World Health Organization : The mandate of a specialized agency of the United Nations

PART II : What is WHO's mandate?

Chapter 2

WHO ON THE TRACK OF UNITED NATIONS' GOALS : THE MILLENNIUM DEVELOPMENT GOALS

As a specialised agency of the United Nations, the World Health Organization follows the aims and purposes of the 'mother' Organization. An aspect of the WHO's mandate is, therefore, inevitably determined by the linkage with the UN. In order to deal with this topic, the present chapter will identify the feature of WHO's mandate that is strictly linked to its nature as a specialised agency of the UN: its role in the international development agenda.

With this purpose, I will first describe the recent evolution and renewal of the UN's mandate in the new era; secondly, I will deal with one of the highest goals of process in the development field , which emerges in the Millennium Development Goals (MDGs); finally, after determining the reason why the WHO should be involved in the development area, I will face the central issue of the role that the WHO plays in the achievement of the MDGs. Following these steps, I will be able to start to adequately respond to the main question of this dissertation: what is WHO's mandate?

2.1. A new millennium for the United Nations

The end of the twentieth century and the beginning of the twenty-first century represented the "turn of an era"[1] for the United Nations, as well as for many other actors, and it constituted itself the reason and opportunity for a change. As the General Assembly suggests, "the year 2000 constitutes a unique and symbolically compelling moment to articulate and affirm an animating vision of the UN"[2]. The UN reform process started in 1997[3], led by the new Secretary-General, Kofi Annan. He took up his duties as seventh Secretary-General on 2 January 1997, and he started a process of wide-ranging reforms, aimed at closing the gap between expectation and performance of the UN system[4].

In 1997, in paragraph 91 of his report entitled 'Renewing the United Nations: a programme for reform', the Secretary-General proposed that "the opportunity provided by the advent of the new century and the millennium be used to designate the session of the General Assembly to be held in the year 2000 a 'Millennium Assembly', with a summit segment devoted to a review of the role of the United Nations vis-à-vis the prospects and challenges of the future. The high-level segment of the Millennium Assembly could be called the 'Millennium Summit'"[5]. In addition, a Millennium Forum for nongovernmental organisations and other actors of the civil society, as well as a Special Commission to analyse the relations among the UN system components, should be convened. The Assembly should be seen as the focal point for all the millennium-related events, whereas the Summit should be a mean for encouraging the attendance of heads of State and Government. In the end, the deliberations of the Summit would provide the guidance required by the UN system as a whole in order to enter the new millennium. It will be requested to answer to a fundamental question: what kind of UN do member states desire in a world that is radically different from fifty-five years ago?

The General Assembly decided, by resolution 53/202 of 17 December 1998, to "designate the fifty-fifth session of the General Assembly 'the Millennium Assembly of the United Nations' and to convene, as an integral part of the Millennium Assembly, a 'Millennium Summit' of the United Nations"[6].

As a consequence, the Millennium Assembly[7] opened at the headquarters of the UN in New York on 5 September 2000, and the Millennium Summit[8] was convened from 6 to 8 September 2000.

At the end of the Millennium Summit, 147 heads of State and Government – and 191 nations in total – adopted the 'United Nations Millennium Declaration'[9] contained in General Assembly resolution 55/2. This historic achievement contains a statement of values, principles and objectives for the international agenda for the twenty-first century. In particular, it refers to peace, security and disarmament (section II), development and poverty eradication (section III), protection of the environment (section IV), human rights, democracy and good governance (section V), protection of the vulnerable (section VI), meeting the special needs for Africa (section VII), and strengthening the UN (section VIII). With this document, heads of State and Government reaffirm their "faith in the Organization and its Charter as indispensable foundations of a more peaceful, prosperous and just world"[10].

With resolution 55/162[11], the General Assembly asked the Secretary-General to prepare a framework for the implementation of the commitments embodied by the United Nations Millennium Declaration. The Secretary-General presented a 'Road Map towards the implementation of the United Nations Millennium Declaration'[12], which sets out principles and strategies for being responsive to the established aims, both at national and international level.

With the purpose of this contribution, we will not analyse the eight sections of the Declaration, but we will focus only on the third one entitled 'Development and poverty eradication: the millennium development goals'. The reason of this choice is that, because of the inextricable link between health and economic development which will be subsequently traced, the WHO takes up a fundamental role in the development field and, in particular, in the achievement of the Millennium Development Goals (MDGs).

2.2. The Millennium Development Goals

In the third section of the 'United Nations Millennium Declaration', the heads of State and Government commit themselves "to making the right to development a reality for everyone and to freeing the entire human race from want"[13]. Paragraphs 19 and 20 of the document are a list of goals whose achievement has been declared fundamental in the international development agenda for the next fifteen years. They have been identified as the Millennium Development Goals (MDGs).

The MDGs represent a partnership between developed and developing countries determined "to create an environment – at the national and global levels alike – which is conducive to development and to the elimination of poverty"[14].

This paragraph will touch three points in order to define the boundaries of the development context within which WHO acts: firstly, a short mention about the history of the MDGs, with particular reference to the International Development Goals (IDGs); secondly, a general description of each MDG; and finally, a report on the strategy adopted by the UN system as a whole for their implementation.

2.2.1. The International Development Goals (IDGs)

Before giving an analytical description of each one of the goals, we want to recall briefly that the MDGs are not the first attempt to set a number of targets in the development field.

In 1995, development ministers from the member countries of the OECD Development Assistance Committee (DAC) decided to work on a one-year review of past experiences and planning policies into the next century. The result of the review was a report called 'Shaping the 21st Century: the contribution of development co-operation'[15], published in May 1996. The authors expressed their vision for development progress into the next century. They formulated a "broad strategic framework aimed at realizing seven goals drawn from the resolutions of international conferences and summit meetings"[16]: the International Development Goals (IDGs)[17].

Coming from the agreements and resolutions of the world conferences organised by the UN in the first half of the 1990s, starting with the World Summit for Children in 1990, the IDGs have guided the international development agenda. These conferences constituted the means for the international community to agree on steps needed to reduce poverty and achieve sustainable development.

After the seven IDGs were determined, expert groups, sponsored by the OECD, United Nations, World Bank, NGOs, UN funds and programmes, met to establish a set of targets and indicators for each goals. In particular, being the IDGs measurable, they became extremely useful for identifying "where progress is exceeding expectations or falling behind"[18], and they represented a "unique opportunity for coordinating efforts and aligning forces of a diverse range of development partners to maximize the impact on poverty reduction"[19].

The seven goals, each addressing an aspect of poverty[20], were:

• Halving the proportion of those in extreme poverty between 1990 and 2015;
• Enrol all children in primary school by 2015;
• Make progress towards gender equality and empowering women by eliminating gender disparities in primary and secondary education by 2005;
• Reduce infant and child mortality rates by two-third between 1990 and 2015;
• Reduce maternal mortality ratios by three-quarters between 1990 and 2015;
• Provide access for all who need reproductive health services by 2015;
• Implement national strategies for sustainable development by 2005 so as to reverse the loss of environment resources by 2015.

