In the year 2000, the largest-ever gathering of world leaders committed to an ambitious agenda to save lives and improve the quality of life of the world’s poorest people. The United Nations Millennium Development Goals (MDGs) set eight goals and 18 targets to be met by the end of 2015. Three of the goals are directly aimed at improving health (reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other diseases) and the other five goals have an indirect but critical impact on health (such as eradicating extreme poverty and hunger).
Since 2000, the World Health Organization (WHO) has focused a large part of its work on helping countries to reach MDG health-related targets. As we approach the 2015 milestone, it is time to reflect on how efforts to achieve the goals have improved the health of the world’s people and changed our approaches to public health and consider what is needed for the future in this changing world.
Progress in Global Health
Perhaps the most important effect of the MDGs has been to inspire global action by the international develop- ment community. These specific and measurable goals have focused political attention and generated much-needed funds for some of the biggest health challenges of the past 15 years.
In just 15 years, we have saved millions of lives and improved the health and well-being of millions more, thanks to direct efforts by governments and partner organizations to achieve the MDGs. Some of the achievements are stunning.
As reported in WHO’s 2015 World Health Statistics, by the end of this year if current trends continue, global targets for turning around the epidemics of HIV, malaria and tuberculosis and increasing access to safe drinking water will be met. Worldwide we will also have made substantial progress in reducing child deaths, hunger, maternal and child deaths, and increasing access to basic sanitation.
Progress in child survival is one of the greatest success stories of international development. Over the past 20 years, child deaths have been almost halved. In 1990 – the benchmark year against which progress on the MDGs is being measured – one in 10 children died before the age of five. Today, it is one in 20.
We can thank immunization for much of this success.
As one of the “best buys” for preventing childhood illness and deaths, immunization is estimated to save two to three million lives each year. Increased coverage of the measles vaccination alone is estimated to have saved 14 million lives since 2000.
Vaccines for preventing diarrhoea and pneumonia – two of the biggest childhood killers – are making a difference in recent years as vaccines are rolled out at unprecedented rates in countries like Ghana, which introduced both vaccines simultaneously in 2011. Improvements in access to clean water and sanitation, better nutrition, and access to medicines like antibiotics and oral rehydration salts have also contributed to saving children’s lives.
The number of women who die each year due to complications during pregnancy and childbirth has also nearly halved in the past 20 years. In 1990, more than half a million women died of these complications. Maternal deaths have fallen all over the world as more women have access to contraceptives and skilled care in pregnancy and child- birth. Yet, we still have work to do. In 2013, an estimated 289,000 women died of maternal complications. Almost all of these deaths could have been prevented if these women had access to skilled care, good hygiene and inexpensive drugs to manage complications like severe bleeding and pre-eclampsia (caused by high blood pressure).
Improving maternal health is one of WHO’s priorities. The Organization provides countries with evidence-based guidance, advocates for more affordable and effective treatments, designs training materials and guidelines for health workers and supports countries to implement policies and programs to save more women’s lives.
We have turned the tide on the HIV epidemic. In 2013, an estimated 2.1 million people were newly infected with HIV, down from 3.4 million in 2001. By the end of 2013, 11.7 million people were receiving antiretroviral therapy (ART) in low- and middle-income countries (and close to 13 million worldwide), as compared with an estimated 300 000 people on ART at the end of 2002. Fewer people are dying from AIDS-related causes now, thanks to increased availability of ART and a decrease in the number of newly infected people. In 2005, around 2.4 million people died of AIDS- related causes. This dropped to 1.5 million people in 2013.
We have also met the target of reversing the incidence of malaria – a mosquito-borne disease that kills more than half a million people every year, most of them African children less than ve years of age. The estimated total number of malaria cases fell from 227 million in 2000 to 198 million in 2013. During that same period, malaria deaths dropped 50 percent worldwide and even more in Africa. This extraordinary change came about through widespread distribution of bed nets among other preventive measures and e ective treatment.
The estimated number of people falling ill with tuberculosis each year is declining slowly, which means that the world is on track to achieve the MDG target to reverse the spread of this infectious disease by 2015. An estimated 37 million lives were saved through improved tuberculosis diagnosis and treatment between 2000 and 2013.
The MDGs have been good for public health but, although some targets have been met worldwide, there are still wide gaps in progress in individual countries and population groups within those countries. Some countries have made impressive gains while others are falling behind, particularly those affected by economic hardship, conflict, and high levels of HIV infection.
