Two months from now, world leaders will meet at the UN in New York to review progress with the Millennium Development Goals. The many reports coming across my desk suggest that the MDGs have been good for development.
They have been a powerful force in the fight to reduce poverty and inequity in a decade full of competing challenges. They have made us realize the importance of interdependence – between rich, poor and emerging economies; between education, gender, health, and the environment; and between setting goals and ensuring access to the human, financial and material resources needed to achieve them. They have forced us to think about what works and why. And a set of time-bound, quantitative targets has forced us to be better at measuring what we do.
But have they made a difference to people’s lives?
WHO reports every year on the health related MDGs and you can find a good summary of progress here: http://www.who.int/mediacentre/factsheets/fs290/en/index.html. As you will see, there are some real success stories in reducing child deaths; in extending treatment for AIDS and in preventing new HIV infections; and in controlling malaria and tuberculosis. But success is patchy – with some interventions progress has been rapid, with others it is almost static. Huge inequities remain between and within regions and countries. Where there has been success, the gains can be fragile. And there is much, much more to do if we are to reach the 2015 targets.
This brings me to the main theme of this posting. How can we sustain momentum for the achievement of the MDGs in a world where fatigue with development issues is a reality, and in a world too easily distracted by competing claims for public attention? Here is my own checklist.
First, we have to be clear about priorities and where we have to do more. MDGs four and five – improving women and children’s health – are the goals against which progress has been most disappointing. Reducing the number of women that die in childbirth is the major challenge.
But what does doing more actually mean? Technically, we know what works: access to family planning, effective ante-natal care, safe facility-based delivery, routine immunization, and the prevention and treatment of childhood illness. We know that scaling-up programmes that provide these interventions is necessary. But we have also learnt that this will be insufficient without efforts to strengthen health delivery systems and to address the broader determinants of women’s health. So we have to be clear that it is the outcome – fewer preventable deaths among women and children – not a programme or an intervention – that is the real priority. It is a concern for the lives and welfare of women and children what will help drive and sustain public support for the health MDGs.
The next part of my checklist is about the elements necessary for success.
We cannot deliver better outcomes without better health systems. What this means in practice is a well-trained and adequately paid workforce; financing policies that protect people from impoverishment when they fall sick; information on which to base policy and management decisions; logistics that get medicines and vaccines to where they are needed; well-maintained facilities organized as part of a referral network; and leadership that provides clear direction and harnesses the energies of all stakeholders – including communities.
Some people would argue that a focus on better lives for women and children represents a fundamental change in direction, the latest trend in the fickle world of international development. I agree this is a risk. But we must not rob Peter to pay Paul – shifting resources from one set of programmes to another.
This means that keeping the promises made in the fight against HIV and AIDS is vital (and I write as the International AIDS Conference opens in Vienna). AIDS, TB and malaria cause death and disability among women and children. But they are priorities in their own right – especially where gains are fragile and new threats (such as drug resistant TB) are emerging. In the language of the opening statements of the conference: no retreat from commitments – but no retreat into separate silos either. Synergy and integration are the watchwords.
The purpose of the MDGs is to reduce poverty and as I have said elsewhere: to miss poverty is to miss the point. Poverty is both a cause and an outcome of all forms of ill health. This means that high on my checklist is a concern that countries address the growing burden and risk factors underlying non-communicable diseases – diabetes, cancer, mental health and cardiovascular disease. Although they are not reflected in a specific target, their human and economic impact will act as a serious brake on development unless we act now.
Continuing the theme of inter-dependence: improving the health of women and children will not happen without attention to poor diets and under nutrition; preventing exclusion from health care on the basis of gender, age or ethnicity; dealing with the health impacts of urbanization and migration; reducing exposure to environmental toxins; and increasing access to safe water and sanitation. Health is an outcome of all policies. The list is long. The links with better health are well established. The challenge is sustained action and accountability for results.
And that brings me to the final point in this list. Joining the dots. Countries and their international partners face tough decisions in the face of growing demands and finite resources. Sustaining support for the MDGs requires that ministries of finance, parliaments, donors and the public have confidence that progress will be achieved. Developing a robust national health policy and strategy allows the participation of different stakeholders in decision making, shows how choices have been made, and sets out how all the elements needed to improve health outcomes come together. In countries that receive significant levels of aid, national strategies are the best means of ensuring alignment between external inputs and national priorities.
Ensuring that every woman has the greatest chance of delivering her children in safety and in dignity is one of the greatest challenges in any country’s development. There is much that can be done, but there is no simple one-off technical solution. It requires that nearly everything we do in health has to come together: the health systems, the facilities, the technical interventions, the political leadership, the social and economic policies, the staff, the money and the equipment. Of course this is a challenge. But, if we can ensure safe delivery – we can be confident that many other benefits will be sure to follow.