POSSIBILITY OR OTHERWISE OF ACHIEVING THE HEALTH MILLENNIUM DEVELOPMENT GOALS BY 2015

LEGAL EMPERORS

POSSIBILITY OR OTHERWISE OF ACHIEVING THE HEALTH MILLENNIUMDEVELOPMENT GOALS BY 2015

HEALTH MILLENNIUM DEVELOPMENTGOALS

ONYEKACHI DURU ESQ3/12/2014

The Millennium Development Goals (MDGs) were heralded asopening a new chapter in international development, and have ledto the use of global goals and target-setting as a central instrumentdefining the international development agenda. The declaration ofMillennium Development Goals is one of the strategies to overcomethe world’s health challenges through global partnership fordevelopment in the entire world and in particular, the developingcountries which Africa region cannot be exempted. Government atdifferent countries has introduced various policies to achieve healthrelated Millennium Development Goals in their respective countries.This paper focuses on the possibility or otherwise of achieving thehealth Millennium Development Goals by 2015.

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POSSIBILITY OR OTHERWISE OF ACHIEVING THE HEALTH MILLENNIUMDEVELOPMENT GOALS BY 2015. *

Abstract

The Millennium Development Goals (MDGs) were heralded as openinga new chapter in international development, and have led to the use ofglobal goals and target-setting as a central instrument defining theinternational development agenda. The declaration of MillenniumDevelopment Goals is one of the strategies to overcome the world’shealth challenges through global partnership for development in theentire world and in particular, the developing countries which Africaregion cannot be exempted. Government at different countries hasintroduced various policies to achieve health related MillenniumDevelopment Goals in their respective countries. This paper focuses onthe possibility or otherwise of achieving the health MillenniumDevelopment Goals by 2015.

Introduction

The health-related Millennium Development Goals and

targets need to be considered in the context of the right to

health, taking into account the ethical, social, technical and

political aspects of this right. Good health is crucial to the

well-being of individuals, families and communities, and it is

also a prerequisite for human development with equity.

Furthermore, people are entitled to fair, efficient and

conscientious health care, and society as a whole has to

ensure that no one is excluded from access to health services

* Prepared by Onyekachi Duru Esq. DIL, LLB (Hons), BL, PGD (Legislative Drafting) and LLM in view: Email: [email protected]; for LEGAL EMPERORS: Email: [email protected]; Web. www.legalemperors.com

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and that these services provide high-quality care to all

users.

Identifying and combating shortcomings and social divides

in health conditions and care should be viewed strategically

as a vital component of comprehensive public action to break

the vicious circle of poverty and, ultimately, to attain

sustainable human development. For these reasons, a

significant number of the Millennium Development Goals concern

health. They include the reduction of maternal and child

mortality; the control of diseases such as HIV/AIDS, malaria

and tuberculosis; greater access to safe drinking water and

sanitation; the reduction of poverty and relief of hunger and

under-nutrition; and access to health services, including

essential drugs.

This paper deals mainly with the three health-related

Millennium Development Goals and the four targets covered by

them, which relate explicitly to health and which the health

sector will have to pursue by means of measures and actions

undertaken jointly with other sectors. As the Secretary-

General of the United Nations has stressed on a number of

occasions, there is a close relationship between the Goals and


the outcomes of global conferences such as the World Summit

for Children, the International Conference on Population and

Development, the World Summit on Sustainable Development and

the World Conference on Women, among others.

Specifically, and as has been argued in other

international reports on progress towards the Millennium

Development Goals (IDB, 2004), advances towards the health-

related Goals will significantly increase a country’s capacity

to combat poverty and hunger and achieve environmental

sustainability. Although the developed and developing

countries differ greatly in terms of their development levels

and health situations, when it comes to attaining the health-

related Millennium Development Goals, they face certain common

challenges that manifest themselves to varying degrees in the

different countries.

First, the effort will require faster progress towards a

substantial reduction in health inequities, including those

linked to poverty, exclusion, gender, race/ethnicity and age.

Second, it must entail major progress with respect to health-

care coverage under social protection schemes, without which

there is no prospect of extending the coverage of the most


critical interventions that the population’s health situation

requires. Third, public-sector current and investment spending

in the sector has to be increased, and the quality of resource

allocation needs to improve substantially. Fourth, health-care

services should be reoriented towards a new primary health-

care strategy that encourages active involvement by all users

of the system. Fifth, sustained improvements are needed in

public health infrastructure. Sixth, progress is urgently

needed in formulating and implementing cross-sectoral policies

and actions that have a real impact on the political, economic

and socio-cultural determinants of the health targets

associated with the Millennium Development Goals.

All this is necessary to increase social cohesion and

strengthen citizens’ right to health. Accordingly, these aims

should be integrated into the health policies, plans and

programmes of the world’s countries so that, in conjunction

with the actions taken in other sectors, the countries will

succeed in meeting the commitments they have undertaken for

2015.

The Millennium Development Goals: Overview


The United Nations global conferences of the 1990s drew

up a number of different key global development goals and

targets to focus, equalize and harmonize the needs and status

of the people all over the world. These goals and targets were

known as the International Development Targets. Again in 2000,

the representatives of 189 nations, including 147 heads of

state and Government adopted the Millennium Declaration during

the Millennium Development Summit (September 6-8, 2000) of the

United Nations. The Millennium Declaration focused on peace,

security and development concerns comprising environment,

human rights and good governance.

