Final Report of the Commission on Social Determinants of Health
World Health Organization (© 2008)
In the spirit of social justice, the Commission on Social Determinants of Health was set up by the World Health Organization (WHO) in 2005 to marshal the evidence on what can be done to promote health equity, and to foster a global movement to achieve it.
As the Commission has done its work, several countries and agencies have become partners seeking to frame policies and programmes, across the whole of society, that influence the social determinants of health and improve health equity. These countries and partners are in the forefront of a global movement.
The Commission calls on the WHO and all governments to lead global action on the social determinants of health with the aim of achieving health equity. It is essential that governments, civil society, WHO, and other global organizations now come together in taking action to improve the lives of the world’s citizens. Achieving health equity within a generation is achievable, it is the right thing to do, and now is the right time to do it.
…The Commission takes a holistic view of social determinants of health. The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples lives – their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities – and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics. Together, the structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries.
The global community can put this right but it will take urgent and sustained action, globally, nationally, and locally. Deep inequities in the distribution of power and economic arrangements, globally, are of key relevance to health equity. This in no way implies ignoring other levels of action. There is a great deal that national and local governments can do; and the Commission has been impressed by the force of civil society and local movements that both provide immediate local help and push governments to change.
[THIS IS A REFERENCE TO THE ACTIVIST COMMUNITIES AROUND THE WORLD THAT PROMOTE 'SOCIAL PARITY' OVER 'ECONOMIC, TECHNOLOGICAL & SOCIAL PROGRESS'.]
A new approach to development
['NEGATIVE' ENVIRONMENT & HEALTH-CENTRIC SUSTAINABLE DEVELOPMENT]
The Commission’s work embodies a new approach to development. Health and health equity may not be the aim of all social policies but they will be a fundamental result.
Take the central policy importance given to economic growth: Economic growth is without question important, particularly for poor countries, as it gives the opportunity to provide resources to invest in improvement of the lives of their population. But growth by itself, without appropriate social policies to ensure reasonable fairness in the way its benefits are distributed, brings little benefit to health equity.
(p.1 EXECUTIVE SUMMARY)
… The Commission’s overarching recommendations:
…2. Tackle the Inequitable Distribution of Power, Money, and Resources
In order to address health inequities, and inequitable conditions of daily living, it is necessary to address inequities – such as those between men and women – in the way society is organized. This requires a strong public sector that is committed, capable, and adequately financed. To achieve that requires more than strengthened government – it requires strengthened governance: legitimacy, space, and support for civil society, for an accountable private sector, and for people across society to agree public interests and reinvest in the value of collective action. In a globalized world, the need for governance dedicated to equity applies equally from the community level to global institutions.
… Three principles of action:
2. Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally.
…1. Improve Daily Living Conditions
The inequities in how society is organized mean that the freedom to lead a flourishing life and to enjoy good health is unequally distributed between and within societies.
…SOCIAL PROTECTION ACROSS THE LIFECOURSE
All people need social protection across the lifecourse, as young children, in working life, and in old age. People also need protection in case of specific shocks, such as illness, disability, and loss of income or work.
Evidence for action
Low living standards are a powerful determinant of health inequity. They influence lifelong trajectories, among others through their effects on ECD. Child poverty and transmission of poverty from generation to generation are major obstacles to improving population health and reducing health inequity. Four out of five people worldwide lack the back-up of basic social security coverage (ILO, 2003).
Redistributive welfare systems, in combination with the extent to which people can make a healthy living on the labour market, influence poverty levels. Generous universal social protection systems are associated with better population health, including lower excess mortality among the old and lower mortality levels among socially disadvantaged groups.
Budgets for social protection tend to be larger, and perhaps more sustainable, in countries with universal protection systems; poverty and income inequality tend to be smaller in these countries compared to countries with systems that target the poor.
Extending social protection to all people, within countries and globally, will be a major step towards securing health equity within a generation…
What must be done
Reducing the health gap in a generation requires that governments build systems that allow a healthy standard of living below which nobody should fall due to circumstances beyond his or her control. Social protection schemes can be instrumental in realizing developmental goals, rather than being dependent on achieving these goals – they can be efficient ways to reduce poverty, and local economies can benefit.
