Urgent opportunity for action

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The successes of the past are only a beginning. The global health community has reached a critical juncture in that now, more than ever before, the knowledge, innovative technologies, and proven tools to help millions of people in need are within reach. But, despite demonstrated success in tackling certain health issues, the gap continues to grow between what can be done with existing knowledge, and what is actually being done in disadvantaged communities.45 Existing interventions are not widely used even though many are inexpensive and easy to administer.46 In the area of child mortality, for example, the tremendous gains made in child survival during the past half-century have actually slowed or been reversed since the mid-1990s.47 At the same time, chronic diseases (such as diabetes and heart disease) have joined the traditional list of infectious “poor country” diseases in an extraordinary global epidemiologic transition.

If the global community neglects its responsibilities at this critical moment, health outcomes for the most vulnerable populations will remain static or decline, progress achieved in poverty reduction thus far will be threatened, and the poorest countries will continue to be left behind. The global health community should act now. The progress seen in recent years in Latin America and Southeast Asia should be replicated in the poorest countries in sub-Saharan Africa and South Asia.

Achieving the Millennium Development Goals by 2015

The globally recognized MDGs were adopted by the Member States of the UN in 2000 to achieve demonstrable reductions in poverty and improve specific health outcomes by 2015. Three of the eight goals pertain directly to health (Goals 4, 5, and 6) and the other five indirectly (see Box 1). While progress has been made, as discussed below, the MDG targets remain a distant goal for many countries, particularly in sub-Saharan Africa and South Asia.48

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Box 1

United Nations Millennium Develpment Goals. Target 1: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate Target 1: Reduce by three quarters the maternal mortality ratio

MDG 4: Reducing child mortality. Global child mortality rates have dropped steadily during the last 50 years. But between 1990 and 2006, about 27 countries—the large majority in sub-Saharan Africa—made little or no progress in reducing childhood deaths (see Figure 1).49 This reality is made sharper by the knowledge that existing health interventions could reduce child mortality by as much as 63 percent if they could reach those in need.50 While progress has been made in important areas—for example, deaths from measles fell by two-thirds between 2000 and 2006 due to dramatically improved vaccination programs covering 80 percent of children in developing countries51—the lack of well-functioning health care systems severely constrains the delivery of many essential health interventions.52

Figure 1. MDG 4: Under five deaths per 1,000 live births (1990, 2006, and 2015 target).

Figure 1

MDG 4: Under five deaths per 1,000 live births (1990, 2006, and 2015 target). SOURCE: The Millennium Development Goals report, 2008.

MDG 5: Improving maternal health. Ninety-nine percent of maternal deaths occur in low-resource settings, with sub-Saharan Africa and South Asia accounting for 86 percent of all such deaths (see Figure 2). Less than half of all births are attended by health professionals in these regions: 47 percent in sub-Saharan Africa and 40 percent in South Asia. Meanwhile, progress in North Africa and Southeast Asia has been remarkable, demonstrating that substantial progress in maternal health is possible.53 What is required is the commitment to establish countrywide systems of qualified and adequately equipped personnel, and effective infrastructure that allows women to be referred and transported for emergency obstetrical care.54 Without these, one in six women living in the world’s poorest settings will continue to die from treatable or preventable complications in pregnancy and child birth.55

Figure 2. MDG 5: Maternal deaths per 100,000 live births (1990, 2005, and 2015 target).

Figure 2

MDG 5: Maternal deaths per 100,000 live births (1990, 2005, and 2015 target). SOURCE: The Millennium Development Goals report, 2008.

