《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2003_Shaping the Future_Chapter2 Millennium Health Goals：paths to the future

Chapter Two Millennium health goals paths to the future The Millennium Development Goals(MDGs) place health at the heart of development and represent commitments by gov- ernments throughout the world to do more to reduce poverty and hunger and to tackle ill-health, gender inequality, lack of education, access to clean water and environmental degra dation. Three of the eight goals are directly health-related; all of the others have important indirect effects on health. This chapter traces the origins of the Mdgs and tracks the progress so far towards achieving them. It warns that without signifi cantly strengthened commitments from both wealthy and de veloping countries, the goals will not be met globally

Millennium Health Goals: paths to the future 23 Chapter Two Millennium Health Goals: paths to the future The Millennium Development Goals (MDGs) place health at the heart of development and represent commitments by gov￾ernments throughout the world to do more to reduce poverty and hunger and to tackle ill-health, gender inequality, lack of education, access to clean water and environmental degra￾dation. Three of the eight goals are directly health-related; all of the others have important indirect effects on health. This chapter traces the origins of the MDGs and tracks the progress so far towards achieving them. It warns that without signifi￾cantly strengthened commitments from both wealthy and de￾veloping countries, the goals will not be met globally

Millennium health goals paths to the future The Millennium Development Goals(MDGs)adopted by the United Nations in 2000 pro- vide an opportunity for concerted action to improve global health. They place health at the heart of development and establish a novel global compact, linking developed and develop ng countries through clear, reciprocal obligations. Seizing the opportunity offered by the MDGs will not be easy. Wealthy countries have so far failed to live up to all of their responsibilities under the compact, which include establishing fairer international trade policies, increasing official development assistance, delivering debt relief and accelerating technology transfer. Despite progress in some cases, many developing countries are not currently on track to achieve their health-related MDG objectives without significantly strengthened commitments from both developed and developing countries, the MDGs will not be met globally, and outcomes in some of the poorest countries will remain far below the hoped-for achievements. WHO and international health partners must inten- sify their cooperation with Member States to speed up progress towards the MDGs and en sure that gains are made by those most in need International commitments at the millennium summit In September 2000, representatives from 189 countries, including 147 heads of state, met at the Millennium Summit in New York to adopt the United Nations Millennium Declaration (1). The declaration set out the principles and values that should govern international rela tions in the 21st century. National leaders made specific commitments in seven areas: peace, security and disarmament; development and poverty eradication; protecting our common environment; human rights, democracy and good governance; protecting the vulnerable eeting the special needs of Africa; and strengthening the United Nations. The Road Map(2) prepared following the Summit established goals and targets to be reached by 2015 in each of these seven areas. The goals in the area of development and poverty eradi cation are now widely referred to as the Millennium Development Goals. They represent commitments by governments worldwide to do more to reduce poverty and hunger and to tackle ill-health, gender inequality, lack of education, lack of access to clean water, and envi- ronmental degradation. They also include commitments to reduce debt, increase technology transfers and build development partnership

Millennium Health Goals: paths to the future 25 2 Millennium Health Goals: paths to the future The Millennium Development Goals (MDGs) adopted by the United Nations in 2000 pro￾vide an opportunity for concerted action to improve global health. They place health at the heart of development and establish a novel global compact, linking developed and develop￾ing countries through clear, reciprocal obligations. Seizing the opportunity offered by the MDGs will not be easy. Wealthy countries have so far failed to live up to all of their responsibilities under the compact, which include establishing fairer international trade policies, increasing official development assistance, delivering debt relief and accelerating technology transfer. Despite progress in some cases, many developing countries are not currently on track to achieve their health-related MDG objectives. Without significantly strengthened commitments from both developed and developing countries, the MDGs will not be met globally, and outcomes in some of the poorest countries will remain far below the hoped-for achievements. WHO and international health partners must inten￾sify their cooperation with Member States to speed up progress towards the MDGs and en￾sure that gains are made by those most in need. International commitments at the Millennium Summit In September 2000, representatives from 189 countries, including 147 heads of state, met at the Millennium Summit in New York to adopt the United Nations Millennium Declaration (1). The declaration set out the principles and values that should govern international rela￾tions in the 21st century. National leaders made specific commitments in seven areas: peace, security and disarmament; development and poverty eradication; protecting our common environment; human rights, democracy and good governance; protecting the vulnerable; meeting the special needs of Africa; and strengthening the United Nations. The Road Map (2) prepared following the Summit established goals and targets to be reached by 2015 in each of these seven areas. The goals in the area of development and poverty eradi￾cation are now widely referred to as the Millennium Development Goals. They represent commitments by governments worldwide to do more to reduce poverty and hunger and to tackle ill-health, gender inequality, lack of education, lack of access to clean water, and envi￾ronmental degradation. They also include commitments to reduce debt, increase technology transfers and build development partnerships

The World Health Report 2003 A compact to end poverty The idea of the MDgs as a compact, in which both rich and poor countries have responsibili ties, was further developed in early 2002 at the International Conference on Financing for Development, in Monterrey, Mexico. The resultant Monterrey Consensus(3)reaffirms the importance of the MDGs and provides a framework for building the partnerships that will be needed to achieve them. A few months later, in September 2002, the World Summit on Sustainable Development, held in Johannesburg, South Africa, took the process a step fur ther by recognizing that poverty reduction and the achievement of the mdgs were central to the overall sustainable development agenda(4). Both the World development report 2003 and the Human development report 2003 have further developed the concept of a compact, with a view to informing policy The MDGs summarize some of the key commitments made at the major United Nations conferences of the 1990s. They also build on the international development targets prepared by the Organisation for Economic Co-operation and Development(OECD) in 1996(5) However, it is the two-way nature of the compact that sets the MDGs apart from their predecessors. Developing countries are committed to achieving Goals 1-7. Goal 8 concerns developed countries and the actions that they can take in order to create a more enabling environment in the areas of trade, development assistance, debt, essential medicines and tech nology transfer. Without progress on Goal 8, it is unlikely that the poorest countries will be able to tackle the structural constraints that keep them in poverty, or sustain the levels of nvestment requ uired to achieve the other goals New concepts of poverty and development Since the early 1990s, the concepts of poverty and development have evolved away from ar exclusive emphasis on income towards a fuller notion of human well-being, as found in the United Nations Development Programmes Human Development Index(HDI) and other multifactorial indices, which provide alternatives to per capita gross national income(GNi as a measure of development(6) In this new understanding, poverty means not just low income but the undermining of a whole range of key human capabilities, including health. The term human poverty refers to deprivation of the means to achieve capabilities(for example, physical access to health care) and of basic"conversion" factors that facilitate this achievement(such as social access to health care)(7). Human development refers to processes that enlarge people's choices to en able them to achieve capabilities (for example, the freedom to choose a healthy lifestyle)(8) The interaction of health and development This more complex concept of poverty and development takes account of the interactive processes that are crucial to the social dynamics of health improvement. For example, economic capabilities affect health, as low income constrains access to health care and health promoting opportunities Equally significantly, ill-health limits people's ability to earn higher comes, and contributes to povert The two-way causal relationship between economic development and health has been high lighted by the Commission on Macroeconomics and Health, in order to underline the crucial role of health in economic growth(9). The importance of health within a multidimensional del of sustainable human development is also a key message of the MDGs