In this connection, the Declaration tried to mainstream a

set of interconnected and mutually reinforcing development

goals into a global agenda. The international development

targets and the development goals were merged together and

renamed as the Millennium Development Goals (MDGs). There are

eight MDGs that include:

1. Eradicate extreme poverty and hunger

2. Achieve universal primary education

3. Promote gender equality and empower women

4. Reduce child mortality


5. Improve maternal health

6. Combat HIV/AIDS, malaria and other diseases

7. Ensure environmental sustainability

8. Develop a global partnership for development.

These goals had been decided and fixed earlier in many

international forums and conventions. What is new about the

Millennium Development Goals (MDGs) is setting of targets

under each goal. A joint meeting of UN Secretariat,

specialized UN agencies, the World Bank, IMF and OECD

identified a list of indicators for monitoring the Millennium

Development Goals (Nepal Government and United Nations Country

Team, 2003). A list of 18 numerical targets and 48 indicators

has been agreed upon to ensure comparability across countries

and facilitate tracking of the progress at global, regional

and national levels. Under the Millennium Development Goals

(MDGs), the major development priorities to be achieved by

2015 are also highlighted.

The Millennium Development Goals (MDGs) have marked

today’s prevailing development paradigm because of the

unprecedented political consensus and support they have

reached globally. Millennium Development Goals (MDGs) are easy


to understand, quantitative and time-bound goals that attempt

to prioritize the provision of the utmost basic human needs in

every developing country. In September 2000, the United

Nations Millennium Declaration was endorsed by all UN member

states, and came as the result of a decade of United Nations

conferences and summits on diverse issues surrounding

development. From this Declaration, key targets were extracted

and translated into a “free-standing category” (Vandemoortele,

2011:5).

This task was performed by a group of UN experts,

including experts from the International Monetary Fund (IMF)

and the World Bank (WB), the Development Assistance Committee

of the Organization for Economic Cooperation and Development

(DAC/OECD). The targets were taken verbatim from the

Declaration; a timeframe in which these would be met was set

(1990-2015) as well as the indicators to keep track of the

progress (Vandemoortele, 2011). The result of this roadmap

came to be known as the Millennium Development Goals: eight

specific goals with twenty one targets and sixty indicators,

(Olvera, 2014: 7).


The purpose behind the Millennium Development Goals

(MDGs) was to help countries embed these objectives into their

development agendas considering evidence-base national

priorities and possible strategies; the Millennium Development

Goals (MDGs), at least in principle, do not outline a policy

framework to realize these objectives (Vandemoortele, 2011).

Today, 193 countries and 23 leading development institutions

have committed to eradicating extreme poverty and its multiple

dimensions covered in the Millennium Development Goals (MDGs).

At the World Summit on the Millennium Development Goals (MDGs)

in 2010, a number of world leaders from developed and

developing countries pledged over $40 billion in resources

over the next five years, showing the magnitude of the support

the Millennium Development Goals (MDGs) have galvanized

(Olvera, 2014: 7).

A shared sense of responsibility, which has brought Non

Governmental Organizations and citizens into the picture, is

easily observed in the official Millennium Development Goals

(MDGs) campaign slogan: “We can end poverty by 2015”. Nayyar

synthesizes the dimensions of the significance of the

Millennium Development Goals (MDGs):


“It was an explicit recognition of thereality that a large proportion of peoplein the world were deprived and poor. Itwas a statement of good intentions thatsought a time-bound reduction in povertyto improve the living conditions of thosedeprived and excluded. It was an attemptto place this persistent problem, untilthen a largely national concern, on thedevelopment agenda for internationalcooperation” (Nayyar, 2012:6).

As the 2015 deadline approaches many questions arise:

Have all these unprecedented efforts paid off? Were the

intentions behind them achieved? Is the humanistic approach to

development they provide enough and if not, how could it be

improved? I will present a short summary of the discussion

around these questions as they relate to health-related

Millennium Development Goals in the following pages.

The Possibility of Achieving the Millennium Development Goalson Health: Prospects and Challenges

Health has always been a theme that is one of the easiest

and, at the same time, most difficult to understand. Health is

indeed a very complex, multi-factorial and multidimensional

concept that has been constantly undergoing evolution- in a

spiral pattern along with civilization. Early civilizations

understood health in primitive holistic view- as a resultant

of complex interactions between various components of Nature-


including stars and planets, environment and seasons, humans

and animals, good spirits and bad spirits.

Over last several centuries, it gradually started being

understood in terms of very objective and more mechanistic

sense and was brought deeply into the domain of biomedical

sciences. And now, discussions that revolve around the

question- whether it belongs to the bio-medical or the

societal domain- are bringing health into a much broader

holistic vision. For many, WHO has made life easy by defining

health as “…a state of complete physical, mental and social

wellbeing and not merely the absence of disease or infirmity”.

This definition has been in use for more than half a century

now. And very few efforts to examine it in relation to

changing human life have been in the scene.

The Millennium Development Goals (MDGs) on health cover a

broad range of topics, such as reducing the under-five

mortality rate by two-thirds and the maternal mortality rate

by three-quarters and halting and having begun to reverse the

spread of HIV/AIDS, malaria, tuberculosis, and other major

diseases. This segment appraises the possibility of achieving

the Millennium Development Goals (MDGs) on health.


1. Reduce Child Mortality

Improving child health is seen not only as the goal in

itself, it is rather taken as the preconditions for the health

development in general. The international community has always

shown a greater concern about the childhood and health of

children. These concerns are expressed in several important

global events. Approval of Convention on the Rights of the

child by the United Nations General Assembly in 1989 is among

the landmark events, which recognized child as an independent

entity with its special needs for the development. The

Assembly was followed by the World Summit for Children in 1990

where the Heads of the States and Governments expressed their

commitments for the survival, protection and development of

children. The countries took initiative to develop plan of

actions in this direction and set national targets to be

achieved by the year 2000.