The Millennium Declaration incorporated most of the IDGs, so that it is correct to say that the MDGs are built on the IDGs. Consequently, consultations were held among members of the United Nations Secretariat and representatives of the IMF, OECD and the WB, in order "to harmonise reporting on the development goals in the Millennium Declaration and the international development goals"[21]. Although this connection is undeniable, some changes can be still individuated[22].

2.2.2. Definition and description of the Millennium Development Goals (MDGs)

The Millennium Development Goals refer to the list of commitments stated in the III section of the 'United Nations Millennium Declaration', 'Development and poverty eradication'. The multiple and various commitments have been formulated in a list of 8 goals, 18 targets and 48 indicators. They represent some of the priority areas that must be addressed to eliminate poverty and promote development.

The reason for giving such an order is "to help focus national and international priority-setting"[23]. With this purpose, the Secretary-General advise that "goals and targets should be limited in number, be stable and over time and communicate clearly to a broad audience. Clear and stable numerical targets can help to trigger action and promote new alliances for development"[24]. Goals, targets and indicators can be described as follows[25].

Goal 1: Eradicate extreme poverty and hunger

The first of the MDGs is to halve, by the year 2015, the proportion of people living in extreme poverty, whose income is less than US$1 per day, and to halve the proportion of people who suffer from hunger. Income and hunger are taken as measures of poverty.

As far as it concerns income (Figure 2), since 1990, the number of people living on US$1 per day has declined from 1.3 billion to 1.2 billion. However, the decline has not been even for all the countries[26].

Source: Report of the Secretary-general on implementation of the Millennium Declaration. Data Based on World Bank estimates.
*$ 1 a day is expressed in Purchasing Power Parity (PPP).

Considering the graph above, on one side, the fastest growing region was East Asia and the Pacific, where GDP per capita increased by two-thirds, increasing more than 6% annually, and poverty declined from 27.6% to 14.2%. On the other side, sub-Saharan Africa is characterised by the highest proportion of people living in extreme poverty and approximately the 50% of the population lives on less than US$1 per day[27]. The aim is to make this change feasible for all the countries.

With respect to hunger (Figure 3), between 1990-1992 and 1996-1998, the number of malnourished people fell by 40 million in the developing world. However, the developing world still has some 826 million people who are not getting enough food to lead normal, healthy and active life[28].

Figure 3: Prevalence of underweight children in selected regions

As for income, the development changes according to the regions. Regions as Latin America and South Asia, East Asia and the Pacific are on the track to meet this goal by 2015 at current rates. I consider the percentage of underweight children as an index to measure the level of hunger. In East Asia, 19% of under-five were underweight in 1990 and 10% in 2000; in South Asia, 38% in 1990 and 28% in 2000 and in Latin America, 11% in 1990 and 8% in 2000; whereas, in regions as Eastern Europe and Central Asia, Middle East and North Africa, the proportion of the population which was undernourished increased in the 1990s.

Goal 2: Achieve universal primary education

The second of the MDGs is to ensure that, by the year 2015, children everywhere, boys and girls alike, will be able to complete full course of primary schooling and that girls and boys will have equal access to all levels of education (Figure 4).

Figure 4: Percentage of children enrolled in primary school

Source: Report of the Secretary-General on implementation of the Millennium Declaration. Data based on UNESCO estimates. Northern Africa, Latin America, the Caribbean, Eastern Asia, Central Asia and the Pacific.

The progress towards this goal is usually measured by the net enrolment rate, which measures the ratio of enrolled children of official school age to the number of children of the same age in the population[29].

Progress towards universal primary enrolment was not achieved during the 1990s. During this period, only about a fifth of the progress needed was reached. In 1998, still the 97% of 113 million school-age not enrolled children, lived in developing countries[30]. In fact, the average net enrolment ratio for primary education increased only from 78 in 1990 to 83 in 2000[31]. Furthermore, it should be added to these facts that, in developing countries, one child in three does not complete five years of schooling and the quality of education remains low for many[32]. Therefore, in order to achieve the goal by 2015, progress will need to be accelerated two-fold in many regions. At the current rate, the global education target will not be reached until the year 2030[33].

Goal 3: Promote gender quality and empower women

The third of the MDGs calls for gender equality and the empowerment of women, with a target of equal enrolment of boys and girls in primary and secondary education, preferably by 2005, and in all stages of education by 2015 (Figure 5).

Figure 5: Gender disparity in school enrolment

Source: Report of the Secretary General on implementation of the Millennium Declaration. Data based on UNESCO estimates.

It is important to recall that "women are still the poorest of the world's poor, representing two-thirds of those living under a dollar a day […] the relationship between being female and being poor is stark"[34]. The number of women living in absolute poverty has increased of 50%, as opposed of 30% for men[35].

One of the means to try to reduce this level of inequality is to guarantee to females the access to education, and consequently to reduce disparities in enrolment between girls and boys[36]. In general, girls' enrolments are lowest in the regions with the lowest net enrolments, as sub-Saharan Africa and South Asia.

Nevertheless, there has been remarkable progress over the past decade in many countries where girls' enrolments have risen faster than boys'. In developing countries, the number of girls per 100 boys enrolled in primary school increased from 83 in 1990 to 87 in 2000[37]. In countries as Algeria, Angola, China, Bangladesh, Egypt, India and Gambia, gender differences at the primary level have been eliminated or greatly reduced[38].

Still, in order to achieve the goal by 2015, the process has to be accelerated four-fold. Otherwise, at the current rate, the goal will not be met until the year 2025[39].

Goal 4: Reduce child mortality

The fourth of the MDGs calls for reducing by two-thirds, between 1990 and 2015 the under-five mortality rate (Figure 6).

Figure 6: Under-five mortality rates

Source: Report of the Secretary-General on implementation of the Millennium Declaration.

Data based on estimates of the WHO and UNICEF.

Although this goal appears highly ambitious, there has been progress towards its achievement during the 1990s. All regions, except sub-Saharan Africa, reduced under-five mortality rates. The rates are declining: under five-mortality decreased from 103 to 91 per 1,000 live births between 1990 and 2000. 31 low and middle-income economies reduced their under-five mortality rates fast enough to achieve the goal of a two-third reduction by 2015[40].

However, 11 million children under-five still die annually in developing countries, mostly from preventable diseases[41], such as pneumonia, diarrhoea, measles, malaria, HIV/AIDS. Almost half of the under-five deaths occur in sub-Saharan Africa.

To achieve the goal by 2015, it is necessary a sudden and dramatic improvement in the reduction of child mortality. Meeting the global target will require that the rate of reduction increases more than five-fold between 2000 and 2015[42].

Goal 5: Improve maternal health

The fifth of the MDGs calls for reducing maternal mortality ratios by three-quarters of their 1990 level by 2015 (Figure 7).

Figure 7: Estimates of maternal mortality ratios

Source: Report of the Secretary-General on implementation of the Millennium Declaration Data based on estimates of WHO and UNICEF

Estimates of maternal mortality indicate that about 515,000 women die each year of pregnancy related causes, 99% of them in developing countries[43]. It is frightening to compare the average maternal mortality ratio in rich and poor countries: respectively 21 deaths per 100,000 live births and 1,100 deaths for 100,000 live births[44].