Establish and strengthen universal comprehensive social protection policies that support a level of income sufficient for healthy living for all.
• Progressively increase the generosity of social protection systems towards a level that is sufficient for healthy living.
……UNIVERSAL HEALTH CARE
Access to and utilization of health care is vital to good and equitable health. The health-care system is itself a social determinant of health, influenced by and influencing the effect of other social determinants. Gender, education, occupation, income, ethnicity, and place of residence are all closely linked to people’s access to, experiences of, and benefits from health care. Leaders in health care have an important stewardship role across all branches of society to ensure that policies and actions in other sectors improve health equity.
Evidence for action
Without health care, many of the opportunities for fundamental health improvement are lost. With partial health-care systems, or systems with inequitable provision, opportunities for universal health as a matter of social justice are lost.
…The Commission considers health care a common good, not a market commodity. Virtually all high-income countries organize their health-care systems around the principle of universal coverage (combining health financing and provision).
HEALTH EQUITY IN ALL POLICIES, SYSTEMS, AND PROGRAMMES
Every aspect of government and the economy has the potential to affect health and health equity – finance, education, housing, employment, transport, and health, just to name six. Coherent action across government, at all levels, is essential for improvement of health equity.
Evidence for action
Different government policies, depending on their nature, can either improve or worsen health and health equity (Kickbusch, 2007).
…Reaching beyond government to involve civil society and the voluntary and private sectors is a vital step towards action for health equity. The increased incorporation of community engagement and social participation in policy processes helps to ensure fair decision-making on health equity issues.
…Making health and health equity a shared value across sectors is a politically challenging strategy but one that is needed globally.
What must be done
Place responsibility for action on health and health equity at the highest level of government, and ensure its coherent consideration across all policies.
• Make health and health equity corporate issues for the whole of government, supported by the head of state, by establishing health equity as a marker of government performance.
• Assess the impact of all policies and programmes on health and health equity, building towards coherence in all government action.
… Fair Financing
Public finance to fund action across the social determinants of health is fundamental to welfare and to health equity.
Evidence for action
For countries at all levels of economic development, increasing public finance to fund action across the social determinants of health – from child development and education, through living and working conditions, to health care – is fundamental to welfare and health equity. Evidence shows that the socioeconomic development of rich countries was strongly supported by publicly financed infrastructure and progressively universal public services.
The emphasis on public finance, given the marked failure of markets to supply vital goods and services equitably, implies strong public sector leadership and adequate public expenditure. This in turn implies progressive taxation – evidence shows that modest levels of redistribution have considerably greater impact on poverty reduction than economic growth alone. And, in the case of poorer countries, it implies much greater international financial assistance.
… What must be done:
Strengthen public finance for action on the social determinants of health.
• Build national capacity for progressive taxation and assess potential for new national and global public finance mechanisms.
Increase international finance for health equity, and coordinate increased finance through social determinants of health action framework.
• Honour existing commitments by increasing global aid to the 0.7% of GDP commitment, and expand the Multilateral Debt Relief Initiative; enhance action on health equity by developing a coherent social determinants of health focus in existing frameworks such as the Poverty Reduction Strategy Paper.
Fairly allocate government resources for action on the social determinants of health.
• Establish mechanisms to finance cross-government action on social determinants of health, and to allocate finance fairly between geographical regions and social groups.
Markets bring health benefits in the form of new technologies, goods and services, and improved standard of living. But the marketplace can also generate negative conditions for health in the form of economic inequalities, resource depletion, environmental pollution, unhealthy working conditions, and the circulation of dangerous and unhealthy goods.
Evidence for action
Health is not a tradable commodity. It is a matter of rights and a public sector duty. As such, resources for health must be equitable and universal.
There are three linked issues. First, experience shows that commercialization of vital social goods such as education and health care produces health inequity. Provision of such vital social goods must be governed by the public sector, rather than being left to markets.
Second, there needs to be public sector leadership in effective national and international regulation of products, activities, and conditions that damage health or lead to health inequities. These together mean that, third, competent, regular health equity impact assessment of all policy-making and market regulation should be institutionalized nationally and internationally.
The Commission views certain goods and services as basic human and societal needs – access to clean water, for example, and health care. Such goods and services must be made available universally regardless of ability to pay. In such instances, therefore, it is the public sector rather than the marketplace that underwrites adequate supply and access.
