—from Epidemiological Bulletin , Vol. 25 No. 2, June 2004—

The Millennium Development Goals in the Americas

In September 2000, at the United Nations Millennium Summit, world leaders of 189 states adopted a set of timebound and measurable goals and targets for combating poverty, hunger, disease, illiteracy, environmental degradation, discrimination against women, and commiting to principles of human rights, good governance and democracy. They were outlined in the Millennium Declaration, which since then has been summarized and operationalized as a package of 8 goals, 18 targets, and 48 indicators, commonly referred to as the Millennium Development Goals (MDGs) to be reached by the year 2015 (Box 1).

Country ownership of the MDG process is essential and in the Americas was addressed at a high-level conference in Brasilia in November 20031. The Brasilia Declaration is a call to action and implementation that reinforces the partnership principle inherent in the Millennium Declaration and prior agreements of previous Summits of the Americas.

Three of the eight MDGs explicitly refer to health issues: reducing child and maternal mortality, and combating HIV/AIDS, malaria, tuberculosis and other diseases. Further, seven of the 18 Targets are directly related to the responsibility of the health sector – Target 2 for malnutrition, Target 5 for child mortality, Target 6 for maternal mortality, Target 7 and 8 for HIV/AIDS, malaria and other diseases, Target 10 for safe drinking water, and Target 17 for essential drugs. The 18 targets may also be seen as macro determinants from different layers that have traditionally been defined as impacting health, from very proximal to more distal levels. This clearly gives health a high profile within the global development agenda and provides the health sector with great opportunities for political commitment to advancing the health and welfare of the populations of the world.

Situation in the Region
The world has been making progress towards the MDGs but this progress has been very uneven and, in many countries, too slow to reach the 2015 Targets. In the Americas, some of the greatest challenges lie within the health area. Presently, the situation varies markedly between the countries of the Region and different population groups, as well as between the targets indicators. As data below suggest, it is difficult to say that the Region as a whole will reach the ambitious health Targets.

In 2003 in the Region, the infant mortality oscillated between 5.3 per 1,000 live births in Canada to 80.3 per 1,000 in Haiti2. Although this indicator has been improving over the past decade, a PAHO case study has shown that if current trends continue, the reduction in infant and under-5 mortality in the Region would reach 54%, well below the two-thirds established in Goal 4. The situation of another MDG indicator for Goal 43, measles vaccine coverage, is also varied, with a regional average of 91%. Estimates for the indicators of Goal 5 reflect that the situation of maternal mortality is also extremely varied. In 2000, the maternal mortality ratio was estimated at 16 per 100,000 live births in Cuba and 680 per 100,000 live births in Haiti. In addition, over the past decade, some countries saw an increase in maternal mortality and some others a significant decrease. Further, other estimates show that the annual reduction needed between 2000 and 2015 to reach the target varies from a low rate of 1.6% in Uruguay, to 15.1% in Panama4.

The HIV/AIDS epidemic is well established in the Americas, with a national HIV prevalence of at least 1% in 12 countries, all of them in the Caribbean, and with HIV prevalence among pregnant women exceeding 2% in six of them5. In most of the other countries of the Region, the epidemic is more concentrated in certain areas or population groups. The deceleration needed to halt and reverse the epidemic by 2015 and reach Goal 6 is currently not seen in the Region. The incidence of malaria also varies greatly in the countries of the Region, but it is estimated that in 2002 31% of the population of the Americas lived in areas with some potential risk of transmission of the disease, with 80% of the reported cases originating in the nine countries that share the Amazon rain forest in South America6. Given the wide variations in incidence over the last decade, it is difficult to say whether the goal of reversing the epidemic as defined in Goal 6 is under way. In 2002, there were 223,057 cases of tuberculosis in the Americas, 50% of them in Brazil and Peru. The total of cases in the Region decreased 11% between 1999 to 20027.

The water and sanitation evaluation carried out by PAHO showed that water supply and sanitation coverage in Latin America and the Caribbean were 84.6% and 79.2%, respectively, around 2000. In total in the Region, more than 76 million people have no access to a water supply, and 103 million are without any sanitation facilities for the elimination of wastewater and excreta. In 1995, only 23 countries reported that water supplies in urban areas met the WHO safety guidelines, but this is not applicable to rural areas. There are severe inequalities in access to water in the Region, usually linked to income and place of residence8.