Although a decline in maternal mortality has been registered in some countries, there are no reliable data in those countries where the problem is more acute. To measure maternal mortality results difficult, because deaths as a result of pregnancy or child birth may not be registered in general purpose surveys or those with small sample sizes. This is more likely to happen in countries which lack good administrative statistics or where many births are taking place outside of the formal health system[45].

An improvement in maternal mortality seems to be strictly linked to an improvement in health care systems. In order to reach the goal, it is necessary to provide assistance to expectant mothers and to adolescent girls who often do not have the power to make decisions for themselves. For this reason, it is important to increase the number of skilled attendants, who also provide to mothers information about prenatal and postnatal care for themselves and their children[46].

Goal 6: Combat HIV/AIDS, malaria and other diseases

The sixth of the MDGs calls for halving and beginning to reverse the spread of HIV/AIDS, the scourge of malaria and other major diseases that afflict humanity, by 2015.

Approximately 3,000,000 people died of HIV/AIDS in 2000 alone, and some 36,000,000 people are currently living with HIV/AIDS[47] (Figure 8).

The average age of people infected with HIV/AIDS is 15-24 years old. For example, in the late 1990s, surveys in sub-Saharan African countries found that half the teenagers do not know that a healthy looking person can be HIV-positive. Moreover, over 80% of young people, in Albania, Azerbaijan, Chad, Niger, Somalia, Tajikistan and Uzbekistan, do not know that HIV/AIDS cannot be transmitted by mosquitoes[48].

HIV/AIDS prevalence rates are still increasing for men and women in the developing world. The rate is seven times higher in developing countries than developed countries for women, and almost three times higher for men[49]. Certain studies in Africa show that teenage girls are five to six times more likely to be infects by the HIV virus than boys their age[50].

Figure 8: Percentage of young people living with HIV/AIDS (1999)

Source: Report of the Secretary-General on implementation of the Millennium Declaration.

Data based on Report on the Global HIV/AIDS epidemic 2002 UNAIDS

8,000,000 people develop active tuberculosis and nearly 2,000,000 die annually. Multi-drug resistance tuberculosis and the combination with HIV/AIDS bring further decline. Over 90% of the cases are in developing countries[51].

1,000,000 people die from malaria, and the number has been increasing over the past two decades[52].

No improvement seems to have been made towards the achievement of this goal. It does not even seems to be achievable if heads of States and Government do not entirely commit themselves to tackle these diseases.

Goal 7: Ensure environmental sustainability

The seventh of the MDGs has three different targets. The first one calls for the integration of principles of sustainable development. The second adopts a version of the World Water Forum goal of providing access to a sustainable water source by 2025 to all people. The third one focuses on achieving a significant improvement in the lives of at least 100 million slum dwellers, by 2020.

About 80% of the people in the developing world now have access to improved water sources (Table 1). In fact, coverage of improved drinking water sources rose from 71 % in 1990 to 78% in 2000[53]. However, approximately 1 billion people are still denied access to clean water supplies and 2.4 billion people lack access to basic sanitation[54].

The fastest progress was made in South Asia, whereas little or no progress was made in developing countries, in particular in rural areas. For example, in sub-Saharan Africa, only 45% of the rural population have access to safe water against 83% for the urban counterparts[55].

Table 1: Access to improved water source

Source: WHO[56]

As far as it concerns the last target, the increase of the urban population, above all in developing countries, will carry with itself an increase in poverty and squatter settlements. A quarter of the world’s population who live in cities do not have adequate housing and often lack access to basic social services[57].

Still this goal sounds broad and vague, so that "additional work remains to be done to validate the proposed indicators and specify operational targets for the environmental goal"[58].

Goal 8: Develop a global partnership for development

The eight MDG does not explicitly deals with social and environmental aspects as the previous one, but the attainment of this goal deeply influences the attainment of all the others. Without a strong commitment from different actors, an evident development in the world’s life will not ever be visible.

The targets of this goal are various: from a commitment to good governance, both at the international and national level, through the development of a non-discriminatory trading and financial system, to assistance to the least developed countries or to small island developing states, and to facing the debt problems of the developing countries to make it sustainable in the long term[59]. Furthermore, they concern cooperation with developing countries, in order to develop and implement strategies for decent and productive world for youth, with pharmaceutical companies to provide access to essential drugs, and with the private sector to make available the benefits from new technologies[60].

Once the principles are stated, the following steps for the UN is to do all can be done to implement them. Therefore, after having briefly described the Millennium Development Goals, the next paragraphs will deal with a description of the strategy that the UN adopted for their implementation.

2.2.3. The United Nations and the Millennium Development Goals

The Millennium Development Goals constitute a general framework for the UN system as a whole to work coherently together towards a common end. There are different actors and various initiatives which are involved in the implementation of the MDGs (Figure 9).

Figure 9: Actors involved around MDGs in UN system

As far as it concerns the actors, among the UN institutions, the United Nations Development Group[61] (UNDG) has been given the task to ensure that the MDGs remain at the centre of the UN system efforts.

The UNDG was created in 1997[62], as part of the general UN reform, to bring together UN entities dealing with development issues. It is led by an Executive Committee, chaired by the Administrator of the United Nations Development Programme (UNDP) and composed of four UN development agencies: UNDP, UNFPA, UNICEF and WFP. The UNDG Office acts in New York as the substantive secretariat to support the Executive Committee and the chair of the UNDG and to facilitate the cooperation and coordination among programmes, funds and agencies. The principal goal of the UNDG is to strengthen the policy and programme coherence and effectiveness of UN development activities. Among UNDG members are: UNFPA, UNICEF, WFP, UNDP, WHO, UNESCO, FAO, UNIDO, ILO, UNDP, UNAIDS and UNCTAD.

Figure 10: UNDG

The UNDG deals with MDGs, in particular, through the work of a Working Group on MDGs[63]. The main purpose of this working group is to ensure that the MDGs are placed in the centre of national planning and to align country programmes with the MDGs. In other words, UNDG priority is to support quality and effectiveness of country level programming and focusing on the MDGs.

With respect to the initiatives, one of the most recent UN achievement has been the issue of the document 'United Nations and the MDGs: a core strategy' endorsed at the 25th UNDG Meeting on 1 July 2002. The main objective of the UN strategy is to "ensure that the MDGs become an integral part of the priorities and action of a broad range of actors globally, regionally and in individual countries"[64].

The components of the strategy are four: (a) monitoring, that is to track and review progress towards MDGs, (b) analysis, that is to pass from an inspirational to a practical measure of the needed policy, institutional reforms and investment to achieve MDGs, (c) campaigning/mobilisation, that is to mobilise the commitments and capacities of broad sections of society to gain support for action on priorities, policies and resource allocations, (d) operational activities, which refers to the goal-driven assistance to address key limits to progress on the MDGs.

