Table of Contents

Pages

Abstract _____________________________________________________________________ 2

Background __________________________________________________________________ 3

The eight MDG _______________________________________________________________ 3

Global Progress: Are we on track to meet the MDG by 2015?___________________________ 4

Eradicating extreme poverty and hunger ___________________________________________ 4

Achieving universal primary education ____________________________________________ 6

Reduce child mortality _________________________________________________________ 6

Improve maternal health ________________________________________________________ 8

Combat HIV/AIDS, malaria and other diseases _____________________________________ 10

Ensure environmental sustainability ______________________________________________ 11

Challenges __________________________________________________________________ 12

The global picture: Life expectancy improves – but not for all ______________________________ 12

Global economic crisis _____________________________________________________________ 12

New Health Challenges _____________________________________________________________ 12

Country-specific challenges _________________________________________________________ 12

Whose goals are they anyway? _______________________________________________________ 13

What can be done with limited resources? ______________________________________________ 13

Bibliography ________________________________________________________________ 14

List of Figures

Figure 1: Regional share of people living on less than $2 a day _________________________________ 5

Figure 2: Under five child mortality trend by regions _________________________________________ 7

Figure 3: Maternal maternity rates by region _______________________________________________ 9

Figure 5: Trends in HIV prevalence _____________________________________________________ 11

Health-Related Millennium Development Goals: Progress and Challenges

Abstract

The Millennium Development Goals (MDG) represent an unprecedented partnership among

nations to better the lives of hungry and poor people across the globe. Health is at the heart of the

MDG. As the 2015 target date approaches, many developing countries have already made

extraordinary progress, improving the lives of millions of people. But not all countries or regions

of the world are on track to meet the MDG. At the halfway mark to the Millennium Development

Goals (MDG) deadline of 2015, the world has not made the necessary progress, but success is

still possible given certain conditions, said World Bank economist Zia Qureshi, lead author of

2008 Global Monitoring Report (World Bank, 2008).

Developing nations face many barriers to achieving the MDG, some unique and country-specific,

others broadly shared. Common problems faced by many nations can be grouped into six areas:

poor starting conditions, weak governance and institutions, conflict and instability, increasing

food prices, environmental degradation, and above all the current global economic crisis.

To meet the MDG and create a sustainable path to development, countries must adopt policies

and programs to overcome these problems. With the resources they have, countries should be

able to replicate programs that have been proven to produce the necessary outcomes. Developed

countries have a role to play in overcoming these barriers. Aid donors, particularly the United

States, must ensure that developments achieved so far are not stalled and reversed due to the

economic crisis.

Secretary General of the UN, Ban Ki-Moon (2010) says, “We have made important progress in

this effort, and have many successes on which to build. But we have been moving too slowly to
meet our goals. And today, we face a global economic crisis whose full repercussions have yet to

be felt. At the very least, it will throw us off course in a number of key areas, particularly in the

developing countries. At worst, it could prevent us from keeping our promises, plunging millions

more into poverty and posing a risk of social and political unrest. That is an outcome we must

avoid at all costs.”

Background

In September 2000, 189 heads of state adopted the UN Millennium Declaration and endorsed a

framework for development. The plan was for countries and development partners to work

together to increase access to the resources needed to reduce poverty and hunger, and tackle illhealth,
gender inequality, lack of education, lack of access to clean water and environmental

degradation (United Nations, 2008; World Health Organization, 2009).

The declaration established eight Millennium Development Goals (MDG), set targets for 2015,

and identified a number of indicators for monitoring progress, several of which relate directly to

health. The objective of this paper was to review related sources on the MDG and see the

progresses achieved so far and the challenges encountered to meet the goals. The paper also

highlights the potential predicaments and remedies during the remaining five years of the MDG

deadline.

Health is at the heart of the Millennium Development Goals (MDG). Goals 4, 5 and 6

specifically focus on health, but all the MDG have health-related aspects; achieving health goals

will not be possible without progress on food security, gender equality, the empowerment of

women, wider access to education and better stewardship of the environment (Haines, 2004;

Wagstaff et al, 2006; WHO, 2009).

