Equity as a shared vision for health and development
In 2000, 189 countries signed up to the UN Millennium Declaration—a global commitment to halve extreme poverty and achieve equitable and sustainable development for all. The agreement led to the creation of a historic framework centred around eight Millennium Development Goals (MDGs), designed to tackle poverty, education, gender, health, environment, and global partnerships—all to be met by 2015. On September 20—22, world leaders will gather in New York to attend the UN MDG review summit, to renew commitments and determine how to accelerate progress in the coming years. Overall, progress is uneven, with some regions, especially in the poorer countries, lagging woefully behind. Clearly, it cannot be business as usual in the next 5 years if the promises made a decade ago are to be met.
This week’s Lancet publishes the results of a Commission jointly supported by The Lancet and the London International Development Centre (LIDC). The Millenium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015 uses a cross-cutting analysis to examine the origins of the goals and targets, their strengths and weaknesses, and the challenges of implementing them. On the positive side, the MDGs have achieved much. They have mobilised unprecedented political support, advocacy efforts, financial resources, and have encouraged improved monitoring and evaluation of programmes.
However, the Commission argues that the targets were narrow and fragmented. Potential linkages and synergies between goals have not been fully realised. An article by Emmanuela Gakidou and colleagues in this week’s issue supports this view, showing clear gains in health through education attainment. The study found that over the past 40 years improvements in women’s education (MDG 2) has reduced child mortality (MDG 4) substantially, averting 4·2 million deaths globally. Furthermore, the results point to the importance of a reduction of the gender gap in educational achievement, thereby promoting gender equity and empowering women (MDG 3).
The addition of new targets over time has also been unsuccessful, as seen with universal access to reproductive health. Newer priorities facing the world, such as non-communicable diseases (NCDs) and climate change, have been slow to be accepted in the current framework, although the focus on NCDs at the next UN General Assembly in September, 2011, is an important step forward. Given these problems and challenges, the Commission proposes that the next MDG framework be built on a shared vision of development across the life course rather than on separate goals and targets.
Central to the Commission is the issue of equity. Conventional wisdom is that more lives are saved by focusing on populations easier to reach with proven interventions than those who are marginalised. But the poorest communities have the worst health outcomes. Addressing the needs of the better-off simply widens disparities between the richest and poorest within communities and between countries. New UN child mortality estimates in this issue show a one-third decline in deaths in children under 5 years since 1990, far short of its 67% target. But now reports from UNICEF and Save the Children conclude that targeting the most disadvantaged children is not only morally right, but could also save the lives of millions more children. The UNICEF study found that using an equity-focused strategy, a US$1 million investment in reducing deaths in children under 5 years in a low-income, high-mortality country would avert an estimated 60% more deaths than the current approach.
Undoubtedly a key agenda item at the forthcoming summit will be future financing for global health. In times of economic austerity, foreign aid will need to be more effective and sustainable. Having public support for aid to developing countries is crucial if donors are to increase their aid budgets in line with international commitments. In a comment from Japan this week, the public supports foreign aid assistance for health. However, by contrast, a UK public survey from the Institute of Development Studies found that although most people feel development aid is morally right, over half of respondents believe aid is wasted. They do not support ring-fencing aid spending. The fact that the public are not convinced that aid works is troubling. The development community should reflect on why this is so.
The Lancet—LIDC Commission proposes a different way of approaching health and development, replacing goals and targets with principles. A revitalised effort to reach the poorest between now and 2015 would do much to ensure that the spirit of the Millennium Declaration continues to motivate all those concerned with human health in a global setting.