Carla AbouZahr*; Ties Boerma
Department of Health Systems and Informatics, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland
At the May 2010 World Health Assembly, ministers of health will discuss the health-related Millennium Development Goals (MDGs). Other events during 2010 - including the United Nations General Assembly in September - will also generate probing questions. What has been achieved? What are the challenges and how can they be overcome? World health statistics 2010, which will be launched during the World Health Assembly, provides World Health Organization estimates of progress on key health-related indicators. While there are notable achievements, progress is poorly distributed across interventions and populations. Better country data are needed to track progress and identify those being left behind.
Globally, child mortality has fallen by 30% since 1990 and the pace of change is accelerating. In Africa, the annual rate of decline has doubled since 2000, reaching 1.8% compared with only 0.9% during the 1990s. These trends are underpinned by improvements in nutrition, immunization coverage and access to safe water. Since 1990, underweight rates in children aged less than 5 years have fallen by 7% and measles immunization coverage increased by 10%. The world is on track to achieve the MDG target on access to safe water. New HIV infections fell by 16% between 2001 and 2008 and access to treatment has expanded dramatically; by the end of 2008, more than 4 million people in low-income and middle-income countries were receiving antiretroviral therapies. Tuberculosis cases have continued to fall gradually. Thirty-eight countries are on course to meet the MDG malaria target, largely due to use of insecticide treated mosquito nets.
Striking improvements have occurred in countries across the income spectrum, including in those emerging from conflict and disaster where the constraints are greatest. Low-income countries such as Liberia, Mozambique, Rwanda and Sierra Leone have achieved rates of progress towards the child mortality target that wealthier countries would do well to emulate.
Nonetheless, daunting challenges remain. Increases in access to safe sanitation have not kept pace with population growth. Lack of safe water and sanitation contributes to the toll of child deaths due to diarrhoea which, together with pneumonia, kills an estimated 3 million children aged less than five each year. Malaria causes an estimated million deaths annually, mostly in children. Affordable preventive and treatment options are available to prevent these deaths: the challenge is to ensure that they are accessible to all.
Successes in increasing access to complex treatments for HIV infection have not been matched by improvements in coverage of simple treatments for common diseases, such as oral rehydration for diarrhoea, antibiotics for respiratory infections and artemisinin combination therapy for malaria. Relatively low-cost, generic medicines are not widely available in public health facilities, forcing patients to purchase medicines privately, where they cost on average 630% more than their international reference price.
The most vulnerable in society face the biggest hurdles in accessing care. These in-country inequalities are often hidden when data are presented only as national averages. The poor, those living in rural areas, and less-educated people fare poorly, with low coverage of care and high levels of mortality and morbidity. Reducing inequalities requires multisectoral action to addressthe socialand economic determinants of health. This is captured in the MDG goals on poverty, education, employment, gender equity and environmental sustainability.
Strategies to address the multidimensional nature of deprivation and exclusion are urgently needed if the world is to reach the MDG goal on maternal health. Despite a 12% increase in contraceptive use between 1990 and 2005, many couples cannot access family planning. Globally, less than half of pregnant women have the minimum of four antenatal visits as recommended by the World Health Organization. In sub-Saharan Africa and south-eastern Asia, in 2008 less than half of all births were assisted by a skilled health worker; in sub-Saharan Africa, there has been virtually no progress at all since the 1990s. Tackling these issues is essential for the health and survival of both women and infants: deaths during the first month of life account for two out of five child deaths.
A reflection of the failure to prioritize maternal health is the limited availability and poor quality of data on maternal mortality. A decade after the Millennium Declaration, few low-income and middleincome countries have health information systems able to generate reliable mortality data. Global monitoring is heavily dependent on statistical modelling which can result in divergent and highly contested estimates. The paucity of country data on cause of death is a challenge for tracking all the health-related goals. With only five years remaining until the 2015 deadline, it is time for a call to action for countries and development partners to seriously invest in counting births, deaths and causes of death.
The variable progress achieved begs the question of the feasibility of the MDG goals and targets. The child mortality target of a two-thirds reduction between 1990 and 2015 requires an average annual decline of 4.3%, which few high-mortality countries are likely to achieve.The MDGs were initially defined globally;1 their translation into country-specific targets gives little consideration to baselines, contexts and implementation capacities. The global targets were ambitious and based on little evidence of feasibility in low-income countries. Perhaps rather than making targets ends in themselves, it would be more realistic and relevant to focus instead on the overall direction and pace of change.
1. Manning R. Using indicators to encourage development: lessons from the Millennium Development Goals. Copenhagen: Danish Institute for International Studies; 2009.