Since the adoption of Convention, there have been remarkable

and visible improvements in some of the indicators of child

health globally. Service provisions like immunization, oral

re-hydration and other, essential for the child survival, are

substantially increased. Some concrete results are achieved


during this period. Between 1990 and 2000 under-five mortality

declined by 11 percent worldwide (Nepal: 2006 and Aleyomi:

2013). The global child deaths from diarrhea declined by half

during the decade of 1990-2000, and this saved about one

million lives. Underweight among the children in developing

countries fell from 32 to 28 percent (Nepal: 2006).

However, these noted improvements were not considered to be

enough to meet the auspicious vision of child rights

Convention. It was admitted that conditions of millions of

children did not match the vision of Convention. Childhood of

these children continued to be under threat. More had to be

done to avoid premature loss of lives and ensure the quality

of childhood. Millennium Development Goals (MDGs) set by the

UN Millennium Summit in 2000 set the development targets to be

achieved by the year 2015. The Millennium Development Goals

(MDGs) have once again laid an important emphasis on child

development. One of these goals, Millennium Development Goal

(MDG) Goal 4, is to reduce child mortality, which targets to

reduce by two thirds the mortality rate among the children

under five.


Realizing that failure to achieve the Millennium Development

Goals (MDGs) target means tragic consequences for children,

particularly those in developing countries, the United Nations

General Assembly Special Session on Children in 2002 pledged

the member states and the world community to accelerate

progress on child development. The Special Session demanded

commitment from all sectors to address the issues of

development of children in comprehensive way by creating 'A

World fit for Children'.

Despite that some improvements are made, meeting Millennium

Development Goal (MDG) target of reducing under-five mortality

is seen as the most difficult one among other goals. According

to UNICEF Report 2005, around 29,000 children under-five years

of age die every day – 10.6 million every year, from

preventable causes such as diarrhea, acute respiratory

infections, measles, and malaria. Progress towards meeting the

targets to reduce under-five mortality rate is considered as

seriously off track. While the Millennium Development Goal

(MDG) 4 targets to 4.4% annual reduction of under-five

mortality rate, in 45 countries annual reduction is less than

1%.


Poverty, armed conflict and HIV/AIDS are perceived as key

threats for developing countries to translate the Millennium

Development Goal (MDG) 4 into a reality. Over 1 billion - more

than half the children in developing countries - are deprived

of services required for their survival and development;

poverty has been the root cause of high rates of child

morbidity and mortality in these countries. Millions of

children are caught in the trap of armed conflict. Since 1990,

out of 3.6 million people directly killed in conflict, more

than 45% - at least half of the civilian casualties - is

estimated to be children. Apparently, it is predicted that

without a concerted effort by the government, multi and bi-

lateral donors and all concerned sectors to address the issues

affecting child development, meeting targets of Millennium

Development Goal (MDG) 4 may not be possible.

2. Improve Maternal Health

Here, it is worth mentioning that maternal health is not a

new thing that has emerged only in the modern civilization. It

has been important for centuries. But it was important only to

the extent that the body of that mother should be biologically

fit enough to produce the desired offspring. In discussing


maternal health, we are involved, explicitly or implicitly, in

defining two concepts: one, Mother and two, Health. What is

Mother? And what is Health? These questions may sound absurdly

simple. But a huge difference in understanding them will be

evident as soon as they are discussed and this ‘absurdly

simple’ exercise suddenly starts taking the form of either a

profound intellectual discourse or a noisy, amorphous

‘anarchistic’ chaos (Saroj Dhital: 2006).

Furthermore, when maternal health is being discussed in the

context of Millennium Development Goals (MDGs), a whole myriad

of other questions and elements come into the scenario –human

and non-human, objects and processes, direction and

destination, science and politics, state and revolution … and

the list goes on. But trying to avoid the pain of accepting

realities only invite more pain and that is not really safe.

Redundant as it may seem, definitions still needs to be

revisited.

In reconsidering the accepted definition of Health, the

following questions are apt. Is health a ‘state’ that can be

measured in certain fixed parameters or something to be

understood in terms of relationship between the individual and


Nature at large (both of which are always in motion)? Should

health be taken as a static condition or considered in dynamics of

interaction of the ‘worlds’ within and outside an individual?

What measures and parameters or what physical and mental tests

in current use can properly reflect good or ill health? And

how does the “complete wellbeing” as mentioned in the WHO

definition really relate to this all?

How much of a difference it means to regard health as a

‘state’ (a static condition within a certain time frame) and to

understand it as an ability of an individual (to maintain useful,

desired and rewarding relationship with the whole universe in

perpetual motion) will be obvious if we look at someone with a

terminal illness or someone with serious physical disability.

Do they have the possibility to live ‘healthy’ hours or days

or weeks in spite of their infirmity? If health is a

measurable state, then they don’t. If health is an ability (to

maintain a dynamic relationship), then they do. If they do have the

possibility, then that possibility needs to be taken care of.

Whatever health system we create, the system should be able to

address the needs of people who can be ‘differently able’ in

spite of their disability or ‘differently healthy’ in spite of


their grave illness. Health, defined differently, could also

be hope, communication, commitment and assertiveness.

Looking for a proper definition of Health is much more than

a leisure-time intellectual discourse. It has a very practical

importance. Actually, how we define health has implications

that have enormous impact on shaping world strategies in and

beyond health. Nobody will disagree that we want to build a

nation with healthy people. Then, musing over what it means to

be healthy is not something that we can afford to dismiss as

futile exercise. It is not only a taste of civil society or

intellectuals, but is equally important for the state.

