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Millennium Development Goals and Global Public Health Priorities PUBHLTH 350 Matthew L. Boulton, MD, MPH September 8, 2014

Outline Global health metrics Public health successes United Nations-endorsed goals –Millennium Development Goals (MDGs): pre-2015 –Sustainable Development Goals (SDGs): post-2015 Other global public health priorities Cost-effectiveness analyses

10 Great Public Health Achievements of the 20 th Century Immunizations Motor-vehicle safety Workplace safety Control of infectious diseases Declines in deaths from heart disease and stroke Safer and healthier foods Healthier mothers and babies Family planning Fluoridation of drinking water Tobacco as a health hazard Future directions of public health

10 Great Global Public Health Achievements: Reductions in child mortality Expanded vaccination coverage Increased access to safe water and sanitation Prevention and control of malaria Prevention and control of HIV/AIDS Control of tuberculosis Control of neglected tropical diseases Control of tobacco Increased awareness of road safety Improved preparedness to global health threats

Millennium Development Goals (MDGs) Adopted by the United Nations member nations in 2000 and aim to significantly reduce global poverty by 2015 Health considerations were major components Clear evaluation strategy –8 goals –18 targets –48 indicators Different UN agencies (e.g., World Bank, WHO, UNICEF) were in charge of evaluating different indicators

Eradicate Extreme Hunger and Poverty Target 1. Halve, between 1990 and 2015, the proportion of people whose income is less than $1 a day Indicators 1. Proportion of population below $1 (1993 PPP) per day (World Bank) Target 2. Halve, between 1990 and 2015, the proportion of people who suffer from hunger Indicators 4. Prevalence of underweight children under five years of age (UNICEF- WHO) 5. Proportion of population below minimum level of dietary energy consumption (FAO) (Some indicators omitted from these slides)

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 Indicators 6. Net enrollment ratio in primary education (UNESCO)

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 Indicators 9. Ratio of girls to boys in primary, secondary and tertiary education (UNESCO)

Reduce Child Mortality Target 5. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Indicators 13. Under-five mortality rate (UNICEF-WHO) 14. Infant mortality rate (UNICEF-WHO) 15. Proportion of 1 year-old children immunized against measles (UNICEF-WHO)

Improve Maternal Health Target 6. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio Indicators 16. Maternal mortality ratio (UNICEF-WHO) 17. Proportion of births attended by skilled health personnel (UNICEF- WHO)

Combat HIV/AIDS, Malaria, and Other Diseases Target 7. Have halted by 2015 and begun to reverse the spread of HIV/AIDS Indicators 18. HIV prevalence among pregnant women aged years (UNAIDS-WHO-UNICEF) 19. Condom use rate of the contraceptive prevalence rate (UN Population Division) 19a. Condom use at last high-risk sex (UNICEF-WHO) 19b. Percentage of population aged years with comprehensive correct knowledge of HIV/AIDS (UNICEF-WHO) 19c. Contraceptive prevalence rate (UN Population Division) 20. Ratio of school attendance of orphans to school attendance of non- orphans aged years (UNICEF-UNAIDS-WHO)

Combat HIV/AIDS, Malaria, and Other Diseases (cont.) Target 8. Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Indicators 21. Prevalence and death rates associated with malaria (WHO) 22. Proportion of population in malaria-risk areas using effective malaria prevention and treatment measures (UNICEF-WHO) 23. Prevalence and death rates associated with tuberculosis (WHO) 24. Proportion of tuberculosis cases detected and cured under DOTS (internationally recommended TB control strategy) (WHO)

Ensure Environmental Sustainability Target 9. Integrate the principles of sustainable development into country policies and programs and reverse the loss of environmental resources Indicators 25. Proportion of land area covered by forest (FAO) Target 10. Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation Indicators 30. Proportion of population with sustainable access to an improved water source, urban and rural (UNICEF-WHO) Target 11. Have achieved by 2020 a significant improvement in the lives of at least 100 million slum dwellers Indicators 32. Proportion of households with access to secure tenure (UN- HABITAT)

Develop a Global Partnership for Development Target 12. Develop further an open, rule-based, predictable, nondiscriminatory trading and financial system Target 13. Address the special needs of the Least Developed Countries Target 14. Address the special needs of landlocked developing countries and small island developing states 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 Target 16. In cooperation with developing countries, develop and implement strategies for decent and productive work for youth Target 17. In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries Target 18. In cooperation with the private sector, make available the benefits of new technologies, especially information and communications technologies

