[Title] Toyako Framework for Action on Global Health - Report of the G8 Health Experts Group - , G8 Hokkaido Toyako Summit
This report is the recommendation from the G8 Health Experts Group to the G8 leaders.
I Introduction
1. In developing this report, the Framework for Action, the Japanese Presidency set up a G8 Health Experts Group. Drawing on inputs from various stakeholders as appropriate, the G8 Experts have produced this report, which outlines the current situation, the principles for action, and actions to be taken on health. To ensure accountability, the report also includes annexes that show G8 implementation of its past commitments, building on what was agreed and initiated at St. Petersburg Summit in 2006 and the work conducted in 2007 during the German Presidency.
2. This year marks the mid-point of the Millennium Development Goals (MDGs). The goal of scaling up towards universal access by 2010 regarding HIV/AIDS is also approaching us. In order to show determination, the G8 will demonstrate progress through annual review, including holding ourselves accountable for meeting past commitments, while maintaining an open dialogue with other key stakeholders.
II Current Situation
3. At the G8 Kyushu Okinawa Summit in 2000, infectious disease was taken up for the first time as a major item on the agenda of the Summit. Since then, international awareness of global health issues including infectious diseases has risen and led to increased bilateral support as well as the establishment of new funding mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, which we believe are great achievements of the G8. During this time, there has also been a substantial shift of landscape, with the formation of various partnerships and enhancement of activities of private foundations and civil societies.
4. Substantial progress has been made in helping partner countries make progress on endpoints related to HIV/AIDS, tuberculosis, malaria and polio. Access to anti-retroviral therapy (ART) has expanded to 31% in 2007, while deaths from AIDS have been leveling off since 2003 in Sub-Sahara Africa; some 3 million people now have access and 1 million people started on treatment last year alone, around a 46.5% increase from the previous year. Other achievements include increased coverage of anti-malaria interventions, an overall decline in TB incidence worldwide ranging from 0.5%-3.2% in different regions, 91% fall in the death rate from measles in Africa and the most geographically focused in history in the incidence of polio. But progress is uneven, significant challenges remain and these diseases continue to claim millions of lives.
5. In contrast there has been far less progress in improving maternal health and in reducing the newborn portion of under-five child mortality, particularly in Sub-Saharan Africa. There has been significant progress in reducing vaccine preventable diseases, notably measles, yet malnutrition still contributes to half of all child deaths.
III Principles for Action
6. The G8 will continue to work to meet its previous commitments, while addressing new challenges, through coordinated and complementary action.
7. The G8 will approach the health related MDGs in a comprehensive manner. The health related goals are inter-related as can be seen by the contribution of malaria and mother-to-child transmission of HIV/AIDS to under-five mortality. It is also clear that health systems strengthening is important for effectively addressing health challenges as a whole. Disease specific approaches and health systems strengthening should be mutually reinforcing and both must contribute to achieving all of the health-related MDGs. Furthermore gender-sensitive approaches, focusing on the special needs of girls and women and boys and men are needed to help overcome the remaining health challenges.
8. In addressing global health challenges, the human security perspective focusing on protection and empowerment of individuals and communities is critical, given that the health challenges directly affect human dignity and, in the words of the preamble to the World Health Organization Constitution, the right to the highest attainable standard of health, which is one of the fundamental human rights of every human being. Local communities are indispensable in tackling such health challenges.
9. In order to effectively address global health challenges, a longer-term perspective which extends beyond the 2015 deadline for the MDGs is needed. In addition to sustained awareness raising and prevention, supporting research and development is essential to identify the root causes of problems, find effective remedies for them and inform evidence based policies. It is equally necessary to strengthen assistance to build the capacity of developing countries to conduct biomedical research to promote the development of new and innovative diagnostics, vaccines and drugs for infectious diseases, behavioral research, and operational research to improve methods of addressing public health problems including research on evaluation methods and indicators.
10. In order to tackle various global health challenges in partner developing countries, financial and human resources need to be mobilized from a wide range of stakeholders, such as partner developing countries themselves, as well as donor countries, civil society, and the private sector. The effective utilization of those resources requires the leadership and good governance of developing countries and the respect of their ownership consistent with the Paris Declaration on Aid Effectiveness. The G8 welcomes the efforts of the Providing for Health Initiative as well as the International Health Partnership and the Catalytic Initiative. These health-related initiatives should enhance in a coherent manner the efforts of partner developing countries. The G8 will work to ensure its assistance to partner developing countries is well coordinated in support of national health plans.
IV Actions to be taken
A. Health Systems Strengthening
11. Health systems are multi-dimensional. The international community should tackle various aspects of health systems such as the health workforce and human resources for health; health information; good governance; essential infrastructure; quality assurance; management of medical products and essential drug supply systems; and sustainable and equitable health financing of the health systems. Aiming to work towards universal access to health services, the G8 emphasizes the importance of comprehensive approaches to address the strengthening of health systems including social health protection, and will work with partner countries to promote adequate coverage of recurrent costs in health systems.
