We begin the year 2015 with a warning to our readers regarding the need to examine carefully the policies currently in play in global health. This year is crucial for criticism, renovation or alteration of the "Millennium development goals" (MDG) adopted by the United Nations in 2000. At the time, it was thought that 2015 would be the deadline to meet eight goals (three of which were directly related to health: reducing child mortality, significantly improving maternal health and radically combatting HIV/AIDS, malaria and other diseases). The Declaration was translated into a roadmap setting out time-bound and measurable goals to be reached by 2015. Undoubtedly, progress has been made in reducing child and maternal mortality, increasing the treatment of people affected by TB and HIV/AIDS and protecting people living in malaria-infested areas. However, as is abundantly clear to the majority of specialists, the fulfillment of the goals of the MDG has been uneven and generally speaking most countries will not meet them.
Although it is unclear how the process of renewal of the MDG will be negotiated, or what the new priorities might be, it would seem that protecting the environment, defending human rights and combatting what are considered "non-priority" diseases (such as cancers caused by tobacco consumption) will feature in any future reformulation. However, there is a danger of reverting to a recurrent pattern in the history of international public health, namely changing the goal when difficulties are encountered. An example of this pattern was the goal of "Health for all by the year 2000," which was proposed at the Primary Health Care Conference of 1978. Another example was the "3 X 5" initiative, with the goal of treating 3 million people infected with HIV/AIDS with antiretroviral drugs by 2005, launched a few years ago by the World Health Organization (WHO). As the year 2000 drew near in the first case, and 2005 in the second, many international health managers evaded discussing the problems that might explain why the proposed objectives were not being attained on schedule. Indeed, the topic was then changed. For example, proponents of primary care said that what was really important was "Health for all" and in the case of the "3 X 5" initiative, the advance in free access to antiretrovirals was highlighted. It is true that in both cases the idea of universal health care for individuals made some headway. However, it is also true that opportunities to analyze the pending obstacles carefully were missed. In the case of the MDG, we can end the year celebrating the achievements reached in reducing poverty and improving the health of the population to a certain extent.
For this reason, it is necessary to consider some lessons from the experience of the MDG. For example, the MDG gave excessive emphasis to obtaining good indicators on national averages, masking internal inequalities affecting the poorest, the most vulnerable and the marginalized population groups. Inequality was especially acute in Latin America where there are urban neighborhoods in which some residents seem to have a standard of living level on a par with that of an industrialized city. However, the living conditions of some social groups and disadvantaged regions were not very different from the poor areas of a country in Sub-Saharan Africa. Despite the social variations, national averages were good and close to the "Millennium development goals".
The second point is that the MDG were defined by private donors and bilateral agencies, with some involvement of multilateral agencies and little participation of low- and middle-income countries. An anecdote that illustrates this process is the day I visited the WHO headquarters in Geneva a few years after the goals were approved. I was impressed by the colorful posters on nearly all the walls and the sophisticated vocabulary about them pronounced by officials of the agency. Shortly thereafter, I visited the Peruvian Ministry of Health where a manager explained routine immunization programs and basic sanitation. I naively asked him, "and how is Peru faring with the Millennium Development Goals?" He looked at me silently and slightly bewildered as he clearly knew nothing of the matter. Fortunately, a young assistant who was with our group interrupted the conversation to say ironically: "Those are on the fourth floor." Somewhat incredulous, I arrived on the fourth floor where the office of international relations of the ministry was located and found a small replica of the WHO headquarters: the same posters, slightly faded, and officials who reiterated the same memorized words and definitions I had heard in Geneva that sounded decidedly hollow. Leaving the ministry, I had the feeling of having visited two different ministries, or that there was a ministry within the ministry where one party did not know what the other party was doing. In fact, the MDG failed to permeate the policies of the Ministry of Health, much less Peruvian government policies, as one would have expected. Maybe it is utopian, albeit important, to aspire to an inclusive process in developing or reworking the new goals that will give them greater flexibility, sustainability, local participation and empowerment. Also, we have the right to imagine that an inclusive process will cause the collapse of the schizophrenic policy of governments in poor and medium-income nations, which have introduced structural economic adjustment measures in recent decades that increased poverty and, at the same time, have approved health policies to alleviate poverty.
Although there are still many issues to be resolved, such as the financial mechanisms for implementing reformulated development policies, it would seem that two visions will compete to define the directions of global health in 2015. First, a holistic agenda partly inspired by the reports of the Commission on Social Determinants of Health that include the eradication of extreme poverty and the universality of not only curative but also preventive and rehabilitative quality health services. The other technocratic view seems inclined to propose specific goals as a restricted version of universal health coverage.
In this issue of the journal, several vital topics for debate in contemporary global health are addressed such as bioethics, the potential of South-South cooperation to redefine the international health agenda and overcome the fragmentation of national and international health agencies and the interface between international, national and local dimensions in the history of Latin American and global health.
This issue would not have been possible without the valuable cooperation and support of the Pan American Health Organization. The important role that this organization plays on issues addressed here is reflected in some of the studies we have published. We trust that reading the articles in this issue will help us all to comprehend and tackle the challenges we face and will continue to face in 2015 and in the years to come.
Marcos Cueto
Publication Dates
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Publication in this collection
Jan-Mar 2015
