Equity in Health

In 2000, world leaders agreed on the Millennium Development Goals (MDGs). MDG 4 called for a two-thirds reduction in the under-5 mortality rate between 1990 and 2015. The authors aimed to estimate levels and trends in under-5 mortality for 195 countries from 1990 to 2015 to assess MDG 4 achievement and then intended to project how various post-2015 targets and observed rates of change will affect the burden of under-5 deaths from 2016 to 2030. To provide insights into the global and regional burden of under-5 deaths associated with post-2015 targets, the authors constructed five scenario-based projections for under-5 mortality from 2016 to 2030 and estimated national, regional, and global under-5 mortality rates up to 2030 for each scenario. The global under-5 mortality rate has fallen from 90·6 deaths per 1000 livebirths (90% uncertainty interval 89·3–92·2) in 1990 to 42·5 (40·9–45·6) in 2015. The global under-5 mortality rate reduced by 53% (50–55%) in the past 25 years and therefore missed the MDG 4 target. Based on point estimates, two regions—east Asia and the Pacific, and Latin America and the Caribbean—achieved the MDG 4 target. 62 countries achieved the MDG 4 target, of which 24 were low-income and lower-middle income countries. Between 2016 and 2030, 94·4 million children are projected to die before the age of 5 years if the 2015 mortality rate remains constant in each country, and 68·8 million would die if each country continues to reduce its mortality rate at the pace estimated from 2000 to 2015. If all countries achieve the Sustainable Development Goal of an under-5 mortality rate of 25 or fewer deaths per 1000 livebirths by 2030, the authors project 56·0 million deaths by 2030. About two-thirds of all sub-Saharan African countries need to accelerate progress to achieve this target. Despite substantial progress in reducing child mortality, concerted efforts remain necessary to avoid preventable under-5 deaths in the coming years and to accelerate progress in improving child survival further. Urgent actions are needed most in the regions and countries with high under-5 mortality rates, particularly those in sub-Saharan Africa and south Asia.

Despite successes in global health to combat specific diseases, progress remains slow particularly in sub-Saharan Africa. In this paper, researchers discuss two challenges in the global health landscape currently: the changes in global health governance and the recurrent pendulum swing between horizontal (health systems focused) to vertical (single-disease focused) programming by external funders and agencies. Using Ethiopia as a case study, their analysis highlights leadership actions that promoted both vertical and horizontal objectives. These included: clarity and country ownership of purpose, authentic engagement with diverse partners, appropriately focused objectives, and the leveraging of management to mediate policy decisions and front-line action. The authors conclude that effective leadership in global health can reconcile vertical and horizontal objectives.

Over the past year, at a range of international conferences, including the Conference on Social Determinants in Rio and COP-17 in Durban, there have been side events introducing work on the link that exists between health and climate change. In the run-up to Rio+20 climate conference in June 2012, the need for a sustainable approach to global health will become even more important, the author of this article argues. It will require a shift in focus away from disease-specific thinking to an approach that more fully considers climate change and environmental degradation as important determinants of health. The author argues that the Istanbul Declaration, which calls on the world community to take bold action jointly against global social inequities and environmental deterioration, is a useful tool to achieve this end. It points to the need to integrate equity within the links made across health, economy and environment, reinforcing similar issues raised at the World Conference on the Social Determinants of Health, held in October 2011.

The Millennium Development Goals have centred on social outcomes, primarily in the fields of poverty, health and education. The goal of halving extreme poverty globally has already been met, albeit in large part thanks to the remarkable performance over three decades of the Chinese economy. Greater ambition is expected for a post-2015 agenda, with the eradication of extreme poverty a possible new goal. However, this goal is very unlikely to be reached by 2030 if business as usual is the order of the day. Paradoxically, this partly reflects the lack of ambition in the conventional poverty line of $1.25 per day, which is by any standard extremely low. However UNCTAD also argue that it is also because poverty eradication, even at this level of ambition, will not happen without addressing the more challenging issue of global inequality.UNCTAD argue that there is an emerging consensus that existing levels of inequality are not only morally unacceptable, but also economically and politically damaging. Moving beyond the Millennium Development Goals, inequality should therefore become a prominent part of the post-2015 development narrative.