12. An adequate health workforce is central to effective health systems. There is an estimated shortage of about 4 million health workers globally and 1.5 million in Africa. In order to work towards universal access to health services also for the most vulnerable and disadvantaged, the international community must act as a whole, addressing this gap with a sense of urgency. The G8 members will work towards increasing health workforce coverage towards the WHO threshold of 2.3 health workers per 1000 people, initially in partnership with the African countries where we are currently engaged and that are experiencing a critical shortage of health workers as is shown in the annexes to this report, while taking into account the specifically needed skill mix as well as regional disparities and individual country needs.
13. It is important to increase the use of skilled health workers and empower them in the field; promote capacity-building for central and district health officers; secure well-being and vitality of health workers; and provide technical assistance for strengthening planning capacity for human resources development. In order to increase and improve the supply of health workers, measures such as 'Treat, Train and Retain' (TTR) of health workers and task-shifting between health workers should be encouraged. The G8 encourages the WHO work on a voluntary code of practice regarding international ethical recruitment of health workers. The G8 takes note of the Kampala Declaration and Agenda for Global Action in March 2008 adopted at the First Global Forum on Human Resources for Health that articulated the importance of retention of health workers and their equitable distribution, and described priority steps, with the Global Health Workforce Alliance facilitating its implementation.
14. Appropriate monitoring and evaluation of health systems help to enable policy-makers to base their decisions on accurate health information and progress evaluations of national and international health policies, including policies that target achieving polio eradication, the health related MDGs and expanding the health workforce. In this respect, the G8 recognizes the value of using maternal health indicators to help track and assess health systems performance. G8 encourages further collaboration among stakeholders with the aim of standardizing health metrics to collect, analyze and evaluate health data for policy planning and evaluation.
15. The international community must enhance the capacity of health systems to respond to newly emerging health challenges such as human cases of H5N1 avian influenza and other viruses with pandemic potential, as well as natural disasters.
B. Maternal, Newborn and Child Health
16. Maternal, newborn and child health and care, and sexual and reproductive health are important for promoting health in individuals, families and communities. While there have been gains in reducing overall child deaths, there has been little progress in reducing newborn and maternal mortality.
17. Significant gains have been made in reducing under-five mortality through increased coverage of measles and other routine vaccinations, micro-nutrients supplementation, and proven malaria interventions. However, almost ten million children under the age of five continue to die every year, mostly from preventable causes. We recommend that the G8 will continue to support the scale up of comprehensive packages of child health interventions, including those listed above, especially at the community level. In addition, the G8 will work to decrease neonatal mortality, the largest remaining area of under-five mortality.
18. We recommend that the G8 will contribute to support a comprehensive approach to reducing maternal and newborn mortality through investment across the continuum of care work to improve access to quality antenatal and postnatal care, increasing access to skilled birth attendants bearing in mind the target agreed at the ICPD+5 in 1999, 90% of all births should be assisted by skilled attendants by 2015, backed by access to emergency obstetric care, to reach the MDGs target of a three quarters reduction in maternal deaths during the period 1990 to 2015. An effective approach will maximize the contacts between the health worker and the mother and child and maximize linkages across programs to deliver a range of effective interventions. It will invest in the health workforce, health facilities and culturally appropriate referral systems and tools such as simple and culturally appropriate handbooks for maternal and child health. Reproductive health should be made widely accessible.
19. The major causes of under-five mortality are acute respiratory infections including pneumonia, diarrheal diseases, neonatal and prenatal conditions, malaria, and malnutrition. Cost-effective tools to address these conditions, such as ORT (oral rehydration therapy) and zinc and basic hygiene for diarrheal diseases and antibiotics for pneumonia must be provided.
20. Good nutrition is a fundamental requirement for health, and it is critical to the success of various health programs including maternal, newborn and child health and infectious disease programs. The therapeutic benefits of treatments for AIDS, tuberculosis and malaria or preventive effects of regular immunizations are enhanced with adequate nutrition and appropriate supplies of micro-nutrients. In any nutrition programs, the inter-relationship between infectious disease measures, education programs and poverty alleviation measures should be considered. The G8 will consider the recent rise in food prices which could jeopardize the nutritional status of vulnerable groups, in implementing any nutrition programs so that targeted interventions can address the risk and consequences of malnutrition among those groups.
C. Infectious Diseases
21. The international community needs to continue to strengthen its efforts in scaling up towards the goal of universal access to prevention, treatment, and care and support of HIV/AIDS by 2010, including by meeting our pledges at Heiligendamm to support life-saving ART through bilateral and multilateral efforts for approximately 5 million people, to prevent 24 million new infections, and to care for 24 million people, as well as to scale up coverage of programs for the prevention of mother to child transmission of HIV/AIDS in Africa. In order to tackle the causes of the disease, accelerating efforts for comprehensive and evidence based prevention including prevention of mother to child transmission and addressing sexual exploitation and gender based violence remain critical. Given the vulnerability and susceptibility of women to HIV infections and steadily increasing proportion of women among those newly infected, there is a need for gender analysis, promotion of gender equality and actions to address the specific needs of women and girls. Support for sexual and reproductive health should be made available and accessible to adolescents and to other highly vulnerable groups. Barriers of discrimination, stigma and exclusion which prevent access to HIV prevention, treatment, care and support should be eliminated. The G8 supports ongoing work to review travel restrictions for HIV positive people with a view to facilitating travel and we are committed to follow this issue.