26 The World Health Report 2003 A compact to end poverty The idea of the MDGs as a compact, in which both rich and poor countries have responsibili￾ties, was further developed in early 2002 at the International Conference on Financing for Development, in Monterrey, Mexico. The resultant Monterrey Consensus (3) reaffirms the importance of the MDGs and provides a framework for building the partnerships that will be needed to achieve them. A few months later, in September 2002, the World Summit on Sustainable Development, held in Johannesburg, South Africa, took the process a step fur￾ther by recognizing that poverty reduction and the achievement of the MDGs were central to the overall sustainable development agenda (4). Both the World development report 2003 and the Human development report 2003 have further developed the concept of a compact, with a view to informing policy. The MDGs summarize some of the key commitments made at the major United Nations conferences of the 1990s. They also build on the international development targets prepared by the Organisation for Economic Co-operation and Development (OECD) in 1996 (5). However, it is the two-way nature of the compact that sets the MDGs apart from their predecessors. Developing countries are committed to achieving Goals 1–7. Goal 8 concerns developed countries and the actions that they can take in order to create a more enabling environment in the areas of trade, development assistance, debt, essential medicines and tech￾nology transfer. Without progress on Goal 8, it is unlikely that the poorest countries will be able to tackle the structural constraints that keep them in poverty, or sustain the levels of investment required to achieve the other goals. New concepts of poverty and development Since the early 1990s, the concepts of poverty and development have evolved away from an exclusive emphasis on income towards a fuller notion of human well-being, as found in the United Nations Development Programme’s Human Development Index (HDI) and other multifactorial indices, which provide alternatives to per capita gross national income (GNI) as a measure of development (6). In this new understanding, poverty means not just low income but the undermining of a whole range of key human capabilities, including health. The term human poverty refers to deprivation of the means to achieve capabilities (for example, physical access to health care) and of basic “conversion” factors that facilitate this achievement (such as social access to health care) (7). Human development refers to processes that enlarge people’s choices to en￾able them to achieve capabilities (for example, the freedom to choose a healthy lifestyle) (8). The interaction of health and development This more complex concept of poverty and development takes account of the interactive processes that are crucial to the social dynamics of health improvement. For example, economic capabilities affect health, as low income constrains access to health care and health￾promoting opportunities. Equally significantly, ill-health limits people’s ability to earn higher incomes, and contributes to poverty. The two-way causal relationship between economic development and health has been high￾lighted by the Commission on Macroeconomics and Health, in order to underline the crucial role of health in economic growth (9). The importance of health within a multidimensional model of sustainable human development is also a key message of the MDGs

Millennium Health Goals: paths to the future Improvements in health are important in their own right, but better health is also a prerequi site and a major contributor to economic growth and social cohesion. Conversely, improve- ment in people's access to health technology is a good indicator of the success of other development processes. All of these relationships are evident in the MDGs. Thus, three of the eight goals, eight of the 18 targets required to achieve them, and 18 of the 48 indicators of progress are health-related (see Table 2.1). The MDGs are interrelated and interdependent. In many countries, it will be impossible to achieve a 50% reduction in income poverty(Goal 1, Target 1)without taking steps to ensure a healthier population. Similarly, eliminating gender disparities( Goal 3)and increasing en- rolment rates for primary education( Goal 2)are prerequisites for success in improving health outcomes. Population health can no longer be considered in isolation from questions of the stewardship of natural resources and environmental sustainability(Goal 7). It is therefore mportant that the health-related MDGs are not seen in isolation-as discrete programmes but as the result, or desired outcome, of a development agenda with several parts working One of the most challenging goals, to achieve a two-thirds reduction in child mortality(goa 4, Target 5), requires technical interventions that tackle the major causes of child deaths, such as malnutrition, infections and parasitic diseases. But the effectiveness of these interventions ll be mediated through a network of public and private delivery systems, and will depend on adequate levels of financing. Their effect will be reinforced by actions such as those that ensure greater food security and access to education, essential medicines and clean water, and by improved public expenditure management. The ability of governments to finance these fforts will be influenced by both the domestic and international policy and trade environ ments, and, in poorer countries, by the availability of external financial assistance. The MDGs are consequently a way of assessing and tracking progress in development on a number of critical fronts. They are a shorthand for the ends, or outcomes, that governments have com mitted themselves to achieving, rather than a prescription for the means by which those ends are to be achieved Progress and prospects Despite political consensus and the avowed commitment of countries throughout the world, the MDGs will not be achieved at current rates of progress. The Human development report 2003 notes that if global progress continues at the same pace as in the 1990s, only the Millennium Development Goals of halving income poverty and halving the proportion of people without access to safe water stand a realistic chance of being met, thanks mainly to China and India. Sub-Saharan Africa would not reach the goals for poverty until the year 2147 and for child mortality until 2165. And for HIVIAIDS and hun ger, trends in the region are worsening". There are some areas where optimism is justified, but the general outlook, in particular for sub-Saharan Africa, is bleak. Even in countries that making overall progress, gaps in health status between rich and poor may be widening(see Box 2.1) It is generally agreed that reducing child mortality by two-thirds before 2015 is the fur of all the health-related goals from being realized. Infant and child mortality is the complex development indicator, as it is considered to include systemic as well as socioeco nomic and cultural factors(see Box 2.2). Overall, the Caribbean, central Asia, Europe, Latin America, some countries of the Eastern Mediterranean Region and northern Africa may be

