How could the Millenium Development Goals fit better to Latin America and Caribbean needs?
André Medici
Alfredo Solari[1]
Introduction
Health conditions are related to and influenced by, the entire set of Millenium Development Goals (MDGs), not only those three directly aimed at health. Improved health status and increased access, effectiveness and equity of health services, provides synergistic support for the achievement of the MDGs not directly related to health. Given the synergy between health and all the MDGs, the new proposed targets are related not only with those MDGs aimed directly at health status (i.e.: Children and Maternal Mortality and AIDs, Malaria and Tuberculosis), but also with NonH-MDGs.
The advanced phase of the demographic and epidemiologic transitions being experienced by most LAC countries reduces in this region the relative importance of the health related MDGs. Achieving the “original” MDGs would impact only 17% of the regional burden of disease, compared with 95% in Sub Saharan Africa and 42% in all developing countries. Two thirds of the burden of disease in the LAC region is associated with non-communicable diseases (cardiovascular, cancer and mental disorders), and an additional 14% is related to injuries due to external causes, where violence and traffic accidents predominate.
These health problems affect mostly the poorest population groups and the socially excluded. Thus, the most salient dimensions of non-communicable diseases and injuries should be considered by the countries of the LAC region and by the international community, as valid targets for poverty reduction in the framework of the MDGs.
The achievement of the original health-related MDGs is addressing important poverty needs in the LAC Region. However, given the epidemiological profile of the poor in LAC, those goals need to be supplemented by others related to their predominant health needs. It should be considered that the epidemiological profile varies extremely across countries within the region, with Life Expectancy at Birth of just 53 years in Haiti and 78 years in Chile, Costa Rica or Cuba.
This precludes the establishment of identical goals for all the countries in the region. Thus, each country should evaluate its specific burden of disease as well as its distribution across income level, and identify its relevant health priorities. Based on that, they can set the goals and select the indicators that better reflect their health needs. Therefore, although this section suggests some additional targets, it does not preclude each country from setting its own priorities, goals and targets.
Thus, the methodological approach of results based management proposed by the MDGs becomes a common approach to all countries, regardless of their specific priorities, goals and targets.It is suggested that countries consider the following topic areas to adapt the original health-related MDGs to the changing epidemiological profile: obesity in children; access to school health programs; access to contraceptive services and products; reduce violence, specifically domestic violence; and reduce incidence of relevant communicable diseases, like Chagas and Tuberculosis, among others.
Proposing new targets for 2015
Reducing obesity among childhood – The second target of the first MDG (Malnutrition) would likely be achieved by most countries of the region with the exception of Central American countries, where nutritional status actually deteriorated during the 90´s. Making sure that this negative trend is reverse and the goal is achieved by all countries constitutes a priority for national and international action. But there is an emerging nutritional threat looming in the LAC horizon: the increasing proportion of obesity among all age groups starting with children under five years of age.
The proportion of obese young children, measured as weight for height, in LAC is 4.4%, compared with 3.3% as an average in all developing countries. Within LAC there are differences by sub-region: the proportion of obese children is lower in Central America, larger in the Caribbean and the largest in the Southern cone countries where it reaches almost 5%. It is suggested that the LAC countries considered children obesity as a development priority and, using the Body Mass Index (BMI) as an indicator, target the reduction of the proportion of overweight children by the year 2015.
Access to school heath programs – Universal coverage of primary education by LAC countries opens up a practical (school based) setting to improve health promotion and disease prevention, through health education aimed at school-age children. These programs have huge impact to guarantee good nutritional standards, control of communicable diseases in childhood, access to immunization and basic orientation about healthy behavior among children, teenagers and even families.
Many LAC schools are developing these types of programs, although there is little systematized information about this trend. Accessing this information through the Ministries of Education and Health it would be feasible to establish a base-line for 2006 and a target for the year 2015. The indicator could be the percentage of schools (or students) that have implemented health promotion programs. This could be a new target associated with MDG 2 of universal completion of primary education.
Access to contraceptive services and products for women of reproductive age – The improvement of maternal health, in particular the reduction of maternal mortality is the most challenging health-related MDG in LAC. There has been limited or no progress in this indicator from 1990 to the present. On the contrary in some countries of the region Maternal Mortality is increasing.
The indicator selected to reflect improvements in maternal health is the proportion of deliveries births attended by skilled personnel. This indicator covers only the curative response to the problem. Lower maternal mortality in LAC has resulted from timely access to contraceptive services and supplies, showing the importance of this intervention for improving maternal health. The rate of contraceptive use, among women in reproductive age in stable unions, is under 40% in countries like Haiti, Peru, Guatemala and Guiana. The effective access to contraceptive services is not only important for maternal health per se, but also contributes to gender equity and women empowerment.
Thus, improving access to contraceptive benefits could be established as a target in relation to two MDGs: 3 (gender) and 5 (maternal health). The Demographic and Health Surveys, undertaken regularly in many countries of the region, or general-purpose household surveys, can provide the information required to monitor this variable in the coming years in LAC.
Domestic violence – In countries like Guatemala and Peru in 2000, household surveys showed domestic violence to be suffered by over 41% of women in stable unions. Violence is not only widespread; it is also a serious development challenge in LAC for two reasons: it increases the costs of social programs and it detracts from productivity and investment. Domestic violence is a particular challenge because of its negative effects upon women and children.
Thus in LAC, an indicator of domestic violence would be an important contribution to ensuring better health status and gender equity. Given its relevance, household surveys done in the region are figuring out ways to improve measurement and avoid under-reporting of domestic violence. The improvement of the data on domestic violence could be one of the targets associated with MDG 5.
Reducing the incidence of Tuberculosis and Chagas– In LAC these two diseases cause a burden that is five to ten times larger than that of Malaria. Public health programs aimed at preventing and controlling Tuberculosis and Chagas in LAC are worsening in many LAC countries. The inclusion of specific targets related with these two diseases is a good way to improve the response of the national epidemiological surveillance systems and to improve the health status of millions in the next decade in LAC.
Reducing Violence - With 10 DALY lost per 1000 people per year LAC presents the highest violence rates of the developing world (3 per thousand). Most episodes of violence are associated with organized crime and drug dealing – problems that are present in many countries in the Region. The fight against violence constitutes one of the bigger challenges to promote a stable economic and social environment and to develop an adequate institutional setting to achieve all MDG. A specific target associated with reducing violence could be established under the umbrella of the MDG 8. The reduction of the number of homicides could be the proxy indicator associated with this target.
Final Remarks
The discussion about indicators and policies to promote appropriated health targets to LAC countries cannot be missed. The Inter-agency expert group, coordinated by the UNDP, will meet at the end of October in Rome, and the inclusion of new indicators will be discussed there. If your planned proposal targets this; we would be able to provide more information later at the end of September, since we are in the process of convening an expert review group that will look at the suggested indicators more in detail.
Other related references about MDG could be find in:
http://idbdocs.iadb.org/wsdocs/getdocument.aspx?docnum=591088 and http://www.iadb.org/sds/publication/publication_3594_e.htm
[1] Alfredo Solari is an independent consultant in health and nutrition and former Ministry of Health of Uruguay.
