SUMMARY This report aims to describe global health in 2015, looking back 15 years at the trends and positive forces during the Millennium Development Goal (MDG) era and assessing the main challenges for the coming 15 years The 2030 Sustainable Development Agenda is of unprecedented scope and ambition, applicable to all countries, and goes well beyond the MDGs. While poverty eradication, health, education, and food security and nutrition remain priorities, the Sustainable Development Goals(SDGs) comprise a broad range of economic, social and environmental objectives and offer the prospect of more peaceful and inclusive societies Progress towards the MDGs, on the whole, has been remarkable, including, for instance, poverty reduction, education improvements and increased access to safe drinking-water. Progress on the three health goals and targets has also been considerable. Globally, the HIV, tuberculosis(TB) and malaria epidemics were"turned around", child mortality and maternal mortality decreased greatly (53% and 44%, respectively, since 1990), despite falling short of the MDG targets During the MDG era, many global progress records were set. The mDgs have gone a long way to changing the way we think and talk about the world, shaping the international discourse and debate on development, and have also contributed to major increases in development assistance. However, several limitations of the MDGs have also become apparent, including a limited focus, resulting in verticalization of health and disease programmes in countries, a lack of attention to strengthening health systems, the emphasis on a"one-size-fits-all development planning approach, and a focus on aggregate targets rather than equity The 17 goals and 169 targets, including one specific goal for health with 13 targets, of the new development agenda integrate the three dimensions of sustainable development around people, planet, prosperity peace and partnership. The health goal is broad: "Ensure healthy lives and promote well-being for all at all ages" Health has a central place as a major ntributor to and beneficiary of sustainable development policies. There are many linkages between the health and other goals and targets, reflecting the integrated approach that is underpinning the SDGs. Universal health coverage (UHC), one of the 13 health goal targets, provides an overall framework for the implementation of a broad and aml health agenda in all countries Monitoring and review of progress will be a critical element of the SDgs. an indicator framework is still being developed and is scheduled to be adopted in 2016 FROM MDGS TO SDGS: GENERAL INTRODUCTON
SUMMARY This report aims to describe global health in 2015, looking back 15 years at the trends and positive forces during the Millennium Development Goal (MDG) era and assessing the main challenges for the coming 15 years. The 2030 Sustainable Development Agenda is of unprecedented scope and ambition, applicable to all countries, and goes well beyond the MDGs. While poverty eradication, health, education, and food security and nutrition remain priorities, the Sustainable Development Goals (SDGs) comprise a broad range of economic, social and environmental objectives, and offer the prospect of more peaceful and inclusive societies. Progress towards the MDGs, on the whole, has been remarkable, including, for instance, poverty reduction, education improvements and increased access to safe drinking-water. Progress on the three health goals and targets has also been considerable. Globally, the HIV, tuberculosis (TB) and malaria epidemics were “turned around”, child mortality and maternal mortality decreased greatly (53% and 44%, respectively, since 1990), despite falling short of the MDG targets. During the MDG era, many global progress records were set. The MDGs have gone a long way to changing the way we think and talk about the world, shaping the international discourse and debate on development, and have also contributed to major increases in development assistance. However, several limitations of the MDGs have also become apparent, including a limited focus, resulting in verticalization of health and disease programmes in countries, a lack of attention to strengthening health systems, the emphasis on a “one-size-fits-all” development planning approach, and a focus on aggregate targets rather than equity. The 17 goals and 169 targets, including one specific goal for health with 13 targets, of the new development agenda integrate the three dimensions of sustainable development around people, planet, prosperity, peace and partnership. The health goal is broad: “Ensure healthy lives and promote well-being for all at all ages”. Health has a central place as a major contributor to and beneficiary of sustainable development policies. There are many linkages between the health goal and other goals and targets, reflecting the integrated approach that is underpinning the SDGs. Universal health coverage (UHC), one of the 13 health goal targets, provides an overall framework for the implementation of a broad and ambitious health agenda in all countries. Monitoring and review of progress will be a critical element of the SDGs. An indicator framework is still being developed and is scheduled to be adopted in 2016. FROM MDGs TO SDGs: GENERAL INTRODUCTION 3