Millennium Health Goals: paths to the future 27 Improvements in health are important in their own right, but better health is also a prerequi￾site and a major contributor to economic growth and social cohesion. Conversely, improve￾ment in people’s access to health technology is a good indicator of the success of other development processes. All of these relationships are evident in the MDGs. Thus, three of the eight goals, eight of the 18 targets required to achieve them, and 18 of the 48 indicators of progress are health-related (see Table 2.1). The MDGs are interrelated and interdependent. In many countries, it will be impossible to achieve a 50% reduction in income poverty (Goal 1, Target 1) without taking steps to ensure a healthier population. Similarly, eliminating gender disparities (Goal 3) and increasing en￾rolment rates for primary education (Goal 2) are prerequisites for success in improving health outcomes. Population health can no longer be considered in isolation from questions of the stewardship of natural resources and environmental sustainability (Goal 7). It is therefore important that the health-related MDGs are not seen in isolation – as discrete programmes – but as the result, or desired outcome, of a development agenda with several parts working together. One of the most challenging goals, to achieve a two-thirds reduction in child mortality (Goal 4, Target 5), requires technical interventions that tackle the major causes of child deaths, such as malnutrition, infections and parasitic diseases. But the effectiveness of these interventions will be mediated through a network of public and private delivery systems, and will depend on adequate levels of financing. Their effect will be reinforced by actions such as those that ensure greater food security and access to education, essential medicines and clean water, and by improved public expenditure management. The ability of governments to finance these efforts will be influenced by both the domestic and international policy and trade environ￾ments, and, in poorer countries, by the availability of external financial assistance. The MDGs are consequently a way of assessing and tracking progress in development on a number of critical fronts. They are a shorthand for the ends, or outcomes, that governments have com￾mitted themselves to achieving, rather than a prescription for the means by which those ends are to be achieved. Progress and prospects Despite political consensus and the avowed commitment of countries throughout the world, the MDGs will not be achieved at current rates of progress. The Human development report 2003 notes that “if global progress continues at the same pace as in the 1990s, only the Millennium Development Goals of halving income poverty and halving the proportion of people without access to safe water stand a realistic chance of being met, thanks mainly to China and India. Sub-Saharan Africa would not reach the goals for poverty until the year 2147 and for child mortality until 2165. And for HIV/AIDS and hun￾ger, trends in the region are worsening”. There are some areas where optimism is justified, but the general outlook, in particular for sub-Saharan Africa, is bleak. Even in countries that are making overall progress, gaps in health status between rich and poor may be widening (see Box 2.1). It is generally agreed that reducing child mortality by two-thirds before 2015 is the furthest of all the health-related goals from being realized. Infant and child mortality is the most complex development indicator, as it is considered to include systemic as well as socioeco￾nomic and cultural factors (see Box 2.2). Overall, the Caribbean, central Asia, Europe, Latin America, some countries of the Eastern Mediterranean Region and northern Africa may be

The World Health Report 2003 Table 2.1 Health-related Millennium Development Goals, targets and indicators Goal: 1. Eradicate extreme poverty and hunger Target: 2. Halve, between 1990 and 2015, the proportion of people who suffer from hunger Indicator: 4. Prevalence of underweight children under five years of age 5. Proportion of population below minimum level of dietary energy consumption Goal: 4. Reduce child mortality Target: 5. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Indicator: 13. Under-five mortality rate 14. Infant mortality rate 15. Proportion of 1-year-old children immunized against measles Target: 6. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio 17. Proportion of births attended by skilled health personnel Goal: 6. Combat HIVIAIDS. malaria and other diseases Target: 7 Have halted by 2015 and begun to reverse the spread of HIVIAIDS Indicator: 18. HIV prevalence among young people aged 15 to 24 years 19. Condom use rate of the contraceptive prevalence rate 20. Number of children orphaned by HIv/AID Target: 8 Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Indicator: 21. Prevalence and death rates associated with malaria 22. Proportion of population in malaria-risk areas using effective 23. Prevalence and death rates associated with tuberculosis 24. Proportion of tuberculosis cases detected and cured under rectly Observed Treatr Goal: 7. Ensure environmental sustainability Target: 9. Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources ator: 29. Proportion of population using solid fuel Target: 10. Halve by 2015 the proportion of people without sustainable access to safe drinking-wat Indicator: 30. Proportion of population with sustainable access to an improved water source urban and rural Target: 11. By 2020 to have achieved a significant improvement in the lives of at least 100 million slum dwellers Indicator: 31. Proportion of urban population with access to improved 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 Indicator: 46. Proportion of population with access to affordable essential drugs on a sustainable basis b Indicators from the mbg list reformulat and United Nations General Assembly Special Session on HIV/AIDS

28 The World Health Report 2003 Table 2.1 Health-related Millennium Development Goals, targets and indicators Goal: 1. Eradicate extreme poverty and hunger Target: 2. Halve, between 1990 and 2015, the proportion of people who suffer from hunger Indicator: 4. Prevalence of underweight children under five years of age 5. Proportion of population below minimum level of dietary energy consumptiona Goal: 4. Reduce child mortality Target: 5. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Indicator: 13. Under-five mortality rate 14. Infant mortality rate 15. Proportion of 1-year-old children immunized against measles Goal: 5. Improve maternal health Target: 6. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio Indicator: 16. Maternal mortality ratio 17. Proportion of births attended by skilled health personnel Goal: 6. Combat HIV/AIDS, malaria and other diseases Target: 7. Have halted by 2015 and begun to reverse the spread of HIV/AIDS Indicator: 18. HIV prevalence among young people aged 15 to 24 yearsb 19. Condom use rate of the contraceptive prevalence rate 20. Number of children orphaned by HIV/AIDS Target: 8. Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Indicator: 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) Goal: 7. Ensure environmental sustainability Target: 9. Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources Indicator: 29. Proportion of population using solid fuel Target: 10. Halve by 2015 the proportion of people without sustainable access to safe drinking-water Indicator: 30. Proportion of population with sustainable access to an improved water source, urban and rural Target: 11. By 2020 to have achieved a significant improvement in the lives of at least 100 million slum dwellers Indicator: 31. Proportion of urban population with access to improved 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 Indicator: 46. Proportion of population with access to affordable essential drugs on a sustainable basis a Health-related indicator reported by FAO only. b Indicators from the MDG list reformulated by WHO and United Nations General Assembly Special Session on HIV/AIDS