Finally, only five countries (Brazil, Chile, Honduras, Nicaragua, and Panama) have policies specifically dealing with pharmaceuticals. Twenty-one countries have basic drug lists and have incorporated the concept of essential drugs. However, access to medicines continues to be limited, with, for example, only 31% of the population in Brazil having access6. In the Americas, only 53% of the population in need of HIV/AIDS treatment has access to it.

The role of PAHO in achieving the MDGs
As shown above, for the Americas a focus on the reduction of inequalities, particularly in health, is of particular importance in order to reach the MDGs. Indeed reaching the goals is not limited to attaining the level of indicators as a regional or even national average, but looking at what is happening at lower levels of disaggregation. This is particularly important and relevant in a Region as unequal as the Americas, where some of the Gini coefficients for income inequality in 1999 were 0.5 in Peru, 0.6 in Bolivia, 0.59 in Nicaragua, and 0.64 in Brazil9, and where the regional Gini coefficient for infant mortality in 1997 was 0.336.

In this context, PAHO has decided to put the MDGs at the core of its technical cooperation, and has defined a series of strategic objectives to assist countries in reaching them. At the center of this action lie the strategic dimensions defined as the Organization’s guiding principles: to reduce inequalities by addressing the unfinished health agenda in the Region, preserving the progress made so far, and reacting to new and emerging health issues. PAHO’s strategy relies on: advocacy to raise awareness on the health priorities set by the MDGs; supporting progress towards the MDGs through health policy initiatives in the context of national health development; integration of the MDGs with other existing national and regional health targets; increasing cooperation with different ministerial, legislative, and other partners involved in working towards the goals; ensuring that communities are empowered and involved in the processes in place to reach the MDGs, particularly ethnic groups, indigenous populations, and women; monitoring progress towards the MDGs; and initiating research to strengthen the evidence base and generate new knowledge for reaching the goals.

These lines of action reflect that the MDG process will require support from reliable epidemiological systems, particularly in the measurement of progress towards the targets. Just as the goals themselves must be adapted and led by the countries, the process and product of monitoring the MDGs must be country-owned and driven. It includes the definition of how the MDGs apply to the country’s current situation and how their achievement needs to be addressed through national development strategies, policies, and programs. In many countries of the Region, the follow-up of the health MDGs requires the development of sustainable statistical systems and skills to analyze and use data for policy-making and programming. The PAHO Core Data Initiative and other cooperation strategies in support of the development of national health information systems will provide great input to the monitoring effort. The measurement and follow-up of the MDGs also reflect the particular importance of quality disaggregated data at regional, sub regional, and country levels.

The MDGs underline the need to have clear, measurable goals for global challenges and give a clear message of the priority needed to invest in people through health and other dimensions of development. PAHO is committed to tackle the challenge to guarantee more equity among the peoples of the Region of the Americas.