… Public sector leadership does not displace the responsibilities and capacities of other actors: civil society and the private sector. Private sector actors are influential, and have the power to do much for global health equity. To date, though, initiatives such as those under corporate social responsibility have shown limited evidence of real impact. Corporate social responsibility may be a valuable way forward, but evidence is needed to demonstrate this. Corporate accountability may well be a stronger basis on which to build a responsible and collaborative relationship between the private sector and public interest.
[A responsible private sector - Private sector actors can behave in ways that undermine public interest, but they can also contribute powerfully to public good. There is some evidence of small moves towards greater social contribution, but it is of limited credibility. Corporate social responsibility has been promoted as a vehicle for improving the positive social impacts of private sector actors. To date, however, corporate social responsibility is often little more than cosmetic. One of its principal shortcomings is that, being voluntary, it lacks enforcement (Box 12.20), but also that little evaluation has been attempted. An exception to this problem is the Ethical Trading Initiative. An independent evaluation of the impact of the Ethical Trading Initiative Code of Labour Practice, for example, reported a number of areas of improvement (Barrientos & Smith, 2007). But voluntary initiatives will inevitably be limited in their impact. Corporate accountability may be a more meaningful approach. (p. 142) – FINAL REPORT]
…Good Global Governance
Dramatic differences in the health and life chances of peoples around the world reflect imbalance in the power and prosperity of nations. The undoubted benefits of globalization remain profoundly unequally distributed.
…Through the recognition, under globalization, of common interests and interdependent futures, it is imperative that the international community re-commits to a multilateral system in which all countries, rich and poor, engage with an equitable voice. It is only through such a system of global governance, placing fairness in health at the heart of the development agenda and genuine equality of influence at the heart of its decision-making, that coherent attention to global health equity is possible.
What must be done
Make health equity a global development goal, and adopt a social determinants of health framework to strengthen multilateral action on development.
• The United Nations, through WHO and the Economic and Social Council, to adopt health equity as a core global development goal and use a social determinants of health indicators framework to monitor progress.
• The United Nations to establish multilateral working groups on thematic social determinants of health
– initially early child development, gender equity, employment and working conditions, health-care systems, and participatory governance.
Strengthen WHO leadership in global action on the social determinants of health, institutionalizing social determinants of health as a guiding principle across WHO departments and country programmes.
Above, we set out the key actions called for in the recommendations. Here, we describe those on whom effective action depends. The role of governments through public sector action is fundamental to health equity. But the role is not government’s alone.
An overarching Commission recommendation is the need for intersectoral coherence – in policy-making and action – to enhance effective action on the social determinants of health and achieve improvements in health equity. Multilateral specialist and financing agencies can do much to strengthen their collective impact on the social determinants of health and health equity…
WHO is the mandated leader in global health. It is time to enhance WHO’s leadership role through the agenda for action on the social determinants of health and global health equity.
…National and local government
Underpinning action on the social determinants of health and health equity is an empowered public sector, based on principles of justice, participation, and intersectoral collaboration. This will require strengthening of the core functions of government and public institutions, nationally and sub-nationally, particularly in relation to policy coherence, participatory governance, planning, regulation development and enforcement, and standard-setting. It also depends on strong leadership and stewardship from the ministry of health, supported by WHO.
As community members, grassroots advocates, service and programme providers, and performance monitors, civil society actors from the global to the local level constitute a vital bridge between policies and plans and the reality of change and improvement in the lives of all. Helping to organize and promote diverse voices across different communities, civil society can be a powerful champion of health equity.
The private sector has a profound impact on health and wellbeing. Where the Commission reasserts the vital role of public sector leadership in acting for health equity, this does not imply a relegation of the importance of private sector activities. It does, though, imply the need for recognition of potentially adverse impacts, and the need for responsibility in regulation with regard to those impacts. Alongside controlling undesirable effects on health and health equity, the vitality of the private sector has much to offer that could enhance health and wellbeing.
• Strengthening accountability: Recognize and respond accountably to international agreements, standards, and codes of employment practice; ensure employment and working conditions are fair for men and women; reduce and eradicate child labour, and ensure compliance with occupational health and safety standards; support educational and vocational training opportunities as part of employment conditions, with special emphasis on opportunities for women; and ensure private sector activities and services (such as production and patenting of life-saving medicines, provision of health insurance schemes) contribute to and do not undermine health equity.