On 25 September 2015, the United Nations(UN) and targets, and discusses how the monitoring of progress General Assembly adopted the new development agenda towards the health-related SDG can be accomplished Transforming our world: the 2030 agenda for sustainable development". The new agenda is of unprecedented scope and ambition, and applicable to all countries. MDGS The post-2015 framework goes far beyond the MDGs, which nevertheless provided an important framework for combatting poverty and promoting development in low- In September 2000, the UN General assembly adopted the and middle-income countries during the past 15 years. Millennium Declaration, establishing a global partnership While poverty eradication, health as a basic human right, of countries and development partners committed to eight education, and food security and nutrition remain priorities, voluntary development goals, to be achieved by 2015 he SDGs comprise a broad range of economic, social and Representing ambitious moral and practical commitments, ivironmental objectives, as well as offering the promise the MDGs called for action to: (1)eradicate extreme of more peaceful and inclusive societies. The 17 goals and poverty and hunger;(2) achieve universal primary 169 targets, including one specific goal for health with 13 education; (3) promote gender equality and empower targets, have many linkages and cross-cutting elements, women; (4)reduce child mortality; (5) improve maternal reflecting the integrated approach that underpins the SDGs. health; (6)combat HIV/AIDS, malaria and other diseases 7)ensure environmental sustainability; and(8)develop This report aims to describe global health in 2015, looking a global partnership for development. Three of the eight back 15 years at the trends and positive forces during the MDGs are focused on health, while health is also a MDG era and assessing the main challenges for the coming component of several other MDGs(nutrition, water and 15 years. The following chapter describes the context, sanitation) cluding population and epidemiological changes, and the economic, social and environmental determinants of There has been unprecedented mobilization of resources health. The subsequent six chapters present the trends and around MDG-related activities across a wide spectrum challenges for the main health areas that are prominent in of global and national initiatives and the development the health goal of the SDGs: UHC; reproductive, maternal, community has convened on a regular basis to assess newborn, child and adolescent health; infectious diseases: progress. major global events related to the MDgs include noncommunicable diseases(NCDs); mental health and the 2001 and 2011 UN special sessions on HIV/AIDS ibstance abuse and injuries and violence. Some chapters convened to intensify international activity to fight the cover multiple health targets and, where relevant, refer to epidemic; d the 2005 World Summit, which reaffirmed the SDG targets that are in other goals. The final chapter reflects commitments to the millennium Declaration; the 2008 on the implications of the SDg for health high-level event at the Un in New York, at which there was a call to accelerate progress towards the mdgs, Each chapter summarizes the achievements and progress the 2010 Millennium Development Goals Summit, which towards the health-related MDGs since 2000, or trends concluded with the adoption of a global Action Plan and in areas that were not prioritized in the mdgs. Key the announcement of multiple initiatives against poverty factors that have contributed to the success of the past hunger and disease, as well as initiatives designed to 15 years are identified, ranging from country actions to accelerate progress on womens and childrens health, and global partnerships, funding increases and scale-up of at which specific MDG-related commitments were made new interventions. The major challenges for health in 2015 by countries and others, and, most recently, the 2013 and the next 15 years are also summarized. The last part UN special event to follow up on MDG-related efforts. 6 of each chapter puts together the strategic priorities as Many regional and country events have also been held to defined in the SDG targets, and links those to World Health review progress and make new commitments Organization(WHO) resolutions, global action plans and other critical strategic documents. For many areas, the The mdgs have gone a long way to changing the way we World Health Assembly has already laid out what countries think and talk about the world, shaping the international and the international community should prioritize to make discourse and debate on development, and stimulating significant progress towards the new SDG targets. In many popular awareness of moral imperatives such as achieving other areas, the sdgs offer a new, broader and integrated gender equality and ending poverty and starvation perspective that needs further concretization and impetus The mdgs have also contributed to major increases in in regard to UHC and intersectoral approaches development assistance, 9, 10 as evidenced by the 66% jump in official development assistance (oda, in real terms) This introductory chapter starts with a brief review of the between 2000 and 2014 when it reached an unprecedented general health-related MDG achievements, strengths and US$ 135 billion More aid has flowed into education and imitations. The second part describes the health-related public health, while also being directed towards poorer SDG targets, including how health is reflected in other goals countries to supplement the increases in domestically HEALTH IN 2015: FROM MDGs TO SDGs
