Global Health Goal Hits and Misses

A review of the Millennium Development Goals winding down in 2015 offers insights on global health efforts that could inform an even more ambitious UN initiative set to launch this year, writes CFR’s Laurie Garrett. 

April 7, 2015

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This year marks the wind down of one hugely ambitious fifteen-year global development plan and the launch of another even more far-reaching one. At the moment, the new United Nations initiative—the Sustainable Development Goals (SDGs)—looks deeply flawed, featuring an encyclopedic wish-list for costly global accomplishments envisioned for the coming fifteen years.

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But its predecessor, the Millennium Development Goals (MDGs), also seemed impossibly aspirational, and only moderately achievable when ratified by the UN General Assembly in 2000. The MDGs, which set eight big goals, will reach their deadline for completion (or failure) this New Year’s Eve.

Children attend math lessons at the Al Miskin Allawenidi IDP school in Mogadishu. (Photo: UNICEF/Courtesy Reuters)

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The eight MDGs include three that are directly related to global health. Combined, they aim to dramatically reduce childhood and infant mortality; improve the health and survival of pregnant women; provide universal access to treatments for tuberculosis, malaria, and HIV; and reduce the incidence of those diseases. As an exercise in galvanizing global financial action, there is much positive news to report.

The MDGs focused the imaginations and finances of the Group of Eight governments, foundations, thousands of religious and nongovernmental groups and national governments. According to UN Undersecretary Jose Antonio Ocampo and the OECD, direct donor support for the MDGs averaged $80 billion per year from 2000 to 2009, then increased to $130 billion per year in 2010, totaling roughly $1.4 trillion by 2015. Recipient governments contributed modestly, increasing MDG-related domestic spending by an average of 0.5 percent of GDP annually. A private entity, the Bill & Melinda Gates Foundation, has contributed billions of dollars to support MDGs related to health and other areas.

The following is a rundown on progress toward health targets:

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  • Reducing Child Mortality. Progress has been dramatic on the fourth MDG, with the number of children dying before reaching their fifth birthdays cut by half, far more children having access to clean drinking water and education, and HIV infections passed from mother to child radically reduced—to nearly zero in much of the world. In 1990, when the world population was considerably less than today, 12.6 million babies and children died before age five. In 2013 just 6.3 million children succumbed. But Anthony Lake, executive director of UNICEF, writes, “Unless progress accelerates markedly, MDG 4 will not be achieved in all countries until 2028.”
  • Improving Maternal Health. Progress has been spotty, especially concerning the goal of reducing by 75 percent the total number of maternal deaths associated with childbirth. This is on track to fail. German Chancellor Angela Merkel writes that maternal mortality rates “are still unacceptably high and too many women and children face a fight for survival during pregnancy, childbirth, and infancy.” And UK Prime Minister David Cameron adds that “The figures are shocking: 130 million women in our world are affected by female genital mutilation, with 63 million more potentially at risk by 2050. 700 million women alive today were married as children, with 250 million married before 15 years old.”
  • Combatting HIV/AIDS, Malaria, and Other Diseases. Six million children have been spared deaths from such diseases as measles, diphtheria, and polio thanks to massive expansion of child immunization programs. Malaria deaths have been cut in half, tuberculosis mortality is down by 45 percent, the HIV contraction rate has been cut by a third compared to 2000, and more than ten million people worldwide are alive, despite HIV infection, thanks to access to medicines. But vaccines still remain out of reach for many children, and malaria and AIDS continue to cause high numbers of deaths each year, write Mark Dybul, executive director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and Seth Berkley, chief executive of GAVI. 

The lion’s share of failure to meet the MDGs is focused on a small number of extremely impoverished or conflict-torn areas. For example, while twenty-seven developing countries are expected to hit child mortality targets, many African nations won’t come close to meeting them until 2030, or perhaps even 2050.

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"Health has improved so dramatically worldwide since 1990 that we almost live on a statistically different planet."

The MDGs will form a backdrop to thousands of global health and humanitarian activities throughout the remainder of 2015. Meanwhile, the same agencies, NGOs, think tanks, government agencies, and foundations that are scrambling on the MDGs are also haggling over the details of the next fifteen-year targets, the Sustainable Development Goals, or SDGs

The intention is to reach agreement by September 2015 on a set of goals that ought to be sustainable with countries’ own resources and will eliminate acute poverty. But even the term sustainable is controversial, as environmentalists and conservation advocates insist it be used less as a reference to country financial capacity than to “green” principles of protection of resources, animal and plant diversity, and the planetary environment.

