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Ambitious Goals Galvanize Nations
In 2003, a radical proposal was put forward by WHO and UNAIDS to galvanize global efforts to address the devastating problem of HIV/AIDS in sub-Saharan Africa as well as in China, India, and Southeast Asia. A goal was set by Director General J.W. Lee and the head of WHO's AIDS Program, Jim Kim, our former colleague at Harvard Medical School, of providing antiretroviral therapy to three million people in developing countries by the end of 2005--a target covering at least half of all who need treatment. When the "3 by 5 Initiative" was launched, about six million men, women, and children in developing nations were in need of antiretroviral therapy, but only 400,000, or eight percent, had access to treatment. As of June of this year, WHO reported that approximately one million people have had access to life-prolonging antiretrovirals, but achieving the goal of three million by the end of the year appears very unlikely.

While it is easy for cynics to criticize WHO for promising more than could be delivered, that ambitious goal has clearly galvanized countries to do better. Of the 49 nations hardest hit by HIV/AIDS, 40 have declared national treatment targets, 34 have drafted national scale-up plans, and 14 have already achieved the goal of treating at least half of all people who needed treatment. These strides have been made despite industrialized countries' inability to deliver fully on their commitment to provide the resources necessary for developing the infrastructure for treatment and for acquiring the needed drugs, even given a significant drop in the cost of these drugs.

It is thus a welcome development that during the annual G-8 Summit at Gleneagles, Scotland, in July, the leaders of industrialized nations in Asia, Europe, and North America freed up millions in the form of debt relief, which can now be used to purchase antiretrovirals. Importantly, the G-8 nations declared as a goal "universal access" to these medications for the first time. Clearly, continued leadership by WHO and UNAIDS and sustained commitments from the G-8 countries, the Global Fund for AIDS, Tuberculosis, and Malaria, other nongovernmental organizations, and bilateral development assistance will be essential if we are ever to surmount the global threat posed by HIV/AIDS.

Improving World Health Through Accountability
How will we know whether these goals and targets have been met? How can we measure the outcomes on health, not just the inputs, to say nothing of health's impact on economic and social development? With eight percent of the global economy now devoted to health, governments are under increasing pressure to show what they are getting for their huge financial investments, and to determine whether there might be still more cost-effective ways to invest their resources in order to improve health.

Harvard University and its School of Public Health are poised to contribute in a unique way to answering these questions through some exciting new developments, including a Grand Challenges in Global Health grant from the Bill and Melinda Gates Foundation, in conjunction with the Foundation for the National Institutes of Health. We are planning with philanthropist Larry Ellison, the founder and chief executive officer of Oracle Corporation, to start an exciting new global health initiative focused on creating a network of experts who share the aim of improving world health through accountability. Our goal is to link faculty members at Harvard with health experts in many countries, including those at WHO and other international organizations, to measure and analyze the state of health and health care in countries around the world.

Policy makers will need to address a number of key questions in order to set priorities and make the wisest decisions in allocating scarce resources to health: What is the burden of disease in terms of premature mortality and avertable morbidity due to the known causes of disease within each country? What are the key risk factors that predispose populations to these diseases, the prevention of which might reduce their burden? What are individual nations' financial inputs into their health sectors, and what are the health outcomes? What are the key health problems for which current interventions are inadequate, and that can help to define priority areas for research? How can the quality of care, and access to that care, be measured and improved? These are some of the key issues that we at Harvard will take on with help from our collaborators and supporters.

Recognizing that providing a sound basis for accountability will require new and better research methods, the Bill and Melinda Gates Foundation, as part of its Grand Challenges in Global Health initiative, has awarded $18.8 million to a research team led by Christopher Murray, the Richard B. Saltonstall Professor of Population Policy in the Department of Population and International Health at HSPH. The aim is to spur the development of sophisticated health-measurement tools and methodologies to develop an evidence base for decision making that will be inexpensive and readily applicable in developing countries.

The larger aim of all of these efforts? To help policy makers set meaningful priorities to improve population health in all countries, and to enable the world's citizens to hold their governments accountable. As breathtakingly grandiose as these goals may seem to us now, they represent one significant way that we in public health can contribute to narrowing the yawning gap in health between the rich and the poor, within and between countries of this world.

Barry R. Bloom
Dean of the School
Joan L. and Julius H. Jacobson II
Professor of Public Health

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