A new agenda for Health: the Millennium Development Goals present health as both an outcome and a determinant of countries' development. As such, they give public health advocates a valuable new opportunity to promote their cause.

The Millennium Development Goals have defined a new roadmap for global development that defines health as both a destination and a point of departure. Three of the eight goals refer explicitly to health issues, while seven of the 18 more specific targets fall directly within the responsibility of the health sector (see box p. 11). This emphasis reflects a new global consensus that health is not only an outcome of development but also one of its core determinants.

The idea is not new. It was part of the call for "Health for All" made at the First International Conference on Primary Health Care at Alma Ata 25 years ago. But today the millennium goals, with their broad base of international support, provide the public health community with a new and invaluable point of entry for advocating their cause.

With their emphasis on equity, the Millennium Development Goals have special significance for the Americas, the world's most unequal region. The inequities and gaps in our region's development often find their starkest expression in health status. Throughout the region, the means to better health exist, but they are largely out of reach for the poorest and most vulnerable groups. For Latin America and the Caribbean, the millennium goals provide an opportunity to join efforts in a concerted approach that recognizes health as a regional public good to be shared by all the countries and all their peoples.

Heads of state and other leaders have promised, at successive Summits of the Americas and other fora, to increase investments in health and social protection. Yet strengthening the region's commitment to the millennium goals remains a major challenge. A recent analysis by the United Nations Economic Commission on Latin America and the Caribbean concluded that no country in the region is on track to reach all of the millennium targets by 2015. Some, such as Bolivia, could well see increased inequity, while others, such as Nicaragua, are lagging well behind on poverty reduction. No country seems set to reach two key health targets: improving infant and maternal mortality.

Making progress toward the millennium goals in health in the Americas requires concerted action in three key areas. Countries must reduce inequities through targeted interventions, increase investment in health and health systems, and develop partnerships for health development. These imperatives form the backbone of the Pan American Health Organization's strategy for helping its member countries progress toward the millennium goals.

For its own technical cooperation efforts, PAHO has designated five priority countries: Bolivia, Guyana, Haiti, Honduras, and Nicaragua. These countries rank the lowest in the region in terms of life expectancy and per capita income, and most of them fall well below the regional average on measures including the percentage of physician-attended births and the number of physicians per 1,000 inhabitants. In Bolivia, there are only 1.3 doctors per 1,000 inhabitants, and in Haiti, only 0.2. According to the 2004 World Health Report, life expectancy in Haiti fell from 57 in 1993 to 50 years in 2002, primarily as a result of AIDS. Maternal mortality rates in the five countries are comparable to rates in the 1930s and 1940s in the United States.

Yet a country focus is not enough. Many of the region's health inequities are based on geography, ethnic origin, gender and socioeconomic status. The huge disparities cannot be resolved by aggregate economic growth alone but will require targeted interventions. Research consistently shows that even small reductions in inequality can have large impacts on poverty reduction. This calls for policies and actions that target the rural poor in neglected regions as well as marginal urban groups, such as unemployed youths and female-headed households.

Successful examples of ways to address these challenges can be found throughout the region. But scaling these up can be achieved only with additional aid. A recent discussion paper by the World Health Organization argues that even in a context of faster economic growth, many countries will be able to reach the health and nutrition goals only with specially funded efforts to improve the coverage and quality of health and nutrition services.

The Millennium Development Goals provide a unique opportunity to promote increased financing of health, by giving new legitimacy and urgency to the need to invest in people. By underlining health as a key determinant of development, they provide public health advocates with new inroads to ministries of finance, planning and development. In terms of both policy and financing, the millennium goals can help get health on the agenda of economic and social development strategies, loan projects and negotiations with donors.

This is critically important. In recent decades the countries of Latin America and the Caribbean have instituted broad-reaching health reforms that in some cases have weakened public health systems and reduced access to primary health care. Making up for these losses by investing in the health sector is crucial if the region is to make progress on the specific millennium goals.

In their call for a "global partnership for development" and their intersectoral approach, the millennium goals also provide new opportunities for public and private organizations to work on a common agenda with new partners. In Latin America and the Caribbean, these include ministries of health, education and the environment, as well as nongovernmental organizations and international agencies such as PAHO, the United Nations Development Program (UNDP), the World Bank and the Inter-American Development Bank. A particular challenge for PAHO is to help strengthen the role of health in strategies for poverty reduction and to develop more integrated approaches to technical cooperation.

One of the chief objectives of the Millennium Development Goals is to encourage transparency and accountability in government and to foster democratic participation. Indeed, one reason for keeping the goals simple and straightforward was to allow ordinary people to be part of the process. The 2003 UNDP Human Development Report proposed that the millennium goals be posted on the door of every village hall. Ideally, communities at all levels should be involved in setting national goals and strategies as well as in monitoring and debating governments' performance on the basis of empirical data.