With only five years remaining to 2015, there are signs of progress towards the achievement of

the health-related Millennium Development Goals in many countries. In others, mainly SubSaharan
countries, progress has been limited because of conflict, poor governance, economic or
humanitarian crises, and lack of resources. The effect of the global food, energy, financial and

economic crises on health is having severe repercussions on the MDG (Munoz, 2008; WHO,

2009; UN, 2009).

The eight MDGs

According to the UN (2008), the eight MDG are:

Goal 1: Eradicate extreme poverty and hunger

Goal 2: Achieve universal primary education

Goal 3: Promote gender equality and empower women

Goal 4: Reduce child mortality

Goal 5: Improve maternal health

Goal 6: Combat HIV/AIDS, malaria and other diseases

Goal 7: Ensure environmental sustainability

Goal 8: Develop a Global Partnership for Development

The eight MDG break down into 21 quantifiable targets that are measured by 60 indicators

(UN, 2008).

Global Progress: Are we on track to meet the MDG by 2015?

So far there are significant advances together with important set-backs. Every region faces

particular challenges but has the opportunity to work together in order to achieve the MDG.

While each MDG is reviewed in the next sections, the 2009 MDG report released recently by

UN (2009) summarizes progress:

- Those living in extreme poverty in the developing regions accounted for slightly more than a

quarter of the developing world’s population in 2005, compared to almost half in 1990.

- Major accomplishments were also made in education. In the developing world as a whole,
enrolment in primary education reached 88 per cent in 2007, up from 83 per cent in 2000.

And most of the progress was in regions lagging the furthest behind. In sub-Saharan Africa

and Southern Asia, enrolment increased by 15 percentage points and 11 percentage points,

respectively, from 2000 to 2007.

- Deaths of children under five declined steadily worldwide — to around 9 million in 2007,

down from 12.6 million in 1990, despite population growth. Although child mortality rates

remain highest in sub-Saharan Africa, recent survey data show remarkable improvements in

key interventions that could yield major breakthroughs for children in that region in the years

ahead. Among these interventions are the distribution of insecticide-treated bed nets to

reduce the toll of malaria — a major killer of children. As a result of ‘second chance’

immunizations, dramatic progress is also being made in the fight against measles.

- At the global level, the world came together to achieve a 97 percent reduction in the

consumption of substances that deplete the Earth’s protective ozone layer, setting a new

precedent for international cooperation.

The UN report (2009), however, underlines the bleak situation in achieving the MDG due to the

increase of food prices in 2008 aggravated by the current global economic crisis.

Eradicating extreme poverty and hunger

Target: Halve, between 1990 and 2015, the proportion of people whose income is less than one

dollar a day.

In light of this, some pertinent facts (United Nations, 2008) include:

- The World Bank’s latest estimates show that 1.4 billion people in developing countries were

living in extreme poverty in 2005.

- Recent increases in the price of food have had a direct and adverse effect on the poor and are

expected to push many more people - an estimated 100 million - into absolute poverty.

- The proportion of children under five who are undernourished declined from 33 per cent in
1990 to 26 per cent in 2006. However, by 2006, the number of children in developing

countries who were underweight still exceeded 140 million.

According to United Nations (UN) (2008), the MDG target of cutting in half the proportion of

people in the developing world living on less than $1 a day by 2015 remains within reach for the

world as a whole. However, this achievement will be largely the result of extraordinary success

in Asia, mostly East Asia. In contrast, little progress has been made in reducing extreme poverty

in sub-Saharan Africa.

New estimates released by the World Bank in August 2008 show that the number of people in

the developing world living in extreme poverty may be higher than previously thought. Using a

new threshold for extreme poverty now set at $1.25 a day (purchasing power parity) in 2005

prices, the Bank concluded that there were 1.4 billion people living in extreme poverty in 2005

(World Bank, 2008) (see Fig. 1). Based on these data, poverty rates are estimated to have fallen

from 52 per cent in 1981 to 42 per cent in 1990 and to 26 per cent in 2005. Over a 25-year

period, the poverty rate in East Asia fell from nearly 80 per cent to under 20 per cent. In subSaharan
Africa, the poverty rate remained constant at around 50 per cent (UN, 2008).

Even though the proportion of people worldwide suffering from malnutrition and hunger has

fallen since the early 1990s, the number of people lacking access to food has risen. With recent

increases in food prices, it is estimated that 1 billion people will go hungry, while another two

billion will be undernourished (UN, 2008).

