United Nations Millennium Declaration, 2000, paragraph 2

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2 We have a collective responsibility to uphold the principles of human dignity, equality, and equity at the global level... We have a duty therefore to all the world s people, especially the most vulnerable. United Nations Millennium Declaration, 2000, paragraph 2

3 What are the Millennium Development Goals? At the UN Millennium Summit in September 2000 the 189 states of the United Nations reaffirmed their commitment to work toward a world in which eliminating poverty and sustaining development would have the highest priority. The Millennium Declaration was signed by 147 heads of state and passed unanimously by the members of the UN General Assembly. The Millennium Development Goals, which grew out of the agreements and resolutions of world conferences organized by the United Nations in the past decade, have been commonly accepted as a framework for measuring development progress. The goals focus the efforts of the world community on achieving significant, measurable improvements in people s lives. They establish yardsticks for measuring results not just for developing countries but for the rich countries that help to fund development programs and for the multilateral institutions that help countries implement them. The first seven goals, directed at reducing poverty in all its forms, are mutually reinforcing. The eighth goal global partnership for development is about the means to achieve the first seven. Many of the poorest countries will need additional assistance and must look to the rich countries to provide it. Countries that are poor and heavily indebted will need further help in reducing their debt burdens. And all countries will benefit if trade barriers are lowered, allowing freer exchange of goods and services. The complete list of Millennium Development Goals, including targets and indicators, is shown at the end of the booklet. 1 The Millennium Development Goals 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 8. Develop a global partnership for development Health and the Millennium Development Goals The first seven Millennium Development Goals are directly or indirectly linked with the activities of the health, nutrition, and population sector in the World Bank, either as health and nutrition status indicators or as determinants of health outcomes. There are many synergies among these activities, so that working with other sectors such as education, water and sanitation, and gender is likely to be the most effective way of achieving progress.

4 2 Poverty reduction and the health, nutrition, and population sector The multisector framework Analysis of the health, nutrition, and population sector using the multisector framework of the Poverty Reduction Strategy Paper process shows that health outcomes and impoverishment are the result of interactions among households, communities, health services, other sectors, and government. The process of developing Poverty Reduction Strategy Papers offers an opportunity to bring these levels together for a common goal. Levels of action Good health is a main goal of development and can make an enormous difference in the lives of poor people. Achieving good health requires action at multiple levels: At the household level health outcomes reflect behaviors and risk factors as well as available resources. At the community level values and norms influence the use and availability of services, and community involvement can greatly affect the quality and accountability of health services. At the health system level access to services as well as the cost, availability, and quality of drugs, vaccines, and other key inputs are important determinants of health outcomes. Other parts of the health sector and other sectors are frequently vital to achieving health outcomes. Government policies and actions play a major role in financing and regulating health services and other sectors that affect health services. Good health requires action at multiple levels Factors determining health and nutrition Key outcomes Households and communities Health system and other sectors Government policies and actions Millennium Development Goals for health, nutrition, and population Impoverishment Out-of-pocket spending Household actions and risk factors Use of health services; dietary, sanitary, and sexual practices; lifestyle Household assets Human, physical, and financial Health service provision Availability, accessibility, prices and quality of services Health finance Public and private insurance, financing and coverage Health policies Macro, health system, and micro levels Community factors Cultural norms, community institutions, social capital, environment, and infrastructure Supply in related sectors Availability, accessibility, prices and quality of food, energy, roads, water and sanitation, and others Other policies Infrastructure, transport, energy, agriculture, water and sanitation, and others

5 3 In November 2001 the World Bank convened a consultation of operational and technical specialists from UN agencies, the World Bank, and other organizations to examine useful indicators that could be measured regularly and reliably to assess progress toward the health, nutrition, and population-related Millennium Development Goals and identify which are critical for making progress toward the goals. The multisectoral framework of the Poverty Reduction Strategy Papers process was used to identify key determinants and corresponding indicators of health outcomes. The recommended indicators are listed in the table. The indicators selected in a specific context have to be useful, measurable, representative, simple, easy to understand, accessible, likely to be available at country level, scientifically robust, and ethical. Health, nutrition, and population-related Millennium Development Targets Halve, between 1990 and 2015, the proportion of people who suffer from hunger Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio Have halted by 2015 and begun to reverse the spread of HIV/AIDS Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Recommended intermediate or proxy indicators Prevalence of underweight children under five Proportion of infants under six months who are exclusively breastfed Proportion of children 6 59 months who received one dose of vitamin A in the past six months Proportion of one-year-old children immunized against measles Proportion of children with diarrhea in the past two weeks who received oral rehydration therapy Proportion of children with fast or difficult breathing in the past two weeks who received an appropriate antibiotic Proportion of women with any antenatal care Proportion of births with skilled birth attendant or institutional delivery Contraceptive prevalence rate Proportion of people using a condom during last higher risk sexual act Proportion of clients with sexually transmitted infection who are appropriately diagnosed and treated Proportion of HIV-positive women receiving antiretroviral treatment during pregnancy Proportion of patients with uncomplicated malaria who received treatment within 24 hours of onset of symptoms Proportion of children and pregnant women sleeping under insecticide-treated nets Proportion of women receiving antenatal care who receive at least two or three preventive malaria treatments during pregnancy Proportion of registered new smear-positive tuberculosis cases in a cohort that were successfully treated Proportion of estimated new smear-positive tuberculosis cases that were registered under the directly observed treatment short-course approach For a complete list of recommended core intermediate and optional indicators, see Health, Nutrition, and Population Development Goals: Measuring Progress Using the Poverty Reduction Strategy Framework,November 2001.