Countless meetings involving thousands of participants have already been convened, culminating to date in a synthesis report by the secretary-general on the post-2015 development agenda: The Road to Dignity by 2030: Ending Poverty, Transforming All Lives and Protecting the Planet.

At this point there are seventeen SDGs, stated in a vague, aspirational manner with no clear metrics for achievement. Beneath each of the seventeen goals are dozens of sub-goals and aspirations, forming a laundry list of 169 targets.

The first five SDGs are:

1. Ending poverty in all its forms everywhere;
2. Ending hunger, achieve food security and improved nutrition and promote sustainable agriculture;
3. Ensuring healthy lives and promote well-being for all at all ages;
4. Ensuring inclusive and equitable quality education and promote lifelong learning opportunities for all;
5. Achieving gender equality and empower all women and girls;

Much haggling remains, and the coming months will see escalating debate over every detail of the UN scheme. Australia was meant to host a November 2014 meeting intended to sharpen and pare down the massive list of goals and targets, but the gathering was cancelled when the administration of Prime Minister Tony Abbott cut the meeting’s budget and slashed Australia’s overall foreign aid spending by $7.6 billion.

If the list remains in its current form, all aspects of global health will be squeezed into goal three: “Ensure healthy lives and promote well-being for all at all ages.”

What does that mean? Nobody is sure. One paper defines this as eliminating forty percent of premature deaths and improving “health care at all ages (by) avoiding two-thirds of child and maternal deaths; two-thirds of deaths due to tuberculosis, HIV, and malaria; a third of premature deaths from non-communicable diseases (NCDs); and a third of those from other causes (other communicable diseases, under-nutrition, and injuries).”

Meanwhile, the world population will swell over coming decades, with the most radical increases in Africa and the Indian subcontinent. The global population is expected to top eleven billion by 2100, which means that any hope for “healthy lives” for all of humanity must begin with recognition that there will be billions more people scrambling for food, water, and resources on less available land and more-depleted seas.

"There are seventeen SDGs, stated in a vague, aspirational manner with no clear metrics for achievement."

But the debate over SDGs begins with recognition of real achievements, especially in health, which has improved so dramatically worldwide since 1990 that we almost live on a statistically different planet. The Global Burden of Disease Study, published in late 2013, pools and assesses millions of bits of data from thousands of agencies and studies worldwide. It released startling findings: Overall life expectancy across 188 countries rose from an average 1990 level of 65.3 years to 71.5 years. Tremendous improvements in child-focused health (such as immunizations) and environmental pathogen exposure (clean water) have paid off. But the study found that unacceptably high causes of preventable death remain, including, “HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anemias.”

Moreover, despite improvements in life expectancy and child survival, the WHO finds a growing gap in such achievements. The ten societies with the greatest longevity break down as shown in this WHO table (below), with a Japanese baby girl born in 2012 likely, statistically speaking, to live to age 87. But her counterpart born in a low-income country can expect to live to just age 63. A 2014 Johns Hopkins University study found that the primary difference in life expectancy between nations still rested with wide gaps in infant and child mortality in sixty-seven poor countries. 

 

This year’s final battle over the health targets of the SDGs will boil down to the following three things:

  • Health targets will have to be framed within the context of poverty reduction. Health advocates must identify targets that not only improve morbidity and mortality, but reduce impoverishment. Leading the list for that achievement is Universal Health Coverage, which seeks to create financing schemes that eliminate personal bankruptcy caused by medical expenses and improve national capacity to provide healthcare (through public and/or private insurance means) to entire populations.
  • The core fight this year for SDG 3, cited above, will be over the dozens of proposed health targets, including suggestions that every unmet health MDG simply be folded into the new SDGs, along with a mountain of other targets. The “sustainability” language implies countries will be expected to foot their own bills, eventually, for everything from HIV drugs to wheelchair ramps for disabled, open heart surgery, and epidemic and disaster responses.
  • Dealing with noncommunicable diseases. Cancer and cardiovascular ailments already dominate the global burden of disease and represent far more costly investments in treatment, chronic maintenance, and in some cases, prevention than is the case for infectious diseases. Assuming the poverty reduction targets are critical, how will financing schemes for poor nations possibly result in equitable global access to such things as cardiac bypass surgery, personalized medicine, stem cell therapy, psychiatric interventions, and cancer diagnostics? 
The real challenge for the diverse, often internally competitive global health community will be to forge a path forward that protects and expands the gains made with the MDGs, while adding layers of commitment to chronic ailments, traumatic and accidental injuries, mental illnesses, and the diseases of aging populations. With so many major institutional players on the stage still quite young—fewer than fifteen years in existence—this year will test the maturity of the global health community and its leadership. 
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