According to the UN (2008), microfinance has helped many of the world’s poor to increase their

incomes through self-employment and empowerment. With access to small loans and other

financial services such as savings and micro-insurance, microfinance clients, mostly women,

have formed micro-enterprises that generate income. Through microfinance, the poor are able to

establish support networks for improving health and education in their communities.

Figure 1: Regional share of people living on less than $2 a day

Achieving universal primary education

Target 2: Ensure that, by 2015, children everywhere, boys and girls alike, will be able to

complete a full course of primary schooling.

According to the UN (2008):

- Globally, 570 million children are enrolled in school. The number of children of primary

school age who were out of school fell from 103 million in 1999 to 73 million in 2006. In

that year, primary school enrolment in developing countries reached 88 percent on average,

up from 83 percent in 2000.

- In sub-Saharan Africa, the net primary school enrollment ratio has only recently reached 71

per cent, even after a significant jump in enrollment that began in 2000. Around 38 million

children of primary school age in this region are still out of school.

- In Southern Asia, the enrolment ratio has climbed above 90 per cent, yet more than 18

million children of primary school age are not enrolled.

In almost all regions, the net enrolment ratio in 2006 exceeded 90 per cent, and many countries

were close to achieving universal primary enrolment. The number of children of primary school

age who were out of school fell from 103 million in 1999 to 73 million in 2006, despite an

overall increase in the number of children in this age group. These successes underscore that

much can be accomplished with the political will of governments and with adequate support

from development partners (WHO, 2009; World Bank 2008).

In sub-Saharan Africa, however, the net enrolment ratio has only recently reached 71 per cent,

even after a significant jump in enrolment that began in 2000. Around 38 million children of

primary school age in this region are still out of school. In Southern Asia, the enrolment ratio has

climbed to 90 per cent, yet more than 18 million children of primary school age are not enrolled
(WHO, 2008; UN, 2008; World Bank, 2009).

For children to reach their full potential and countries to develop, the gains made in universal

primary education must be replicated at the secondary level. At present, less than 55 percent of

children of the appropriate age in developing countries attend secondary school. In Oceania, for

instance, almost two-thirds of children of secondary school age are out of school. In sub-Saharan

Africa, only a quarter of children of secondary school age are in secondary school (UN, 2008).

Reduce child mortality

Target: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate.

According to UN (2008):

- Worldwide, deaths of children under five years of age declined from 93 to 72 deaths per

1,000 live births between 1990 and 2006.

- A child born in a developing country is over 13 times more likely to die within the first five

years of life than a child born in an industrialized country. Sub-Saharan Africa accounts for

about half the deaths of children under five in the developing world.

- Between 1990 and 2006, about 27 countries, the large majority in sub-Saharan Africa, made

no progress in reducing childhood deaths.

Globally, child mortality continues to fall (see Fig. 2). In 2008, the global annual number of child

deaths fell to 8.8 million, down by 30 percent from the 12.5 million estimated in 1990. The

under-five-year-old mortality rate in 2008 was estimated at 65 per 1000 live births. Reducing

child mortality increasingly depends on tackling neonatal mortality; globally, about 40 percent of

under-five-year-old deaths are estimated to occur in the first month of life, most in the first week.

The greatest reductions in child mortality have been recorded among the wealthiest households

and in urban areas (WHO, 2009).

Much of the progress in reducing child mortality can be attributed to increased immunization
coverage, use of oral rehydration therapies during episodes of diarrhea, use of insecticide-treated

mosquito nets, and reduced disease incidence due to improved water and sanitation (Wagstaff et

al, 2007; Munoz 2008; WHO, 2009). However, because the availability and use of proven

interventions at the community level remain low, pneumonia and diarrhea still kill 3.8 million

children under five each year (WHO, 2009).

Malnutrition is estimated to be an underlying cause in more than one-third of all deaths in

children under five. The decrease in child malnutrition has been slow; the proportion of children

under five who are undernourished declined from 33 percent in 1990 to 26 percent in 2006.

However, by 2006, the number of children in developing countries who were underweight still

exceeded 140 million (UN, 2008; WHO 2009).