Furthermore, the strategy is oriented on two dimensions: the global and the country dimension. The strategy can be summarised in four elements, two at global and two at country level. They are:

• The Millennium Project, which analyses policy options and will develop plan of implementation for achieving the MDGs.
• The Millennium Campaign, which mobilises political support for the Millennium Declaration among developed and developing countries.
• Country-level monitoring of progress towards achieving the MDGs.
• Operational country level activities coordinated across agencies across the UNDG, which help countries implement policies necessary for achieving the MDGs

It would be too technical and far from the aim of this contribution to analyse the projects taken both at global and country level for the achievement of the MDGs. Therefore, as an example of the implementation phase of the MDGs, I take into consideration only one of the global level elements: the Millennium Project. The reason why I have chosen it is that, according to WHO Secretariat, its action and results seem to be more evident than those of the other initiatives. In fact, it should always be borne in mind that the topic I am dealing with, in this chapter, is recent and even if the principles are stated, there is still much to be organised and achieved.

The Millennium Project[65] was established by the UN Secretary-General, after the adoption of the United Nations Millennium Declaration and it is currently directed by Professor Jeffrey Sachs, based at the Columbia University in New York. The project's objective is to propose the best strategies for meeting the MDGs. Over a period of three years the Millennium Project will work to devise a recommended plan of implementation that will allow all developing countries to meet the MDGs and, consequently, to improve the human condition by 2015. The Millennium Project research focuses on identifying the operational priorities, organisational means of implementation, and financing structures necessary to achieve the MDGs. The Millennium Project reports directly to the UN Secretary-General and to the administrator of the UNDP.

The research is carried out by ten thematically oriented task forces[66]. The themes correspond to each single MDG and they are: (1) poverty and economic development, (2) hunger, (3) education and gender equality, (4) children’s and maternal health, (5) HIV/AIDS, malaria, TB and access to essential medicines, (6) environmental sustainability, (7) drinking water and sanitation, (8) slum dwellers and urbanisation, (9) open, rule-based trading and financial system, science, (10) technology and development policy. Each task force is composed of 15-20 persons, representing academia, public and private sector, civil society organisations, UN agencies, who are global leaders in their area and who are selected on the basis of their technical expertise and practical experience.

The Millennium Project itself has also two advisory group: the UN Expert Group that oversees UN participation in the project, and the International Advisory Panel[67], that brings together globally recognised experts in the relevant fields to provide technical and independent advice. Interim reports of the taskforces must be completed during 2003, with final reports ready by 2004 or 2005. The complete report of the entire Millennium Project is due on 30 June 2005.

The UNDG and initiatives, as the Millennium Project, are just an example of the impressive effort of the UN system towards the achievement of the MDGs.

At this point, it is important to recall that the purpose of this chapter is to define one aspect of the WHO’s mandate: the role of the WHO in the international development agenda. With this aim, a description of the economic development context, dominated by the Millennium Development Goals, has been set out in the previous paragraphs.

The next part will focus on the role that WHO maintains and should keep in the achievement of the Millennium Development Goals. However, in order to follow the traditional method, I will first reflect on the reason why WHO should be involved in the economic development agenda. Once this question is answered, I will concentrate on how the WHO should be involved.

2.3. WHO's role in the achievement of the Millennium Development Goals

Given the fact that 3 of the 8 goals, 5 of the 18 targets and 17 of the 48 indicators are related to health, one cannot avoid wondering what health has to do with economic development. Once a clear answer is given to this question, it will be evident that the WHO has to be involved with the achievement of the Millennium Development Goals, and as such is interesting to analyse the terms of this involvement.

Therefore, I will first deal with the reason why there is an inevitable connection between economic development and health, and, second, I will focus on the modality adopted by the WHO to achieve the MDGs.

2.3.1. Economic development and health

This paragraph will try to briefly identify the link between economics and health in order to define the reason for why the WHO needs be involved in achieving the MDGs. A report of some of the theories which describe such a relation will be followed by the description of the work elaborated by the Commission on Macroeconomic and Health and, at the local level, by the National Commissions.

2.3.1.1. Health as a determinant of economic development

Economic development has to do with health and health has to do with economic development. As Behrman says, "health and economic growth are inherently intertwined: theoretically, health can strongly affect economic growth and economic growth can strongly affect health"[68]. With the different terms of economic development, economic growth and economic performance, I refer to two dimensions: "the levels of economic poverty and the distributive aspects of economic well-being"[69].

There is a bi-directional relationship between economic development and health. The first side of this relation is the 'common wisdom'[70] that increasing levels of development improve the health situation of the population. It has been the object of multiple studies, all stressing the fact that "higher per capita incomes, through steady and stable economic growth, increase a nation's capacity to purchase the necessary economic goods and services that promote health"[71]. Therefore, economic development brings better health conditions.

The second side of the relation has been given less attention. The linkages of health "to poverty reduction and to long-term economic growth are powerful, much stronger than is generally understood"[72]. However, it has been just recently recognised at global level, that "better health translates into greater and more distributed wealth by building human and social capital and increasing productivity"[73]. This is the aspect this paragraph is mainly interested in.

The approach described above is based on the human capital view[74]. Two Nobel Laureates Theodore Shultz and Gary Becker[75] demonstrated that health, as well as education, are the basis of an individual's economic productivity. Human qualities, as the health of the individuals, should be improved because of their value as a factor or capital in augmenting the production possibilities of the economy that, in turn, also enhance the income-earning abilities of people. For example, it is worth to invest in health if the rate of return exceeds the cost of the investment in human capital. Therefore, health is considered a form of human capital that is vital for achieving economic stability, whereas unhealthy societies impede the process of economic development.

According to Behrman, health has an impact on the marginal productivity of individuals in economic activities such as the production of good and services[76]. Marginal productivity can be seen as a function which depends directly on various characteristics of the individual, the factors of production with which the individual works and the state of technology, such that:

W = W (H,E,T,CC,A,K,F,…)

where W is the marginal productivity of labour, H is health status, E is effort, T is time spent working, CC is cognitive capabilities, A is ability, K is physical capital stock and F is intermediate inputs[77]. Therefore, "the direct impact of current increases in health on labour productivity is simply the change in productivity that occurs with a change in health, all else being constant"[78]. This direct effect can be fairly immediate, due to current intake of calories or macronutritients. The author also considers an indirect impact of health on productivity. Health has indirect effects, if it affects any of the other variables in relation for the marginal productivity of labour[79].

Hamoudi and Sachs[80] report some mechanisms by which health determines economic performance. One is the fact that illness brings treatment costs and lost labour productivity. To make an example, one study finds that "treatment of a single episode of malaria in Tigray, Ethiopia costs the affected household US$0.80 to US$1.60, and results in about 12-26 days of work lost. Therefore, the annual private cost of malaria in this region amounts to an average of 5-8% of household income"[81]. Even persons who do not change their work habits in response to illness still are expected to perform sub-optimally during the term of their illness.

Another mechanism is the influence that long term diseases can have on economic performance, even in the absence of severe clinical disease. An example can be the disease caused by geohelminths. These are worms that invade a human host and infest the small intestine, sapping nutritients and making the host anemic, more easily tired, melancholic and distracted. As a consequence, the productivity of workers dramatically decreases[82].

Other studies on the relation between health and economic development show that about 40% of economic growth in developing countries can be ascribed to improved health and nutritional status[83].

Gallup, Luke and Sachs showed that while malaria-affected countries have grown only 0.4% annually in the period 1965-1990, non malaria-affected countries have grown 2.3%[84].