MDG Uses and Successes Uses Shape direction of development and investment Development agencies use MDGs to evaluate activities Successes Encourage global political consensus Provide focus for advocacy Improve flow of aid Improve monitoring of development projects Waage. Lancet. 2010; DOI: /S (10)

MDG Criticisms and Challenges May not be an adequate prioritization of development needs Use targets that are easier to monitor Goals may be too specific – considerable gaps in coverage of developmental ideals Lack of synergy in implementation (e.g. among education, health, poverty, and gender) Lack of ownership of some goals by international agencies May encourage focus on easiest to reach groups Waage. Lancet. 2010; DOI: /S (10)

Sustainable Development Goals (SDGs) Adopted by the United Nations member nations to follow and expand on MDGs which expired in goals, 169 targets and 304 indicators covering a broad range of sustainable development issues Waage et al. The Lancet (2010): Natural environment Infrastructure Wellbeing Multilevel view on development:

Evolution of SDGs from MDGs Integrated goals which are globally applicable in all countries Take into account differences in culture, level of development and capacities among nations Incorporation of SDGs into national planning processes, strategies, and policies is decided by each government The interdependence of sustainable development and ongoing relevant developments in social, economic and environmental fields is recognized

SDGs under Wellbeing framework End poverty in all its forms Ensure healthy lives and promote wellbeing Ensure inclusive and equitable education Achieve gender equality and empower women and girls Reduce inequality within and among countries Promote peaceful and inclusive societies for sustainable development Waage et al. The Lancet (2010):

SDGs under Infrastructure framework Ensure availability and sustainable management of water and sanitation for all Ensure access to affordable, reliable, sustainable, modern energy for all Promote sustained, inclusive, and sustainable economic growth Make cities and human settlements inclusive, safe, resilient, and sustainable End hunger, achieve food security and improved nutrition, and promote sustainable agriculture Build resilient infrastructure; promote inclusive sustainable industrialization Ensure sustainable consumption and production patterns Waage et al. The Lancet (2010):

SDGs under Natural Environment framework Take urgent action to combat climate change and its impacts Conserve and sustainably use oceans, seas, and marine resources Protect, restore and promote sustainable use of terrestrial ecosystems SDG that interacts across all 3 frameworks Strengthen the means of implementation and revitalize the global partnership for sustainable development Waage et al. The Lancet (2010):

SDGs: Potential Challenges and Conflicts The interdependent health and other wellbeing goals require cooperation between different sectors delivering them, but can be challenging Lack of direct benefits to wellbeing from natural environment goals make it difficult to demand appropriate action Since infrastructure goals draw on common natural resources, they may conflict with other goals at same or different levels Effective governance mechanisms required for infrastructure goals to prevent exhausting natural resources while achieving wellbeing goals Waage et al. The Lancet (2010):

Cost-Effectiveness Goal is to insure that funds used are effective at achieving their planned outcomes and make efficient use of financial and other resources Most effective are interventions that are inexpensive, easily distributed, and are targeted to children and young adults High tech solutions, like MRI, are among least cost effective interventions

Global Health Cost-Effectiveness Analysis in South Asia DiseaseBurden of target diseases (DALYs) InterventionCost effectiveness (Cost in $ per DALY averted) Childhood vaccine- preventable diseases 28.4 millionImmunizations8 HIV/AIDS7.4 millionCounseling and testing 9 to 126 Heart disease25.9 to 39.1 millionAspirin and beta blockers 9 to 304 Heart disease and lung cancer 15.7 millionIncrease cigarette taxes by 33% 14 to 374 Maternal health problems 37.7 to 47.8 millionIncreased primary- care coverage 127 to 394 Laxminarayan. Lancet (9517).

Limitations of Cost-Effectiveness Focus on previously used interventions that have data for the analysis Require judgments on what a healthy life is worth

Costs of Inaction Lost productivity due to disease, disability, and premature death is a significant economic burden to individuals, families, and countries Often must spend money to save money

Sustainability Sustainability aims to provide for current human needs without compromising the ability of future generations to meet their needs Sustainable programs do not promote overconsumption and do not rely on external funding

Question of the Day Are Sustainable Development Goals that set a global standard for health improvement for all countries the best way to go? Is it a better model for some types of countries than others?