How health is defined will shape policies and priorities. It

will decide the state’s vision and health plans for the whole

country. If these visions and plans are not compatible to the

need of the people, citizen’s groups will be taking measures

to fulfill their own dreams or, more commonly, to express

their discontent with the state. And that may mean

perpetuation of conflict often expressed in explosions of

discontent. If that’s not what we want for our democratic

future, we have to be serious about it.


Again, who is Mother? What is Mother? Living in 21st

century, actually, we can’t ignore the ever expanding

definition of this word and confine ourselves to the issues of

‘biological’ mother alone. However, for the purpose of

convenience and in an effort to avoid being involved in

extensive discussions, probably there is no harm in starting

with biological mother. Interestingly though, with the

advances in science and technology in the area of reproductive

medicine and genetics, even the definition of biological

mother has become quite complicated and confusing.

Newer dimensions of motherhood have emerged along with more

and more test-tube babies being born. And the threatening

possibility of uterus being ‘rented out’ will create even more

confusion. Not only these ‘problems’ have to be addressed,

seemingly even more ‘weird’ concept of male mothers may need

to be addressed soon. So far limited largely to intellectual

discussions or sporadic events in socio-cultural domain, such

‘weird’ concept may become events belonging to the realm of

bio-sciences any time in near future.

We may further confine ourselves to ‘conventional’ or

‘natural’ biological mothers. But then we may again find


ourselves tangled in ‘outmoded’ old questions like: When does

an individual start the process of being a mother? When does

that process cease? And till how long after the birth of a

baby does ‘maternal health’ still mean something to the

natural biological mother? “Governments have a responsibility

for the health of their peoples which can be fulfilled only by

the provision of adequate health and social measures.” This is

what WHO says. Obviously, then, how the state recognizes a

mother must be important for maternal health.

The following questions are therefore germane. Is mother a

biological machine owned by a family or a community that

produces babies or is she an independent individual

experiencing series of special physiological and psychological

events? Is mother to be seen only in relation to other

individuals or does she have her independent existence? Is she

only a function of the society and culture or an actor who can

shape the society and culture? Should mother be seen as a

citizen that is contributing to society by securing the future

of the race and nation or as a person ‘paying’ for what she

did or suffering for whatever happened to her?


Government systems differ a lot. Economies differ, too. It

is obvious that our world can neither remain a collage of a

thousand systems yet uniformly full of justice nor can it be

monochrome, grey and cold world. Whole spectrum of economies

ranging from ultra liberalism to centralized economy will

continue to exist, at least for a few decades. Commonness and

agreements essential for existence of an international

community and institutions like United Nations are sought

within the limits of this reality. Then what could be the

basis of commonness in maternal health if it is not the

understanding of the very word Mother? While controversies will

continue, at least an inclusive, workable and rational

definition acceptable to all for moving ahead is needed.

The Millennium Development Goal targets are ‘set’ for 2015.

The world will not remain the same till then. It would be

better if we work with projection based on the dynamics of the

changing world. And changing world means more than numbers and

figures- it includes everything human and para-human. Under

usual circumstances, we are basically in the sociopolitical

domain when talking about the health of the deprived ones, and

more in the technical domain while talking about the health of


elites. And, the very reason for Improving Maternal Health to

be one of the Millennium Development Goals (MDGs) is the

acknowledgement that most mothers (or would-be mothers) in

present day world are deprived.

Accordingly, it is but natural to think that improving

maternal health is more of a broader socio-political issue

than something belonging to biomedical plane alone. Naturally,

achieving the declared goal of Improving Maternal Health by

avoiding social interventions is not conceivable. But, in the

first place, what do we really mean by ‘maternal health’? And

why is such terminology needed, or how is it really useful? It

is surprising to see that most of the publications under

titles related to maternal health are actually not dealing

with maternal health. They are, at the most, dealing with ill-health

and most of the times, actually, only with maternal mortality.

Tolerating high mortality rate is a crime. Maternal

mortality rate definitely has to be reduced if not abolished.

There is no question about that. But is preventing death alone

equivalent to achieving health? Birth should be attended by

skilled health personnel. We must do everything possible to

make it a common happening. It may reduce Maternal Mortality


Rate. It may also contribute to maternal health. But is that

all about maternal health? Why do we tend to forget or ignore

even the WHO definition of Reproductive Health? Actually, it

might have been much better and rational to put the Goal # 5

in Millennium Development Goals (MDGs) simply as decreasing

Maternal Mortality Rate rather than putting it as Improving

Maternal Health. Improving Maternal Health is a much broader

objective. It should be taken much more seriously (Macdonald:

1993).

Maternal Mortality Rate has been defined as “the number of

women who die while pregnant or during the first 42 days

following delivery per 100,000 women of reproductive age in a

given year for any cause related to or aggravated by

pregnancy, but not from accidental or incidental causes”

(Sander: 1985). If we were to take this as a reference to

extend the WHO definition of Health to that of Maternal

Health, we could probably put it as “…a state of complete

physical, mental and social wellbeing and not merely the

absence of disease or infirmity in a woman from the time of

conception to 42 days after the child birth” . Given the


complexity of being a mother- even natural biological mother-

such definition would not probably carry much sense.