Chakraborty illustrates that at low per capita income levels, overall expenditure on health, as well as average life expectancy are low. This may lead to a decrease in investment, because populations are not willing to give up present consumption in perspective of a poor future. Furthermore, low life expectancy reduces investment in education and skill accumulation and thus returns to physical capital[85].

Not to forget the historical evidence which shows that several of the great takeoffs in economic history were supported by important breakthroughs in public health, disease control and improved nutritional intake[86]. I refer to the productivity growth observed in Britain during the first phase of the industrial revolution, to the rapid growth of US South and Japan in the early 20th century and to the development of Europe and East Asia beginning in the 1950s and 1960s.

With respect to the industrial revolution, Hamoudi and Sachs report the theory of Professor Robert Fogel, who posits a 'technophysio' evolutionary process, whose primary outcome has been extremely rapid population growth and longer life expectancy, primarily driven by improvements in nutrition. He stresses the relation between body size and food supply and shows it to be critical for long-term labour productivity. He states that "the increase in the amount of calories available for work over the past 200 years must have made a nontrivial contribution to the growth rate of the per capita income of countries such as France and Great Britain"[87].

2.3.1.2. The work of the Commission on Macroeconomic and Health

Some of the major results concerning the strict linkage between health and economic development have been achieved by the Commission on Macroeconomics and Health (CMH)[88]. The work of the CMH is a challenge for the traditional argument that health will automatically improve as a result of economic growth, and it shows the contrary argument that improved health is a prerequisite for economic development in poor societies.

What was the reason for the establishment of such a Commission?[89] The connection between health and economic development, and in particular the linkage between health and poverty reduction, which is now one of the main goals of the international development agenda, is something not totally new at the global level.

The International Development Goals set out in 1995 already made reference to the importance of acting on health.

When Dr Brundtland took over in 1998, "she was already convinced of the significance of an investment in health, although she was aware of the scarcity of the resources. She thought that it was necessary to show to the world, and in particular to people with money, to Prime Ministers and Ministers of Finance, that to invest in health is worth"[90]. Therefore, one could interpret the establishment of the CMH as one of the way Dr Brundtland adopted to respond to one of her main directions of work: to put health on the international development agenda. She always believed that "you cannot make real changes in society unless the economic dimension of an issue is fully understood […] This is a lesson I took with me to my work in health"[91] from the World Commission on Environment and Development[92]. Its "findings managed to change the course of development only because the arguments succeeded in reaching Finance Ministers and heads of State"[93]. Dr Brundtland deemed vital to move health to the highest levels of political leadership. She said that she learnt over the years that "to reach the minds of those who hold sway over real financial and political power, we have to communicate in a language that these decision-makers understand. Good health is intrinsically good in its own right. But we cannot ignore the fact that governments will take more notice when faced with robust evidence showing the true economic impact of avoidable illness. This information has to be presented in such a way that it stands out amongst all the other information and choices that governments face every day"[94].

The World Health Report 1999 emphasised health as a key item in the development agenda, including a focus on health investments to improve health outcomes of the poorest billion in the world.

In May 1999, the WHO and the United Kingdom's Department for International Development (DFID) organised a meeting called 'World health opportunity: developing health, reducing poverty'. This meeting clearly highlighted WHO's role as the lead technical agency on health to provide the analytical and operational basis for health to be at the 'hearth' of development[95]. WHO's response to this consultation was the creation of the CMH.

Such a Commission would be extremely important both fixing aim and means. As a political organ, it would identify the aim in placing health at the top of development agenda, and as a technical organ, it would quantify the needed investments in health to obtain economic growth.

The CMH was established by Dr Brundtland in January 2000 to assess the place of health in global economic development. The CMH was supposed to analyse the impact of health on development, and to examine the appropriate modalities through which health related investments could have a positive impact on economic growth and equity in developing countries. On this topic it was in charge of producing reports and scholarly studies. It also had to recommend a set of measures designed to maximise the poverty reduction and economic development benefits of health sector investment[96].

The CMH is composed of the members, six working groups and the Secretariat[97]. The chair of the Commission is Professor Jeffrey Sachs of Harvard University. The members, Chair Senior Economist and Executive Secretary of the Commission were appointed by the WHO Director-General. The Commission members are eighteen of the world's leading economists and policy-makers from academia, governments and international agencies. Among them there are representatives from the World Bank, the International Monetary Fund, the United Nations Development Programme, the Economic Commission on Africa and the Organization for Economic Cooperation and Development. Working groups' members include CMH members, staff of various international agencies, experts from government, academic institutions, NGOs and the private sector. The working groups deal with different subjects: (1) health, economic growth and poverty reduction, (2) international public goods for health, (3) mobilization of domestic resources for health, (4) health and the international economy, (5) improving health outcomes of the poor, (6) development assistance and health. The Secretariat is based partly at the Centre for International Development at Harvard University and partly at WHO headquarters.

The CMH worked to extend the evidence base concerning the following topics:

• The nature and magnitude of the economic outcomes of investing in health;
• The economics of incentives for research and development for drugs, vaccines, and other technologies that address diseases primarily affecting the poor;
• Effective and equitable mobilisation of resources to finance control of major specific health problems of the poor and to develop and sustain health system more generally;
• Health and the international economy, particularly trade-related issues;
• Costs and efficiencies in use of resources to improve health outcomes of the poor, including consideration of interventions and policies within and outside the health sector;
• Development assistance and health[98].

The work of the Commission was to be completed by December 2001 and the CMH had to produce a synthesis report through careful evaluation and analysis of the six working groups.

The Commission findings are consolidated in the report, 'Macroeconomic and health: investing in health for economic development', which was launched in December 2001. In summary, "the report provides compelling evidence that better health for the world's poor is not only an important goal in its own right, but can act as major catalyst for economic development and poverty reduction"[99].

The Report moves from the hypothesis that health is one of the main contributors to economic development. Economic output, is a function of "policies and institutions (economic policies, governance, and supply of public goods) on the one hand, and factor inputs (human capital, technology and enterprise capital) on the other"[100].

A particularity of the work of the Commission is to be aimed at showing in economic and financial terms that investment in health is valuable. We should always bear in mind that the findings of the Report are to be addressed to Ministers of Finance and heads of State. Therefore, "the disease-induced losses are converted into dollar terms: the value of an extra year of healthy life is worth considerably more than the extra market income that will be earned in the year. According to some estimates, each life year is valued at around three times the annual earnings"[101].

The Report individuates three main ways that disease impedes economic well-being and development:

1. The effect of disease on the number of years of healthy life expectancy;
2. The effect of disease on parental investment in children;
3. The effect of disease on the returns to business and infrastructure investment, beyond the effect on individual worker productivity.

By examining in detail these links, the CMH achieve a series of findings, which can be listed as follow[102]:

1. Economic losses from ill health have been underestimated.

Countries with the weakest conditions of health have great difficulties in economic development. In sub-Saharan Africa losses due to HIV/AIDS are estimated to be at least 12% of annual GNP. Economic development in malaria-free zones is at least 1% per year higher than in areas where malaria is endemic.