Sub-Saharan Africa accounts for about half the deaths of children under five in the developing

world. Between 1990 and 2006, about 27 countries, the large majority in sub-Saharan Africa,

made no progress in reducing childhood deaths. In East Asia and Latin America and the

Caribbean, child mortality rates are approximately four times higher than in developed regions.

Disparities persist in all regions: mortality rates are higher for children from rural and poor

families and whose mothers lack a basic education (UN, 2008; WHO 2009).

Figure 2: Under five child mortality trend by regions

Source: World Bank (2008)

Improve maternal health

Target: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio and

achieve, by 2015, universal access to reproductive health.

According to the UN (2008):

- Estimates for 2005 show that, every minute, a woman dies of complications related to

pregnancy and childbirth. This adds up to more than 500,000 women annually and 10 million
over a generation. Almost all of these women – 99 percent – live and die in developing

countries.

- Maternal mortality shows the greatest disparity among countries: in sub-Saharan Africa, a

woman’s risk of dying from treatable or preventable complications of pregnancy and

childbirth over the course of her lifetime is 1 in 22, compared to 1 in 7,300 in developed

regions. The risk of a woman dying from pregnancy-related causes during her lifetime is

about 1 in 7 in Niger compared to 1 in 17,400 in Sweden.

- Every year, more than 1 million children are left motherless and vulnerable because of

maternal death. Children who have lost their mothers are up to 10 times more likely to die

prematurely than those who have not.

Maternal mortality remains unacceptably high across much of the developing world (see Fig. 3).

Every year some 536,000 women die of complications during pregnancy or childbirth, 99

percent of them in developing countries. The global maternal mortality ratio of 400 maternal

deaths per 100,000 live births in 2005 has barely changed since 1990. Most maternal deaths

occur in the African Region, where the maternal mortality ratio is 900 per 100,000 live births,

with no measureable improvement between 1990 and 2005. In sub-Saharan Africa, a woman’s

risk of dying from treatable or preventable complications of pregnancy and childbirth over the

course of her lifetime is 1 in 22, compared to 1 in 7,300 in the developed regions (UN 2008;

WHO, 2009).

Progress in reducing maternal mortality and morbidity depends on better access to, and use of,

good maternal and reproductive health services. The proportion of pregnant women in the

developing world who had at least one antenatal care visit increased from slightly more than half

at the beginning of the 1990s to almost three quarters a decade later. Over the period 2000–2008,

65 percent of births globally were attended by skilled health personnel, 4 percent more than in

1990–1999. (UN, 2008; WHO, 2009).

percent in 2000–2006. Nonetheless, in some regions it remains very difficult to reduce the

considerable unmet need for family planning and the high rates of adolescent fertility. Globally,

there were 48 births for every 1000 women aged 15–19 years in 2006, only a small decline from

51 per 1000 in 2000. (UN 2008; WHO, 2009).

In 2006, nearly 61 percent of births in the developing world were attended by skilled health

personnel, up from less than half in 1990 (see Fig. 4). Coverage, however, remains low in

Southern Asia (40 percent) and sub-Saharan Africa (47 percent) – the two regions with the

greatest number of maternal deaths (UN, 2008; WHO, 2009).

At the global level, maternal mortality decreased by less than 1 percent per year between 1990

and 2005, far below the 5.5 percent annual improvement needed to reach the MDG target.

Northern Africa, Latin America and the Caribbean and South-east Asia managed to reduce their

maternal mortality ratios by about one-third during this period, though progress in these regions

was insufficient to meet the target. In sub-Saharan Africa, the region with the highest level of

maternal mortality, progress was negligible (UN, 2008; WHO 2009).

Figure 3: Maternal maternity rates by region

Sources: World Bank (2008)

Figure 4: Births attended by skilled personnel

Sources: World Bank (2008)

10

Combat HIV/AIDS, malaria and other diseases

Targets: Have halted by 2015 and begun to reverse the spread of HIV/AIDS; achieve, by 2010,

universal access to treatment for HIV/AIDS for all those who need it; and have halted by 2015

and begun to reverse the incidence of malaria and other major diseases.
According to UN (2008):

- Every day, nearly 7,500 people are infected with HIV and 5,500 die from AIDS. Globally, an

estimated 33 million people were living with HIV/AIDS in 2007.

