In 2000, the international community endorsed the Millennium Declaration, which sets out an historic commitment to eradicate extreme poverty and improve the health of the world's poorest people by 2015. The Declaration and the resulting internationally agreed targets for the Millennium Development Goals (MDGs) place health squarely at the centre of the international development agenda and champion it as a key driver of economic progress.
Health is represented in three of the eight MDGs and makes an acknowledged contribution to the achievement of all the others, in particular those related to the eradication of extreme poverty and hunger, education and gender equality. Goal 8, which calls for a global partnership for development, is a unique feature of the MDGs, because it recognizes that there are certain actions that rich countries must take if poor countries are to achieve all the other Goals. MDG 8 is a reminder that global security and prosperity depend on a more equitable world for all.
Health has never before received such international attention or enjoyed such wealth as in recent years. More than 100 partnerships, mainly focusing on individual diseases, have been formed. Official development assistance for health increased sixfold in real terms, from $1.7 billion in 1985 to over $9.7 billion in 2005.1 At the 2005 G8 Summit at Gleneagles, rich countries agreed to double aid to Africa by 2010; many announced timetables to increase their development assistance to 0.7 per cent of their gross national product. Furthermore, the number of innovative financing mechanisms, such as the International Finance Facility for Immunization, Advance Market Commitments and UNITAID, continues to grow. Such mechanisms are seen as an important component for a more sustainable and performance-driven approach to development assistance, and an attempt to address aid shortfalls.
At the midpoint in the countdown to 2015, the target year given so much significance by the Millennium Declaration and its MDGs, we can see several examples of success. In 2007, the global burden of under-five mortality has fallen for the first time below 10 million deaths and is now estimated at 9.7 million per year. Increased coverage of interventions, such as exclusive breastfeeding, measles vaccinations, vitamin A supplements and insecticide-treated bed nets, have contributed to this decline.
In 2005, it was estimated that seven high-burden countries -- Bangladesh, Brazil, Egypt, Indonesia, Mexico, Nepal and the Philippines -- were on track to achieve the MDG 4 target of reducing child mortality, and the number of countries is increasing. Recent surveys have shown a steady mortality decline in other countries, for example, in Madagascar, Malawi and the United Republic of Tanzania. In addition, 6 of 11 African countries heavily affected by HIV reported a decline of 25 per cent or more in HIV prevalence among the 15- to 24-year-olds in capital cities.2 Between 2001 and 2006, the number of people on antiretroviral therapy in low- and middle-income countries increased from 240,000 to approximately 2.1 million.3
However, great health inequities still exist within and between countries. While there are individual stories of progress, current trends suggest that many low-income countries will not reach the health-related MDGs by 2015. The situation is particularly alarming in sub-Saharan Africa, where progress towards the MDGs remains behind schedule and where over 40 per cent of all child deaths occur. For maternal mortality, evidence indicates that declines have been limited to countries with lower levels of mortality. Countries with the highest maternal mortality rates are experiencing stagnation or even reversals, and those affected by armed conflict or generalized HIV epidemics show the least progress or even reversals of previous gains.
Indeed, it is the health of two explicit populations -- women and the people in Africa -- that the World Health Organization (WHO) has committed to use as measures of the effectiveness of its work. In further response to the need to enhance progress towards the MDGs in the continent, the UN Secretary-General recently established the MDGs Africa Steering Group. The initiative brings together the UN system and major development partners to work on accelerating current efforts of African countries to achieve the MDGs.
There is wide recognition that countries need to scale up their efforts in order to accelerate progress towards achieving the health-related MDGs. For example, affordable interventions for malaria -- including effective medication, integrated vector management using long-lasting insecticidal nets, and indoor residual spraying -- are available but are simply not getting to those who need them. Scaling up not only requires significant increases in the level of investment and political commitment to health, but also attention to fundamental and implementation issues, among them:
Health and development. Recognizing that investments in health need to be embedded in broader social and economic development planning, including public-sector reforms, macroeconomic and fiscal planning, health should no longer be seen as a mere consumer of resources, but instead a producer of economic gains. It is central to achieving poverty reduction and greater socio-economic development.