Millennium Health Goals: paths to the future more or less on track, but several countries in each region are not. Some countries of the South-East Asia Region are behind schedule and sub-Saharan Africa, as noted above, is not likely to reach the target until the second half of the next century. If overall trends continue, under-five mortality worldwide will be reduced by approximately one-quarter over the pe- riod 1990-2015, which is very far from the goal of a two-thirds reduction. Lack of progress can be attributed to mother-to-child HIV transmission in some parts of Africa, but for most countries the problem is long-standing underinvestment. This applies to efforts both to re- duce malnutrition and to achieve full coverage of interventions to reduce mortality from diarrhoea, pneumonia, vaccine-preventable diseases, malaria and perinatal causes. The maternal mortality picture shows a similar divide between, on one side, southern Asia and sub-Saharan Africa, and on the other. the rest of the world there is a hundred-fold difference in lifetime risk of dying in pregnancy between the worlds poorest and richest countries. One of the indicators of progress, the proportion of births attended by skilled personnel, is rising slowly from a very low base in parts of the South-East Asia Region, and stagnating in sub-Saharan Africa. Only a dramatic improvement in the quality and coverage of health services is likely to have a significant influence on progress in relation to this goal (see Box 2.3) The global HIVIAIDS pandemic continues to worsen, with over 70% of all infections occur ring in sub-Saharan Africa. Around 40 million people are now living with AIDS, over 5 million new infections occur each year and, in 2002, almost 3 million people died as a result of the disease. Progress is currently measured(for the purposes of tracking Goal 6) by Box 2.1 Progress towards the Millennium Development Goals -the case of Uganda B& e Many sub-Saharan African countries are struggling to make than that required to reach the MDG target(Figure A) ess towards the Millennium Devel opment Goals(MDGs). Never- Progress in reducing mortality in children under five years of age eless, some countries in WHOs African Region have registered has also been substantial. However, it is important to disaggregate the impressive gains (10, 11) inder- 5 mortality data in order to understand the impact on different Uganda, for example, cut poverty sharply in the 1990s and will socioeconomic groups. As Figure B indicates, the gap between the rich achieve the MDG poverty reduction target if present trends continue. est and poorest sections of the population widened in the mid-1990s. pecifically pro-poor economic policies may be needed, however, in or. While the richest made gains in line with the MDGs, much less progress der to distribute the fruits of economic growth more evenly was observed for the poorest households. Since the poor make up over between rich and poor, especially in rural areas. Furthermore, growth a third of Uganda's population, instituting a"bottom-up"approach that self needs to be revived through economic diversification. In control. focuses on the needs of the lowest quintiles first could achieve the MDG ling the spread of HIV, Uganda's progress has actually been more rapid under- 5 mortality target ahead of time Figure A Current and projected progress towards progress toward IDG HIV prevalence target, Uganda MDG under-5 morta e200 100 宝 00 Year

Millennium Health Goals: paths to the future 29 more or less on track, but several countries in each region are not. Some countries of the South-East Asia Region are behind schedule and sub-Saharan Africa, as noted above, is not likely to reach the target until the second half of the next century. If overall trends continue, under-five mortality worldwide will be reduced by approximately one-quarter over the pe￾riod 1990–2015, which is very far from the goal of a two-thirds reduction. Lack of progress can be attributed to mother-to-child HIV transmission in some parts of Africa, but for most countries the problem is long-standing underinvestment. This applies to efforts both to re￾duce malnutrition and to achieve full coverage of interventions to reduce mortality from diarrhoea, pneumonia, vaccine-preventable diseases, malaria and perinatal causes. The maternal mortality picture shows a similar divide between, on one side, southern Asia and sub-Saharan Africa, and on the other, the rest of the world. There is a hundred-fold difference in lifetime risk of dying in pregnancy between the world’s poorest and richest countries. One of the indicators of progress, the proportion of births attended by skilled personnel, is rising slowly from a very low base in parts of the South-East Asia Region, and stagnating in sub-Saharan Africa. Only a dramatic improvement in the quality and coverage of health services is likely to have a significant influence on progress in relation to this goal (see Box 2.3). The global HIV/AIDS pandemic continues to worsen, with over 70% of all infections occur￾ring in sub-Saharan Africa. Around 40 million people are now living with AIDS, over 5 million new infections occur each year and, in 2002, almost 3 million people died as a result of the disease. Progress is currently measured (for the purposes of tracking Goal 6) by Box 2.1 Progress towards the Millennium Development Goals – the case of Uganda Many sub-Saharan African countries are struggling to make progress towards the Millennium Development Goals (MDGs). Never￾theless, some countries in WHO’s African Region have registered impressive gains (10, 11). Uganda, for example, cut poverty sharply in the 1990s and will achieve the MDG poverty reduction target if present trends continue. Specifically pro-poor economic policies may be needed, however, in or￾der to distribute the fruits of economic growth more evenly between rich and poor, especially in rural areas. Furthermore, growth itself needs to be revived through economic diversification. In control￾ling the spread of HIV, Uganda’s progress has actually been more rapid than that required to reach the MDG target (Figure A). Progress in reducing mortality in children under five years of age has also been substantial. However, it is important to disaggregate the under-5 mortality data in order to understand the impact on different socioeconomic groups. As Figure B indicates, the gap between the rich￾est and poorest sections of the population widened in the mid-1990s. While the richest made gains in line with the MDGs, much less progress was observed for the poorest households. Since the poor make up over a third of Uganda’s population, instituting a “bottom-up” approach that focuses on the needs of the lowest quintiles first could achieve the MDG under-5 mortality target ahead of time. Figure B Rich and poor – unequal progress towards MDG under-5 mortality targets, Uganda 250 200 150 100 50 0 Under-5 mortality rate Year 1988 1995 2015 Target Figure A Current and projected progress towards MDG HIV prevalence target, Uganda Year 1990 2000 2006 20 18 16 14 12 10 8 6 4 2 0 HIV prevalence rate, adults aged 15–49 Target Poorest quintile Richest quintile