- The number of people living with HIV rose from an estimated 29.5 million in 2001 to 33

million in 2007. The vast majority of those living with HIV are in sub-Saharan Africa, where

about 60 percent of adults living with HIV in 2007 were women.

- Malaria kills over 1 million people annually, 80 percent of whom are children under five in

sub-Saharan Africa. There continue to be between 350 million and 500 million cases of

malaria worldwide each year.

- An estimated 250 million anti-malaria insecticide-treated bed nets are required to reach 80

percent coverage in sub-Saharan Africa. To date, the funds committed will provide only 100

million nets – less than one half of the requirement.

Every day, nearly 7,500 people become infected with HIV and 5,500 die from AIDS, mostly due

to a lack of HIV prevention and treatment services. Despite these staggering numbers, some

encouraging developments have sparked small victories in the battle against AIDS. Thanks to

improvements in prevention programs, the number of people newly infected with HIV declined

from 3 million in 2001 to 2.7 million in 2007. And with the expansion of antiretroviral treatment

services, the number of people who die from AIDS has started to decline, from 2.2 million in

2005 to 2.0 million in 2007 (UN, 2008; WHO 2009).

Access to antiretroviral therapy rose by 42 percent in 2007 largely financed by the Global Fund

to Fight AIDS, Tuberculosis and Malaria. By the end of 2007, the number of people receiving

AIDS treatment in developing countries reached three million; however, that is only a fraction of

the estimated 9.7 million people in need of treatment. However, the number of people living with

HIV rose from an estimated 29.5 million in 2001 to 33 million in 2007 largely because newly

infected people survive longer. The vast majority of those living with HIV are in sub-Saharan
Africa as shown in Fig. 5 (UN, 2008).

According to UN (2008), progress has been made in malaria control interventions, particularly

through the use of insecticide-treated mosquito bed nets, whose production worldwide jumped

from 30 million in 2004 to 95 million in 2007. Coupled with increased resources, this has led to a

rapid rise in the number of mosquito nets procured and distributed within countries. For example,

UNICEF increased its procurement from seven million in 2004 to nearly 20 million in 2007, and

the Global Fund increased its distribution from 1.35 million in 2004 to 18 million in 2006.

Earlier this year, the UN Secretary-General sounded a call to action to reach full coverage in

Africa by 2010 to end malaria deaths.

The MGD target in respect to halting and reversing the incidence of tuberculosis was met

globally in 2004. Since then, the rate has been falling slowly. Tuberculosis prevalence and death

rates per 100,000 population declined from 296 in 1990 to 206 in 2007 for the former, and from

11

28 in 1990 to 25 in 2006 for the latter. Globally, the tuberculosis case-detection rate under the

DOTS approach increased from an estimated 11 percent in 1995 to 63 percent in 2007. The rate

of improvement in case detection slowed after 2004, largely as a result of earlier successes in the

countries with the largest number of cases. Data on treatment success rates under the DOTS

(Directly Observed Treatment Short-Course) approach indicate consistent improvement, with

rates rising from 79 percent in 1990 to 85 percent in 2006 (UN 2008; WHO, 2009).

Figure 5: Trends in HIV prevalence

Source: World Bank (2008)

Ensure environmental sustainability

Targets: Halve, by 2015, the proportion of people without sustainable access to safe drinking

water and basic sanitation.

According to UN (2008):
- Some 1.6 billion people have gained access to safe drinking water since 1990. At this rate,

the world is expected to meet the MDG target on drinking water. But about 1 billion people

still do not have access to safe drinking water, and 2.5 billion lack accesses to basic

sanitation services.

Lack of safe water and poor sanitation are important risk factors for mortality and morbidity,

including diarrhoeal diseases, cholera, worm infestations and hepatitis. Globally, the proportion

of the world’s population with access to improved drinking-water sources increased from 77

percent to 87 percent between 1990 and 2006, sufficient to achieve the relevant target of the

Millennium Development Goal except in sub-Saharan Africa where, although coverage

increased from 49 percent in 1990 to 58 percent in 2006, it remained well short of the 65 percent

coverage rate needed to achieve the Millennium Development Goal target. On sanitation,

however, current rates of progress are inadequate. In 2006, 1,200 million people had no other

choice than to defecate in the open, resulting in high levels of environmental contamination and

12

exposure to the risks of microbial infections, diarrhoeal diseases, cholera, worm infestations,

trachoma, schistosomiasis and hepatitis (UN, 2008; WHO, 2009).

