculosis pose particular challenges in some regions. 10. New estimates indicate that 2.7 million people were newly infected with HIV during 2007 and that there were two million deaths related to AIDS, bringing the total number of people living with HIV to 33 million. The percentage of adults living with HIV globally has remained stable since 2000. Use of antiretroviral therapy has increased; in the course of 2007, an additional 950 000 people living with HIV received antiretroviral therapy.2 However, despite this, of the estimated 9.7 million people in developing countries that need treatment, only 3 million were receiving the medicines. Progress has been made in prevention, but at the end of 2007 only 30% of HIV-infected women had access to prevention of mother to child transmission. 11. An estimated 1.2 billion people are affected by neglected tropical diseases, chronic disabling infections that thrive in conditions of impoverishment and weak health systems. In 2007, 546 million people were treated to prevent transmission of lymphatic filariasis and only 9585 cases of 1
Global tuberculosis control: surveillance, planning, financing: WHO report 2008. Geneva, World Health Organization, 2008. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector: progress report 2008. Geneva, World Health Organization, in press. 2
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dracunculiasis were reported in the five countries in which the disease is endemic, compared with an estimated 3.5 million reported in 20 such countries in 1985. The global prevalence of leprosy at the beginning of 2008 stood at 212 802 reported cases, down from 5.2 million cases in 1985. 12. Lack of safe water and poor sanitation are important risk factors for mortality and morbidity, including diarrhoeal diseases, cholera, worm infestations, and hepatitis. Globally, the proportion of the population with access to improved drinking-water sources increased from 76% to 86% between 1990 and 2006. Since 1990, the number of people in developing regions using improved sanitation facilities has increased by 1100 million. Nevertheless, in 2006, there were 54 countries in which information was available where less than half the population used an improved sanitation facility. 13. Although nearly all developing countries publish an essential medicines list, the availability of medicines at public health facilities is often poor. Surveys in about 30 developing countries indicate that availability of selected medicines at health facilities was only 35% in the public sector and 63% in the private sector. Lack of medicines in the public sector forces patients to purchase medicines privately. In the private sector, however, generic medicines are often sold at several times their international reference price, while originator brands are generally even more expensive.
ACCELERATING PROGRESS 14. At the midpoint between 2000 and 2015, the analysis reveals encouraging signs of progress, particularly in child health; it points to areas where current gains need to be sustained, particularly in relation to HIV/AIDS, tuberculosis and malaria; and indicates areas where there has been little or no movement, notably maternal and newborn health. More detailed data, not reported here, show that major differences in progress exist between and within countries and regions. 15. Strategies to accelerate achievement of the Millennium Development Goals have received attention from the MDG Africa Steering Group, chaired by the United Nations Secretary-General; in the Toyako Framework for Action on Global Health (welcomed at the G8 Summit held in Hokkaido, Japan, from 7 to 9 July 2008); and at the United Nations High-Level Event on the Millennium Development Goals (New York, 25 September 2008). 16. Based on the Millennium Declaration, the Millennium Development Goals are a way of ensuring that the benefits of globalization are evenly and fairly shared. The values they support echo those in the Declaration of Alma-Ata (1978). In this context, the renewed commitment to primary health care provides a framework and direction for future work on the Millennium Development Goals through its focus on the following: equity, health as an outcome of policy across all sectors, and health systems that advance universal access and respond to people’s needs. 17. A greater focus on equity, solidarity and gender. Detailed analysis of trends reveals that regional and national averages mask important inequities within countries, within regions and between sexes. For example, the greatest reductions in child mortality have been recorded among the richest households and in urban areas; such improvements have been the slowest to achieve among the poor and in rural populations. Similarly, greater reductions in undernutrition have been achieved among boys than among girls. Moreover, the high burden of maternal mortality is a result of many factors including poor access to care, failure to prevent unwanted pregnancies and women’s low status in many societies. Within regions in which performance is generally poor, certain countries are nevertheless making rapid progress; five countries in Africa, for example, have succeeded in reducing child mortality by 40% or more. It is estimated that one third of people living in absolute poverty