GOALS and TARGETS	INDICATORS
Goal 1 Eradicate extreme poverty and hunger
Target 1: Halve, between 1990 and 2015, the proportion of people whose income is less than $1 a day	1a. Proportion of population below $1 a day 1b. National poverty headcount ratio 2. Poverty gap ratio at $1 a day (incidence x depth of poverty) 3. Share of poorest quintile in national consumption
Target 2: Halve, between 1990 and 2015, the proportion of people who suffer from hunger	4. Prevalence of underweight in children (under five years of age) 5. Proportion of population below minimum level of dietary energy consumption
Goal 2 Achieve universal primary education
Target 3: Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling	6. Net enrollment ratio in primary education 7a. Proportion of pupils starting grade 1 who reach grade 5 7b. Primary completion rate 8. Literacy rate of 15 to 24-year-olds
Goal 3 Promote gender equality and empower women
Target 4: Eliminate gender disparity in primary and secondary education preferably by 2005 and in all levels of education no later than 2015	9. Ratio of girls to boys in primary, secondary, and tertiary education 10. Ratio of literate females to males among 15- to 24-year-olds 11. Share of women in wage employment in the nonagricultural sector 12. Proportion of seats held by women in national parliament
Goal 4 Reduce child mortality
Target 5: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate	13. Under-five mortality rate 14. Infant mortality rate 15. Proportion of one-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	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	18. HIV prevalence among 15- to 24-year-old pregnant women 19. Condom use rate of the contraceptive prevalence rate 19a. Condom use at last high-risk sex 19b. Percentage of population aged 15-24 with comprehensive correct knowledge of HIV/AIDS 19c. Contraceptive prevalence rate 20. Ratio of school attendance of orphans to school attendance on non-orphans aged 10-14
Target 8: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases	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 programs and reverse the loss of environmental resources	25. Proportion of land area covered by forest 26. Ratio of area protected to maintain biological diversity to surface area 27. Energy use per unit of GDP 28. Carbon dioxide emissions (per capita) and consumption of ozone-depleting chlorofluorocarbons 29. Proportion of population using solid fuels
Target 10: Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation	30. Proportion of population with sustainable access to an improved water source, urban and rural 31. Proportion of population with access to improved sanitation
Target 11: Have achieved, by 2020, a significant improvement in the lives of at least 100 million slum dwellers	32. Proportion of households with access to secure tenure
Goal 8 Develop a global partnership for development
Target 12: 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) Target 13: Address the special needs of the least developed countries (includes tariff-and quota-free access for exports enhanced program of debt relief for HIPC and cancellation of official bilateral debt, and more generous ODA for countries committed to poverty reduction) Target 14: 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) Target 15: Deal comprehensively with the debt problems of developing countries through national and international measures in order to make debt sustainable in the long term	Official development assistance (ODA) 33. Net ODA total and to least developed countries, as a percentage of OECD/DAC donors gross income 34. Proportion of bilateral, sector-allocable ODA of OECD/DAC donors for basic social services (basic education, primary health care, nutrition, safe water, and sanitation) 35. Proportion of bilateral ODA of OECD/DAC donors that is untied 36. ODA received in landlocked countries as proportion of their GNI 37. ODA received in small island developing states as proportion of their GNI Martket access 38. Proportion of total developed country imports (excluding arms) from developing countries and least developed countries admitted free of duties 39. Average tariffs imposed by developed countries on agricultural products and clothing from developing countries 40. Agricultural support estimate for OECD countries as a percentage of their GDP 41. Proportion of ODA provided to help build trade capacity Debt sustainability 42. Total number of countries that have reached their HIPC decision points and completion points (cumulative) 43. Debt relief committed under HIPC initiative, US$ 44. Debt service as a percentage of exports of goods and services
Target 16: In cooperation with developing countries, develop and implement strategies for decent and productive work for youth	45. Unemployment rate of 15- to 24-year-olds, male and female and total
Target 17: In cooperation with pharmaceutical companies, provide access to affordable, essential drugs in developing countries	46. Proportion of population with access to affordable, essential drugs on a sustainable basis
Target 18: In cooperation with the private sector, make available the benefits of new technologies, especially information and communications	47. Telephone lines and cellular subscribers per 100 population 48a. Personal computers in use per 100 population 48b. Internet users per 100 population

-------

References:
(1) Inter-American Development Bank, United Nations Development Program, Government of Brazil, Economic Commission for Latin America and the Caribbean, World Bank. Brasilia Declaration: Proposal for Implementing the Millennium Development Goals, 17 November 2003.
(2) Pan American Health Organization. Core Health Data System 2003.
(3) Torres C., Mujica O. Salud, equidad y los Objetivos de Desarrollo del Milenio. Rev Panam Salud Publica/Pan Am J Public Health 15(6): 430-439; 2003.
(4) Inter-American Development Bank. Los Objetivos del Milenio en América Latina y el Caribe: Retos, acciones y compromisos. Washington, DC: IDB; 2004.
(5) UNAIDS/PAHO. HIV infection and AIDS in the Americas: lessons and challenges for the future. Meeting of Monitoring the AIDS Pandemic (MAP) Epidemiology Network for Latin America and the Caribbean (EPINET), Cuba, 7-12 of April 2003.
(6) Pan American Health Organization. Health in the Americas: 2002 Edition. Washington, DC: PAHO; 2002. (Scientific and Technical Publication No. 587).
(7) PAHO. Area of Disease Prevention and Control. Epidemiological and operational situation of the TB in the Americas. Presentation in Tegucigalpa in May 2004 in the V Stop TB Inter Agency Meeting.
(8) Pan American Health Organization. Division of Health and Environment. Informe Regional sobre la Evaluación 2000 en la Región de las Américas. Agua y Saneamiento, estado actual. Washington, DC 2001.
(9) Economic Commission for Latin America and the Caribbean, Instituto de Investigación Económica Aplicada, United Nations Development Program. Meeting the Millennium Poverty Reduction Targets in Latin America and the Caribbean. 2002. (Libros de CEPAL No. 70).

Source: Prepared by Ilona Kickbusch, Senior Advisor for Millennium Goals and Health Targets and Anne Roca, Technical Officer, DPM; based on document CE134/10 to be presented to the 45th session of the PAHO Directing Council

Return to index
Epidemiological Bulletin , Vol. 25 No. 2, June 2004