Health, development and the Millennium Development
R. DODD and A. CASSELS
Department for Health Policy, Development and Services (EIP/HDS), World Health
Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
Received 17 January 2006, Accepted 20 January 2006
The Millennium Development Goals (MDG), which emerged from the United Nations Millennium Summit in
2000, are increasingly recognized as the over-arching development framework. As such, the MDG are increasingly
guiding the policies of poor countries and aid agencies alike. This article reviews the challenges and opportunities
for health presented by the MDG.
The opportunities include that three of the eight MDG relate to health — a recognition that health is central to
global agenda of reducing poverty, as well as an important measure of human well-being in its own right. A related
point is that the MDG help to focus attention on those health conditions that disproportionally affect the poor
(communicable disease, child health and maternal health), which should, in turn, help to strengthen the equity
focus of health policies in low-income countries. Further, because the MDG are concrete, it is possible to calculate
the cost of achieving them, which in turn strengthens the long-standing calls for higher levels of aid for health.
The challenges include that, while the MDG focus on specific diseases and conditions, they cannot be achieved
without strengthening health systems. Similarly, progress towards the MDG will require health to be prioritized
within overall development and economic policies. In practice, this means applying a health ‘lens’ to processes such
as civil-service reform, decentralization and the drawing-up of frameworks of national expenditure. Finally, the
MDG cannot be met with the resources available in low-income countries. While the MDG framework has created
pressure for donors to commit to higher levels of aid, the challenge remains to turn these commitments into action.
Data are presented to show that, at current rates of progress, the health-related MDG will not be achieved. This
disappointing trend could be reversed, however, if the various challenges outlined are met.
In the year 2000 the global community
made an historic commitment: to eradicate
extreme poverty and improve the health and
welfare of the world’s poorest people within
15 years. The commitment was the United
Nations Millennium Declaration (United
Nations, 2000) and derived from it are eight
time-bound goals, known as the Millennium
Development Goals (MDG).
Table 1) have gained wide-spread accep-
tance in rich and poor countries alike. They
framework for development efforts, and
benchmarks against which to judge success.
International commitment to the MDG was
re-affirmed in September 2005 at the World
endorsed the goals. With the MDG target
date of 2015 just 9 years away, now is the
time to review progress, take stock of the
achievements, and address the challenges.
In its recent publication, Health and the
2005a), the World Health Organization
(WHO) identified five opportunities offered
by the MDG, and five challenges that
are likely to impede progress towards the
opportunities and challenges and explores
one of the challenges in more detail:
namely, the relationship between health
and development policy. It concludes by
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Annals of Tropical Medicine & Parasitology, Vol. 100, Nos. 5 and 6, 379–387 (2006)
# 2006 The Liverpool School of Tropical Medicine
giving an overview of the WHO’s work on
THE MILLENNIUM DEVELOPMENT
GOALS AND HEALTH
The MDG represent an important set of
opportunities for the health sector.
Firstly, the goals provide a common set of
priorities on how to tackle poverty. This
unprecedented level of agreement between
national governments, international agen-
cies and the United Nations system brings
both political momentum and focus to
development efforts, helping to ensure that
the needs of poor people remain at the top
of the development agenda.
Secondly, health is at the heart of the
MDG,with therecognition that better health
is central to the global agenda of reducing
poverty as well as an important measure of
human well-being in its own right. Health is
represented in three of the eight goals, and
makes an acknowledged contribution to the
achievement of all the others, particularly
those related to education, gender equality
and the eradication of extreme poverty and
hunger. Importantly, the health goals also
focus on problems that disproportionally
affect the poor — communicable disease,
child health and maternal health.
and ambitious targets against which to
measure progress. These provide an indica-
tion of whether efforts to improve health
are on track, and a means of holding
decision-makers to account. Worryingly,
data released in 2005 show that progress
towards the health-related
behind that made towards the other goals
(see Box 1).