3. Combat HIV/AIDS, Malaria and Other Diseases

By setting Millennium Development Goal 6 to combat HIV/AIDS,

Malaria and other Diseases, the member states of United

Nations made their commitment to halt the spread of these

diseases and to reverse the spread of HIV/AIDS. This is really

an encouraging commitment; however, it is quite frustrating to

observe the statistics of around 8000 person dying every day

in 2006 due to absence of anti-retroviral therapy. In 2005

alone, AIDS killed more than 3 million people including

570,000 children (UNAIDS, 2005). From an emerging health

problem two decades ago, HIV/AIDS has transferred itself into

a devastating global development challenge. A UNDP-sponsored

study (1995) has revealed that 1 percent increase in HIV/AIDS

prevalence rate leads to 2.4 year loss in human development as

measured by Human Development Index (UNDP 2005).

Further, when HIV/AIDS had emerged as a public health

concern, majority of the people living with HIV/AIDS (PLWHA)

were men. Today approximately half of the estimated 40 million


PLWHA are women with the greatest increases occurring in young

population between the ages of 15 to 24. Poverty,

discrimination and violence are found responsible for making

women vulnerable to HIV infection. The change in the dimension

of HIV/AIDS and its victims symbolize that it is shifting from

power to powerless, in terms of economies or countries,

communities and sexes. Poor countries, poor communities and

poor people, especially women are becoming the victims of

untimely death.

According to UNAIDS (2006) the AIDS epidemics appears

slowing down globally but new infections are continued to

increase in certain regions and countries. The report observed

important progress made in some countries; however, AIDS

remains an exceptional threat. Improved planning, sustained

leadership and reliable long-term funding to the AIDS

prevention are the daunting challenges for the countries with

high prevalence Negative association of AIDS prevalence with

economy, political stability and improvement in demographic

indicators depict the need for international cooperation.

The Response of Health Systems to the Challenges of Meetingthe Health-Related Millennium Development Goals


The situation existing in most regions during the 1990s

defined the starting conditions and context for the Millennium

Development Goals and the challenges associated with them.

This situation involves a number of different facets. There is

encouragement to be drawn from the strength of democracy and

democratic institutions; significant progress with

macroeconomic stability; a new economic openness; and progress

as measured by social indicators.

On the other hand, disappointing features include slow

growth; the modest extent of the decline in poverty; the

persistence of severe inequity and exclusion; and the scale of

social discontent. Given the close relationship between the

political, economic and social determinants of development,

these negative tendencies, should they persist, may undermine

the progress made to date.

Achieving the Millennium Development Goals depends

crucially on people having access to the goods and services

they need to meet their basic food, education and health

needs, together with the full exercise of their rights. As the

earlier analysis of the health situation shows, there is an


urgent need to reduce the great inequities in health-care

access and outcomes as a condition for achieving the Goals.

In developing countries, the inadequacies and limitations

of health-care systems represent barriers to access that help

perpetuate these inequities and limit the implementation of

cost-effective measures that are available to prevent or treat

the main causes of maternal and infant deaths and those due to

communicable diseases such as HIV/AIDS, malaria and

tuberculosis, as well as the implementation of national and

global strategies to achieve the Millennium Development Goals

in middle- and low-income countries.

Again, insofar as access to health systems is linked to

formal-sector employment, women experience greater exclusion

than men owing to their pattern of labour market

participation. Because of their domestic duties, over half of

all women in the developing regions are not gainfully

employed, and when they are, they are more likely than men to

work in the informal sector and in part-time occupations that

are not usually covered by social security. The fact that they

are often dependants means that they and their children are


heavily reliant on the person who does have health coverage

being employed and remaining in the household.

The segmentation of health systems reflects patterns of

social segmentation and discrimination in the societies where

they operate and severely constrains the prospects for

attaining the Millennium Development Goals. In past decades,

only a few countries in the Americas have implemented national

measures to reduce or eliminate the segmentation of their

health systems, and most countries in the globe still display

a high degree of segmentation.

In respect of the way initiatives are organized and

funding is assigned to them, the greatest shortcomings of the

world’s health systems lie in the allocation, distribution and

training of human resources; in the amount and distribution of

public spending; and in the territorial distribution of the

service network and health infrastructure. As in many of the

world’s regions, health systems in most of the developing

countries face serious problems of scarcity, poor

distribution, deficient training and poor working conditions

for their human resources.


The employment deregulation policies implemented as part

of health reforms and the economic and social crises that have

shaken the world’s countries in the last 30 years have

undermined working conditions in the health sector. The

employment situation of health workers has worsened in terms

not only of pay but also of stability, opportunities for

growth and the satisfaction of individual and family needs.

Few countries in the world have succeeded in implementing

appropriate human resource policies, and this is reflected in

the persistence of chronic imbalances in human resource

distribution, urban concentration, asymmetrical growth in

personnel supply and demand, greater growth in the supply of

educational services than the requirements of health-sector

work warrant, mismatches in human resource quality,

contradictory or ill-defined requirements in terms of

professional qualifications and the stagnation of public-

sector employment.

In some countries this has led to an exodus of health

professionals and increasing emigration by skilled personnel

to developed countries, which has had serious negative effects

on developing countries. Moreover, the economic loss


associated with the cost of training of health workers who

then migrate is considerable.

The scale and distribution of public health expenditure

are powerful tools for achieving higher levels of equity

within health systems. In countries with highly segmented

health systems, public-sector health funding is generally low,

and public-sector coverage is therefore quite limited, while

private expenditure is high and corresponds almost entirely to

expenditures on the part of private individuals. This is the

situation of most developing countries.

In these countries, where poverty affects a large

percentage of the population, low public spending levels plus

high out-of-pocket expenditure (which is proportionately

greater in the poorer of these nations) add up to a serious

problem of equity in health-care access, since this largely

depends on the individual’s ability to pay, as the possibility

of having recourse to the public sector is limited.

