NEWS
IN FOCUS
The knowledge is there to achieve development goals, but is the will?
Clare Nullis-Kapp
Cape Town
Interim reports published in September showed that unless something dramatic happens the world will fall far short of most of the Millennium Development Goals to reduce poverty and improve health in developing countries by 2015.
With a decade to go until the deadline for the Millennium Development Goals, it is clear that key targets on health agreed by heads of state in 2000 will be missed not for want of knowledge and technical tools but lack of political will and resources.
Using a baseline of 1990, the targets state that by 2015: the number of people suffering from malnutrition and extreme poverty should be halved; infant and child mortality reduced by twothirds; maternal mortality be slashed by three-quarters; and the spread of communicable diseases such as HIV/AIDS, tuberculosis and malaria reversed.
Other targets include gender equality; universal access to primary education; and more widespread sanitation and drinking-water.
In his annual report to the General Assembly on implementation of the Millennium Declaration, UN Secretary-General Kofi Annan said a "major breakthrough" would be needed in order to achieve the targets.
Much of Asia and North Africa was on track to halve extreme poverty, he said. Countries in Latin America, the Caribbean and West Asia were making good progress towards goals such as education but were less successful in combating poverty.
Sub-Saharan African and some least developed countries in other regions were "far from making adequate progress on most goals," Annan's report said.
"The record of the last 12 months for the poorest is hardly encouraging," he said. "The number of HIV/AIDS infections was higher in the last calendar year than ever before, raising serious concerns about the development prospects for whole regions of the world in which hundreds of millions of people live."
The document, released at the end of August, drew heavily on the findings of the draft interim reports from the individual task forces of the Millennium Project, chaired by Professor Jeffrey Sachs of Columbia University, and on country reports.
While the interim reports did not provide significant new insights into novel forms of treatment or prevention, they helped draw attention to the lack of resources, according to Dr Andrew Cassels, Director of Health and Development Policy at WHO.
"The knowledge is already out there and being applied," Cassels told the Bulletin. "What's new is the recommendations on how the MDGs can be used to focus attention on the resources needed for their achievement."
Jan Vandemoortele, Director for Poverty Reduction at the UN Development Programme (UNDP), said the interim reports helped put poverty and ill-health "on a front-burner".
But their practical impact would depend on the ability of developing countries to tailor the accumulated knowledge to specific national and local needs, and whether donor governments are willing to finance that effort, he said.
The task force reports made it clear there were no quick fixes to lack of basic infrastructure and crumbling health systems, or the chronic shortage of health workers which was singled out as one of the biggest obstacles to tackling HIV/AIDS, malaria and tuberculosis.
They also reflected hurdles caused by political sensitivities over issues like reproductive health, which was not initially included in the targets, and access to essential medicines, which split the task force to such an extent that its two pharmaceutical industry members issued a dissenting statement.
Infant and maternal mortality
Task Force Four said the overall picture was "worrisome indeed," with 10.8 million children under the age of five dying each year and mortality rates in some parts of sub-Saharan Africa increasing.
It said deaths from diarrhoeal diseases and vaccine-preventable conditions had fallen since the 1970s, but there was little progress on acute respiratory infection. Only 16% of countries were on track to meet the child mortality targets, none of them in sub-Saharan Africa, it said.
The report cited studies published last year in the Lancet of 23 high-impact interventions. It said universal breastfeeding could prevent an estimated 1.3 million deaths (13% of the global total), followed by insecticide-treated materials at 691 000 (7%) and complementary feeding 587 000 (6%). In terms of therapy, the Lancet series calculated that oral rehydration therapy could save 1.477 million lives (15% of the total).
In short, 6 040 000 or 60.6% of the 9 992 000 deaths in the high burden countries in 2000 could have been prevented.
"Given that the MDG for child health is based on a two-thirds reduction of annual under-five year old mortality from 1990 levels, it is clear that the goal is theoretically achievable," the task force said.
Overall levels of maternal mortality remained stubbornly high, with estimated deaths at approximately 530 000 per year, the task force said.
It said countries needed to build a functioning health system with trained community health workers and midwives as well as access to emergency obstetrics care, citing the examples of Malaysia and Sri Lanka which have slashed maternal mortality rates in recent decades.