On 25 September 2015, the United Nations (UN) General Assembly adopted the new development agenda “Transforming our world: the 2030 agenda for sustainable development”.1 The new agenda is of unprecedented scope and ambition, and applicable to all countries. The post-2015 framework goes far beyond the MDGs, which nevertheless provided an important framework for combatting poverty and promoting development in lowand middle-income countries during the past 15 years. While poverty eradication, health as a basic human right, education, and food security and nutrition remain priorities, the SDGs comprise a broad range of economic, social and environmental objectives, as well as offering the promise of more peaceful and inclusive societies. The 17 goals and 169 targets, including one specific goal for health with 13 targets, have many linkages and cross-cutting elements, reflecting the integrated approach that underpins the SDGs. This report aims to describe global health in 2015, looking back 15 years at the trends and positive forces during the MDG era and assessing the main challenges for the coming 15 years. The following chapter describes the context, including population and epidemiological changes, and the economic, social and environmental determinants of health. The subsequent six chapters present the trends and challenges for the main health areas that are prominent in the health goal of the SDGs: UHC; reproductive, maternal, newborn, child and adolescent health; infectious diseases; noncommunicable diseases (NCDs); mental health and substance abuse; and injuries and violence. Some chapters cover multiple health targets and, where relevant, refer to SDG targets that are in other goals. The final chapter reflects on the implications of the SDG for health. Each chapter summarizes the achievements and progress towards the health-related MDGs since 2000, or trends in areas that were not prioritized in the MDGs. Key factors that have contributed to the success of the past 15 years are identified, ranging from country actions to global partnerships, funding increases and scale-up of new interventions. The major challenges for health in 2015 and the next 15 years are also summarized. The last part of each chapter puts together the strategic priorities as defined in the SDG targets, and links those to World Health Organization (WHO) resolutions, global action plans and other critical strategic documents. For many areas, the World Health Assembly has already laid out what countries and the international community should prioritize to make significant progress towards the new SDG targets. In many other areas, the SDGs offer a new, broader and integrated perspective that needs further concretization and impetus in regard to UHC and intersectoral approaches. This introductory chapter starts with a brief review of the general health-related MDG achievements, strengths and limitations. The second part describes the health-related SDG targets, including how health is reflected in other goals and targets, and discusses how the monitoring of progress towards the health-related SDG can be accomplished. MDGs In September 2000, the UN General Assembly adopted the Millennium Declaration, establishing a global partnership of countries and development partners committed to eight voluntary development goals, to be achieved by 2015. Representing ambitious moral and practical commitments, the MDGs2 called for action to: (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; and (8) develop a global partnership for development. Three of the eight MDGs are focused on health, while health is also a component of several other MDGs (nutrition, water and sanitation).3 There has been unprecedented mobilization of resources around MDG-related activities across a wide spectrum of global and national initiatives and the development community has convened on a regular basis to assess progress. Major global events related to the MDGs include: the 2001 and 2011 UN special sessions on HIV/AIDS, convened to intensify international activity to fight the epidemic;4 the 2005 World Summit,5 which reaffirmed the commitments to the Millennium Declaration; the 2008 high-level event at the UN in New York,6 at which there was a call to accelerate progress towards the MDGs; the 2010 Millennium Development Goals Summit, which concluded with the adoption of a Global Action Plan and the announcement of multiple initiatives against poverty, hunger and disease, as well as initiatives designed to accelerate progress on women’s and children’s health, and at which specific MDG-related commitments were made by countries and others;7 and, most