6 4 The poverty goal and health Goal 1: Eradicate extreme poverty Target: Halve, between 1990 and 2015, the proportion of people whose income is less than $1 a day Poverty is both a consequence and a cause of ill health. Ill health, malnutrition, and high fertility are often the reasons that households end up in poverty or sink even further into poverty if they are already poor. The illness of a breadwinner results in lost income as well as unanticipated health care costs. High fertility reduces not only the resources available for other household members, but also the earnings opportunities for women. Malnutrition contributes to ill health and has serious consequences for both mothers and children. But poverty is also a cause of ill health. Poor people experience multiple conditions that together cause greater levels of ill health than the better-off are exposed to. The poor lack the financial resources to pay for health services, food, clean water, sanitation, and other key inputs that help to produce good health. In addition, the health facilities serving the poor are often hard to reach, lacking even basic medicines, and badly run. Poor people are also disadvantaged by a lack of knowledge about prevention and when to seek health care. They tend to live in communities that have weak institutions and social norms that are not conducive to good health. In short, poor people are caught in a vicious circle their poverty breeds ill health, which in turn conspires to keep them poor. Health and poverty are linked in many ways Characteristics of the poor Inadequate use of services; unhealthy sanitary, dietary practices Caused by Lack of income and knowledge Poverty in the community weak institutions, infrastructure, environment, and social norms Weak health services delivery inaccessible, lacking key inputs, irrelevant services, low quality Excluded from health finance system limited insurance Poor health outcomes Ill health Malnutrition High fertility Diminished income Loss of wages High costs of health care Greater vulnerability to catastrophic illness

7 The hunger goal and health 5 Goal 1: Eradicate extreme hunger Target: Halve, between 1990 and 2015, the proportion of people who suffer from hunger The costs of malnutrition are high: Malnutrition is associated with many poor health outcomes Malnutrition rates reflect the multidimensional nature of poverty. Malnutrition is associated with about half of all deaths of children under age five in the developing world. Malnourished children have lower resistance to infection and are therefore more likely to die from childhood ailments such as diarrhea, respiratory infections, and other diseases. Nutritional status is closely related to meeting the other Millennium Development Goals, and progress toward the other goals helps to improve nutrition. At both the national and household levels, income growth has a slow but steady impact on reducing malnutrition. At the same time, although income growth is necessary for achieving the goal of reducing malnutrition, it is not sufficient. There is a strong relationship between child malnutrition (as measured by underweight) and income per capita. The relationship goes both ways: Just as lack of income contributes to malnutrition, malnutrition can impede income growth through such effects as delayed or reduced schooling, reduced stature and productivity, vulnerability to infection, and higher incidence of adult noncommunicable diseases. Malnutrition has declined in recent decades, both across and within countries, suggesting that economic growth does improve nutrition for the malnourished. But even poor countries can achieve improvements through such low-cost measures as nutrition education and food supplementation and fortification. Malnutrition is by far the greatest risk factor Burden of disease due to selected risk factors, 1995 More than half of child deaths are associated with low weight for age Survival prospects are bleak for underweight children Regression of malnutrition on under-five mortality, latest available data Percentage of children who are underweight Malnutrition Water/sanitation Unsafe sex Alcohol Indoor air pollution Tobacco Occupation Hypertension Physical inactivity Illicit drugs Outdoor air pollution Source: World Health Organization Percentage of global disability-adjusted life years lost Under-five mortality rate (per 1,000), 2000 Source: World Health Organization child growth and malnutrition database and World Bank data.