The World Health Report 2003 Box 2.2 Child survival -turning knowledge into action Despite progress in recent decades, globally more than 10 million chil- meta-analysis has shown that children in Brazil, Pakistan and the Philip- en still die every year. The number of children and adolescents who pines who were not breastfed were 5.8 times more likely to die by the died in 2002 was twice the total of adult deaths from AIDS, tuberculosis age of one month than children who received at least some breast milk and malaria combined. All but about 1% of these child deaths occur in (12). There should be a skilled attendant at every birth, infection control developing countries, and more than half are caused by malnutrition, for the newborn, support for exdusive breastfeeding, and identification pneumonia, diarrhoea, measles, malaria, and HIV/AIDS. Effective low- of complications. If necessary, the infant should be referred urgently to cost interventions are available that could prevent at least two-thirds of higher levels of health care these deaths. Some interventions are preventive, for example Child health programmes need to move beyond tackling single breastfeeding, insectioide-treated materials, complementary feeding, zinc, diseases and instead deal with the child' s overall health and well-being vitamin A supplements, improved delivery procedures and immunize- Based on the experiences of Integrated Management of Childhood tion. Others involve treatment, such as oral rehydration therapy, antibi- lness(IMCI), WHO, together with partners, is developing a simple but otics for sepsis and pneumonia, antimalarials and newborn resuscitation. comprehensive framework that will guide countries on implementation The challenge is to deliver these life-saving interventions to the children and scaling-up of effective child health interventions. The framework who need them most. has five components Scaling up effective child health interventions will require increased A situation analysis to assess variables specific to country or context attention to newborn health and the application of an integrated, com. such as burden of child diseases, socioeconomic status, infrastructure, prehensive approach to child health at country level health system capacity, available resources, political stability and Although significant progress has been achieved during the past predictability for investments. 10 years in reducing mortality in childhood, there has been little progress Development and formulation of a concise national child health policy in reducing deaths among newborns. Almost 4 million infants every year with outcome-oriented strategic directions do not survive their first month of life. Most newborn deaths are a con- . ldentification of a set of proven cost-effective child health interven- sequence of poor health and nutritional status in the mother, absent or tions. low-quality care during pregnancy and delivery, and inadequate basic Scaling-up of interventions through a two-pronged approach: increas- care of the healthy baby and management of the sick ing health system efficiency to serve more children, and engaging fami infant Action to improve the health and survival of newborns and their lies and communities more closely in disease prevention and care for mothers is urgently needed. High-quality maternity services, including sick children skilled attendants at delivery, can save both newborns and their moth..Ongoing monitoring designed to inform decision-making at opera- ers. Early and exclusive breastfeeding protects newborn lives. A recent tional level and support countries and partners in measuring progress. reductions in HIV prevalence among pregnant women aged 15-24 years(where in some African cities it is beginning to decline), by the number of HIviaIdS orphans(which is forecast to double by 2010), and by increases in condom use in the 15-24-year age group Some countries could reach the target of reversing the spread of AidS by 2015, but again,not without an unprecedented increase in the level of effort in the worst affected regions Similar prospects overshadow the other health-related targets and indicators-those related to tuberculosis and malaria, improved water sources, improved sanitation, and solid fuel an indicator of indoor air pollution. While limited progress has been made in some coun tries,major differences in achievement exist between and within regions and countries. There are major variations in the provision of essential medicines: WHO estimates that 15%of the world's population consumes 91% of the world,s production of pharmaceuticals(by value Overall progress depends on what happens in the world's largest countries, such as China and India. Above all, success in achieving the health-related MDGs requires much more com mitment and effort between now and 2015 than has been evident since the countdown started The other side of the compact: Goal 8 Most discussion of the MDGs focuses on Goals 1-7. However, a comprehensive assessment of progress requires an examination of both sides of the compact. Defining indicators for oal 8 has been difficult. Indeed, there has been a reluctance on the part of some developed

30 The World Health Report 2003 reductions in HIV prevalence among pregnant women aged 15–24 years (where in some African cities it is beginning to decline), by the number of HIV/AIDS orphans (which is forecast to double by 2010), and by increases in condom use in the 15–24-year age group. Some countries could reach the target of reversing the spread of AIDS by 2015, but again, not without an unprecedented increase in the level of effort in the worst affected regions. Similar prospects overshadow the other health-related targets and indicators – those related to tuberculosis and malaria, improved water sources, improved sanitation, and solid fuel as an indicator of indoor air pollution. While limited progress has been made in some coun￾tries, major differences in achievement exist between and within regions and countries. There are major variations in the provision of essential medicines: WHO estimates that 15% of the world’s population consumes 91% of the world’s production of pharmaceuticals (by value). Overall progress depends on what happens in the world’s largest countries, such as China and India. Above all, success in achieving the health-related MDGs requires much more com￾mitment and effort between now and 2015 than has been evident since the countdown started in 1990. The other side of the compact: Goal 8 Most discussion of the MDGs focuses on Goals 1–7. However, a comprehensive assessment of progress requires an examination of both sides of the compact. Defining indicators for Goal 8 has been difficult. Indeed, there has been a reluctance on the part of some developed Box 2.2 Child survival – turning knowledge into action Despite progress in recent decades, globally more than 10 million chil￾dren still die every year. The number of children and adolescents who died in 2002 was twice the total of adult deaths from AIDS, tuberculosis and malaria combined. All but about 1% of these child deaths occur in developing countries, and more than half are caused by malnutrition, pneumonia, diarrhoea, measles, malaria, and HIV/AIDS. Effective low￾cost interventions are available that could prevent at least two-thirds of these deaths. Some interventions are preventive, for example breastfeeding, insecticide-treated materials, complementary feeding, zinc, vitamin A supplements, improved delivery procedures and immuniza￾tion. Others involve treatment, such as oral rehydration therapy, antibi￾otics for sepsis and pneumonia, antimalarials and newborn resuscitation. The challenge is to deliver these life-saving interventions to the children who need them most. Scaling up effective child health interventions will require increased attention to newborn health and the application of an integrated, com￾prehensive approach to child health at country level. Although significant progress has been achieved during the past 10 years in reducing mortality in childhood, there has been little progress in reducing deaths among newborns. Almost 4 million infants every year do not survive their first month of life. Most newborn deaths are a con￾sequence of poor health and nutritional status in the mother, absent or low-quality care during pregnancy and delivery, and inadequate basic care of the healthy baby and management of the sick infant. Action to improve the health and survival of newborns and their mothers is urgently needed. High-quality maternity services, including skilled attendants at delivery, can save both newborns and their moth￾ers. Early and exclusive breastfeeding protects newborn lives. A recent meta-analysis has shown that children in Brazil, Pakistan and the Philip￾pines who were not breastfed were 5.8 times more likely to die by the age of one month than children who received at least some breast milk (12). There should be a skilled attendant at every birth, infection control for the newborn, support for exclusive breastfeeding, and identification of complications. If necessary, the infant should be referred urgently to higher levels of health care. Child health programmes need to move beyond tackling single diseases and instead deal with the child’s overall health and well-being. Based on the experiences of Integrated Management of Childhood Illness (IMCI), WHO, together with partners, is developing a simple but comprehensive framework that will guide countries on implementation and scaling-up of effective child health interventions. The framework has five components: • A situation analysis to assess variables specific to country or context such as burden of child diseases, socioeconomic status, infrastructure, health system capacity, available resources, political stability and predictability for investments. • Development and formulation of a concise national child health policy with outcome-oriented strategic directions. • Identification of a set of proven cost-effective child health interven￾tions. • Scaling-up of interventions through a two-pronged approach: increas￾ing health system efficiency to serve more children, and engaging fami￾lies and communities more closely in disease prevention and care for sick children. • Ongoing monitoring designed to inform decision-making at opera￾tional level and support countries and partners in measuring progress