One of the key challenges for the public health sector will be to find ways of improving public confidence in public institutions. Organizations such as PAHO can contribute to this task by working with legislators and other leaders at the regional, local and community levels and by seeking new ways to work with the private sector and civil society organizations involved in health. One important message to get across is that it is a sign of true democracy when citizens' access to primary health care does not depend upon their ability to pay.

Integrated approach

The millennium goals in health require PAHO and its member countries to concentrate on three other areas: improving health systems, strengthening essential public health functions, and further developing human resources in the health sector. A key challenge for PAHO is to support its member countries in developing an integrated approach to these tasks, building on its work in such areas as maternal and child health and infectious diseases, as well as health systems development and social protection. All parties who have responsibilities in these areas must be involved.

Achieving the millennium health goals will also require better epidemiologic and socioeconomic information analysis. This area is still hampered by the varied sources of statistical information, a lack of harmonization, and disaggregation of data. For example, in its Human Development Report for 2003, the UNDP reports that under-5 mortality in Latin America and the Caribbean was reduced from 56 per 1,000 live births in 1990 to 35 per 1,000 in 2001. Extrapolating from this trend, the region could be expected to achieve and surpass Goal 2 by 2015. Using data from the United Nations Division of Population, PAHO has reached a different, less optimistic conclusion, which has significant policy implications.

Finally, the region's health and social sectors must work efficiently. Although most countries in Latin America and the Caribbean increased social spending as a percentage of GDP during the 1990s, these increases did not produce the expected results. The lesson here is that countries must not only increase spending in the health sector and on specific programs but also do a better job of assessing which mix of allocations produces the most cost-effective interventions and the greatest reductions in inequities.

Every country in the region faces its own special challenges in the pursuit of the Millennium Development Goals, in regard to health as well as other issues. Yet all would benefit from a policy framework that includes a commitment to universal access to health care and to strengthening the essential public health functions of the state.

Some of the millennium goals may be easier to achieve than others, but to fulfill the overarching goal of reducing inequities, countries must strive to reach beyond the minimum millennium targets, which are based on national averages. They must be willing to "raise the bar." This is a historic task that will require unprecedented political commitment, leadership, innovation and creativity. It requires the region of the Americas to muster the necessary will and resources to ensure that health makes its proper contribution to social cohesion, poverty reduction and better quality of life.

Millennium health targets

Goals and targets

Goal 1 Eradicate extreme poverty and hunger

Target 2: Halve, between 1990 and 2015, the proportion of people who suffer from hunger

Goal 2 Achieve universal primary education

Goal 3 Promote gender equality and empower women

Goal 4 Reduce child mortality

Target 5: Reduce by two-thirds, between 1990 and 2015, the under-5 mortality rate

Goal 5 Improve maternal health Target 6: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio 

Goal 6 Combat HIV/AIDS, malaria, and other diseases

Target 7: Have halted by 2015 and begun to reverse the spread of HIV/AIDS

Target 8: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases

Goal 7 Ensure environmental sustainability

Target 10: Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation

Goal 8 Develop a global partnership for development

Target 17: In cooperation with pharmaceutical companies, provide access to affordable, essential drugs in developing countries

Indicators

4. Prevalence of underweight in children (under 5 years of age)

5. Proportion of population below minimum level of dietary energy consumption

13. Under-5 mortality rate

14. Infant mortality rate 

15. Proportion of 1-year-old children immunized against measles

16. Maternal mortality ratio

17. Proportion of births attended by skilled health personnel

18. HIV prevalence among 15- to 24-year-old pregnant women

19. Condom use rate of the contraceptive prevalence rate

19a. Condom use at last high-risk sex 

19b. Percentage of population aged 15-24 with comprehensive correct knowledge of HIV/AIDS

19c. Contraceptive prevalence rate

20. Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14

21. Prevalence and death rates associated with malaria

22. Proportion of population in malaria-risk areas using effective malaria prevention and treatment measures

23. Prevalence and death rates associated with tuberculosis

24. Proportion of tuberculosis cases detected and cured under directly observed treatment short course (DOTS)

30. Proportion of population with sustainable access to an improved water source, urban and rural

31. Proportion of population with access to improved sanitation

46. Proportion of population with access to affordable, essential drugs on a sustainable basis

Achieving the goals

The Pan American Health Organization (PAHO) is working with its 35 Member States and other partners to help Latin America and the Caribbean achieve the Millennium Development Goals. Its work in this area is based on eight main lines of action:

* Advocacy among a wide range of audiences

* Health policy initiatives

* Technical cooperation with countries to reach the goals

* Integration of the millennium goals into other health initiatives

* Partnerships with other organizations and institutions

* Empowerment of communities

* Monitoring of progress toward the goals

* Research to generate new knowledge on health and development

Ilona Kickbusch is special advisor to the Pan American Health Organization on the Millennium Development Goals. She is on leave from Yale University, where she is professor and head of the Division of Global Health in the Department of Epidemiology and Public Health, School of Medicine.