8 6 The education goal and health Goal 2: Achieve universal primary education Target: Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling The targets for the education and gender goals are closely related, referring to education for all boys and girls alike. Primary net enrollment in developing countries was 82 percent in 1998, up from 78 percent in But a gender gap in enrollment remains at all levels of education. In 1998 the female to male ratio was 0.87 in primary education and 0.82 in secondary education. So, eliminating the barriers to girls schooling is essential to attaining both goals. Educational attainment and health outcomes closely linked The relationships between educational attainment and several health outcomes are well-established. In most countries the higher the mother s level of education, the lower the mortality rates of her children. Educated women tend to marry later, reducing exposure to pregnancy and childbirth and the risk of illness and death associated with bearing children. Contraceptive use is higher among more educated women, leading to longer birth intervals, which are associated with improved health and survival of children. Immunization rates for children are higher when mothers are literate. Access to antenatal care and skilled delivery care is similarly higher among more educated women. There is a well-established connection between nutrition and education that works through several factors, including the increased earnings made possible by more education, increased status and confidence, basic literacy and numeracy skills, and the specific nutritional knowledge that may be gained through education. Raising awareness in other ways But as much as education contributes to nutrition, formal schooling is not necessary for learning about nutrition. Carefully designed and targeted programs can convey information and knowledge about factors influencing growth, breastfeeding, weaning strategies, and micronutrients. Raising awareness creates an impact that is additional to that obtained through formal schooling. Thus as useful and worthwhile as expanded educational opportunities are, primary education is not in itself an informative indicator for the Millennium Development Goal on hunger. The association between mothers education and children s death is strong and strongest after infancy Relative risk of dying in childhood by mother s level of education (averages for all sample countries) Relative risk (primary incomplete = 1.00) No education Primary incomplete Neonatal Postneonatal Under-five Child Primary complete Secondary and higher No education Primary incomplete Primary complete Secondary and higher Source: Selected Demographic and Health Surveys No education Primary incomplete Level of education Primary complete Secondary and higher No education Primary incomplete Primary complete Secondary and higher

9 The gender goal and health 7 Goal 3: Promote gender equality and empower women Target: Eliminate gender disparity in primary and secondary education In most low-income countries girls are less likely than boys to attend school and more likely to drop out Empowering women and promoting gender equality are effective ways to improve health status. In most low-income countries girls are less likely to attend school than are boys. And even when girls start school at the same rate as boys, they are more likely to drop out often because parents think boys schooling is more important or because girls work at home seems more valuable than schooling. Concerns about the safety of girls or traditional biases against educating them can mean that they never even start school or do not continue beyond the primary stage. Girls reach adulthood with lower literacy rates than boys (except in Latin America and the Caribbean). Informal training, such as adult literacy classes, can make up some of the difference. But many girls, who begin with fewer opportunities than boys, are at a permanent disadvantage. Starting life in second place Youth literacy rate (ages 15 24), 2000 (percent) Male Europe and Central Asia Female East Asia and Pacific Source: UNESCO and World Bank staff estimates. Latin America and Caribbean Middle East and North Africa Sub-Saharan Africa South Asia Why educating girls matters Educating women and giving them equal rights is important for many reasons. It increases their productivity, raising output and reducing poverty. It promotes gender equality within households, thus reducing fertility rates and improving maternal (and child) health. And it increases children s chance of surviving to become healthier and better educated because educated women do a better job caring for children.

10 8 The child mortality goal and health Goal 4: Reduce child mortality Target: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Over 10 million children die annually in the developing world the vast majority from causes preventable in the developed world through a combination of good nutrition, care, and medical treatment. That number, though appalling, represents a significant improvement in recent years. Mortality among children under five years of age has been declining at an average rate of about 1 percent a year for the past 35 years. The decline has occurred even as the number of births worldwide has increased, resistance to antibiotics and antimalarial drugs has risen, and the HIV/AIDS pandemic has spread. Although child death rates have been declining in every region, progress has not occurred evenly, and gaps remain both across and within regions. In some countries, however, infant and child mortality rates are increasing. In 1998 more than 50 countries had child mortality rates greater than 100 deaths per 1,000 live births. Twelve countries 11 in Africa had mortality rates of more than 200 deaths per 1,000 live births. Child deaths arise from perinatal causes (22 percent), acute respiratory infection (20 percent), diarrhea (12 percent), malaria, measles, HIV/AIDS, and other causes. Malnutrition plays a role in over half of child deaths. At the current rate of progress only a few countries are likely to achieve the Millennium Development Goal of reducing child mortality. At the end of the 20th century only 36 countries were on a path to do so most of them middle-income countries. For low-income countries, and for Sub- Saharan Africa in particular, the challenge remains daunting. Although child deaths have been declining, progress has not occurred evenly Regional trends in under-five mortality, Under-five mortality per 1,000 (estimates at five-year intervals) Africa Western Pacific Europe Source: World Health Organization Eastern Mediterranean Malnutrition plays a role in more than half of child deaths What are children dying of? Americas Southeast Asia Other 29% Acute respiratory infections 20% Perinatal causes 22% Source: World Health Organization. Deaths associated with malnutrition 54% HIV/AIDS 4% Diarrhea 12% Measles 5% Malaria 8%