When you break down health statistics into population subgroups – the poorest, least educated, most socially marginalized, and those living in rural areas – the picture remains bleak in many places. People in the most disadvantaged ranks of society, in the great majority of countries, still have less access to quality health services and poorer health outcomes as a result.
Natural disasters and disease outbreaks have also hampered progress in some countries. For example, we know that the Ebola outbreak has caused a major setback to health progress in Guinea, Liberia, and Sierra Leone in the past year.
In short, we still have much unfinished business. Unsurprisingly, many of the countries with the poorest health outcomes in 1990 are still in that position.
Four out of every five deaths of children under the age of five occur in sub-Saharan Africa and southern Asia. A large proportion of these deaths are among newborn babies whose deaths could be prevented by access to skilled health workers and simple, inexpensive solutions such as steroid injections that cost less than a dollar per treatment and resuscitation devices that cost less than USD 5.
The proportion of mothers who die during childbirth is still 14 times higher in developing countries than in high income countries. Half of all women living in sub-Saharan Africa don’t have access to skilled care during pregnancy and childbirth.
And one in 4 African women who wants to prevent or delay childbearing does not have access to modern contraceptives.
While we have achieved the target of placing 15 million people on ART in low- and middle-income countries by 2015, too many people living with HIV are missing out on these life-saving medications. More than 30 million people live with HIV in low- and middle-income countries, and only one third of them have access to ARTs. As many as half of them do not even know their HIV status. And many people on treatment are now requiring chronic care services for a range of health conditions, including co-infections such as viral hepatitis.
Despite the millions of bed nets that have been distributed in Africa in recent years, around 270 million African households do not even have access to one bed net to prevent malaria-carrying mosquitoes from infecting families while they sleep.
Between 1990 and 2013, deaths from tuberculosis fell by 45 percent. Nevertheless, the disease still has a high burden, with 9 million people becoming ill and 1.5 million dying from it in 2013. Multi-drug-resistant strains of the bacterium that causes tuberculosis threaten progress.
A Changing World
While the MDGs have been successful in focusing global attention on the health challenges of the day, the world has changed dramatically since the year 2000.
The global population has grown from 6 billion people in 2000 to more than 7 billion, and 2.5 billion of them live in China and India combined. In almost every country, the proportion of people aged more than 60 years is growing faster than any other age group. By 2050, the world is expected to have 2 billion people aged more than 60, and almost 400 million aged more than 80 years.
The demography of poverty has changed. Today, 70 percent of the world’s poor live in countries classified as middle-income by the World Bank. As countries experience unprecedented economic growth, others struggle to recover from the worst nancial crisis in decades. Countries like China and India lifted millions of their citizens out of poverty. In many other countries, the benefits of growing wealth have gone to a privileged few.
Just a few decades ago most of the world’s people lived in rural areas. Since the year 2000, the population of urban areas has grown by more than a billion. More than half of the world’s people now live in cities.
While rapid urbanization has improved living standards and access to health services for many, it also has created many challenges. Sedentary lifestyles, globalized marketing of unhealthy products, and increased air pollution have led to a rise in lifestyle-related diseases.
When the MDGs were being developed, infectious disease were viewed as the greatest threat to global health. Now noncommunicable diseases – such as heart disease, stroke, cancer, and diabetes – have overtaken them as the biggest global killers and are responsible for 60% of all deaths worldwide. While these diseases did not even rate a mention when the MDGs were being developed, they threaten to reverse much of the progress made in improving healthy life expectancy in the coming decades if nothing is done to address them.
Once considered a problem only for rich countries, obesity is on the rise in low- and middle-income countries, particularly in urban areas. In 2014, close to 2 billion adults were overweight and more than 600 million were obese. More than 40 million children aged less than five years were overweight or obese. Many countries face a double burden of disease: it is not uncommon to find wasting due to inadequate food and obesity side-by-side in the same country, even in the same household.
The Sustainable Development Goals (SDGs)
Building on the momentum generated by the MDGs, the United Nations has been working with governments and a variety of organizations focused on development to shape the agenda for the next 15 years.
In September, world leaders will agree on new and ambitious global goals for 2030 at the United Nations General Assembly in New York. In addition to finishing the MDG agenda, the post-2015 agenda needs to tackle emerging challenges including the growing impact of noncommunicable diseases and changing social and environmental determinants that affect health.
The draft post-2015 agenda reaches for 17 goals, including an overarching health goal to “ensure healthy lives and promote well-being for all at all ages”. This goal has 9 targets: three related to the MDGs, three on noncommunicable diseases and injuries, and three that focus on broader health issues such as universal health coverage.