Fourthly, it is possible to calculate what it
would probably cost to achieve the MDG,
and this, in turn, draws attention to the
massive funding gap between what is avail-
able and what is needed. This provides
additional support to the long-standing calls
from the health sector for its funding to be
Fifthly and finally, a unique feature of the
MDG is that the eighth goal calls for a
global partnership for development, recog-
nizing that there are certain actions rich
countries must take if poor countries are to
achieve goals 1 to 7. Goal 8 is a reminder
that global security and prosperity depend
on a more equitable world for all.
Importantly, the MDG have also helped to
crystallize the challenges. As developed and
developing countries begin to look seriously
at what it would take to achieve the health-
related MDG, the bottlenecks to progress
have become clearer. These challenges —
again, five have been identified — are
summarized below. They also represent
core elements of the WHO’s strategy for
achieving the MDG, as discussed below.
The first challenge is to strengthen health
systems. Without more efficient and equi-
table health systems, countries will not be
able to scale up the programmes for disease
prevention and control that are required to
meet the specific health goals — of reducing
child and maternal mortality and rolling
back HIV/AIDS, tuberculosis and malaria.
Survival has estimated that universal access
to broad-based health services could, on its
own, meet 60%–70% of the decreases in
decreases in maternal mortality required to
achieve the relevant MDG (Claeson et al.,
2003). In practice, the strengthening of
Group on Child
The eight Millennium Development Goals
Goal 1: Eradicate extreme poverty and hunger
Goal 2: Achieve universal primary education
Goal 3: Promote gender equality and empower women
Goal 4: Reduce child mortality
Goal 5: Improve maternal health
Goal 6: Combat HIV/AIDS, malaria and other diseases
Goal 7: Ensure environmental sustainability
Goal 8: Develop a global partnership for development
DODD AND CASSELS
Progress Towards the Health-related MDG
From the 1990 baseline date for the targets, 2006 is well past the half-way mark on the path
towards the MDG target date of 2015. The health data available so far are not encouraging.
They indicate that, if the trends observed during the 1990s continue, most poor countries
will not meet their health-related MDG.
None of the poorest regions of the developing world are currently on track to meet their
target level of child mortality, for example (Fig. 1). Declines in maternal mortality have
been limited to countries with already low levels; countries that had high levels of maternal
mortality in 1990 are recording no change or even an increase.
The data on the coverage of some health interventions are more hopeful. The percentage
of women who have a skilled medical person with them during delivery, for example, has
increased rapidly in some regions — especially in Asia, albeit from a low baseline. Use of
insecticide-treated bednets has risen, and coverage of effective anti-tuberculosis treatment
has expanded. Unfortunately, coverage of child-health interventions does not appear to be
following this encouraging pattern: the median coverage of the key preventive and curative
interventions for improving child survival remains at between 20% and 25%.
It is important to recognize the inter-dependence of the goals: progress with one health
goal (particularly the containment of the AIDS epidemic) will affect progress with others,
such as child mortality. Similarly, progress towards the health goals will have a positive
impact on overall poverty, and the efforts in health will have a mutually reinforcing
relationship with the efforts to improve education and water supplies.
FIG. 1. Regional progress in reducing mortality among children aged ,5 years towards the target levels set, as part
of the fourth Millennium Development Goal, for 2015 (United Nations, 2005). The data shown are the baseline
values in 1990 (%), the values recorded in 2003 (&), and the target values for 2015 (indicated by horizontal bars).
CIS, Commonwealth of Independent States.
MILLENNIUM DEVELOPMENT GOALS
health systems has a number of elements,
from tackling the human-resources crises to
establishing an equitable health-financing
system (which ensures both that poor
people can access care and that health costs
do not cause impoverishment) and strength-
ening each government’s regulation and
Although these complex issues are not the
subject of this article, their importance to
the achievement of the MDG cannot be
stressed enough. If the poor record of
progress towards the health-related MDG
(see Box 1) is to be reversed, health planners
and donors will need to pay more attention
to health-systems constraints in future.