Besides the amount of public spending, its

progressiveness, that is to say, its distribution among the

poorest groups in the population, is a vital factor in the

access of these groups to health services. Out-of-pocket


spending in the poorest households is lower in countries where

the distribution of public spending is tilted towards low-

income groups.

The concentration of physical and technological health

infrastructure in urban centres and the wealthiest areas means

that access to this infrastructure is restricted for

population groups living in poor, rural and remote

geographical areas. One measure of access is use of health

services, which reflects the proportion of resources that each

subsystem expends on the different population groups. In turn,

this is an indicator of equity in the system in general. In

most countries, services are used inequitably, since greater

use is made of them by the wealthier quintiles in all

subsystems, including the public subsystem.

Disparities in access to health products, services and

opportunities are reflected in unfair differences in health

outcomes. Both maternal and infant mortality in the world are

concentrated among the poorest segments of the population. The

situation with respect to the quality of health services in

developing countries cannot be regarded as encouraging. The

comparatively poor results and low coverage of health systems


in developing countries are largely a reflection of this, as

is the neglect of public health.

Reforms in the world’s health sector have mainly

concentrated on structural, financial and organizational

changes to health systems and on adjustments in service

delivery. Public health has been neglected as a social and

institutional responsibility; just at a time when even more

attention needs to be paid to this issue and when most support

should be forthcoming from Governments to modernize the health

care infrastructure. Some of the current processes have not

been effective enough in tackling health inequities linked

with the growth of economic inequalities.

Proposals for the provision of maternity insurance for

mothers and newborns as part of the public health insurance

system are being formulated. This strategy of targeting social

programmes is designed to address alarming levels of

inequality. Although insurance of this kind focuses on women’s

and children’s health, its scope is restricted in that it

centres on maternity while neglecting broader sexual and

reproductive health issues such as cancer prevention,


violence, fertility and differentiated treatment for

adolescents (male and female).

Globally, there has been an improvement in the quality of

sexual and reproductive health policies, programmes and

standards based on the concept of reproductive rights as human

rights, social and gender equity, and the empowerment of women

and adolescents. National adolescent health programmes have

been created, with specific units being set up to cater to

adolescents in medical establishments and in the provision of

educational, preventive and treatment services, with an

emphasis on sexual and reproductive health aspects and actions

directed specifically at the prevention of unplanned

pregnancies and care for adolescent mothers. Personnel have

also received greater training in methods of care, improvement

of health service quality and the supply of contraceptives to

adolescents, and workshops have been held with groups of young

people to explain their health and reproductive rights.

Despite all this, greater political support is required

in order to place priority on adolescents’ sexual and

reproductive rights as part of health-sector reforms, since it

will be impossible to attain the Millennium Development Goals


related to maternal health unless resources are invested and

effective action take among the adolescent and youth

population.

Proposed Guiding Principles of Health Policy for Attaining theHealth Related Millennium Development Goals before 2015

The question that has to be asked is whether current

economic and social policies in developing countries are

enough to attain the Millennium Development Goals or whether

changes are required. As was noted earlier, if the current

trend holds, many of the indicators associated with the

health-related Goals will not reach the levels set as targets

for 2015 unless corrective measures are applied.

For the Millennium Development Goals to be meaningful in

the context of national policymaking, they have to be regarded

as an essential component and driver of national health

development and of national intersectoral health goals and

targets, particularly since the sector has recently undergone

a succession of reforms that in some countries have weakened

public health systems and reduced access to services.

The main policy challenges to be met in order to achieve

the health-related Millennium Development Goals are therefore

as follows:


1. Promoting inter-sectorality and inter-institutionality

Health is multidimensional and requires intersectoral

strategies that form part of broader development and poverty

reduction strategies. To attain health improvements, then,

efforts must be directed at a wider range of social policies,

transcending the idea that these are watertight compartments

and recognizing how interdependent the targets are, since

achieving or falling short of one will have repercussions in

terms of the others. It is important to capture the synergies

between public policies and interdisciplinary and

intersectoral measures targeted on the most vulnerable groups

and on the most disadvantaged areas and countries.

Empirical data show that it is when health and education

work together that real inroads can be made into infant and

maternal mortality rates. Aspects of sexual and reproductive

health also require responses that are coordinated with other

areas, such as the labour market or the justice system, and

efforts to empower individuals and communities, particularly

adolescents and women.

Again, when the percentage of the population with access to

drinking water is analyzed, it transpires that this is highly


correlated with the reduction of infant mortality rates. This

evidence suggests that intersectoral programmes can be used to

transform people’s living environment by targeting the most

vulnerable groups and taking as their basis of measurement the

family, the school, the community, organized civil society

groups or the municipality. It also calls for the creation of

intersectoral organizational structures.

Lastly, harmonization is fundamental for achieving the

Millennium Development Goals. The importance of this has been

expressed in meetings and agreements between Governments,

international aid organizations and other social actors with a

presence in the countries of the world. Within this context,

regional and sub-regional agreements on aspects relating to

migration and the portability of benefits need to be

strengthened and further developed.

2. Improving equity and extending social protection in

health

The rise in the absolute number of people living in poverty,

like the widening gap between those who have access to the

benefits of development and those who lack them, has its

counterpart in social protection in health. Marked inequities


in the area of health, particularly those linked to gender,

race/ethnicity and age, have a heavy cost: such inequities

debar people from taking up their right to development and

health, reproduce poverty levels and reduce the impact of

economic development, as well as eroding social cohesion and

jeopardizing democratic processes in the region.