2. The role of health in economic growth has been greatly undervalued.

For example, the Report shows that each 10% improvement in life expectancy is associated with an economic growth of about 0.3% to 0.4% per year, other growth factors being equal.

3. A few health conditions account for a high proportion of avoidable deaths.

The Report refers to HIV/AIDS, malaria, TB, childhood infectious diseases, maternal and perinatal conditions, tobacco-related illness and micronutrient deficiencies. Around 8 million deaths per year could be averted by the end of the decade in a well-focused programme.

4. The level of spending on health in low-income countries is insufficient to address the health challenges they face.

The Report estimates that minimum financing needs to be around US$ 30-US$ 40 per capita to cover essential interventions. However, current health spending is much lower, above all in the least developed countries (US$ 13) and in other low-income countries (US$ 24).

5. Poor  countries can increase the domestic resources they mobilize for health and allocate what they have more efficiently.

The Report advises on an increase in domestic budgetary resources from 1% of GNP by 2007 and 2% by 2015.

6. Despite increased domestic resources a major financing gap will remain.

Current donor assistance from donors is about $6 billion. If the minimum financing need is US$ 30-US$ 40 per capita, the Report estimates that to finance the necessary interventions and additional infrastructure and delivery system will require US$ 27 billion per year in donor grants by 2007, rising to US$ 38 billion in 2015.

7. Poverty will be more effectively reduced if investment in other sectors is increased as well.

The Report affirms that donor funding should regard also other aspects, as education, water, sanitation and other sectors that will have an impact on health.

8.  Within the health sector, the highest priority is for a 'close-to-client' system.

The Report affirms that the highest priority is to create a service delivery system at the local level, complemented by nationwide programs for some major diseases. The success of this program requires political and administrative commitment, strengthening of country technical and administrative expertise, substantial strengthening of public management system and creation of system of community accountability.

9. To achieve an impact on the health of the poor will require increased investment in global public goods.

The Report refers to collection and analysis of epidemiological data, surveillance of infectious diseases, research and development towards new drugs, vaccines and diagnostics for tackling the disease of poor countries.

10. There is much to be done to increase poor people's access to life-saving medicines.

The Report recommends coordinated actions by the pharmaceutical industry, governments of low-income countries, donors and international agencies to ensure that the world's low income countries have access to essential medicines.

11. The recommended increase in spending is large, but so is the potential return.

The Report estimates the aggregate additional cost  of scaling up interventions in the order of US$ 66 billion per year, with around half of this amount coming from donors. The predicted result, however, is to save around 8 million lives a year and generate economic benefits of US$ 360 billion – i.e. a six-fold return on investment.

To conclude, the findings of the CMH can be numerically summarized as follow: US$ 30-US$ 40 per capita are needed to cover essential interventions; to achieve this allocation the donor's assistance will have to increase from US$ 6 billion to US$ 27 billion by 2007 and to US$ 38 billion by 2015; the final result will be the saving of about 8 million of lives and an economic benefit of US$ 360 billion by 2015.

2.3.1.3. At country level: National Commissions on Macroeconomic and Health

Findings of the CMH shall encourage countries to improve their investment in health. With this purpose, at country level, several governments have established National Commissions on Macroeconomics and Health (Ghana, Mexico and Thailand), while others have begun using mechanisms to build on the CMH recommendations (Indonesia, Sri Lanka). Furthermore, other countries have requested WHO assistance in implementing the CMH process (Ethiopia, Malawi, Mozambique, Uganda)[103].

From a conversation with the Executive Secretary of the CMH, Dr Spinaci[104], this process does not seem so linear. As in Figure 11, a fundamental component of economic development is given, besides factor inputs as human capital, by the policies and institutions of the countries. The assistance received from the WHO and from other funds, as the Global Fund to fight AIDS, TB and malaria can be misused, if the country governments do not understand the importance of investing in health. Dr Spinaci explained to me that many countries fix annual expenditure ceilings for the health sector that have to fit within the overall expenditure budget. Therefore, the grants go to the government treasury, from where it may be utilised for different aims.

Taking Uganda as a significative example, French Ambassador to Uganda Jean Bernard Thiant said that, "the rampant corruption in government departments will scare away donors if not tackled" and he queried, "the way the Government had handled the US$ 100 million grant from the WHO to the health ministry. The fund, meant for the fight against malaria, TB and AIDS, had been diverted to other sectors […] My job is to tell the Government that we are willing to give help, but if we give you $4 million and only $1million reaches the grassroots, then we won't give more"[105]. Referring again to Uganda, head of the UK's Department for International Development (DFID) office, Michael Hamond, comments that Uganda should make a decision. "If we come and change their priorities then it becomes a dictatorship, not a partnership", he said[106]. Uganda, as all the countries, should become conscious of the fact that investment in health is vital for economic growth. National governments, represented by heads of State and the Ministers of Finance shall start thinking in this way and change their policies and institutions in order to take up the assistance given.

The reverse consequence could be the withdrawal of aid. For example, Dr Cassels affirms that "a question being raised in some donor agencies is whether development assistance should focus primarily on those countries which are judged to be making a serious effort to reduce poverty and inequity"[107]. However, it seems hard to define what constitutes a serious effort, looking at the on-the-edge situation in which most of those countries live. A legitimate question is whether donors should "continue to provide assistance to the poor even in countries with inadequate policies"[108].

The issue is delicate and it is not easy to take a definitive position on the problem because it involves different factors dependent on the countries under consideration. I might agree, however, with the fact that national governments shall make a decision on whether it is worth to invest in health in order to have economic development. If heads of State and Ministers of Finance are convinced of this point, it will be much easier to assist to an actual economic growth.

At the same time, one should not forget that a further component of economic development is education (Figure 11). It is not enough to allocate resources for the development of the poorest countries. It is not even enough that the political leadership is willing to employ them in the correct way. The recipients of such resources have to be in the conditions to be able to understand the importance of the donations, to use them properly and to gain from them. However, such a consciousness can be taught only on a personal level. This holistic perspective, which considers the person as a whole, is typical of the people working in the field[109]. They spend their lives in direct contact with the poorest populations and with their needs, and they are aware of the fact that resources are easily wasted if such populations are not educated.

On one side, therefore, it is necessary that the WHO and, in particular, the CMH are committed to place health at the top of the development agenda, in order to raise funds. However, it is not sufficient in absence of a direct human relationship with people in the greatest need[110].

2.3.2. The commitment and action of the WHO to the achievement of the Millennium Development Goals

The WHO is a specialised agency of the United Nations. As a consequence, WHO's mandate is affected and influenced by the main directions of work of the 'mother' Organization, the UN[111]. The WHO is, therefore, totally involved in the process of working towards the achievement of the Millennium Development Goals, as a main set of goals agreed on by the UN members at the Millennium Summit at the beginning of a new era.

The previous paragraph isolated the reason for this collaboration, by showing an insoluble linkage between health and economic development. In this paragraph, I will look at the modality through which the WHO actually contributes to the achievement of the MDGs.

First, I will analyse some of the documents and occasions which set out the main policy of the Organization with this respect and, second, I will emphasise the practical actions taken by the Organization with this purpose.

