Education And Debate

# Can the millennium development goals be attained?

BMJ 2004; 329 (Published 12 August 2004) Cite this as: BMJ 2004;329:394
1. Andy Haines, dean1,
2. Andrew Cassels, director, health and development policy2
1. 1 London School of Hygiene and Tropical Medicine, London WC1E 7HT
2. 2 World Health Organization, 1211 Geneva 27, Switzerland
1. Correspondence to: A Haines

To achieve the UN's goals worldwide, less developed countries need to address weaknesses in health systems and policy makers need to look beyond aggregate national figures to inequalities in outcomes

## Introduction

In September 2000 the largest ever gathering of heads of state ushered in the new millennium by adopting the UN Millennium Declaration.1 The declaration, endorsed by 189 countries, was then translated into a roadmap setting out goals to be reached by 2015.2

The eight goals in the section on development and poverty eradication are known as the millennium development goals. They build on agreements made at major United Nations' conferences of the 1990s and represent commitments to reduce poverty and hunger, to tackle ill health, gender inequality, lack of education, lack of access to clean water, and environmental degradation (box). The big difference from their predecessors is that rather than just set targets for what developing countries aspire to achieve, the goals are framed as a compact that recognises the contribution that developed countries can make through fair trade, development assistance, debt relief, access to essential medicines, and technology transfer. Without progress in these areas (summarised in the final goal) the poorest countries will face an uphill struggle to achieve the other goals. The notion of the goals as a compact between North and South was reaffirmed at the international conference on financing development in Monterrey, Mexico, in 2002.3

Achieving the millennium development goals requires steep declines in maternal and child mortality

Credit: DIETER TELEMANS/PANOS

## Who benefits if the goals are achieved?

The health goals are expressed as national averages, rather than gains among poor or disadvantaged groups. This means that significant progress in non-poor groups can result in the achievement of goals even though only minor improvements in the health of the poorest have been made.11 The use of aggregate data may mask growing inequalities, but such inequalities are not inevitable, as countries such as Guatemala and Bangladesh have shown.5

## What needs to be done?

The problem is not simply a lack of effective interventions. There is, of course, a need for new drugs, vaccines, and diagnostics—and thus an important research agenda in relation to the millennium development goals. However, countries are not “off track” because knowledge is lacking on how to treat a child with pneumonia, to prevent diarrhoea, to deliver babies safely, or even to prolong the life of people living with AIDS. But effective interventions often fail to reach the people who need them.

Resources are important. Current health spending in most low income countries is insufficient for achieving the health goals. We have global estimates of what is needed—a doubling of aid from around $50bn in 2001 to$100bn a year for the goals as a whole; \$10bn per year total spending on HIV/AIDS; and a fivefold increase in donor spending on health.12 The proposed International Finance Facility could help to achieve the needed increase by using long term commitments from government donors to leverage immediate and additional resources from private markets13—thus enabling the frontloading of aid when it is most needed.14 Progress, though, cannot depend on aid alone: reducing trade barriers erected by wealthy nations to exports from developing countries can make a big difference. Developing countries too have to make greater efforts. In this context, African ministers set their own target to increase health spending (for example, to 15% of total government expenditure15).

Although few would dispute the need for more money, there are concerns about the current capacity of poor countries to effectively absorb major increases in aid. In addition, a debate remains between ministries of finance, the Bretton Woods institutions, and others about the extent to which a rapid scale-up of aid will affect macroeconomic stability.12 Increases in aid can influence exchange rates and competitiveness, but HIV/AIDS and other major causes of ill health will hit economies hard for a long time. Fiscal policy should reflect the urgency of the situation in countries where high death rates among civil servants, teachers, police, and health workers threaten the stability of societies.

More money is only part of the picture. Progress equally depends on getting policies right; making the institutions that implement them function effectively; building health systems that work well and treat people fairly; generating demand for better and more accessible services; and—perhaps the most neglected factor of all—ensuring there are enough staff to do all the work that is required.

In many countries, particularly in southern Africa, the shortage of health service and other public sector staff has now become one of the most serious rate limiting factors in scaling up the response to HIV/AIDS and other public health problems. The reasons for this crisis are multiple. Health workers are dying. They are leaving public service because the conditions are poor, and getting worse. They are seeking better paid jobs in the private sector, or leaving health care altogether for better paid jobs. They are migrating to countries that can pay more for their services within Africa. Others go further afield and add to the brain drain from sub-Saharan Africa. Although extensive analysis of these issues is available,16 17 a concerted attempt to remedy the situation has so far been wanting.

## In summary

Achieving the health millennium development goals represents some of the greatest challenges in international development, not least because they include the goal of reversing the global epidemic of HIV/AIDS. To this we have to add the steep declines required in child and maternal mortality, where progress lags far behind aspirations in many parts of the world. Improving health outcomes will not be possible without major improvements in healthcare delivery systems, which in turn depend on changes in public sector management, new forms of engagement with the private sector (leading, for example, to wider availability of affordable drugs, vaccines, and diagnostics), more research directed at improving health systems, as well as policies and interventions well beyond the health sector itself. Moreover, improvements in health are essential if progress is to be made with the other millennium development goals, including the reduction of absolute poverty.

#### Summary points

Improving health outcomes will not be possible without major improvements in healthcare delivery systems

Improvements in health are essential for progress with other millennium development goals

Without more resources and changes in policies, the goals cannot be attained—but accelerated progress is possible

In answer to the question posed in the title, if none of the changes described in this article take place then the answer is almost certainly no, the goals cannot be attained. But accelerated progress is possible, and lies within reach. It is a matter of political choice in both the developed and developing world. We also know that substantial progress, even if it were to fall short of the targets set four years ago, could dramatically transform the lives of millions of the world's poorest people. The millennium development goals are one means of exerting the leverage that can make this happen.

We thank Becky Dodd and Carla Abou Zahr, WHO, for their comments and advice.

## Footnotes

• Contributors and sources AH has had a longstanding interest in global health issues and has written articles on a range of relevant topics. AC is director of the department within the World Health Organization concerned with coordinating WHO's work on the health related millennium development goals. In addition to quoted publications, the article draws on discussions at the High Level Forum on the Health MDGs held in Geneva in January 2004. Both authors are guarantors of the paper.

• Competing interests None declared.

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