To address these unwarranted inequalities, the world’s

countries need to make a firm commitment to the imperatives of

equity and solidarity and for synergistic, convergent measures

to be taken at different levels, such as: reducing inequality

in access to services; making institutions work better for the

benefit of all; strengthening the capacity of the State to

distribute resources; and increasing social participation in

the design, monitoring and implementation of public health

policies.

The Millennium Development Goals cannot be met unless the

starting point is respect for the cultural diversity of the

different groups in society, measures are taken to support

equitable and sustainable economic growth and development is

centred on human beings. Extending social protection in health


is a necessary condition for achieving the Millennium

Development Goals.

A large proportion of the world’s population is still

excluded from the social mechanisms that protect people

against the risks of disease and its consequences. Social

protection strategies designed to put an end to exclusion

entail public-sector interventions aimed at guaranteeing

citizens’ access to decent and effective health care and at

reducing the negative economic and social impacts of personal

difficulties, such as illness or unemployment, or of general

events, such as natural disasters, on the population at large

or the most vulnerable social groups.

3. Increasing the amount and progressiveness of current andinvestment spending on health

Given the amount and composition of national health

expenditure and its distribution among the population, it is

important to revisit the issues of public financing and the

efficiency and distributive impact of spending. This re-

examination should be undertaken in the light of the necessary

balance between health services and goods and the consumption

of other goods that have an impact on health (food, housing,


education, sanitation) and contribute to individual and social

well-being.

Based on the evidence on health financing available in the

world, it can be argued that greater government investment in

public health programmes and personal health services is

needed. Such investments would have to be funded by raising

taxes or improving tax collection mechanisms, or by increasing

social security contributions.

4. Improving health systems’ response capacity

It is important to stress the link between the Millennium

Development Goals and the changes required in health systems.

To achieve the Goals it will be necessary to work on specific

programmes, such as sexual and reproductive health initiatives

and infectious disease control plans, and to develop health

systems and services so that these programmes and

interventions reach all of the world’s citizens.

Where health systems are concerned, it is necessary to work

simultaneously on management, financing, insurance and health-

service delivery so that the actions taken in each of these

areas are consistent and mutually reinforcing and will promote


equity. The challenges to be met in these areas are as

follows:

a. With regard to the management of public health policy and

the exercise of authority over health matters by public

authorities, the challenge is to strengthen this function

and make the machinery for it more efficient.

b. In the area of financing, the challenge lies in

collectively organizing the various sources of financing

to meet the health needs of the population within a

framework of solidarity and equity. Specifically,

sustainable, distributional financing mechanisms are

needed to ensure funding for both personal health

services and public health measures.

c. In the area of health insurance, the challenge lies in:

guaranteeing provision of a range of universal services

for citizens by striking a reasonable balance between

public insurance schemes with contributive or social

financing and privately-financed schemes and reducing the

transaction costs as well as inequities stemming from the

segmented, fragmented and weakly regulated schemes that

prevail today in the world.


d. In the area of service delivery, the challenge lies in:

(a) building up a network of services that make the

universal right to health, including individuals’

reproductive rights, a reality; (b) reorienting the care

model around educational and preventive criteria and

strengthening primary care strategies; (c) introducing

appropriate incentives for intermediate and final

providers to act in a way that furthers the achievement

of health goals and prevents exclusion; (d) prioritizing

strategies to make health services more accessible; (e)

ensuring continuity of service between the different

levels and subsystems of the health system; (f)

backstopping the demand for services by population groups

at the greatest risk of exclusion (example; the poor,

indigenous people, Afro-descendants, etc.); and (g)

enhancing users’ ability to familiarize themselves with

and exercise their rights to health care.

Furthermore, it is important to establish policies for

expanding the basic level of primary health care (PHC) as the

fundamental strategy for the creation of a platform for

extending health systems on the basis of equity. This can be


done by integrating vertical approaches and strengthening

intersectoral collaboration and social participation in health

care. Primary Health Care has been shown to have great

potential as a vehicle for meeting five health challenges that

await the world in future, namely;

i. guaranteeing health citizenship status and universal

access, while giving priority to the health of the

least privileged groups;

ii. reducing inequalities in health and in health-care

systems, including gender, race/ethnicity and

generational inequalities;

iii. improving the health of the population at large,

with significant reductions in the risk of infant

and maternal death, increases in life expectancy and

quality-of-life improvements;

iv. providing health care through an integrated network

of effective, high-quality services which meet the

needs of individuals, families and communities and

in which they all participate;

v. coordinating the different health-care providers and

strengthening the infrastructure and institutional


capabilities necessary for the performance of

essential public health functions.

Additionally, where human resources in the health sector are

concerned, it is important to:

(a) provide advocacy services that reinforce the

centrality of human resource policies in the world;

(b) enhance the countries’ capacity to organize

concerted, sustainable political consensus building

processes for the implementation of human resource

policies that take account of the large proportion of

women in the workforce;

(c) strengthen and develop the public-sector health

workforce based on a long-term perspective involving the

introduction of concrete incentives to reorient

professional training;

(d) orient the labour market towards needed areas, with

emphasis on primary health care;

(e) upgrade professional performance through regulation

and ongoing education; and


(f) expedite the development of institutional

capabilities that can help improve the performance of

health services.