2.3.2.1. The commitment

The WHO expressed its commitment to the Millennium Declaration and, therefore, to the achievement of the Millennium Development Goals at the 109th Executive Board in 2002. The EB recommends to the 55th WHA the adoption of a resolution to request the Director-General "to report to the Executive Board to its 111th Session and to the 56th World Health Assembly on measures taken by WHO to contribute to the attainment of the development goals of the Millennium Declaration"[112].

The resolution is adopted by the 55th WHA in May 2002 and it requests the Director-General to report to the 111th EB and 56th WHA on the WHO's contribution to achieving the MDGs[113].

The Report by the Secretariat to the last 111th EB states clearly the WHO's commitment to the achievement of the MDGs.

The Secretariat stresses the fact that "not only does the WHO contribute to the collective effort of the United Nations, but its work on the MDGs is an integral part of its own activities"[114]. The meaning of this statement is what I am interested in, in order to identify the commitment and action of the WHO towards the MDGs. During my stay at the WHO, I have actually encountered some problems in clearly isolating the current work of the WHO towards achieving the MDGs. It has been repeated that the commitment is clear, but also a recent aspect of WHO's mandate. Therefore, the WHO Secretariat is working hard to define the precise role of the WHO towards the given purpose.

The 111th EB session, during which it was affirmed the strategic importance of the MDGs, started to answer this issue[115]. The MDGs are being used "to focus and reorient the work of individual programmes, and as a benchmark against which to assess overall agency performance"[116]. With this respect, it was interesting the comment made by Dr Cassels in this occasion: "the MDGs are a set of outcomes towards which our work, as well as that one of national governments and of other international organisations has to be directed". Also the Executive Board member representing the United Kingdom defined the MDGs as "a powerful framework for collective action, where the WHO represents one of the main actors in guiding the effort". This is demonstrated by the fact that there is not a particular Department in the WHO which works exclusively on this topic. Dr Cassels again affirmed that "the existence of a goal does not mean the existence of a program for that goal". The already existing Clusters and Departments, however, have reshaped their policies according to the purpose of achieving the MDGs. From conversation with civil servants[117] working on the MDGs issue, I have gained the impression that all the WHO is working for the achievement of the MDGs in the general current work. They are considered general guidelines of work underneath what it is usually done. The MDGs are, therefore, defined as a cross-cutting issue, meaning that they are relevant to all aspects of the WHO's work, and thus relevant to each Cluster and Department.

Besides the policy documents, the commitment to the achievement of development was expressed by the WHO also within the context of two significative international conferences, the International Conference on Financing for Development, and the World Conference on Sustainable Development. The significance of such conferences is actually given by the fact that, besides the importance of the discussed topics, "many people use them to promote their image and their political-ideological agenda"[118]. Therefore, these recent conferences constituted an occasion also for the WHO to highlight the fundamental linkage between health and development and to reconfirm the commitment of the Organization to the achievement of the MDGs.

The International Conference on Financing for Development (FFD)[119] was held in Monterey, Mexico, from 18 to 22 March 2002. Fifty heads of State or Government, over 200 ministers, as well as leaders from the private sector and civil society, and senior officials of all the major financial, trade, economic and monetary organisations convened at this conference to address key financial and development issues pertaining to global development. A General Assembly resolution set out the main purposes of the Financing for Development Event: "to address national, international and systemic issues relating to financing for development in a holistic manner in the context of globalisation and interdependence, and to identify means for ensuring the availability of sufficient financial resources to reach the goals set by the major United Nations conferences during the 1990s, in particular with regard to poverty eradication"[120]. The agenda covered six major interconnected themes, each integral for financial development: mobilising domestic financial resources for development; mobilising international resources for development: foreign direct investment and other private flows; international trade as an engine for development; increasing international financial and technical cooperation for development through official development assistance; external debt; addressing systemic issues: enhancing the coherence and consistency of the international monetary, financial and trading systems in support of development[121].

Financing for development, thus, means mobilising the financial resources and achieving the national and international economic conditions needed to fulfil internationally agreed development goals to reduce poverty and improve human condition.

In this context, Dr Brundtland intervened to reaffirm the commitment of the WHO to achieving economic development. Financing is a necessity for development, although healthy people are a precondition to have a productive use of the given resources. In the beginning of her speech at the Financing for Development Conference, Dr Brundtland questioned: "how do we make sure that financing for development brings useful benefits to the people who need the most? How can we ensure that resources lead to real improvements in the lives of the poorest 2 billion? My view on this issue is clear. Development is not possible unless people are healthy. Investing in people is crucial. It will yield enormous benefits and allow millions of people to move out of poverty. Better health will bring real improvements to their lives"[122]. Later, at a Round Table during the Conference, she said that "trade is an important engine of growth. However, only a fortunate few will benefit unless all women and men are healthy and educated"[123].

The World Summit on Sustainable Development (WSSD)[124] took place in Johannesburg, South Africa, from 26 August to 4 September 2002. Heads of State and Government, national delegates, leaders from nongovernmental organisations, representatives from the private sector convened, after ten years since the earth Summit in Rio de Janeiro[125], to focus the world's attention and direct action towards sustainable development.

The term sustainable development was originally defined in the Dr Brundtland's Commission report as "development that meets the needs of the present, without compromising the ability of the future generations to meet their own needs"[126]. In other words, it means meeting people's development needs in a manner that will not, in the long tem, exceed the earth's carrying capacity[127]. Furthermore, sustainable development is based on three pillars: the economic, the social and the environmental one.

If sustainable development is defined in this way, it definitely concerns people and their survival, and it is therefore strictly connected to health[128]. Principle 1 of the Rio Declaration on Environment and Development states that "human beings are at the centre of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature"[129]. For this reason, the World Summit was seen as "an unprecedent opportunity to place health higher on the environmental and development agenda"[130]. It is actually important to recognise that "healthy life is of course an outcome of sustainable development, but what we have to realize is that it is also a powerful and undervalued means of achieving it. We need to see health as a precious asset in itself, and as a means of stimulating economic growth and reducing poverty"[131].

Health[132], therefore, becomes one of the main themes treated during World Summit on Sustainable Development, together with energy, clean water, sanitation, adequate shelter, food security and the protection of bio-diversity. The priority of the subject depends on several reasons which are listed by Dr Brundtland as follows: "Firstly, investment in people's health is an essential element of sustainable development […] the world is beginning to accept that health is a means of stimulating economic growth, protecting the environment and reducing poverty; […] secondly, we can make the case for investment with much greater precision, based on the work of the Commission on Macroeconomic and Health; […] thirdly, we have a growing body of evidence on which to base strategies to address the risk to people’s health – particularly those that arise from the environment; […] fourthly, we have to acknowledge the need for long term and equitable access to natural resources, which are critical to people’s health and life itself"[133].

2.3.2.2. The action

This section will describe the strategy and action of the WHO to achieving the MDGs. This is stated in the already mentioned document which has been presented by the Secretariat to the 111th Executive Board in January 2003, entitled 'WHO's contribution to achievement of the development goals of the United Nations Declaration'[134]. This document define the MDGs as a framework for the whole work of the Organization. The WHO will act, as a consequence, always bearing in mind the adopted development goals. The document, furthermore, assigns specific tasks to the Organization. The WHO will have to fulfil these functions in order to respect its theoretical commitment.

