The South East Asia Region (SEAR) has recorded many improvements over the past three decades in its health systems and yet, it is struggling to achieve important health outcomes, especially among the poor, vulnerable and hard-to-reach groups. Therefore, while addressing global commitments made under the Millennium Development Goals (MDGs) are crucial, equally strategic is addressing these goals with “Equity” in the centre-stage. Equity in accessibility, affordability and quality of services to the most vulnerable, hard-to-reach and desperate population groups will be a key to the region's success on health.
Left with only five years to achieve the MDGs in 2015, it is time to review the progress made and identify the challenges and the lessons learnt, particularly relating to communicable diseases in the SEA Region.
On reflection, of the eight MDGs established in September 2000 by 189 heads of state, three relate directly to health. These include reducing child mortality by two-third (MDG 4), reducing maternal mortality by three-quarters (MDG 5) and halting and reversing the spread of HIV, malaria and other major diseases such as TB (MDG 6). The MDGs are, however, interdependent since other goals have an indirect influence on health.
Progress on health-related MDGs
Overall, fair progress has been made in the region towards achieving the MDGs, but the progress remains unequal and challenging. In relation to MDG 6, HIV/AIDS prevalence among young adults (15-24 years) has been on the decline in various countries (Fig.1), with an overall prevalence in the region of 0.3 per cent. The coverage of prevention intervention has increased, while the coverage of antiretroviral treatment (ART) is, unfortunately, low and must be scaled up in order to achieve universal coverage.
In TB, a treatment success rate of 88 per cent has been achieved in the region (Fig. 2). The incidence of TB and infection rates has declined in many countries. It is estimated that TB prevalence has been halved and mortality reduced by a third, putting us back on track on achieving the TB-related MDG.
However, the progress on reducing malaria mortality is insufficient and the mortality rate for 100,000 population remains at 2.1. There has been some progress in bed-net distribution but not enough to make a difference. Overall progress in malaria control in the region is far behind the exemplary progress being made in Africa.
With regard to MDG 4, the under-five mortality rate (deaths per 1,000 live births) is estimated at 63, as compared to 14 in Europe. More than 2.4 million children and adults die in the region of acute diarrhoea and respiratory infections despite simple, effective and low-cost interventions being available. Priority must be accorded to scaling up prevention and control interventions using an inter-sectoral and coordinated approach, going beyond mere case management.
Tragically, the region is performing poorly on MDG 5 — reducing maternal mortality — with deaths per 100,000 live births remaining as high as 450. In South East Asia and Africa, less than 50 per cent of women receive skilled care during childbirth and the region contributes more than 170,000 maternal deaths each year. The inequities in terms of wealth and mothers' education are unacceptably high. Contraceptive prevalence is also increasing rather slowly.
In light of the above facts, it is clear that we are on track on achieving the MDGs relating to communicable diseases. However, rapid reduction in maternal and child mortality is of utmost priority. Strengthening the health system, including use of the Global Fund and GAVI (Global Alliance for Vaccines and Immunisation) resources will be critical to achieving all health-related MDGs. In this regard, the following issues are relevant:
1. Focusing on “delivery” of effective interventions and, to do so, ensuring the appropriate ratio of healthcare workers to population.
2. Improving monitoring and evaluation systems including the health information system and use of data for planning national policies and strategies.
3. Identifying social, behavioural, cultural and economic determinants of health and addressing these.
4. Optimising resources and services and delivering a comprehensive package of effective health interventions, targeted at populations at risk, through an integrated approach.
MDGs are indeed a powerful advocacy tool in the fight against diseases and in rendering equity and social protection. As a priority, data generated on MDGs should be used for fine-tuning national policy and strategy. Miles have been covered, yet a long road still lies ahead should civil society and leaders be keen on achieving the MDGs. The un-finished agenda under various health issues, especially communicable diseases, surely warrant investment in quality services, perhaps more so in scaling up best-practice models in various countries in the SEA Region.
As many studies have demonstrated, some immediate strategic investments are required such as: evidence-based advocacy with key policy makers, elected leaders and civil society; strengthening institutional capacities of bodies that are best poised to plan and deliver; enhancing technical and managerial skills of providers in delivering quality health services; translating field-based scientific research into policy and programmes; ensuring equitable accessibility, affordability and quality of drugs and services to the most vulnerable and hard-to-reach population groups and; fostering Public-Private partnerships including use of civil society resources thereby ensuring that the existing resource-gap is bridged.
Finally, we have to agree that ensuring investment in the health of the socially vulnerable — in particular, women and children — is not only good but also the right thing to do.
(The author is Senior Director, Department of Communicable Diseases, World Health Organisation, Regional Office for South East Asia.)