• Investing in research: Commit to research and development in treatment for neglected diseases and diseases of poverty, and share knowledge in areas (such as pharmaceuticals patents) with life-saving potential.
…• Generating and disseminating social determinants of health knowledge: Ensure research funding is allocated to social determinants of health work; support the global health observatory and multilateral, national, and local crosssectoral working through development and testing of social determinants of health indicators and intervention impact evaluation; establish and expand virtual networks and clearing houses organized on the principles of open access, managed to enhance accessibility from sites in all high-, middle-, and low-income settings; contribute to reversal of the brain drain from low- and middle-income countries; and address and remove gender biases in research teams, proposals, designs, practices, and reports.
…ACTIONS FOR MARKET RESPONSIBILITY
The Commission recommends that:
12.1 WHO, in collaboration with other relevant multilateral agencies, supporting Member States, institutionalize health equity impact assessment, globally and nationally, of major global, regional, and bilateral economic agreements (see Rec 10.3; 16.7).
A key recommendation from the Commission is that caution be applied by participating countries in the consideration of new global, regional, and bilateral economic (trade and investment) policy commitments. Before such commitments are made, understanding the impact on health and health equity is vital. WHO should re-affirm its global health leadership by initiating a review of trade and investment agreements – working collaboratively with other multilateral agencies – with a view to institutionalizing health equity impact assessment as a standard part of all future agreements.
WHO can also strengthen the capacity of Member States, their ministries of health, and civil society organizations to prepare positions for bilateral and multilateral trade negotiations. To do this, WHO will need to augment its existing research and policy expertise, including economics, law, and the social sciences. Specific attention needs to be given to addressing trade-related negotiations on domestic regulation, subsidies, and government procurement – and those affecting globally organized production and financial markets – and trade in goods and services with direct effects on health.
BOX 12.4: WORLD HEALTH ORGANIZATION: DIAGNOSTIC TOOL AND
COMPANION WORKBOOK IN TRADE AND HEALTH – A PRIORITY FOR 2008/2009
WHO is working with WTO, the World Bank, World Intellectual Property Organization, UNCTAD, international experts, and trade and health policymakers from 10 countries to develop a diagnostic tool and companion workbook on trade and health. This new phase of work adopts a more systematic and broader perspective on the linkages between trade and health. The diagnostic tool examines five components of that relationship: 1) macroeconomics, trade, and health; 2) trade in health-related products, including medicines and intellectual property related issues; 3) trade in products hazardous to health, such as tobacco products; 4) trade in health services – e-commerce, health tourism, foreign direct investment in health, cross-border movement of health professionals; and 5) trade in foodstuffs.
The diagnostic tool and its companion workbook, which document best practices, data sources, decision trees, and international norms and standards, will be ready for implementation in 2009. The implementation of the diagnostic tool will enable policy-makers to develop national policies and strategies related to trade and health and to identify their capacity-building needs in this area.
…Health equity impact assessment in economic agreements
Since the health equity implications of international agreements and their impact on national policies and programmes are not always fully evident, health equity impact assessment is key to coherent cross-government policies and programmes. It is essential that health equity assessment be applied to policies or major programmes outside the health sector, too (MEKN, 2007a) (see Chapter 16: The Social Determinants of Health: Monitoring, Research, and Training).
The institutionalization of health equity impact assessment is clearly still in its infancy – and presents real issues in terms of required technical skills and institutional capacity in many countries, especially those with low and middle incomes. However, the example of environmental impact assessment provides some basis for optimism. Notwithstanding serious recognized shortfalls in the methodology, conduct, and enforcement of environmental impact assessment, environmental impact has become – in the space of a generation – a widely acknowledged criterion in the processes of policy-making across the board.
Flexibility in agreements
Commitment to trade agreements should not constrain signatory countries, after signing, from acting to mitigate unforeseen adverse impacts on health and health equity. There is a clear need for more flexibility in the way signatory status to international agreements can be modified over time. The General Agreement on Trade in Services (GATS) provides exceptions in cases of environmental or health hazard, but the provision is narrow and appears to require demonstration of actual harm, limiting national capacity to exercise precautionary measures (Box 12.7).