The specific role of the WHO, besides addressing its entire activity towards the achievement of the MDGs, consists in "tracking progress and measuring achievements"[135] through design of indicators and reporting.

With respect to the design of indicators, I have shown that each MDG has its own targets and indicators. The WHO, in collaboration with other organisations of the UN system and with the Department of Economic and Social Affairs, works to identify indicators associated with each health-related goal and target.

Different kinds of problems have arisen concerning the indicators. For example, it seems to be a problem that goals, targets and indicators agreed on at the special session of the UN General Assembly on HIV/AIDS have not been integrated in Goal 6. Regarding to HIV/AIDS, one of the indicators used – contraceptive prevalence rate – does not seem to be appropriate and it should be used for Goal 5 on maternal health. Furthermore, there are doubts about the fact that the outcomes of the World Summit on Sustainable Development are actually inserted in the MDGs. It is also questioned that the progress against malaria and others diseases is correctly measured by the indicator of disease-specific mortality. It is suggested to add a footnote to this indicator, so that estimates of healthy life expectancy at birth should be used instead. Another problem to be faced is the absence of indicators for noncommunicable diseases, chronic conditions, behaviour-related risk factors, mental health, occupational health and health systems. The WHO has tried to respond to this problem by defining a strategy which will provide in the long-term a series of core health indicators to be reported on periodically in the statistical annex of The World Health Report[136].

As far as it concerns the reporting activity, as one of the leading agencies in global reporting of progress, the WHO is required to provide regularly updated data, accompanying analytical narratives and detailed descriptions of data sources, methods and data uncertainty[137]. In particular, the WHO together with the UNICEF is responsible for reporting on child mortality, maternal health, childhood nutritional status, malaria prevention measures and access to clean water. Furthermore, the WHO and the UNAIDS collaborate to achieve HIV-prevention targets. The WHO alone is responsible for indicators on TB prevention and treatment, use of solid fuels and access to essential drugs. The validation of the data on the MDGs at country level will see the simultaneous participation of WHO, UNICEF, UNDP and UNFPA. However, the WHO is supposed to be the authority for the health content of the MDGs. The purpose is to avoid duplication of the data and to ensure that conflicting health data are not reported through parallel channels.

The steps of the reporting process see the involvement of all organisational levels of the WHO: headquarters, Regional Organizations and Country Offices. They can be listed as follows:

1. Setting data quality standards.

A validation process for health information provide five quality criteria for core health indicators: validity, comparability across populations and countries, reliability, audit trial, validation at country level.

2. Developing measurement tools, maintaining a data collection platform and building capacity to generate the data.

The WHO creates an ongoing work to strengthen local capacities in survey administration, regarding both the conduct of surveys and the analysis of the collected data, through the World Health Survey Project.

3. Country consultation process.

Diverse country-consultation initiatives will be convened in order to establish a consolidated WHO process for the validation of country-based data.

4. Reviewing and validating the data.

The data collected by the WHO will be analysed, inventoried, catalogued, validated and released thanks to WHO corporate support. The validation of the WHO data will be undertaken through global peer review.

5. Data dissemination.

The data will be available through the WHO Country websites and through The World Health Report.

The WHO also takes into account the MDGs in the preparation of the strategic programme budget for 2004-2005. For example, the areas of work which concern malaria and tuberculosis refer to the Goal 6 of the MDGs[138]. The presence of the MDGs in such a political document as the budget shows that they constitute a basic strategic direction of work for the WHO.

A side of WHO's mandate is therefore the achievement of the MDGs, whose realisation may be considered the maximum expression of economic development. However, what is the real purpose of such ambitious and nearly unreachable goals? The answers to such a question are various, but they can be reduced to two general categories.

On one side, there are those who do not believe in such a hopeless commitment to vague 'good principles' and who look at the practical aspect of the implementation. While staying at the WHO, I have realised that most of the scepticism towards the work of the international organisations derives from the absence of an authoritative actor who deals with the implementation of the principles. Richard Horton, editorialist of The Lancet, for example, finds a fault in reaching the aim of pulling 1.2 billion people out of the poverty of less than US$ 1 a day. The problem is that "there is no implementing institution to do so. Globalisation lacks governance. Without a Global Development Organization (GDO) there is no prospect that UN's development goals will be met"[139]. The purpose of a GDO would be, says Horton, "to advocate for global action on human development; to be the lead scientific and technical agency for development; to coordinate bilateral and multilateral development programmes and to set out standards for development work"[140]. Once the policy is stated, its execution and its implementation cannot be missed. However, it is practically impossible to make these goals effective in the absence of an authoritative implementing institution.

On the other side, the EB document states that, "the MDGs help to shape WHO's work on health and poverty, which aims to identify pro-poor health interventions and to convince policy-makers of the benefits of investing in health"[141]. The Financing for Development Conference and the World Summit on Sustainable Development themselves are to be considered tools to attract the attention of heads of State and Government, as well as of Ministers of Finance, to the importance of health in the achievement of development. Therefore, this kind of meetings, as well as many of the initiatives organised by the UN, is often useful "to state good principles which serve to fix those essential guidelines for obtaining a consensus which will be likely to become action"[142].

I therefore interpret the commitment of the WHO to the MDGs as an advocacy instrument to highlight the linkage between health and economic development. A conversation with a member of the WHO Secretariat[143] suggested me to think that the MDGs are more than anything else a promotion tool used by the WHO to increase world's attention over the health issue. If what Dr Brundtland wants is to place health at the top of the development agenda, the MDGs are one of the most proper means to reach this aim.

Nevertheless, there is a risk. The mistake would be to restrict WHO's mandate to one of its several aspects. The WHO's role in achieving the MDGs is just one of the elements of the global mission of the Organization. An element which can be considered, as I said, an advocacy tool to attract the attention of the world over the development-health linkage.

Horton pointed out a paper of the UK's Department for International Development (DFID), 'Working in partnership with the World Health Organization'[144], issued in August 2002, as an expression of such a risk. In this document, according to Horton, "the DFID defines WHO's work entirely within the context of human development […] it repeatedly identifies WHO's chief purpose as being an instrument to achieve the Millennium Development Goals"[145], whereas, "DFID ignores the agency's global role in building health programmes and health systems, and in setting norms and standards"[146]. Horton recognises the importance of such goals, however he affirms that, "none of this would matter if WHO was being provided with additional resources to achieve these development targets. But no extra resources are expected to be forthcoming […] The next Director-General will almost certainly have to cut back work on WHO's broader health agenda to fulfil an over-riding UN mandate"[147]. The risk would be therefore to compromise the WHO's broader mandate, which will be described in the next chapter.

It could be that Horton's position is overstated[148], but it surely provides a warning against a misleading interpretation of WHO's mandate.

Burci and Vignes, in a manuscript which will be soon published, note that "while most development organizations have started to concentrate their resources almost exclusively on the reduction of absolute poverty, WHO has a global mandate which goes beyond poverty reduction. The incorporation of this new priority necessitates therefore finding a balance with the other strategic directions in the corporate strategy"[149]. This point will be covered in the next chapter.

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Edited by Aldo Campana,