Millennium]HealthGoals:paths to the future Box 2.3 Fighting maternal mortality-making pregnancy safer For more than 30 million women each year, pregnancy and childbirth feasible, even in poor settings. mean unnecessary suffering, ill-health or death. More than half a mi Through its Making Pregnancy Safer initiative, WHO works with lion women die annually of pregnancy-related complications, 99% of countries to achieve their Safe Motherhood goals. The fundamental idea them in developing countries. Yet most maternal deaths and disabilities of the initiative is to increase the proportion of pregnancies and births could be avoided through better-quality health services and good ma. attended by skilled health personnel. For national policy-makers, the ernal nutrition most important issues for improving maternal health are: Of all health statistics, those for matemal mortality represent some Promoting legal reform and community mobilization to enable women of the greatest disparities between developing and developed coun- to have access to proper care during pregnancy, childbirth and the tries. The lifetime risk of dying from maternal causes in sub-Saharan postpartum period Africa is 1 in 16, compared with 1 in 160 in Latin America and 1 in 4000 .Developing and implementing plans to train and deploy sufficient num- in western Europe. In poor countries, as many as 30% of deaths among bers of skilled health workers, providing them with essential supplies women of reproductive age (15-49 years)may be caused by pregnancy. and equipment, and ensuring that they are present in poor and rural related causes, compared with a rate of less than 1% in Australia, communities. Europe, Japan, New Zealand and North America Ensuring that all women and their newborn babies have access to Each maternal death is a tragedy. Every year, millions of children quality skilled care, including antenatal care; birth care; obstetric emer- are left motherless and an estimated one million children die as a result gency care; postpartum care; newborn care; management of abortion of the death of their mother. Babies who survive their mother's death complications and post-abortion care; family planning services: seldom reach their first birthday. The risk of death for children under five adolescent reproductive health education and services; and also safe years of age is doubled if their mother dies in childbirth abortion care, where abortion is legal Although the causes of high maternal and perinatal morbidity and . Ensuring that the coverage and use of maternal health services are ways of preventing and treating them are well known, progress in many monitored, and the findings used to strengthen future activities and countries remains slow. However, some countries- including very poor improve the quality of care. ones-have been successful in reducing maternal mortality. Maternal Strengthening research networks and dissemination of critical find- and newborn deaths can be significantly reduced by the use of evidence- ings to improve planning and decision-making regarding critical inter- based maternal health interventions that are reliable, cost-effective and ventions. countries to endorse the MDGs because of the very existence of Goal 8. Moreover, the commitment by OECD countries to transfer to low-income countries 0.7% of their annual GNP as a contribution to development assistance(agreed since the early 1970s)has been met by only a very few. The average development assistance transfer for OECD countries percentage of GNP, is still extremely low Three aspects of the partnership for development are seen by most countries as being particularly important and offering the chance of progress: the World Trade Organization (WTO)round of trade talks at Doha, Qatar, in 2001(although the September 2003 rial conference discussions in Cancun, Mexico, must also be considered), the Monterrey Con sensus on development financing, and the Highly Indebted Poor Country (HIPC) Initiative on debt relief. Their importance has both substantive and symbolic elements: substantive because of the influence of trade, debt and development assistance on national economies; and symbolic because of the need to build trust in an increasingly polarized debate between developed and developing countries around roles and responsibilities for developm Five issues continue to dominate the trade and development agenda: the Trade-Related As- pects of Intellectual Property Rights(TRIPS)agreement and public health; trade in health ervices; tariffs and subsidies for agriculture and market access for non-agricultural prod ucts;aligning special and differential treatment with national development priorities; and capacity strengthening in least developed countries. The first two issues have an obvious and irect impact on health. The others are equally important, in the light of their impact on the economies of the developing world