recently, the 2013 UN special event to follow up on MDG-related efforts.6 Many regional and country events have also been held to review progress and make new commitments. The MDGs have gone a long way to changing the way we think and talk about the world, shaping the international discourse and debate on development, and stimulating popular awareness of moral imperatives such as achieving gender equality and ending poverty and starvation. The MDGs have also contributed to major increases in development assistance,8,9,10 as evidenced by the 66% jump in official development assistance (ODA, in real terms) between 2000 and 2014 when it reached an unprecedented US$ 135 billion.3 More aid has flowed into education and public health, while also being directed towards poorer countries to supplement the increases in domestically 4 HEALTH IN 2015: FROM MDGs TO SDGs
sourced development finance The influence on donor MDGs and has conducted annual reviews of progress policies and practices and-more variably -on governments since 2009, based on a report prepared by the Secretariat the developing world, has been considerable. For derived from the WHo annual statistical overview and instance, the MDGs(specifically MDG 6) were integral WHO Global Health Observatory data. 4. 15 considerations in the policy formation of the global Fund to Fight AIDS, Tuberculosis and Malaria( Global Fund), which Health in the MDG: achievements was created in 2002 Progress towards the MDGs has, on the whole, been Tracking progress towards the mdgs has required a remarkable. With regard to extreme poverty for example, significant investment in measuring the 60 key indicators the number of people living on less than US$ 1.25 per which are used to monitor the 8 MDGs and their 21 targets. day has declined by more than half, from 1.9 billion in Annual progress reports are produced by the Inter-agency 1990 to 836 million in 2015. Similarly, the proportion and Expert Group( IAEG)on MDG indicators, coordinated of undernourished people in the developing regions has by the UN Statistics Division, and based on the contributions fallen from 23% in 1990-1992 to 13% in 2014-2016. The of technical agencies In 2008, the World Health Assembly child undernutrition indicator target has almost been met called for regular monitoring of progress towards the health (Table 1.1) Table 1.1 Global and WHO regional status of the health-related MDGs Met or on track Half way Insufficient progress Target Global AFR AMR SEAR Halve. between 1990 and 2015. the proportion of people who suffer from Percent reduction in proportion of underweight 50 44 35 6349 children under-five years of age, 1990-2015 Percent reduction in under-five mortality 67535465646548 get 4.A educe by two thirds, between 1990 and Measles immunization coverage among one-year-olds(%), 2014 90 可-- Percent reduction in maternal mortality 75 44 44496963 Caithe by kle hath persone 90 I 73 s4 g6 s9 967ss Antenatal care coverage (%): at least one visit, 2013 15. universal access to Unmet need for family planning (96), 2015 0 24551927284210 ed by 2015 and begun to reverse Percentreduction in HIN incidence, 2000-2014>0455928 <50 Percent reduction in incidence of malaria. Target 6 2000-2015 nd other major Percent reduction in incidence of tuberculosis,>017 1990-2014 171412 to improved drinking-water 50 恤5mpm105 Percent reduction in proportion of population ithout access to improved sanitation, 50 31 47322854 1990-2015 Target for births attended by skilled health personnel was set by the Intemational Conference on Population and Development. FROM MDGS TO SDGS: GENERAL INTRODUCTON
Table 1.1 Global and WHO regional status of the health-related MDGs Target Global AFR AMR SEAR EUR EMR WPR Target 1.C Halve, between 1990 and 2015, the proportion of people who suffer from hunger Percent reduction in proportion of underweight children under-five years of age, 1990–2015 50 44 35 63 49 85 39 82 Target 4.A Reduce by two thirds, between 1990 and 2015, the under-five mortality rate Percent reduction in under-five mortality rate, 1990–2015 67 53 54 65 64 65 48 74 Measles immunization coverage among one-year-oldsa (%), 2014 90 85 73 92 84 94 77 97 Target 5.A Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Percent reduction in maternal mortality ratio, 1990–2015 75 44 44 49 69 63 54 64 Births attended by skilled health personnelb (%), 2013 90 73 54 96 59 99 67 95 Target 5.B Achieve, by 2015, universal access to reproductive health Antenatal care coverage (%): at least one visit, 2013 100 88 81 99 84 99 79 95 Unmet need for family planning (%), 2015 0 24 55 19 27 28 42 10 Target 6.A Have halted by 2015 and begun to reverse the spread of HIV/AIDS Percent reduction in HIV incidence, 2000–2014 >0 45 59 28 50 -16 < -50 27 Target 6.C Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Percent reduction in incidence of malaria, 2000–2015 >0 37 42 78 49 100 70 65 Percent reduction in incidence of tuberculosis, 1990–2014 >0 17 1 49 17 14 12 48 Target 7.C Halve, by 2015, the proportion of people without sustainable access to safe drinking-water Percent reduction in proportion of population without access to improved drinking-water sources, 1990–2015 50 62 38 62 74 67 39 84 Percent reduction