Strengthening the health systems. Urgent investment in health systems is needed, with a focus on addressing bottlenecks and improving health service delivery and access to care. It has become increasingly clear that weak systems are a leading impediment to improving health outcomes; many are not able to deliver affordable and essential interventions on the necessary scale to those in greatest need. Greater emphasis must be placed on delivering health services in an integrated manner and addressing the pressing shortfall in human resources for health. Ample evidence demonstrates that health systems founded on primary health care (PHC) values, such as equity, community and intersectoral participation, can achieve improved access and outcomes. To this end, the upcoming WHO World Health Report (2008) will provide a contemporary examination of PHC to better inform policymakers on a PHC-led strategy for reorienting health systems.
Sustainable financing. Countries need long-term predictable aid from development partners that is disbursed according to technical, rather than political, criteria. They also need flexible resources that can support the whole health system. The World Health Report 2006, Working Together for Health, recommends the 50:50 principle -- that 50 per cent of health aid be directed to strengthening the health system, of which at least half is dedicated to supporting emergency health workforce plans. Creating strategic opportunities for country health systems is important. For example, the flexibility provided by the Global Alliance for Vaccines and Immunization (GAVI) Health System Strengthening (GAVI/HSS) window has allowed the Democratic Republic of the Congo to allocate 32 per cent of its grant to human resources issues. On the other hand, development partners require costed health plans and strategies that provide the necessary foundation on which longer-term financing can be based. Plans need to be comprehensive, covering all major causes of death and disability, and to be sufficiently ambitious and commensurate with what is required to achieve the MDGs. They also need to create a clear link between financing and results.
Alignment and harmonization. Increases in the amount of aid are necessary, but more effective aid is also required if progress towards the MDGs is to be sustained. The need for greater harmonization between donors, and for stronger alignment around national policies and plans, is repeatedly being voiced by countries. The reality on the ground is complex, with several initiatives and partnerships, many of which have their own mandate, priorities and administrative processes. Additionally, about 20 per cent of overall health aid is given as general budget or sector support, while as much as 50 per cent is off-budget. Making the Paris Declaration on Aid Effectiveness a reality on the ground is critical if resources for health are to be deployed and used effectively.
Governance and stewardship. Mechanisms that are transparent and inclusive need to be created to hold all partners accountable for their performance against international agreements. The importance of mutual accountability and responsibility has been emphasized in several new initiatives focusing on the MDGs, such as the International Health Partnership in which Governments and development partners define country-level compacts that represent a close-to-binding commitment by all, and provide a framework for monitoring performance.
Health in fragile States. Greater attention should be given to countries in difficult circumstances, the so-called fragile States, which bear a disproportionate burden of disease and mortality, and are progressing slowest towards the MDGs. Even though they are the countries most in need of stable and predictable aid flows, they tend to suffer from the worst volatility, especially during the transition from humanitarian to development funding. In many cases, aid is provided through non-governmental actors, without corresponding support to strengthen the Government's stewardship and leadership role in the health sector.
The international community shares a strong commitment to reaching the health-related MDGs. Several newly launched health initiatives by major donors and development agencies acknowledge the explicit need to invest in the health systems and better coordinate development assistance, and to introduce a framework of mutual accountability that recognizes the need for country-owned and country-led initiatives. WHO is also working closely with the Development Assistance Committee of the Organisation for Economic Co-operation and Development (OECD) on using health as a tracer sector, in which the health sector will be used for overall monitoring at the country level of the implementation of the Paris Declaration. Experiences will be shared at the third High-level Forum on Aid Effectiveness, to be held in Accra, Ghana in 2008. WHO is currently fully engaged within the United Nations system, along with other stakeholders, to further develop this agenda and achieve the health-related MDGs.
Notes
1. This is based on the Aid Activity Database of the OECD/DAC (the Creditor Reporting System), and excludes private funds from non-governmental sources.
2. UNAIDS, Report on the Global Aids Epidemic (Geneva, 2006).
3. WHO/UNAIDS/UNICEF, Scaling up priority HIV/AIDS interventions in the health sector -- Progress report (Geneva, 2006).
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