Millennium Health Goals: paths to the future 31 countries to endorse the MDGs because of the very existence of Goal 8. Moreover, the commitment by OECD countries to transfer to low-income countries 0.7% of their annual GNP as a contribution to development assistance (agreed since the early 1970s) has been met by only a very few. The average development assistance transfer for OECD countries, as a percentage of GNP, is still extremely low. Three aspects of the partnership for development are seen by most countries as being particularly important and offering the chance of progress: the World Trade Organization (WTO) round of trade talks at Doha, Qatar, in 2001 (although the September 2003 ministe￾rial conference discussions in Cancun, Mexico, must also be considered), the Monterrey Con￾sensus on development financing, and the Highly Indebted Poor Country (HIPC) Initiative on debt relief. Their importance has both substantive and symbolic elements: substantive because of the influence of trade, debt and development assistance on national economies; and symbolic because of the need to build trust in an increasingly polarized debate between developed and developing countries around roles and responsibilities for development. Trade Five issues continue to dominate the trade and development agenda: the Trade-Related As￾pects of Intellectual Property Rights (TRIPS) agreement and public health; trade in health services; tariffs and subsidies for agriculture and market access for non-agricultural prod￾ucts; aligning special and differential treatment with national development priorities; and capacity strengthening in least developed countries. The first two issues have an obvious and direct impact on health. The others are equally important, in the light of their impact on the economies of the developing world. Box 2.3 Fighting maternal mortality – making pregnancy safer For more than 30 million women each year, pregnancy and childbirth mean unnecessary suffering, ill-health or death. More than half a mil￾lion women die annually of pregnancy-related complications, 99% of them in developing countries. Yet most maternal deaths and disabilities could be avoided through better-quality health services and good ma￾ternal nutrition. Of all health statistics, those for maternal mortality represent some of the greatest disparities between developing and developed coun￾tries. The lifetime risk of dying from maternal causes in sub-Saharan Africa is 1 in 16, compared with 1 in 160 in Latin America and 1 in 4000 in western Europe. In poor countries, as many as 30% of deaths among women of reproductive age (15–49 years) may be caused by pregnancy￾related causes, compared with a rate of less than 1% in Australia, Europe, Japan, New Zealand and North America. Each maternal death is a tragedy. Every year, millions of children are left motherless and an estimated one million children die as a result of the death of their mother. Babies who survive their mother’s death seldom reach their first birthday. The risk of death for children under five years of age is doubled if their mother dies in childbirth. Although the causes of high maternal and perinatal morbidity and ways of preventing and treating them are well known, progress in many countries remains slow. However, some countries – including very poor ones – have been successful in reducing maternal mortality. Maternal and newborn deaths can be significantly reduced by the use of evidence￾based maternal health interventions that are reliable, cost-effective and feasible, even in poor settings. Through its Making Pregnancy Safer initiative, WHO works with countries to achieve their Safe Motherhood goals. The fundamental idea of the initiative is to increase the proportion of pregnancies and births attended by skilled health personnel. For national policy-makers, the most important issues for improving maternal health are: • Promoting legal reform and community mobilization to enable women to have access to proper care during pregnancy, childbirth and the postpartum period. • Developing and implementing plans to train and deploy sufficient num￾bers of skilled health workers, providing them with essential supplies and equipment, and ensuring that they are present in poor and rural communities. • Ensuring that all women and their newborn babies have access to quality skilled care, including antenatal care; birth care; obstetric emer￾gency care; postpartum care; newborn care; management of abortion complications and post-abortion care; family planning services; adolescent reproductive health education and services; and also safe abortion care, where abortion is legal. • Ensuring that the coverage and use of maternal health services are monitored, and the findings used to strengthen future activities and improve the quality of care. • Strengthening research networks and dissemination of critical find￾ings to improve planning and decision-making regarding critical inter￾ventions

2TheWworldHealthReport2003 Following the ground-breaking Doha Declaration on the TRIPS Agreement and Public Health in 2001, WTO members reached consensus in August 2003 on implementation of the issue of access to medicines by countries with little or insufficient capacity for pharmaceutical pro- duction. The full impact of the agreement will depend on how effectively it can be imple- mented in countries Development assistance Achievement of the MDGs is unlikely in the absence of a significant increase in development assistance. The most commonly quoted overall figure is an annual increase of USs 50 billion roughly double current levels(3). The Commission on Macroeconomics and Health esti- mate of the requirements for investments, primarily in the health sector, was a total annual igure for development aid of US$ 27 billion -implying at least a four-fold increase in cur rent donor spending on health. Given these estimates, the response has generally been mod est,and only a few donor countries have made significant progress towards the 0.7%GNP target. Despite overall trends, however, spending on health and combatting AIDS has in- reased. Another significant trend is the move towards innovative financing mechanisms, such as the United States Millennium Challenge Account; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and the International Financial Facility proposed by the gov ment of the United Kingdom Debt More than six years after its launch, it is clear that the HIPC Initiative has had only limited results. By March 2003 only seven countries had reached their completion point, granting them a 90% reduction in the net present value of their debt service from official creditors. In some HIPC countries, even the modest gains from debt relief have been offset by falls in export earnings owing to deteriorating terms of trade. While the arguments continue about the advantages and disadvantages of the various approaches to debt relief, it is evident that a large and ongoing debt burden acts as a significant counterweight to development assistance, and is a major constraint to increases in domestic funding for human development. More- over,out of 82 countries eligible for the Poverty Reduction and Growth Facility/HIPC/Pov rty Reduction Strategy Paper process, only seven have been through the entire process during the last seven years, which may jeopardize the effectiveness of the debt relief initiative to In summary, an overview of progress towards Goal 8-even in the absence of robust indica- tors-presents a picture similar to that for Goals 1-7. Much greater efforts are required if the global commitments are to be met. Monitoring issues and progress in relation to Goal 8 need to be placed high on the MDg agenda The Millennium Development Goals in practice While there is little doubt that the mdgs represent an important opportunity for promoting mproved health outcomes for poor people, they are the product of a political process and are an imperfect instrument. Several questions and issues have arisen from the practical experi ence of using the MDGs. Some represent areas in which improvements should be made in he future

32 The World Health Report 2003 Following the ground-breaking Doha Declaration on the TRIPS Agreement and Public Health in 2001, WTO members reached consensus in August 2003 on implementation of the issue of access to medicines by countries with little or insufficient capacity for pharmaceutical pro￾duction. The full impact of the agreement will depend on how effectively it can be imple￾mented in countries. Development assistance Achievement of the MDGs is unlikely in the absence of a significant increase in development assistance. The most commonly quoted overall figure is an annual increase of US$ 50 billion, roughly double current levels (3). The Commission on Macroeconomics and Health esti￾mate of the requirements for investments, primarily in the health sector, was a total annual figure for development aid of US$ 27 billion – implying at least a four-fold increase in cur￾rent donor spending on health. Given these estimates, the response has generally been mod￾est, and only a few donor countries have made significant progress towards the 0.7% GNP target. Despite overall trends, however, spending on health and combatting AIDS has in￾creased. Another significant trend is the move towards innovative financing mechanisms, such as the United States Millennium Challenge Account; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and the International Financial Facility proposed by the Govern￾ment of the United Kingdom. Debt More than six years after its launch, it is clear that the HIPC Initiative has had only limited results. By March 2003 only seven countries had reached their completion point, granting them a 90% reduction in the net present value of their debt service from official creditors. In some HIPC countries, even the modest gains from debt relief have been offset by falls in export earnings owing to deteriorating terms of trade. While the arguments continue about the advantages and disadvantages of the various approaches to debt relief, it is evident that a large and ongoing debt burden acts as a significant counterweight to development assistance, and is a major constraint to increases in domestic funding for human development. More￾over, out of 82 countries eligible for the Poverty Reduction and Growth Facility/HIPC/Pov￾erty Reduction Strategy Paper process, only seven have been through the entire process during the last seven years, which may jeopardize the effectiveness of the debt relief initiative to reduce poverty rapidly. In summary, an overview of progress towards Goal 8 – even in the absence of robust indica￾tors – presents a picture similar to that for Goals 1–7. Much greater efforts are required if the global commitments are to be met. Monitoring issues and progress in relation to Goal 8 need to be placed high on the MDG agenda. The Millennium Development Goals in practice While there is little doubt that the MDGs represent an important opportunity for promoting improved health outcomes for poor people, they are the product of a political process and are an imperfect instrument. Several questions and issues have arisen from the practical experi￾ence of using the MDGs. Some represent areas in which improvements should be made in the future