11 9 Effective strategies Several interventions when widely and carefully applied are effective in reducing child mortality. The accumulated experience, supported by research, offers strong evidence about which actions determine good child health outcomes. Effective interventions include breastfeeding and appropriate complementary feeding in young children; immunization against major endemic diseases; measures to prevent malaria; appropriate case management at home and in communities for acute respiratory infection, pneumonia, diarrhea, and malaria; and access to appropriate care, reliable water, and improved sanitation. Widespread coverage of the population with effective interventions is also important. One of the best ways of providing that coverage is through integrated management of childhood illness. Integrated management is a flexible strategy that countries can use to address the major health problems of children under five years of age. It includes preventive and curative interventions, such as improved infant and child nutrition, breastfeeding promotion, immunization, and use of bednets in areas with malaria. It responds to the needs of caretakers and seeks to improve their satisfaction with child health services. It can reduce child mortality by mutually reinforcing efforts at all levels family, community, health worker, and health system. Transforming knowledge into action The multisectoral framework of the Poverty Reduction Strategy Paper is a useful tool for improving child health. Focusing on a limited set of effective interventions in a poverty reduction context can further progress toward the Millennium Development Goal on child mortality. What is needed now to achieve dramatic reductions in child mortality is high coverage levels among poor children using interventions that are already available, while simultaneously pursuing research and development to improve and expand the interventions. Knowledge into action... For the World Bank and its development partners, the challenge is to: Reach all children with known and effective child health interventions Use the multisector framework of the Poverty Reduction Strategy Paper process to help countries achieve the Millennium Development Goals

12 10 The maternal and reproductive health goal Goal 5: Improve maternal and reproductive health Target: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio Worldwide, more than 50 million women suffer from poor reproductive health and serious pregnancy-related illness and disability. More than 500,000 women die every year from complications of pregnancy and childbirth. Nearly all of these deaths occur in the developing world. While most of the deaths occur in Asia, the risk of dying is highest in Africa. Most of the deaths could be avoided if women had access to adequate care during pregnancy and childbirth. Maternal mortality reflects the disparities and inequities between men and women and women s standing in society. Maternal mortality also reflects socioeconomic disparities and inequalities in health services. Women have less access to social, health, and nutrition resources and fewer economic opportunities. They bear a disproportionate share of the global burden of disease from some causes. Progress on maternal health in developing countries in recent decades has been somewhat mixed. Contraceptive use has increased steadily, rising from about 10 percent of married women of reproductive age in 1965 to more than 50 percent today. The rate of high-risk births to girls 15 to 19 years old has fallen, mirroring the overall drop in family size from 5.5 on average in 1970 to about 3 today. The proportion of births attended by a trained health worker has risen, though more slowly, from 48 percent in 1985 to 55 percent in Despite progress on these indicators, however, maternal mortality ratios at the global level have stayed fairly constant. Almost all maternal deaths occur in the developing world Maternal mortality by region Deaths per 100,000 live births 1, Africa Source: World Health Organization Asia Latin America and the Caribbean Developed Everywhere, poor women have less access to skilled care during childbirth World Attended deliveries rates among poor and rich in 44 countries Percent of deliveries attended by doctor, nurse, or nurse-midwife Poorest 20 percent 0 East Asia and Pacific (3 countries) Europe and Central Asia (4 countries) Latin America and Caribbean (9 countries) Richest 20 percent Middle East and North Africa (2 countries) South Asia (4 countries) Sub-Saharan Africa (22 countries) Source: World Bank staff estimates based on national Demographic and Health Surveys. All countries (44 countries)