Health is regarded as a desirable outcome in its own right, an input to other goals, and a reliable measure of progress in sustainable development. While the single health goal captures many of the key aspects of achieving good health, it is closely linked to many of the other 16 proposed goals. Health contributes to, and is affected by, poverty reduction, hunger relief and improved nutrition, safer cities, affordable energy, efforts to combat climate change, and clean water and sanitation. Good health and well-being depend on economic, environmental, and social improvements.
The post-2015 agenda aims to be more relevant to all countries – rich and poor alike – than the MDGs. Ensuring the right to the highest attainable physical and mental health for all is the ultimate goal, and this aspiration serves as a unifying concept. To achieve this will require better integration of the di erent parts of health systems and a greater emphasis on equity and social inclusion reflect the guiding principle of the post-2015 agenda: leave no one behind.
The Global Strategy for Women’s, Children’s and Ado- lescents’Health, which is one important tool that will guide the international health community’s work over the next 15 years, has a rm focus on equity. Its guiding principles are based on human rights and humanitarian ideals that every woman, child and adolescent has the right to access quality health care.
A Changing Mindset
The MDGs brought about significant change: one of perception. The formerly widespread belief that poor people are doomed to low quality health care and poor health is now an idea of the past.
We enter the post-2015 world armed with better knowledge and scientific advances, including vaccines, and a host of new initiatives and strategies. There are three critical areas on which we must focus our efforts as we move forward.
First, the era of delivering health care in isolated and “siloed” programs must come to an end. Effective health services can only be delivered through strong and resilient health systems that reach everyone and can adapt in the face of disasters, disease outbreaks, or conflict. In future years, if we remember little else about the recent Ebola outbreak in West Africa, we should learn from this lesson.
Second, all actors in global health must be firmly committed to transparency, accountability, and measurement of results. Setting numerical targets for entire countries is not enough. When we look closely, stark differences and inequities appear within all countries. We must aim for progress across the board – in remote and rural areas and among the poorest and most disadvantaged residents of urban centers. We need to be able to identify the gaps so that we can allocate limited resources effectively.
Last, and most importantly, our work must be driven by a fierce commitment to equity, social justice, and the right to health; and we must speak about these matters stridently. Today almost every country in the world has committed to ensuring the right to health. We must make this commitment a reality for all.
Working in partnership
WHO has always worked closely with our sister agencies in the United Nations family and with political leaders. We know that success in public health depends on political commitment – from heads of state to local and community leaders.
Over the past 15 years, WHO has increasingly understood the need to work collaboratively with nongovern- mental organizations, civil society groups, and the private sector. Never before in history have there been so many new ventures and collaborations in global health, with United Nations agencies, nongovernmental organizations, government, and grassroots citizen groups working together towards common goals to achieve the MDGs.
Whilst it is not possible in a short article like this one to mention every actor, there are some examples of partnership ventures that emerged during the MDG era and worked well.
In 2000, AIDS, tuberculosis, and malaria together killed around 6 million people a year. Since its creation in 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria has helped mobilize billions of dollars to accelerate the end of the epidemics of these three killer diseases.
Gavi, the Vaccine Alliance – a public-private partnership – was created in 2000 to improve access to new and under-used vaccines for children living in the world’s poorest countries. Its work has helped avert more than 7 million deaths from diseases including hepatitis B, meningitis A, pneumococcal disease, and diarrhoea caused by rotavirus. Gavi has also introduced innovative vaccines –such as the human papillomavirus vaccine – into developing countries, with the aim of reducing the toll of cervical cancer.
In 2005, the Partnership for Maternal, Newborn and Child Health was launched to accelerate action by donors and developing countries to reduce child mortality and improve maternal health and now includes more than 680 partner organizations, Five years later, the United Nations Secretary-General Ban Ki-moon launched the Global Strategy for Women’s and Children’s Health, and the global movement Every Woman Every Child, to galvanize further action. A new Global Strategy for Women’s, Children’s and Adolescents’ Health currently under development will aim to ensure the e ectiveness of the SDGs. The MDGs did not focus on newborn deaths and stillbirths. Adolescents missed out too. As a result, many preventable deaths still occur every year.
WHO is also working more and more with actors who work outside the health domain yet nonetheless play an important role in determining health. Working across different sectors – with food producers, schools, and health workers – is crucial to improving nutrition, for example. Environmental factors, such as water and sanitation, pollution and climate change, and the conditions in which people live, are strong determinants on their health status.
These challenges can only be overcome if there is a strong collaboration amongst a wide range of actors.