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In a small hospital ward in Port-au-Prince, the Haitian capital, Guerline sits propped up in bed, gently squeezing milk from a syringe one drop at a time into the mouth of her tiny son Marc. He is held tightly against her chest for many hours each day by a fabric pouch, with a woollen hat on his head.
This is “kangaroo care”, developed in Latin America and now implemented in a growing number of lower-income countries as a simple, cheap and highly effective way to increase the survival of prematurely born children.
It requires no incubators, sophisticated equipment or electricity. Instead each infant is kept upright and warm using the mother’s own body. Her breathing and beating heart stimulate the child, while the proximity reinforces physical and emotional bonds that substantially raise the chances of survival.
The approach is one of a number of powerful techniques developed, funded and implemented in recent years that have helped to bring about a significant reduction in infant mortality, one of the millennium development goals (MDGs) that has shown considerable progress since the turn of the century, though the full target has still not been met.
Since 1990, the global mortality rate of children under five has more than halved: from an estimated 90 down to 43 deaths per 1,000 live births. “There aren’t that many success stories out there, so as a global collective action the success of the MDGs for health is a remarkable tale,” says Chris Murray, director of the Institute of Health Metrics and Evaluation at the University of Washington.
The three MDGs unveiled in 2001 explicitly focused on health — to reduce infant mortality, maternal mortality, and infectious disease — have seen undoubted progress. More open to question is how far the goals were the cause of advances that would have occurred anyway, and whether further improvements will be diluted or slowed with the far broader objectives of the new Sustainable Development Goals (SDGs).
For health, one of the most significant reasons for progress in recent years has been funding. Global health budgets by donors nearly tripled from $11bn in 2000 to $30bn a year in 2013.
This rise was driven by the establishment of multilateral bodies led by Gavi the Vaccine Alliance and the Global Fund to Fight Aids, Tuberculosis and Malaria, and by bilateral support — including from the specific US entities the President’s Emergency Plan for Aids Relief and President’s Malaria Initiative — as well as greater support from the UK’s Department for International Development.
Domestic support, including from a rising middle class, has also strengthened substantially in some countries, notably in India and China. Economic growth and development, combined with investments in the health system, have contributed more to tackle traditional reasons for premature death than any external support, targets or initiatives.
Globally, technological progress has helped, such as the advent of new vaccines, and combination drug treatments for malaria, tuberculosis and HIV. So, too, has better understanding of the application of existing “tools”: the combined use of bed nets, mosquito insecticide spraying, and widespread drug treatment have reduced the estimated death rates from malaria by nearly 60 per cent since 2000, for instance.
But much remains to be done. On their own terms, the MDG’s ambitious targets in health were not met — although infant mortality has more than halved, the goal was a two-thirds reduction, which the UN’s own final evaluation estimates will take another 10 years beyond 2015 on the current trajectory.
Furthermore, in the past two years, global funding for development has stalled and the momentum of some programmes — such as measles immunisation — has slowed.
For programmes focused less on delivering “commodities” such as drugs and more on complex behavioural interventions such as HIV prevention, progress has been slower still. Social attitudes remain important obstacles to introducing such fundamental and low-cost approaches as supplying contraception, notably in sub-Saharan Africa.
The new SDGs introduce some valuable aspects required for improved health, from a fresh emphasis on non-communicable diseases and the need for broader health systems, processes and coverage levels, to the wider aspects of clean water and air, and poverty alleviation.
But many fear they will also dilute the concentration of effort that has helped to bring about recent advances. Seth Berkley, head of Gavi, says: “The job is not yet done. While we’ve made huge strides . . . there is still a lot to do and we need to maintain our focus and momentum. I do worry that with the broadening of the goals, we risk losing our focus on the most critical human development issues.”
Haiti itself is a sobering reminder of the challenges ahead. More than five years after a devastating earthquake, which triggered substantial international aid and support, the poorest country in the Americas remains on a drip-feed of assistance.
Most people struggle to gain high-quality affordable care, and the emergency charity Médecins sans Frontieres continues to operate some of the most important clinics rather than the government.
It is a reminder that the benefits of progress to health remain unevenly spread, with the poorest and those in the most fragile states still unable to benefit from simple, cheap and powerful interventions that have long available elsewhere in the world.