Although flexibilities are formally written into the Trade-related Aspects of Intellectual Property Rights (TRIPS) agreements, governments – particularly in many low- and middle-income countries with limited technical and institutional capacity – have in many cases derived only limited benefit from such flexibilities, and have in others been encouraged not to use them at all (Box 12.8).
At a more general level, international market-related trade agreements could include more strongly worded provisions by which countries with widely different needs and developmental strategies can opt out of their signatory status (for limited periods and under transparent conditions) where domestic conditions – including evidence of adverse impact on health and health equity – suggest the need (Box 12.9).
A core objective of all health-systems policy must be to ensure that everyone has access to competent, quality care independently of ability to pay (see Chapter 9: Universal Health Care). Theoretically, market regulation can shape the role and behaviour of the private sector within the health system. In practice, evidence that it can do so in ways that enhance health equity is lacking. Until governments have demonstrated their ability to effectively regulate private investment and provision in health services in ways that enhance health equity, they should avoid making any health services commitments in binding trade treaties that affect their capacities to exercise domestic regulatory control. It is not clear that any government, anywhere in the world, has met this test (HSKN, 2007; GKN, 2007). The example of health insurance is instructive. It is clear that health insurance can support health-care financing, but it must not, in so doing, undermine health equity (Box 12.12).
…POWER, MONEY AND RESOURCES PART 4
ACTION TOWARDS FAIRNESS IN VOICE AND INCLUSION
Political empowerment for health and health equity requires strengthening the fairness by which all groups in a society are included or represented in decision-making about how society operates, particularly in relation to its effect on health and health equity. Such fairness in voice and inclusion depends on social structures, supported by the government, that mandate and ensure the rights of groups to be heard and to represent themselves – through, for example, legislation and institutional capacity – and on specific programmes supported by those structures, through which active participation can be realized.
Beyond these, fairness depends on the growth of civil society organizations, networks, and movements and their progressive ability to challenge inequity and push for the installation of equity – in general and in relation to health – in the centre of all existing and emerging political debates.
Legislation for political empowerment – rights and agency The right to the conditions necessary to achieve the highest attainable standard of health – Article 12 of the International Covenant on Economic, Social and Cultural Rights – is principally concerned with disadvantaged groups, participation, and accountability and lies at the heart of the health and human rights movement (Hunt, 2007). General Comment 14 (2000) is a substantive instrument which confirms that the right to the conditions for health not only encompasses access to health care, but also includes the underlying determinants of health, such as safe water, adequate sanitation, a healthy environment, health-related information, and freedom from discrimination (UN, 2000a). Fundamental to the progressive realization of this right is the ratification, operationalization, and monitoring of General Comment 14 and associated actions. WHO, in collaboration with other international agencies and the UN Special Rapporteur on the Right to the Highest Attainable Standard of Health (see Chapter 15:
Good Global Governance), supports states in the adoption and implementation of General Comment 14.
…Underpinning the realization of rights, fair participation, and inclusion in decision-making and action that affects health and health equity are transparent, accountable, and participative political and legal systems that build on and reinforce authentic participation.
…Bottom-up approaches to health equity - While the empowerment of social groups through their representation in policy-related agenda-setting and decisionmaking is critical, so too is empowerment for action through bottom-up, grassroots approaches (Sibal, 2006). The struggles against the injustices encountered by the most disadvantaged in society, and the process of organizing these people, builds local people’s leadership. It is empowering. It gives people a greater sense of control over their lives and future. This empowerment permeates all aspects of their lives.
…The enactment of legal changes to recognize and support community empowerment initiatives will ensure the comprehensive inclusion of disadvantaged groups in action at global, national, and local levels concerned with improving health and health equity.
…BOX 14.8: BARRIO ADENTRO – THE RIGHT TO HEALTH AND SOCIAL INCLUSION IN BOLIVARIAN REPUBLIC OF VENEZUELA
The Venezuelan Constitution firmly establishes the right to health and the citizen’s duty to take an active part in the management of health. The draft bill of the new General Health Law declares that participation and social control in health is a constitutional right of all citizens and that they have the right to make decisions, intervene, and exercise direct control, with autonomy and independence, in all matters related to the formulation, planning, and regulation of health sector policies, plans, and projects, as well as the evaluation, control, and monitoring of health-sector management and financing.