in proportion of population without access to improved sanitation, 1990–2015 50 31 7 47 32 28 54 54 AFR, African Region; AMR, Region of the Americas; SEAR, South-East Asia Region; EUR, European Region; EMR, Eastern Mediterranean Region; WPR, Western Pacific Region. a Target for measles immunization coverage was set by the World Health Assembly. b Target for births attended by skilled health personnel was set by the International Conference on Population and Development. Met or on track Half way Insufficient progress sourced development finance.11 The influence on donor policies and practices and – more variably – on governments in the developing world, has been considerable.12 For instance, the MDGs (specifically MDG 6) were integral considerations in the policy formation of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), which was created in 2002. Tracking progress towards the MDGs has required a significant investment in measuring the 60 key indicators which are used to monitor the 8 MDGs and their 21 targets. Annual progress reports are produced by the Inter-agency and Expert Group (IAEG) on MDG indicators, coordinated by the UN Statistics Division, and based on the contributions of technical agencies.3 In 2008, the World Health Assembly called for regular monitoring of progress towards the health MDGs13 and has conducted annual reviews of progress since 2009, based on a report prepared by the Secretariat derived from the WHO annual statistical overview and WHO Global Health Observatory data.14,15 Health in the MDG: achievements Progress towards the MDGs has, on the whole, been remarkable. With regard to extreme poverty, for example, the number of people living on less than US$ 1.25 per day has declined by more than half, from 1.9 billion in 1990 to 836 million in 2015. Similarly, the proportion of undernourished people in the developing regions has fallen from 23% in 1990–1992 to 13% in 2014–2016. The child undernutrition indicator target has almost been met (Table 1.1). FROM MDGs TO SDGs: GENERAL INTRODUCTION 5
Significant progress has also been achieved with regard to is a cause for celebration, both declines fall well short education, with the primary school net enrolment rate in of the mdg targets of two thirds and three quarters the developing regions reaching 91% in 2015, up from 83% reductions from the 1990 levels. Regional progress has in 2000. Many more girls are now in school compared to also been uneven, as can be seen in Table 1.1, and substantial 15 years ago, with developing regions as a whole having inequalities remain within and across countries. 7More achieved the target to eliminate gender disparity in primary, detailed assessments of the progress made are provided secondary and tertiary education, which is likely to yield in chapters 5 and 6 considerable maternal and child health benefits 16 Strengths and limitations of the MDGs Major progress has been made on water and sanitation, which has a significant impact on the transmission of The mdgs have been more influential than any other fectious diseases In 2015, 91% of the global population is attempt at international target setting in the field of ng an improved drinking-water source, compared to 76% development. The rapid acceleration of global progress in 1990, thus meeting the MDG target, while the proportion towards the poverty reduction, gender, health and education of people practising open defecation has fallen almost by goals since 2000, and particularly since 2005, is just one half. Globally, 147 countries have met the drinking-water example of their beneficial impact. The adoption of a simple, target, 95 countries have met the sanitation target and 77 clear and time-bound framework that is compelling, easy countries have met both to communicate and measurable has been one of the MDGs great strengths, encouraging donor governments, Progress on the specific health-related goals and targets, international agencies and country decision-makers to focus MDG 4, MDG 5 and MDG 6, has also been encouraging attention on areas of need, and to measure the results of (see chapters 4 and 5). Globally, the HIV, TB and malaria initiatives undertaken and while it is hard to isolate specific MDG targets have been met. Child mortality has fallen by causal effects, it seems reasonable to suppose that the 53% and maternal mortality by 43%. Even though this intensity of focus (and investment)has been a key driver of innovation, enabling the scale-up of new interventions, such as antiretroviral therapy(Art), long-lasting insecticidal nets(LLINs), artemisinin-based combination therapies (ACTS), vaccines against pneumonia and diarrhoeal disease and new and better diagnostic tests for multiple diseases The emphasis on measuring results has also had a positive mpact on country data systems. a good example is the provement in country data availability for a subset of 2 official MDG indicators between 2003 and 2014.3While in 2003, only 2% of developing countries had at least two data points for 16 or more of the 22 indicators, by 2014 this figure had reached 79%, reflecting the increased capacity of national statistical systems to address monitoring requirements Development partners played an important role in boosting monitoring capacity, most successfully by providing long-term support to national health surveys. especially the United Nations Childrens Fund (UNICEF)and the United States Agency for International Development USAID). These surveys, mostly conducted by national statistical offices in collaboration with ministries of health also generated data on inequalities in health, especially fo eproductive, maternal and child health indicators. 