MDG 6: Combating HIV/AIDS, malaria, and other diseases. AIDS continues to be the leading cause of death in sub-Saharan Africa and the fourth largest killer worldwide.56 Recent expansion of antiretroviral treatment for HIV-infected individuals has succeeded in reversing the direction of AIDS mortality; between 2005 and 2007, the number of people who died annually from AIDS declined from 2.2 million to 2 million. However, in 2007, 2.7 million people were newly infected with HIV.57

Globally, more than 2 billion people are at risk of malaria.58 Though malaria incidence and mortality has been dramatically reduced in some parts of Africa due to widespread increases in the use of artemisinin-containing medicines and anti-mosquito measures like insecticide-treated bed-nets, approximately 500 million people still contract malaria each year resulting in 1 million deaths.59

Tuberculosis (TB) kills an additional 1.7 million people a year. If global targets are to be met, Africa, China, and India—which collectively account for more than two-thirds of undetected TB cases—will have to improve both the extent and timeliness of the diagnosis of active TB and increase the rate of successful treatment.60 Complicating diagnosis and treatment further, the extremely drug resistant strain of tuberculosis, XDR-TB, leaves patients (including many people living with HIV) virtually untreatable using currently available anti-TB drugs.61

Often overlooked are the neglected diseases of poverty like roundworm and schistosomiasis infection—scourges that have afflicted the world’s poorest since ancient times. These infections continue to be common among the estimated 2.7 billion people living on less than $2 a day, causing conditions that often result in long-term disability and poverty.62

The remaining five MDGs do not exclusively deal with health issues, but are indirectly linked to health outcomes. Nearly one billion people—a sixth of the world’s population—lack access to safe drinking water, and 2.5 billion people are in need of improved sanitation services (MDG 7). In the developing world, one out of every four children under 5 years old is underweight, mostly due to inadequate food, and often also as a result of disease (MDG 1).63 Malnutrition retards growth and also leads to weak cognitive functioning, with consequences for the progress of whole societies. An estimated 200 million children under the age of 5 fail to reach their potential in cognitive development due to poor nutrition, poverty, and deficient care.64 While one in seven people already suffer from food scarcity,65 the threat of climate change is further increasing the risk of crop failure, livestock losses, and subsequent food shortages (MDG 7).66

Educational and economic opportunities are also out of reach for many of the poor, especially young women. Among primary school age children worldwide, more than 90 percent attend school, but 38 million children in sub-Saharan Africa do not go to school (MDG 2). Low rates of school enrollment and attendance are especially devastating to girls as they are linked to their future income, personal health status, and the health status of their future children and families (MDG 3).67

Neglected health systems undermine health progress

Functional health systems are sorely lacking in most poor countries, undermining the achievement of the health-related MDGs.68 A functioning health system, as defined by the WHO, should include access to a well-performing health workforce; reliable and timely health information; essential medical products, vaccines, and technologies; adequate financing; and strategic policy frameworks to provide effective analysis, oversight, and governance.69

More than half of the meager spending on health in low-income countries is in the form of out-of-pocket payments made by patients—the most inequitable type of financing because it disproportionately hurts the poor, and provides no protection from the costs of catastrophic illness. Government assistance for health in low-income countries is only 29 percent of the total expenditure on health compared to 65 percent in high-income countries; in fact, the poorer the country, the lower the proportion of government money devoted to public health.70

Individuals who do gain access to health care are often confronted with a shortage of essential drugs and medical personnel.71 For example, the WHO estimates that 57 countries (36 of which are in sub-Saharan Africa) have critical health workforce shortages72 and nearly 2 billion people do not have regular access to essential medicines.73 These shortages often stem from larger policy failures, such as a lack of capacity to provide health worker training programs, manage a drug supply system, or anticipate health care needs.74

Planning and decision making to improve health systems requires reliable and timely statistics on births and deaths (including the medical causes of death),75 but most people in Africa and Asia are born and die without leaving a trace of any legal record or official statistic.76 Each year, nearly 50 million births are not registered worldwide,77 and half of the countries in Africa and Southeast Asia record no “cause of death” data at all.78

Efforts to improve health outcomes can be much more successful if sector-wide and disease-specific strategies aim to strengthen health systems and expand the reach of existing interventions.79 Successful models do exist. In Tanzania, improved local health system planning and priority setting, together with modest investments in health services and increased coverage of key child-survival interventions, contributed to significant reductions in infant and child mortality.80 Both Thailand and Mexico embarked on health system reform that provided increased financial protection for the poor; in these countries, health systems research was a powerful tool for informing decision making and moving the agenda forward.81 Commitments are therefore needed from low- and middle-income country governments and their donor partners to invest in health systems and research that can aid in the delivery of existing interventions to attain the health-related MDGs, as well as address the emerging challenges of the 21st century.

