Progress in achieving the Millennium Development Goals: have we reached an impasse?
Dr Margaret Chan
Director-General of the World Health Organization
Rector, Minister Torneas, Excellencies, distinguished colleagues,
You have asked me to speak about WHO’s efforts to achieve the health-related Millennium Development Goals. I am happy to express some of my views.
First, some good news. Last year, with support from the GAVI Alliance, childhood immunization coverage reached record highs. In sub-Saharan Africa, deaths from measles have dropped by 75% over the past six years.
Immunization lends itself to a systematic approach. These interventions can be scheduled. Other major causes of childhood mortality cannot be so easily prevented with a scheduled intervention. We are not seeing similar progress in preventing deaths from diarrhoeal disease and pneumonia.
Rates of maternal mortality remain stubbornly and tragically high despite more than two decades of efforts. There are some indications that rates are actually climbing in sub-Saharan Africa. At least 70% of preventable maternal deaths arise from complications of childbirth, and these complications cannot be reliably predicted.
We will not see the annual total of more than half a million maternal deaths go down until more women have access to emergency obstetric care.
HIV/AIDS has become a disease of the developing world, with its greatest burden on the African people. Of people living with this disease, 95% reside in the developing world. Of the 4.3 million new infections in 2006, 65% occurred in sub-Saharan Africa.
On the positive side, 2006 saw an important milestone. In sub-Saharan Africa, the number of people receiving antiretroviral treatment surpassed one million for the first time. This achievement represents a 10-fold increase in treatment access in the region since December 2003.
We have seen steady progress with tuberculosis, thanks to the DOTS strategy. The disease appears to have stabilized in some areas and may now be declining in others. Again, the exception in sub-Saharan Africa, where the annual incidence of tuberculosis remains extremely high.
It was in Africa where a disturbing new form of this disease was first reported last year. This is extensively drug-resistant TB – extremely difficult to treat, and with a mortality approaching 98% in some reports. Known as XDR TB, this form has been detected in other regions of the world, including North America and Europe.
Progress is not good for malaria. Again, sub-Saharan Africa bears the greatest burden, accounting for more than 80% of the annual 1 million deaths from this disease. No country met the targets set for Africa for 2005.
In response, WHO launched an aggressive new Global Malaria Programme at the start of last year. The programme has introduced a new strategy for getting better results quickly. But we have a long way yet to go.
When we look at our international commitments and our progress in meeting them, we have to face some conclusions.
Public health has reached a critical point. The MDGS are all about poverty reduction. They recognize that poor health anchors large populations in poverty. They also recognize that better health allows people to work their way out of poverty. Commitment to these goals has unleashed unprecedented momentum for health development.
For the first time, funds to combat the major diseases of poverty are flowing in a substantial way. We have unprecedented political commitment and international determination. We have powerful interventions and proven strategies for their implementation.
With so many of the essential elements in place, we have our first good opportunity to see what is missing. We do not have the delivery systems for reaching those in need.
Poor people tend to live in underserved areas – in remote rural villages and shantytowns. If we want improved health to work as a poverty-reduction strategy, we must deliver interventions to the poor.
We face a dilemma. In the past decade, we have seen an enormous growth in the number of partnerships and initiatives implementing programmes in countries. These initiatives are focused on delivering specific health outcomes. Outcomes depend on a functioning health system. Yet the strengthening of health systems is rarely a core purpose of these initiatives.
Here is where all this welcome momentum reaches an impasse. Health systems are not able to deliver interventions, on the necessary scale, to those in greatest need.
This is not just the view of WHO.
In 2005, the Millennium Project Task Force issued its assessment of the prospects for achieving the MDGs for child and maternal health.
Here is the conclusion: “The health system that should make interventions available, accessible, and utilized is in a crisis. Only a profound shift in how the global health and development community thinks about and addresses health systems can have the impact necessary to meet the Goals.”
In June 2006, an external evaluation of the 3 by 5 initiative for HIV/AIDS issued its report. The conclusion: the biggest impediment to improving coverage with antiretroviral therapy is the absence of delivery systems and the lack of staff.
I do not have good solutions to this problem. Health systems are very context-specific. There is no universal prescription for a quick fix.
But I do know this: we have no time to start from scratch, to experiment with brand-new proposals. We must look at what already exists, look at the body of evidence and experience, and use the best strategies available.
I have called for a return to integrated primary health care as an approach to strengthening health systems. Decades of experience tell us that this is the best route to universal access, the best way to ensure a sustainable improvement in health outcomes.
I mentioned a milestone achievement last year: one million people receiving antiretroviral treatment in Africa. This was achieved through a public health approach driven by the principles of primary health care.
The values and principles embodied in primary health care and the Health for All movement are strikingly similar to those set out in the Millennium Declaration. Both are all about fairness, solidarity, collective responsibility, participatory approaches, and a duty to take care of vulnerable groups.
I believe this is an appropriate statement to make in the homeland of Dr Halfdan Mahler. The consequences of his vision are still being realized. I am proud to acknowledge my debt to Dr Mahler as an inspiring predecessor and a valued adviser.
Thank you for your attention.