8, 9One mportant benefit of increased monitoring was highlighting the importance of accountability involving a cyclical process of monitoring, review and remedial action. The importance of accountability has been underlined at all levels through or instance. the recommendations of the commission on Information and accountability for Women s and childrens Health, and has not only improved monitoring, but is also gradually leading to more inclusive and transparent reviews of progress involving civil society, politicians and HEALTH IN 2015: FROM MDGs TO SDGs
Significant progress has also been achieved with regard to education, with the primary school net enrolment rate in the developing regions reaching 91% in 2015, up from 83% in 2000. Many more girls are now in school compared to 15 years ago, with developing regions as a whole having achieved the target to eliminate gender disparity in primary, secondary and tertiary education, which is likely to yield considerable maternal and child health benefits.16 Major progress has been made on water and sanitation, which has a significant impact on the transmission of infectious diseases. In 2015, 91% of the global population is using an improved drinking-water source, compared to 76% in 1990, thus meeting the MDG target, while the proportion of people practising open defecation has fallen almost by half. Globally, 147 countries have met the drinking-water target, 95 countries have met the sanitation target and 77 countries have met both. Progress on the specific health-related goals and targets, MDG 4, MDG 5 and MDG 6, has also been encouraging (see chapters 4 and 5). Globally, the HIV, TB and malaria MDG targets have been met. Child mortality has fallen by 53% and maternal mortality by 43%. Even though this is a cause for celebration, both declines fall well short of the MDG targets of two thirds and three quarters reductions from the 1990 levels. Regional progress has also been uneven, as can be seen in Table 1.1, and substantial inequalities remain within and across countries.17 More detailed assessments of the progress made are provided in chapters 5 and 6. Strengths and limitations of the MDGs The MDGs have been more influential than any other attempt at international target setting in the field of development. The rapid acceleration of global progress towards the poverty reduction, gender, health and education goals since 2000, and particularly since 2005, is just one example of their beneficial impact. The adoption of a simple, clear and time-bound framework that is compelling, easy to communicate and measurable has been one of the MDGs’ great strengths, encouraging donor governments, international agencies and country decision-makers to focus attention on areas of need, and to measure the results of initiatives undertaken. And while it is hard to isolate specific causal effects, it seems reasonable to suppose that the intensity of focus (and investment) has been a key driver of innovation, enabling the scale-up of new interventions, such as antiretroviral therapy (ART), long-lasting insecticidal nets (LLINs), artemisinin-based combination therapies (ACTs), vaccines against pneumonia and diarrhoeal disease, and new and better diagnostic tests for multiple diseases. The emphasis on measuring results has also had a positive impact on country data systems. A good example is the improvement in country data availability for a subset of 22 official MDG indicators between 2003 and 2014.3 While in 2003, only 2% of developing countries had at least two data points for 16 or more of the 22 indicators, by 2014 this figure had reached 79%, reflecting the increased capacity of national statistical systems to address monitoring requirements. Development partners played an important role in boosting monitoring capacity, most successfully by providing long-term support to national health surveys, especially the United Nations Children’s Fund (UNICEF) and the United States Agency for International Development (USAID). These surveys, mostly conducted by national statistical offices in collaboration with ministries of health, also generated data on inequalities in health, especially for reproductive, maternal and child health indicators.18,19 One important benefit of increased monitoring was highlighting the importance of accountability involving a cyclical process of monitoring, review and remedial action. The importance of accountability has been underlined at all levels through, for instance, the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health, and has not only improved monitoring, but is also gradually leading to more inclusive and transparent reviews of progress involving civil society, politicians and the media.20,21 6 HEALTH IN 2015: FROM MDGs TO SDGs