Communicable diseases
Task Force Five said national and international responses to the AIDS epidemic, which killed three million people last year, were "wholly inadequate." It proposed two "demanding but attainable" targets for 2015: to reduce prevalence among young people to 5% in the most affected countries and by 50% elsewhere and to ensure that affordable and effective antiretroviral therapy is available to all who need it.
It said there was an urgent need to step up prevention and focus on vulnerable populations. In particular, it appealed to countries expected to suffer an upsurge in cases including China, India, the Russian Federation and Ukraine to stop criminalizing drug users and instead adopt "evidence-based public health approaches" such as needle exchange programmes and opiate substitution services.
"We now have a range of proven, effective ways to prolong life and control the spread of HIV. The task force believes that urgent scaling up of the interventions we have in hand could save millions of lives and bring the epidemic under control," it said, stressing the need for sustained investment in health systems.
On tuberculosis, the task force said it was vital to scale up case detection, make treatment more widely available and step up adherence to this treatment. It said that TB/HIV co-infection and multidrug resistant tuberculosis should be adequately addressed and new drugs, vaccines and diagnostic technology should be developed.
On malaria, the task force also pleaded for a scaled-up, comprehensive approach, saying existing national efforts were fragmented and inadequate.
The draft task force reports are due to be finalized this year. Pilot projects have been launched as part of the Millennium Project in Cambodia, the Dominican Republic, Ethiopia, Ghana, Kenya, Senegal, Tajikistan and Yemen to try to integrate the MDGs into three to five-year poverty reduction strategies. None of the countries chosen was on target to achieve the goals on a "business as usual course".
The results in the pilot projects are expected to be a key indicator of the overall success of the MDGs. Some of the interim national reports have been encouraging. For instance, the UN country team earlier this year predicted that China would reach most of the goals, with HIV/AIDS among its greatest challenges.
Thailand said it had already met the targets and introduced more ambitious "MDG Plus" targets including reducing poverty to below 4% by 2009 (a four-fifths reduction since 1990) and reducing HIV prevalence in adults to 1% by 2006. Specifically Thailand intended to focus on the most vulnerable people in the most vulnerable regions an approach lauded by WHO, UNDP and The World Bank.
Specific success stories were highlighted in a recent study by the What Works working group of the Washington- based Center for Global Development. These included:
measles immunization in seven southern African countries virtually eliminated the disease as a cause of childhood death, and helped reduce the number of cases from 60 000 in 1996 to just 117 in 2000;
trachoma, the leading preventable cause of blindness, was cut by more than 90% in Morocco through a combined strategy of surgery, antibiotics, face-washing and environmental controls;
malaria control in the United Republic of Tanzania was boosted by a social marketing campaign which dramatically increased the use of insecticide-treated bednets in rural areas and increased child survival by nearly one-third;
a guinea worm eradication drive focused on behavioural change resulted in the reduction of disease prevalence by 98% in 20 endemic African and Asian countries;
oral rehydration therapy in impoverished North-east Brazil cut child deaths due to diarrhoeal disease from 13% to 4%.
A separate study by the Center for Global Development contended that the MDG targets were unrealistically high and that this could jeopardize funding. Widespread failure to meet the goals risked giving donors an excuse for not funding vital projects, it argued.
Udaya S. Mishra, Takemi Fellow at Harvard School of Public Health, said that it was vital to achieve a balance between the quantitive and qualitative aspects of each target. "Often 'how much' dominates 'how good'," Mishra said.
There is particular disappointment at the lack of progress toward one of the most important goals: the responsibility of rich countries to offer fair trade, debt relief and increased aid.
Annan's report said that only the Netherlands, Denmark, Luxembourg, Norway and Sweden had met the target of increasing overseas development aid to 0.7% of national income. Five more, Ireland, Belgium, France, Spain and the United Kingdom, have promised to do so over the next 10 years.
At a meeting in the Ethiopian capital, Addis Ababa in July, Jeffrey Sachs complained that key donors such as the United States, Japan and Germany were making no "concrete efforts" towards meeting the development aid targets. "Despite the promises of help, we are getting band-aids, not solutions," Sachs said. 
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