Challenges

The global picture: Life expectancy improves – but not for all

According to WHO (2003), average life expectancy at birth has increased globally by almost 20

years, from 46.5 years in 1950–1955 to 65.2 years in 2002. This represents a global average

increase in life expectancy of four months per year across this period. On average, the gain in life

expectancy was nine years in developed countries (including Australia, European countries,

Japan, New Zealand and North America), and seventeen years in the high-mortality developing

countries (with high child and adult mortality levels), including most African countries (WHO,

2003).
Global economic crisis

As the date approaches, less than six years away, the world finds itself mired in an economic

crisis that is unprecedented in its severity and global dimensions. According to the UN 2009

report on MDG, progress towards the goals is now threatened by sluggish, or even negative

economic growth, diminished resources, fewer trade opportunities for the developing countries,

and possible reductions in aid flows from donor nations. Major advances in the fight against

extreme poverty from 1990 to 2005, for example, are likely to have stalled. During that period,

the number of people living on less than $1.25 a day decreased from 1.8 billion to 1.4 billion. In

2009, an estimated 55 million to 90 million more people will be living in extreme poverty than

anticipated before the crisis (UN, 2009).

Studies estimate that anywhere from US$20 billion to US$75 billion per year of additional

development assistance is required to meet the health MDG, more than four times the current

level. In sub-Saharan Africa, the proportion of government spending on health would need to

increase nearly six-fold to meet the targets, meaning that 12.2 percent of GDP would be spent on

health, which is unrealistic (Wagstaff et al, 2006).

New Health Challenges

The emergence of new health challenges like pandemic influenza (H1N1) and recurrence of

some other diseases places additional challenges to the world and unbearable burdens to the

developing nations. These challenges will have a significant impact on achieving the health goals

of the MDG.

Country-specific challenges

According to Munoz (2008), many developing countries are making progress towards achieving

the Millennium Development Goals. However, some face significant challenges because of:

- Poor Starting Conditions: Countries whose human development indicators are at the lowest

levels must make the greatest investments to achieve the MDG;

- Weak Governance and Institutions: it can cause countries to swiftly regress. Peace, however

fragile, provides an opportunity to make rapid progress;

- Conflict and Instability: it can cause countries to swiftly regress.

- Environmental Degradation: the loss of natural resources can slow long-term efforts to

reduce poverty; and

- Rising food prices

Whose goals are they anyway?

National ownership is important. There is a risk that the Millennium Development Goals are

seen by some developing countries as being of prime concern to donors (Haines, 2004).

What can be done with limited resources?

With limited resources, there are still steps countries can take to speed up progress towards

reaching the MDG (Wagstaff, 2006):

- Target spending to programs that have the greatest impact on the MDG. Immunization, use

of insecticide-treated bed-nets, universal access to essential obstetric care, condom use, and

case management with oral rehydration therapy are examples of interventions that bear great

results at low cost. In the case of child mortality, for example, diarrheal diseases, pneumonia,

and malaria account for 52 percent of deaths worldwide (World Bank 2003). For each of

these major causes of childhood mortality, at least one proven effective preventive

intervention and at least one proven effective treatment intervention exist, capable of being

delivered in a low-income setting.

- Build efficient, streamlined institutions to ensure each dollar is spent productively. Health

systems are broad and there are many steps along the way where dollars can be wasted,

particularly if programs with large overhead and administrative costs do not produce results.

Efficient health systems will help ascertain dollars are spent where they are intended.
- Avoid user charges, particularly for interventions that target the poor and have spillover

benefits.

- Employ public health professionals with core public health competencies. Professionals with

appropriate training can help develop efficient monitoring systems and emphasize health

education, public information, health promotion, disease prevention, and social marketing of

public health issues.

- Invest more in programs that already work well. DOTS for tuberculosis or the integrated

management of infant and childhood illness (IMCI) are examples of programs that may yield

high returns in low income settings.

14

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