Again, health systems will clearly have to be strengthened

if access to health care is to be guaranteed and the

Millennium Development Goals are to be met. For this to be

possible, policies for reinforcing these systems need to focus

on reducing segmentation and fragmentation within them and

introducing powerful mechanisms to promote equity. The key

question (World Bank, 2003b; Gacitúa, Sojo, Davis, 2000;

Bhalla and Lapeyre, 1999; Jordan, 1996) seems to be how health

policies can be designed to include the groups that are

currently excluded from the system.

The portability of guaranteed access to health services is

crucial in this regard, since informal employment, migratory

movements and poverty will remain facts of life in the medium

and long terms. In this context, it is also necessary to

clearly define who will be entitled to this guarantee, with

access to health being understood not as an employment-linked

right but as a citizenship-linked one.


To sum up, making good on the commitments accepted by the

world’s Governments in the form of the Millennium Development

Goals remains a challenge. Few countries have fully

incorporated these Goals into their policy-making.

Furthermore, a number of factors have to be taken into account

when policies are being designed and implemented. Governments

have different ways of perceiving the problems that face them

and deciding upon and prioritizing solutions in the light of

their political agendas. Yet if all the countries apply

different criteria when ranking problems and do not combine

their efforts and outlooks to work in unison, the Millennium

Development Goals are unlikely to be met in the world.

Given current socio-economic conditions, stronger political

will is needed, not just nationally but at the sub-regional

and regional levels as well, so that the public health agenda

for meeting the Goals is given central priority. A major

challenge is to secure recognition for the right to health as

a priority on public agendas and in government efforts.

Consequently, political leadership of the health sector is

critical, as is the capacity to facilitate dialogue between

all those involved in identifying problems and strategies.


Lastly, it should be stressed that, in order to uphold the

right to health, democratic governance has to be strengthened

within a framework of social cohesion and human rights based

on the understanding that genuine democracy cannot be attained

without ensuring that no inhabitant of the world is excluded

from the benefits of development or deprived of the right to

health. This is the path towards the realization of the

universal aspiration reflected in the health-related

Millennium Development Goals for our world.

Conclusion

The Millennium Development Goals (MDGs) have contributed

significantly to realizing the rights of children to health

and development. As the practical implementation of the

commitments of the Millennium Declaration, the existence of

standard goals with quantitative targets, agreed upon by all

countries, has catalyzed progress for maternal and child


survival, nutrition, HIV, malaria, tuberculosis, education and

water and sanitation. The Millennium Development Goals have

also elevated child health in global and national political

agendas, stimulated increased resources from development

partners for health, intensified efforts to improve the

availability of essential health services for children,

nurtured innovation and radically improved monitoring and

reporting mechanisms.

Child survival is a clear example of how the Millennium

Development Goals have assisted in revitalizing efforts to

realize the right to health of children. Concern at lack of

progress on Millennium Development Goal 4 and 5 in the 2000s,

identified through the quantitative monitoring and analysis of

data strengthened as a result of the Millennium Development

Goals, led to urgent efforts at global and national levels to

save the lives of women and children. Global under-5 mortality

has now fallen from approximately 12 million deaths in 1990 to

an estimated 6.9 million deaths in 2011 (a reduction in the

global under-5 mortality rate of 41% during this period),

(UNICEF: 2012).


Projections suggest, on current data, that only 31% of

developing countries will achieve Millennium Development Goal

No. 4 by 2015, although this may be an underestimate,

especially given evidence that progress in child survival is

accelerating in many sub-Saharan African countries. A large

proportion of the countries who may not achieve Millennium

Development Goal No. 4 by 2015 have still made significant

gains and are likely to achieve the target relatively soon

after 2015 if current progress can be maintained.

Despite this encouraging progress in many countries, far

too many women and children continue to be denied their right

to health and die unnecessarily. Rates of maternal and

neonatal mortality, as well as stunting, show less reduction

than for under-5 mortality. Countries reporting the highest

levels of maternal and child mortality are increasingly those

beset by conflict or in otherwise “fragile” situations.

The need for political initiatives to resolve conflict

and address poor governance is fundamental to improving the

health of women and children in these countries. It is

essential that attention to this “unfinished business” is kept

at the highest level, both leading up to 2015 and afterwards.


While many countries will still not achieve Millennium

Development Goals No. 4 and 5 by 2015, the possibility of

ending all preventable child deaths is now widely envisaged.

In June 2012, the Governments of USA, India and Ethiopia,

with UNICEF and WHO, launched A Promise Renewed – a commitment to

reduce under-5 mortality to under 20 deaths/1000 live births

in all countries in the world by 2035, and to reduce

inequalities at the sub-national level. By December 2012, 168

countries had signed a pledge to re-commit to reducing child

mortality rates.

Additionally, the importance of adequate, affordable, and

universal or at least widely accessible health care is

recognized as essential to improving health outcomes. It is

also well understood that mothers’ education is a key

determinant of the well being of children – whether by

reducing fertility or by facilitating the adoption of good

nutritional and hygienic practices. What we have argued,

however, is that achieving the health and education Millennium

Development Goals will require more than health and education

interventions. In particular, infrastructure services have an

important role to play, and a failure to recognize this in


planning Millennium Development Goal strategies will risk

undermining success.

Finally, one cannot undermine the interaction effects

between education, health, and infrastructure variables for

improving health outcomes. For the trio of child mortality,

maternal health, prevention of diseases and malnutrition, the

impact of infrastructure seems to be conditioned by the level

of education and the use of adequate health services. In other

words, achieving the health goals put forward in the

Millennium Development Goals will probably require combined

interventions on many different fronts to build upon cross-

sectoral synergies.


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POSSIBILITY OR OTHERWISE OF ACHIEVING THE HEALTH MILLENNIUM DEVELOPMENT GOALS BY 2015

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