Millennium Health Goals: paths to the future Who owns the mdgs? National ownership is an important issue. The power and purpose of the MDGs is that they represent a means by which people can hold authorities accountable(for this reason, accessi- ble reports in local languages are a key part of the United Nations strategy). There is a risk, however, that the MDGs are seen by some developing countries as being of primary concern to donors; they may be perceived to be a new form of conditionality and too restrictive in their scope to cover the multifaceted nature of development. The second concern also en compasses the fear that an exclusive focus on the mDGs indicates a rejection of the goals of other United Nations conferences(see the discussion on reproductive health below) Maintaining a genuine political consensus in the face of these fears is a critically important challenge How flexible is the approach? Many countries argue that the targets should be adapted more closely to their level of devel opment, questioning the point of striving towards a goal that has little chance of being achieved Other countries recognize the value of targets, but want to make them more ambitious or broaden their scope(sometimes referred to as MDG Plus). Some countries argue that it is nappropriate in many parts of the world to concentrate on communicable diseases, given the rapid increases in the effects of noncommunicable diseases, tobacco-caused illness and injuries on the health of poor populations(see Box 2.4). The current health-related goals, targets and indicators of the MDGs only partially reflect the rapid transition of the disease burden in developing countries. There is an increasing call for a set of regional and global goals with timed targets for noncommunicable diseases and their risk factors, neuropsychiat ic disorders and injuries Clearly there is a need to strike a balance between the need for comparability between coun tries and the need to ensure relevance(and ownership). If standardized indicators are used there is no reason, in principle, why countries should not be able to report on their own as well as international targets; as with the MDGs, timed noncommunicable disease targets and practical policies would require focus and commitment by the international health commu nity. WHO will push for a more ambitious and more complete set of global health goals Box 2.4 Millennium Development Goals in eastern Europe Europe is not usually the main focus of the debate about devel- selected indicators for the other goals match the priority areas for East- in general and the Millennium Development Goals(MDGs)in erm Europe. There is some evidence to suggest that the latter may not be although a number of eastern European countries now have the case in regard to health-related indicators (13) per capita incomes comparable to those in developing countries in In the developing countries of sub-Saharan Africa and the South the African and South-East Asia Regions. Much of todays low level of East Asia Region the key health problems revolve around issues of child economic development is the result of the substantial drop in output and maternal health as well as infectious diseases, but this is not the during the decade following the transition to market economies. case in most eastern European countries, where relatively high adult Strong national and international commitment is required if east. mortality and noncommunicable diseases account for the larges ern Europe is to reach the poverty reduction goal by 2015. Whether this burden of disease. In the special case of eastern Europe, the use of can be achieved depends, among other things, on the degree to which additional health indicators(such as life expectancy) would therefore progress towards the other MDGs is achieved and on whether the be useful

Millennium Health Goals: paths to the future 33 Who owns the MDGs? National ownership is an important issue. The power and purpose of the MDGs is that they represent a means by which people can hold authorities accountable (for this reason, accessi￾ble reports in local languages are a key part of the United Nations strategy). There is a risk, however, that the MDGs are seen by some developing countries as being of primary concern to donors; they may be perceived to be a new form of conditionality and too restrictive in their scope to cover the multifaceted nature of development. The second concern also en￾compasses the fear that an exclusive focus on the MDGs indicates a rejection of the goals of other United Nations conferences (see the discussion on reproductive health below). Maintaining a genuine political consensus in the face of these fears is a critically important challenge. How flexible is the approach? Many countries argue that the targets should be adapted more closely to their level of devel￾opment, questioning the point of striving towards a goal that has little chance of being achieved. Other countries recognize the value of targets, but want to make them more ambitious or broaden their scope (sometimes referred to as MDG Plus). Some countries argue that it is inappropriate in many parts of the world to concentrate on communicable diseases, given the rapid increases in the effects of noncommunicable diseases, tobacco-caused illness and injuries on the health of poor populations (see Box 2.4). The current health-related goals, targets and indicators of the MDGs only partially reflect the rapid transition of the disease burden in developing countries. There is an increasing call for a set of regional and global goals with timed targets for noncommunicable diseases and their risk factors, neuropsychiat￾ric disorders and injuries. Clearly there is a need to strike a balance between the need for comparability between coun￾tries and the need to ensure relevance (and ownership). If standardized indicators are used, there is no reason, in principle, why countries should not be able to report on their own as well as international targets; as with the MDGs, timed noncommunicable disease targets and practical policies would require focus and commitment by the international health commu￾nity. WHO will push for a more ambitious and more complete set of global health goals and targets. Box 2.4 Millennium Development Goals in eastern Europe Eastern Europe is not usually the main focus of the debate about devel￾opment in general and the Millennium Development Goals (MDGs) in particular, although a number of eastern European countries now have per capita incomes comparable to those in developing countries in the African and South-East Asia Regions. Much of today’s low level of economic development is the result of the substantial drop in output during the decade following the transition to market economies. Strong national and international commitment is required if east￾ern Europe is to reach the poverty reduction goal by 2015. Whether this can be achieved depends, among other things, on the degree to which progress towards the other MDGs is achieved and on whether the selected indicators for the other goals match the priority areas for East￾ern Europe. There is some evidence to suggest that the latter may not be the case in regard to health-related indicators (13). In the developing countries of sub-Saharan Africa and the South￾East Asia Region the key health problems revolve around issues of child and maternal health as well as infectious diseases, but this is not the case in most eastern European countries, where relatively high adult mortality and noncommunicable diseases account for the largest burden of disease. In the special case of eastern Europe, the use of additional health indicators (such as life expectancy) would therefore be useful