EDITORIALS
What will it cost to attain the health MDGs?
Anders Nordström; Tessa Tan-Torres Edejer1; David Evans
Health Systems and Services, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland
There is an old saying that "amateurs talk strategy and professionals talk logistics". A professional approach to achieving the health-related Millennium Development Goals (MDGs) requires us to move beyond the discussion of possible strategies that could be used. It requires active planning of the practical actions that need to be taken, including raising the necessary funds to ensure these actions can be financed. This cannot be done without information on the costs of implementing the logistical plans.
Without detailed plans, countries cannot be sure if they will meet the MDGs. Without accurate costing, countries and donors do not know the extent of the additional funds that will be required. This is a particularly important issue now that we are nearly halfway between the signing of the Millennium Declaration and the target date for achievement, 2015. All recent assessments suggest that few countries are on track and that intensified efforts to raise and use funds well are needed. How much additional funding is required, and where should it be spent?
Some, though limited, work relating to the costs of achieving the MDGs already has been undertaken. For example, the Commission on Macroeconomics and Health estimated the cost of providing an essential package of services, most of which addressed the health MDGs.1 However, the package was limited and many key costs were not included. The UN/UN Development Programme Millennium Project also sponsored studies in selected countries, but these were a small, non-random selection of the countries that had signed the millennium declaration.2
In response to the need for better cost estimates, a series of papers will appear in the Bulletin throughout 2007, including two in this issue. These papers estimate the costs needed to scale up interventions that would achieve the MDGs, specifying a wider set of administrative and systems costs and including the countries where the bulk of the remaining burden of disease is found. Separate papers report the costs for maternal health, child health, immunization, malaria, tuberculosis and HIV. A final paper will draw on these results, identifying what it would cost to scale up all interventions across these conditions at the same time. That paper will consider potential synergies that could be realized in scaling up multiple interventions; for example computers, offices and vehicles could be shared, at least in some instances. The concluding paper will also aggregate key system and programme costs, from recruitment and training community health workers to building additional health infrastructure. Such costs would need to be met to ensure all the disease-specific interventions could be undertaken. This will mark the first time a comprehensive cost of scaling up all interventions is reported.
The authors of these papers selected interventions for inclusion specifically because they are prerequisites to achieving the MDG targets. Baseline coverage of each intervention is assessed on a country-by-country basis, and target coverages that would achieve the MDGs are identified. The activities and inputs required to increase coverage to the desired level were developed jointly with technical programmes in WHO based on best practices. The methods also adjust for the fact that some interventions that are scaled up together interact. For example, the use of insecticide treated nets would reduce the need for treatment of fevers over time, and increased use of maternal tetanus toxoid injections would reduce the need for treatment of neonatal tetanus.
Another important contribution of these papers is that the costs needed to organize, plan, monitor and manage programmes, and the system as a whole, are included along with the more usual costs of delivering the interventions. This is not commonly done, and some of the previous work has probably underestimated the true costs of scaling up. In all the papers, costs are estimated on a country-by-country basis, and the global estimates represent the sum of all country costs.
The end result is a set of comprehensive estimates of the costs of scaling up health interventions to achieve the MDGs. These are critical for planning at the country level, and for helping countries and the international community to assess remaining resource gaps that need to be financed. We believe that this type of work will lead to strengthened collaboration across countries and agencies in joint efforts to improve population health and well-being in poor countries. 
References
1. Macroeconomics and Health: investing in health for economic development Report of the Commission on Macroeconomics and Health. Geneva: WHO; 2001.
2. Millennium Project. Millennium development goals needs assessments country case studies of Bangladesh, Cambodia, Ghana, Tanzania and Uganda Working Paper. 17 January 2004. http://www.unmilleniumproject.org/ document/mp-ccspaper-jan1704.pdf
1 Correspondence to Tessa Tan-Torres Edejer (e-mail: tantorrest@who.int).