Emerging challenges for the 21st century

While the MDGs are useful guides for mobilizing and focusing aid resources, much more will need to be done to attain the goal of global health. Investments need to go beyond well-recognized infectious diseases like HIV/AIDS and malaria and take a more comprehensive view of health in developing countries.

Globalization is changing the way that nations must protect and promote health, in part due to the growing number of health hazards that increasingly cross national boundaries. These threats include infectious diseases as well as unhealthy imports, such as tobacco and processed foods, which heighten the risk of many noncommunicable and chronic diseases.82 As a result of rapid urbanization, more than half of the world’s 6.6 billion people now live in cities, where they are exposed to a variety of risk factors for chronic disease.83 City dwellers live more sedentary lives than their agrarian counterparts and have easier access to cheap, high-energy, high-fat food.84

Emerging pandemic threats like bird flu, which can spread with alarming rapidity in today’s globalized world, need urgent preparation. Infectious disease outbreaks have significantly increased during the last several decades85 and are dominated (60 percent) by zoonoses, or diseases contracted from animals.86 This increase in infectious diseases must be attributed to both climate change87 and increasing contact between humans and wildlife.88 Severe acute respiratory syndrome (SARS)—a zoonotic disease thought to have been first transmitted from bats to humans in south China89—infected 8,000 people in 26 countries and caused 774 deaths in a matter of months between 2002 and 2003.90 Its global economic impact was estimated at about $30 billion.91

The rising tide of chronic and noncommunicable diseases in both industrialized and low-resource settings also cannot be ignored any longer. Chronic conditions like cardiovascular disease and diabetes have joined the traditional list of infectious “poor country” diseases in an extraordinary global epidemiologic transition. Remarkably, 80 percent of chronic disease deaths occur in low- and middle-income countries.92 In 2001, cardiovascular disease alone was responsible for almost three times as many premature deaths in low- and middle-income countries as AIDS, malaria, and TB combined.93 Smoking, which greatly increases the risk of acquiring diseases such as TB, heart attacks, and cancer, remains an addiction in many poor countries. Unless large numbers of adults quit, smoking will account for 1 billion deaths this century.94

The prevention and treatment of chronic and noncommunicable diseases should become a priority in global health, along with interventions to reduce risk factors such as tobacco use, obesity, and sedentary lifestyles. As noncommunicable diseases are not included in the MDGs,95 the WHO has called for a global commitment to reduce chronic disease death rates by an additional 2 percent annually or by 36 million deaths by 2015.96

Increased mortality from chronic disease is not merely a result of fewer deaths from infectious disease. In East Asia and the Pacific, for example, the anticipated increase in death rates from chronic disease will be more than five times the predicted drop in mortality rates from infectious disease.97 Both emerging infectious threats and chronic diseases are increasing globally, resulting in the so-called “dual burden” of disease, whereby significant infectious and chronic diseases burden the same country or region (see Figure 3).98 For example, developing countries are experiencing a protracted, polarized epidemiologic transition with high levels of malnutrition alongside high levels of obesity.99 This mix of health challenges demands new approaches that integrate both infectious and chronic disease interventions.

Figure 3. Burden of disease in disability adjusted life years by cause and WHO region (2004).

Figure 3

Burden of disease in disability adjusted life years by cause and WHO region (2004). Source: Committee’s calculations based on WHO, 2008.

Morbidity and mortality from injuries are also on the rise. As the use of motor vehicles rapidly expands in low- and middle-income countries, road traffic accidents have increased dramatically. They now claim 1.2 million lives each year,100 and are the leading cause of death among young people between 10 and 24 years.101 The highest burden of such injuries and fatalities is borne disproportionately by poor people in developing countries, such as pedestrians, cyclists, and the passengers of buses and minibuses.102 Violence is another problem worldwide, resulting in the death of more than 1.6 million people each year.103 For women, in particular, the prevalence of lifetime physical or sexual violence (or both) by an intimate partner ranges from 15 to 71 percent.104