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reside in so-called fragile states that receive up to 40% less aid per capita than other low-income countries. 18. Promoting health as an outcome of all policies. By 2030, eight out of the 10 leading causes of death will be linked to noncommunicable diseases and conditions such as mental disorders, injuries and violence.1 Success in tackling risk factors such as tobacco use, unhealthy diets, physical inactivity and harmful use of alcohol, and the socioeconomic impact of cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, depends not only on effective health-care services but also on actions taken in a wide variety of policy domains. Although noncommunicable diseases are often seen as the main target of intersectoral action, many other health outcomes are determined by policy interventions beyond the health sector – whether it be import duties on essential medicines and technologies, employment and housing policy affecting early childhood development, laws that discriminate against people living with HIV/AIDS, or restrictions on the movement of people or livestock in order to prevent the spread of epidemics. 19. Building stronger health systems based on primary health care. All the health-related Millennium Development Goals depend for their achievement on stronger health systems. As indicated in WHO’s framework for action in this area,2 in order for progress to be made, work is needed on all the main prerequisites for effective health systems, namely: fair systems of finance that protect against impoverishment; a well-trained and adequately remunerated workforce; the application of information systems to support policy and management; reliable systems for procuring and distributing essential medicines and technologies; effective referral systems and service delivery; and the capacity to frame and implement policies that guide all major stakeholders. The core values of primary health care give direction to the following activities for reforming health systems: promoting universal access in support of equity; ensuring a people-centred approach to service delivery; extending the reach of health into other policy areas; establishing a system of governance for steering these reforms. Although it is important to measure the effectiveness of investment made for strengthening health systems, the creation of strong health systems remains a means to an end; the principal aim is to reduce maternal mortality and achieve other key health outcomes. 20. These policy directions have implications for the many stakeholders supporting the achievement of the Millennium Development Goals. Three such directions that are of particular concern to WHO are highlighted below. 21. Monitoring trends. At the global level, monitoring progress towards the Millennium Development Goals is a well-established process coordinated by the United Nations Statistics Division. WHO participates in the Inter-Agency and Expert Group on MDG Indicators. In addition, WHO will report on the most recent estimates for statistics related to the Goals in its annual publication, World health statistics, which appears in May each year. WHO is strengthening its core function of monitoring the global health situation and trends therein by establishing a global health observatory. The observatory will increase access to health data across the Organization, and enhance the quality of the information concerned.
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The global burden of disease: 2004 update. Geneva, World Health Organization, 2008.
Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, World Health Organization, 2007.
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22. Increasing the quantity and quality of resources for health. Although significant and sustained increases in domestic financing and external development aid are needed, there is also an urgent need to improve alignment between the growing numbers of international initiatives seeking to accelerate progress towards the Millennium Development Goals. In this regard, WHO will promote the implementation of the Paris Declaration on Aid Effectiveness: ownership, harmonisation, alignment, results and mutual accountability (2005) and the Accra Agenda for Action. WHO’s support for the international commitments to health system strengthening – the International Health Partnership and Providing for Health – will promote, in respect of the former, the elaboration and use of national health strategies and plans as a means of increasing alignment with national priorities, and in the case of the latter, the provision of more consistent advice on domestic financing policies. In order to increase and safeguard aid for health, the Director-General will join a high-level task force on innovative international financing. 23. Working in partnership. WHO will continue to work in partnership with all actors concerned with improving people’s health. The Organization’s involvement in this area includes pursuing a growing network of relationships with civil society and the private sector. WHO is an active supporter of United Nations reforms to increase the effectiveness of support provided through the United Nations system for development at country level. Global Health Partnerships have established their place as providers of aid – particularly those partnerships that offer significant financing to countries, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the GAVI Alliance. In addition to fighting HIV/AIDS, tuberculosis and malaria and increasing immunization coverage, both partnerships now play a major role in providing financing in support of stronger health systems. 24. The renewal of commitment to primary health care offers a framework for making more rapid and equitable progress towards the Millennium Development Goals. The strategies for accelerating achievement of the health-related Goals in this report are consistent with the conclusions of The world health report 20081 and the report of the Commission on Social Determinants of Health.2
ACTION BY THE EXECUTIVE BOARD 25. The Board is invited to note the report.
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The world health report 2008: primary health care now more than ever. Geneva, World Health Organization, 2008.
“Closing the gap in a generation: health equity through action on the social determinants of health” (document WHO/IER/CSDH/08.1).
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