The second challenge is to ensure that
health is prioritized within overall develop-
ment and economic policies. This means
looking beyond the health system and
addressing the broad determinants of ill-
health — low levels of education, poverty,
unequal gender relations, high-risk beha-
viours, and an unhealthy environment — as
well as raising the profile of health within
national processes for poverty reduction and
government reform. This particular chal-
lenge is elaborated below, in the section on
health and development
The third challenge is to develop health
strategies that respond to the diverse and
evolving needs of countries. The MDG
indicate desirable outcomes in terms of
being. This means designing cost-effective
strategies to address those diseases and
conditions that account for the greatest
share of the burden of disease, now and in
the future. As Figure 2 shows, in addition to
the priorities reflected in the MDG, efforts
to reduce violence and injuries, as well as
non-communicable diseases such as those
tobacco use, will need to be tackled.
Further, reproductive-health interventions
will be essential in all countries.
The fourth challenge is to mobilize more
resources for health in poor countries.
Currently, low-income countries cannot
‘afford’ the MDG and aid is not filling the
gap. Development assistance for health was
estimated at U.S.$8100 million (J6300
million) in 2002, the most recent year for
which figures are available (Michaud, 2003).
This represents a significant rise — up from a
mean of U.S.$6400 million/year between
1997 and 1999 — and reflects an upward
trend in overall aid levels. While these
increases are welcome, they remain far short
of the amounts that are needed. The United
Nations Millennium Project recently esti-
mated that meeting all the MDG would
require an estimated U.S.$135,000 million
of official development assistance in 2006,
rising to U.S.$195,000 million by 2015.
Importantly, the Millennium Project notes
that these increases remain well within the
target adopted by theUnited Nations General
Assembly in 1970 and recently renewed at
Monterrey — that rich countries should
allocate 0.7% of their gross national product
(GNP) as development aid (U.S.$135,000
FIG. 2. The causes of the 57 million deaths, among individuals of all ages, that occurred in 2002 (WHO, 2005a).
DODD AND CASSELS
million is currently equivalent to 0.44% of the
combined GNP of these countries).
Within health, there have been a number
of studies on the need to increase spending.
In 2001,the Commission
economics and Health estimated that a
minimally adequate set of interventions —
and the infrastructure needed to deliver
them — would cost in the region of
Other estimates indicate that as much as
U.S.$60 per capita is needed (WHO, 2000).
While these figures differ markedly, the
over-riding message is clear: in the poorest
countries, health spending needs to be of a
different order of magnitude compared with
its current level, of just U.S.$8–10 per capita
in the least developed countries.
In addition to high levels of aid, donors
are increasingly aware that they need to
provide more effective aid. This has many
implications, among the most important of
which is that donors must improve the
predictability and reduce the volatility of
their aid. Typically, donors only commit aid
12 months in advance, and levels of aid can
vary greatly from year to year. Figure 3
illustrates this problem dramatically for four
countries. When the amount of aid a
country receives is likely to change at short
notice, it is impossible for ministries of health
and finance to make long-term plans, such as
employing more doctors or nurses, widening
access to AIDS treatment or scaling-up
health-service provision. Furthermore, with
the proliferation of new forms of develop-
ment assistance for health — particularly
the larger global-health partnerships, such
Tuberculosis and Malaria — it is critically
strengthen rather than undermine national
The fifth challenge is to improve the
quality of health data in order to measure
each country’s progress towards the MDG.
At a global level, the demonstration of
resources and sustain political momentum
for health-sector investment. At country
level, reliable information can help ensure
that polices are correctly orientated and
targeted at those most in need. The WHO’s
specific role in tracking progress towards the
health-related MDG is discussed below.
HEALTH IN DEVELOPMENT
It has long been recognized that better
health services alone will not improve health
outcomes. Several factors, including levels
FIG. 3. Donor commitment for health, as a percentage of the total annual health expenditure, in Guinea (N),
Benin (#), Burundi (&) and Liberia (%) between 1997 and 2001 (World Bank, 2005).
MILLENNIUM DEVELOPMENT GOALS