13 11 The consequences are far-reaching The poor health and nutrition of women and the lack of care that contribute to their death in pregnancy and childbirth also compromise the health and survival of the infants and children they leave behind. It is estimated that nearly two-thirds of the 8 million infant deaths each year result largely from poor maternal health, inadequate care, inefficient management of delivery, and lack of essential care of the newborn. Good care is essential not only for reducing maternal mortality during pregnancy and childbirth but also for improving reproductive health, ensuring a healthy pregnancy, and reducing maternal illness and death after childbirth. Good care can be provided in a variety of contexts, according to the level of training and the severity of the problem. Skilled care by a midwife, nurse, or doctor during childbirth at home or in a hospital is a critical intervention for making pregnancy and childbirth safer. The skilled attendant must be supported by the right policy and regulatory environment; a functioning health system with adequate supplies, equipment, and infrastructure; an effective system of communication, outreach, and referral; and available transport. Education of communities and families is also important. An important task for the health system and for government policy is deciding on appropriate indicators for each of these factors and ensuring that the data are available to monitor them. Reducing maternal deaths There are three main strategies for reducing maternal mortality: 1. Preventing unwanted pregnancy. Success or failure in preventing unwanted pregnancy is influenced by early marriage and childbearing, access to family planning information and affordable services, coercion and violence, personal or religious beliefs, inadequate knowledge about the risks of pregnancy following unprotected sexual relations, and women s limited decisionmaking power over sexual relations and contraceptive use. Unwanted pregnancies can be reduced through access to high-quality, client-oriented, and gender-sensitive information and services. Improving women s social and economic status and redressing unequal power relations between women and men are also important. 2. Preventing complications. Preventive measures to reduce complications from pregnancy include prenatal care, adequate nutrition, treatment for sexually transmitted infections, management of existing conditions such as malaria, active management of third-stage labor, access to skilled care during delivery, postpartum care, and the availability of post-abortion care. Here, too, determining which indicators best measure progress is an important policy and health systems task. 3. Preventing deaths when complications occur. The factors that determine the ultimate outcome of complications that occur during childbearing, pregnancy, and delivery include access to skilled care, use of emergency obstetric services, and a wellfunctioning health system.

14 12 The communicable diseases goal Goal 6: Combat HIV/AIDS, malaria, and other diseases Target: Have halted by 2015 and begun to reverse the incidence of tuberculosis, malaria, and other major diseases Target: Have halted by 2015 and begun to reverse the spread of HIV/AIDS HIV/AIDS, tuberculosis, and malaria are among the world s leading causes of death from infectious diseases, and all three have their greatest impact among poor countries and poor people. These diseases interact in ways that make their combined impact even worse. Yet much is known about what needs to be done to halt and reverse their spread, and the international community has expressed a global commitment to addressing them. Effective prevention and treatment programs will not only save lives, but will also contribute to economic development and poverty reduction. Tuberculosis Target: Have halted by 2015 and begun to reverse the incidence of tuberculosis, malaria, and other major diseases Tuberculosis, a global public health problem, kills some 2 million people each year one person every 15 seconds. But these are preventable deaths: tuberculosis has been preventable and treatable for over half a century, yet the numbers of tuberculosis cases and deaths have been growing. The reasons include a breakdown in health services in poor countries, the spread of HIV/AIDS, and the emergence of multidrug-resistant tuberculosis. Some 8.4 million people fall ill with tuberculosis each year, 3 million of them in Southeast Asia and 1.6 million in Sub-Saharan Africa. In Eastern Europe the number of tuberculosis cases is growing again after 40 years of decline. Current estimates suggest that if tuberculosis control is not strengthened, nearly a billion people will be newly infected between 2000 and 2020, 200 million people will get sick with active tuberculosis, and 35 million people will die from the disease. Complex interactions More than a health issue, tuberculosis results from a complex mix of poverty and other social and economic conditions. Poor countries and poor communities are more likely than wealthier ones to be infected with the tuberculosis germ and to develop tuberculosis disease. Low-income countries account for 65 percent of the world s tuberculosis cases and more than 70 percent of tuberculosis-caused deaths. The poorer a community, the greater is the likelihood of widespread infection. Lack of basic health services and poor nutrition, housing, and work conditions all contribute to the spread of infection and the development of active tuberculosis. Tuberculosis is not only a consequence of poverty, but also a contributor to it. Tuberculosis costs poor communities some $12 billion a year. The average tuberculosis patient loses three to four months of work time, earnings that can represent up to 30 percent of annual household income. These losses in turn can have a significant impact on national and local economies. Global Partnership to Stop Tuberculosis Addressing tuberculosis requires not just health measures but measures to overcome

15 13 the underlying conditions that contribute to its spread poverty and inequity. The international community has come together in the Global Partnership to Stop Tuberculosis, a coalition of public and private interests, high-burden and donor countries, and international agencies committed to achieving the following targets: By 2005, have diagnosed 70 percent of people with infectious tuberculosis and have cured 85 percent. By 2010, have reduced the global burden of tuberculosis deaths and prevalence by 50 percent over 2000 levels. By 2050, have reduced the global incidence of tuberculosis deaths and prevalence to less than one person per million people. Achieving these targets means building on and improving existing strategies (the directly observed treatment short-course strategy, DOTS, for detecting and curing tuberculosis) and increasing the availability, affordability, and quality of tuberculosis drugs. Achieving the targets also requires adapting strategies to meet emerging threats for example, effective strategies to prevent and manage multi-drug-resistant tuberculosis and to reduce the impact of HIV-related tuberculosis. Finally, achieving the targets requires research to develop new and improved diagnostic tests, drugs, and vaccines and wider adoption of both new and improved tools. The targets can be achieved but not without accelerated effort and progress. Some 8.4 million people fall ill with tuberculosis each year, more than half of them in South Asia and Sub-Saharan Africa Estimated TB incidence rates, 2000 IBRD Per 100,000 population: <10 10 to to to to or more No estimate