22. Although progress has been made in increasing case detection and treatment success rates, the international community is still off the track of the Global Plan to Stop TB, 2006-2015. The Plan aims to cut TB deaths in half by the year 2015 compared to 1990 levels, saving some 14 million lives over this ten year period. The expansion of the STOP TB Strategy including high-quality DOTS (directly observed treatment short-course) is essential for many developing countries with weak surveillance capacities and contributes to strengthening health systems. The G8 must also strengthen surveillance and diagnostic systems for multi-drug resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis (XDR-TB) as well as integrated collaborative approaches to address co-infection of HIV and tuberculosis as recommended by WHO.
23. We recommend that the G8 will continue to work individually and collectively over the next few years to enable the 30 countries in Africa with the highest malaria prevalence to reach at least 85 percent coverage of vulnerable groups with effective measures to achieve a 50 percent reduction in malaria-related deaths. The G8 should continue to expand access to long-lasting insecticide treated nets (LLITN), integrated vector control mechanisms like indoor residual spraying in accordance with the Stockholm Convention on Persistent Organic Pollutants, early diagnosis, and treatment with effective anti-malaria medicines (ACT: artemisinin-based combination therapy) and intermittent preventive treatment of malaria in pregnancy. As part of fulfilling its past commitments on malaria, the G8 will continue to expand access to LLITN with a view to providing 100 million nets through bilateral and multilateral assistance, in partnership with other stakeholders. Continuous vigilance and pre-emptive action should also be supported to help manage and prevent resistance to ACT and the threat to effective treatment that it would bring.
24. The incidence of polio is at its most geographically focused in history and we have the opportunity to eradicate the disease if we intensify our efforts. The G8 will meet its previous commitments to maintain or increase financial contributions to support the Global Polio Eradication Initiative, and encourage other public and private donors to do the same. The G8 supports a strong commitment by polio-endemic countries, and will work with them in the efforts to eradicate polio, bearing in mind the World Health Assembly resolution urging poliomyelitis-affected countries to engage all levels of political and civil society in these efforts.
25. An estimated one billion people are affected by a range of neglected tropical diseases (NTD) which cause substantial health, economic and social burdens in poor countries. Efforts to control or eliminate NTDs need to be reinvigorated. The G8 will work to support the control or elimination of diseases listed by the WHO through such measures as research, diagnostics and treatment, prevention, awareness-raising and enhancing access to safe water and sanitation. In this regard, by expanding health system coverage, alleviating poverty and social exclusion as well as promoting adequate integrated public health approaches, including through the mass administration of drugs, we will be able to reach at least 75% of the people affected by certain major neglected tropical diseases in the most affected countries in Africa, Asia and Latin America, bearing in mind the WHO Plan. With sustained action for 3-5 years, this would enable a very significant reduction of the current burden with the elimination of some of these diseases.
D. Promotion of Cross-Sectoral Approach
26. Health issues cannot be solved by working through the health sector alone. The G8 acknowledges the importance of enhancing linkages between health and other areas, both at the policy and field levels and between health programs. In particular, we recognize the close relationship between the internationally recognized goals on health, poverty, education, gender and safe water and sanitation. Successful disease prevention programs require community action and a strong multi-sectoral response. Development of other basic infrastructure - such as roads, utilities and ICT also contribute to improving health conditions. The reduction of gender inequalities, the empowerment of women and the reduction of violence against women and girls can positively affect health. We recommend that the G8 will advance strategies and programmes that tackle these issues.
27. The G8 will strive to support integrated approaches. Schools, communities and civic organizations are useful platforms for improving health and the awareness on health through, for example, life-skills education, knowledge transfer to families and communities, and school based public health interventions.
28. Concerning climate change, it is important to support the work being done by WHO and other relevant organizations to analyze the potential health impacts related to climate change, while noting that the science in this area is still developing.
E. Resources
29. G8 assistance for health has been increasing since 2002. At Heiligendamm the G8 committed to provide at least $60 billion for fighting AIDS, malaria and TB and strengthening health systems. Already in 2008 significant additional commitments, especially in the context of contributions to the Global Fund, have been provided. The G8 reiterates its commitment to continue efforts, to work towards the goals of providing at least projected $60 billion over the coming years to fight infectious diseases and strengthen health systems. The G8 also reiterates the importance of developing countries allocating more of their own resources for health.
30. The G8 also recognizes that for progress to be made on maternal, reproductive and child health, and emerging and neglected health priorities, additional resources - from both domestic and international sources - are needed if the health MDGs are to be achieved. Polio eradication has urgent funding requirement for the next five years of at least $980 m for 2008 to 2012 according to GPEI; unless met, prospects for eradication will deteriorate.