16 14 HIV/AIDS Target: Have halted by 2015 and begun to reverse the spread of HIV/AIDS Sustained programs can reverse trends in HIV/AIDS Since the human immunodeficiency virus (HIV) was first identified some 20 years ago, more than 60 million people have been infected. HIV/AIDS is now the leading cause of death in Sub-Saharan Africa, and the fourth largest killer worldwide. In some parts of Africa adult prevalence rates exceed 20 percent of the population. Although HIV/AIDS hits all those affected hard, it hits those who are already poor and marginalized hardest. Poor countries, poor communities, and poor people bear the brunt of the disease burden. According to the December 2001 World Health Organization update on the HIV/AIDS pandemic, per capita income and GDP are falling in the hardest hit countries; three-quarters of Africa s population must survive on less than $2 per day. By 2020 many countries could lose more than 20 percent of already low GDPs. The desperately poor have little or no access to social and health services. When they contract HIV/AIDS, care and support services are few. Because the disease takes a heavy toll on young adults, the elderly often take on the burden of managing households and caring for children. Girls may have to quit school to reduce expenses or to take care of sick or younger family members. HIV prevalence among pregnant women in Kampala, Uganda, Percent Source: STD/AIDS Control Programme, Uganda, 2001, HIV/AIDS Surveillance Report Hopeful signs Although there is much work to be done in reversing this trend, there are signs of hope. Positive trends seem to be emerging among adolescents, whose prevalence rates have dropped slightly since Large-scale condom distribution programs seem to be having a positive impact. There is also evidence that sustained AIDS programs can be effective in reversing trends. In Kampala, Uganda, there has been a steady drop in HIV prevalence among pregnant women for the past eight years, from a high of 29.5 percent in 1992 to 11.3 percent in

17 An international commitment At the United Nations General Assembly Special Session on HIV/AIDS in June 2001 the international community set up a framework for the global fight against HIV/AIDS, adopting a Declaration of Commitments and setting targets that build on the Millennium Development Goals. Governments pledged to pursue specific targets related to prevention, care, treatment, and support; lessened impact and vulnerability; children affected by HIV/AIDS; and research and development, among others. The declaration contained more than 90 action points whose overall goal was a significant impact on the prevalence and spread of HIV/AIDS. These targets included: Reducing HIV infection among 15- to 24-year-olds by 25 percent in the most affected countries by 2005 and globally by Reducing the proportion of infants infected with HIV by 20 percent by 2005 and by 50 percent by In support of the commitment made at the Special Session governments are pledging support to the new Global Fund to Fight AIDS, Tuberculosis, and Malaria. International agencies, including the World Bank, are making major new commitments, and nongovernmental organizations and private companies are finding ways to support the effort. 15

18 16 Malaria Target: Have halted by 2015 and begun to reverse the incidence of tuberculosis, malaria, and other major diseases Malaria is endemic to the poorest countries in the world, causing million clinical cases and more than 1 million deaths each year. More than 90 percent of malaria deaths occur in Sub-Saharan Africa, most among children younger than five years. Malaria during pregnancy is a leading cause of low birthweight and death of newborns. Over the past two decades illness and death from malaria have been increasing because of deteriorating health systems, increased drug and insecticide resistance, changing weather patterns, human migration, civil unrest, and population displacement. Like other diseases that disproportionately affect poor people, malaria is both a consequence of and a contributor to poverty. Poor people are not only more likely to acquire malaria, they are also at greater risk of complications and death because of limited access to effective treatment. Roll Back Malaria: A global partnership The global partnership to Roll Back Malaria seeks to reduce the worldwide malaria burden by half by Meeting this goal will require the involvement of governments, the private sector, local communities, and the health, education, agriculture, water, and infrastructure sectors. Roll Back Malaria strategies include widespread use of insecticide-treated materials, rapid diagnosis and effective treatment of people with malaria, prevention of malaria in pregnant women in high-transmission areas, prompt recognition and control of outbreaks, and government commitment to malaria control. Malaria is endemic to the poorest countries in the world Malaria-endemic areas, 2001 IBRD 32221

19 The environmental sustainability goal and health 17 Goal 7: Ensure environmental sustainability Target: Halve, by 2015, the proportion of people without sustainable access to safe drinking water Water supply, sanitation, and health are closely related. Poor hygiene, inadequate quantities and quality of drinking water, and lack of sanitation facilities cause millions of the world s poorest people to die from preventable diseases each year. Women and children are the main victims. Inadequate water, sanitation, and hygiene account for a large part of the burden of illness and death in developing countries: Lack of clean water and sanitation is the second most important risk factor, after malnutrition, in the global burden of disease. Some 4 billion cases of diarrhea a year result in 1.5 million deaths, mostly among children under five. Intestinal worms infect 1 of 10 people in the developing world and can lead to malnutrition, anemia, and retarded growth. Some 6 million people are blind as a result of trachoma, and some 500 million people are at risk. Some 300 million people suffer from malaria. Some 200 million people are infected with schistosomiasis, 20 million of them suffering severe consequences. Approximately one-sixth of the world s population is without water, and two-fifths without access to sanitation. Most of the unserved population lives in Asia and Africa, although even in Eastern Europe and Central Asia poor water, sanitation, and hygiene are among the 10 most important risk factors for disease. Taking population growth into account, reaching the Millennium Development target will require access to safe sanitation for 2.2 billion more people (397,000 people a day) and improved water services for 1.5 billion more people (292,000 people a day). Research findings on the relative public health importance of providing safe drinking water supplies, sanitation, and hygiene education may seem counterintuitive. Improved hygiene (hand washing) and sanitation (latrines) have more impact than drinking water quality on health outcomes. Experience shows that constructing water supply and sanitation facilities is not enough to improve health; key human behaviors must accompany the infrastructure investments. To help ensure that investments in water supply and sanitation result in greater health impact, public health promotion and education strategies to change behaviors are needed. Mounting these strategies will require collaboration between the health sector and other sectors. Most of the unserved population lives in Asia and Africa Access to water and sanitation Distribution of unserved population Water supply 63% 2% 7% Total unserved: 1.1 billion Source: World Health Organization. 28% Sanitation 80% 13% Total unserved: 2.4 billion Europe Latin America and the Caribbean Africa Asia 2% 5%

20 18 Measuring progress Some examples How to measure progress in health, nutrition, and population as with any other development goal is an ongoing question for countries and donor agencies wanting to know whether their investments are improving people s lives. Much has been learned recently about how to select indicators that give a realistic picture of what is actually happening, how to collect and analyze the data, and how to apply the results in future efforts. As the international community makes another push to achieve clearly stated targets, it is important to learn from and build on earlier efforts in data collection and analysis. Two examples are the efforts in the 1990s to meet the goals set out by the World Summit for Children in 1990 and the MEA- SURE Demographic and Health Surveys that collect and use data to monitor and evaluate health, nutrition, and population programs around the world. The World Summit for Children The World Summit for Children, meeting in New York in 1990, set out 27 goals for improving the health and well-being of children by the end of the decade. Progress was to be assessed using more than 70 indicators. Because the data were often weak and incomplete, ways had to be found for improving the data while using available data of less than ideal quality. An important outcome of this effort was the increased amount and quality of data collected in the developing world and the increased capacity of developing countries to collect and use data. The MEASURE Demographic and Health Surveys The MEASURE Demographic and Health Surveys program collects demographic and health data for regional and national health and population programs. It conducts surveys of households, women, and men. The data can be used to obtain estimates both for the country as a whole and for subnational areas. Questionnaires are standardized across countries but can also be adapted to meet a country s needs for specific data. The surveys collect data on many of the indicators used to measure progress on the Millennium Development Goals. The program has been steadily building a database of health, nutrition, and population information in nearly 60 countries; more than half the countries have had at least two surveys.

21 19 Using the Poverty Reduction Strategy Paper framework to measure progress Measuring progress toward the Millennium Development Goals and keeping a focus on the poorest segments of society to ensure that pro-poor policies actually work are important activities. Because poverty and ill health are linked in a vicious circle in which poverty leads to ill health and ill health contributes to poverty, it is essential to incorporate health, nutrition, and population goals into efforts to reduce poverty. And because there is still much that is unknown about how well pro-poor policies work under various conditions, it is critical to monitor the outcomes of any measures that are implemented and to document the reasons for their success or failure. The multisectoral framework of the Poverty Reduction Strategy Paper provides a practical way to measure progress in reaching health, nutrition, population, and other Millennium Development Goals. The framework can be used to diagnose problems, develop solutions, and measure the effectiveness of those solutions.

22 20 Millennium Development Goals Goals and targets from the Millennium Declaration Indicators for monitoring progress Goal 1 Eradicate extreme poverty and hunger Halve, between 1990 and 2015, the proportion of Proportion of population below $1 a day a people whose income is less than $1 a day Poverty gap ratio (incidence times depth of poverty) Share of poorest quintile in national consumption Halve, between 1990 and 2015, the proportion of Prevalence of underweight in children (under five years of age) people who suffer from hunger Proportion of population below minimum level of dietary energy consumption Goal 2 Achieve universal primary education Ensure that, by 2015, children everywhere, boys and Net enrollment ratio in primary education girls alike, will be able to complete a full course of Proportion of pupils starting grade 1 who reach grade 5 primary schooling Literacy rate of 15- to 24-year-olds Goal 3 Promote gender equality and empower women Eliminate gender disparity in primary and secondary Ratios of girls to boys in primary, secondary, and tertiary education education preferably by 2005 and in all levels of Ratio of literate females to males among 15- to 24-year-olds education no later than 2015 Goal 4 Goal 5 Goal 6 Goal 7 Reduce child mortality Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Improve maternal health Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio Combat HIV/AIDS, malaria, and other diseases Have halted by 2015 and begun to reverse the spread of HIV/AIDS Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Ensure environmental sustainability Integrate the principles of sustainable development into country policies and programs and reverse the loss of environmental resources Halve by 2015 the proportion of people without sustainable access to safe drinking water Share of women in wage employment in the nonagricultural sector Proportion of seats held by women in national parliament Under-five mortality rate Infant mortality rate Proportion of one-year-old children immunized against measles Maternal mortality ratio Proportion of births attended by skilled health personnel HIV prevalence among 15- to 24-year-old pregnant women Condom use rate of the contraceptive prevalence rate b Number of children orphaned by HIV/AIDS c Prevalence and death rates associated with malaria Proportion of population in malaria-risk areas using effective malaria prevention and treatment measures d Prevalence and death rates associated with tuberculosis Proportion of tuberculosis cases detected and cured under directly observed treatment short course (DOTS) Proportion of land area covered by forest Ratio of area protected to maintain biological diversity to surface area Energy use per unit of GDP Carbon dioxide emissions (per capita) and consumption of ozone-depleting chlorofluorocarbons Proportion of population using solid fuels Proportion of population with sustainable access to an improved water source, urban and rural

23 21 Goals and targets from the Millennium Declaration Goal 7 Goal 8 Continued Have achieved by 2020 a significant improvement in the lives of at least 100 million slum dwellers Develop a global partnership for development Develop further an open, rule-based, predictable, nondiscriminatory trading and financial system (includes a commitment to good governance, development, and poverty reduction both nationally and internationally) Address the special needs of the least developed countries (includes tariff- and quota-free access for exports, enhanced program of debt relief for and cancellation of official bilateral debt, and more generous ODA for countries committed to poverty reduction) Address the special needs of landlocked countries and small island developing states (through the Program of Action for the Sustainable Development of Small Island Developing States and 22nd General Assembly provisions) Deal comprehensively with the debt problems of developing countries through national and international measures in order to make debt sustainable in the long term In cooperation with developing countries, develop and implement strategies for decent and productive work for youth In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries In cooperation with the private sector, make available the benefits of new technologies, especially information and communications technologies Indicators for monitoring progress Proportion of population with access to improved sanitation Proportion of households with access to secure tenure Some of the indicators listed below will be monitored separately for the least developed countries, Africa, landlocked countries, and small island developing states. Official development assistance (ODA) Net ODA, total and to least developed countries, as a percentage of DAC donors gross national income (GNI) Proportion of bilateral ODA for basic social services (basic education, primary health care, nutrition, safe water, and sanitation) Proportion of bilateral ODA that is untied ODA received by landlocked countries as a proportion of their GNI ODA received by small island developing states as a proportion of their GNI Market access Proportion of total developed country imports (excluding arms) from developing countries and least developed countries admitted free of duties Average tariffs imposed by developed countries on agricultural products and textiles and clothing Agricultural support estimate for OECD countries as a percentage of their GDP Proportion of ODA provided to help build trade capacity e Debt sustainability Total number of countries that have reached their HIPC decision points and completion points (cumulative) Debt relief committed under HIPC initiative Debt service as a percentage of exports of goods and services Unemployment rate of 15- to 24-year-olds, male and female and total f Proportion of population with access to affordable, essential drugs on a sustainable basis Telephone lines and cellular subscribers per 100 people Personal computers in use per 100 people Internet users per 100 people a. For monitoring at the country level, national poverty lines should be used. b. Among contraceptive methods, only condoms are effective in reducing the spread of HIV. c. The proportion of orphan to nonorphan 10 to 14-year-olds who are attending school. d. Percentage of children under five sleeping under insecticide-treated bed nets (prevention) and appropriately treated (treatment). e. The Organisation for Economic Co-operation and Development and the World Trade Organization are collecting data, which will be available from 2001 on. f. An improved measure of the target is under development by the International Labour Organization.

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