…While it is critical that community members share control over processes that affect their lives, without political commitment and leadership and allocation of resources such initiatives can be short lived…
There are notable examples where an explicit rights agenda has been successfully applied to global governance. In the case of TRIPS and AIDS medicines, civil society-driven action from South Africa, with worldwide take-up, created a ‘norm cascade’ leading to immediate and structural changes not only in the market accessibility of life-saving drugs, but in the global understanding of questions of intellectual property and the application of appropriate norms for global health equity (Box 14.12).
For changes in power, there also needs to be space for challenge and contest by social movements. Although social movements and community organizations tend to mobilize around concrete issues in local everyday life, their actions are clearly rooted in and address structures and processes that extend far beyond this local realm. These movements tend to take one of three forms: political societies (e.g. political parties, pressure groups, lobbying groups), which seek influence within the political arena; civil societies such as trade unions, peasant organizations, and religious movements; and civil-political societies that combine or link the activities of political and civil societies (e.g. labour movements, women’s movement, antiapartheid movement).
The People’s Health Movement (http://phmovement. org/) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organized to combat the economic and political causes of deepening inequities in health worldwide and to call for the return to the principles of Alma Ata. Support for People’s Health Movement and other similar civil society organizations such as the global antipoverty movement and labour movement will help to ensure that action on the social determinants of health is developed, implemented, and evaluated.
A society concerned with better and more equitably distributed health is one that challenges unequal power relations through participation, ensuring all voices are heard and respected in decision-making that affects health equity. Being more inclusive requires social policies, laws, institutions, and programmes to protect human rights. It requires inclusion of individuals and groups to represent strongly and effectively their needs and interests in the development of policy. And it requires active civil society and social movements. It is clear that community or civil society action on health inequities cannot be separated from the responsibility of the state to guarantee a comprehensive set of rights and ensure the fair distribution of essential material and social goods among population groups (Solar & Irwin, 2007). Top-down and bottom-up approaches are equally vital.
BOX 14.12: TAKING ACTION ON RIGHTS AND TRADE: THE CASE OF AIDS MEDICINES
“The human right to health requires the provision of essential medicines as a core duty that cannot be traded for private property interests or domestic economic growth. This right may provide a means of achieving a more public health-oriented formulation, implementation and interpretation of trade rules by domestic courts, governments and the WTO alike. The growing power of this right is similarly reflected in an emerging jurisprudence where medicines have been successfully claimed under human rights protections”.
A decade ago, the high cost of AIDS medicines led WHO and UNAIDS to advise that treatment was not a wise use of resources in poorer countries. Prevention of HIV/AIDS was preferred over treatment. There was no international funding for developing countries to purchase drugs and companies gave extremely limited price concessions. A dramatic battle for AIDS medicines ensued that peaked in 2001 in the Pharmaceutical Manufacturer’s Association case in South Africa. Between 1997 and 2001, the United States and 40 pharmaceutical companies used trade pressures and litigation to prevent the South African government from passing legislation to access affordable medicines.
Industry claimed that the legislation (and the parallel importing it authorized) breached TRIPS and South Africa’s Constitution and threatened industry’s incentive to innovate new medicines. The pharmaceutical companies went to court in South Africa. An extraordinary level of public action accompanied the case, attracting global censure against the corporations. In April 2001, the pharmaceutical companies withdrew their case.
A norm cascade followed, with a sharp upsurge at the UN in international statements on treatment as a human right and articulations of state obligations on antiretroviral therapy. The same year saw the WTO issue its Declaration on TRIPS and Public Health.
These rhetorical commitments were matched by considerable policy and price shifts. Antiretroviral therapy prices in many low-income countries dropped from US$ 15 000 to US$ 148-549 per annum. New global funding mechanisms were created, such as the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, the United States PEPFAR and the World Bank Multi-Country HIV/AIDS Program for Africa. In 2002, WHO adopted the activist goal of placing 3 million people on antiretroviral therapy and, in late 2005, shifted upwards to the goal of achieving universal access to treatment by 2010, a goal similarly adopted by the UN General Assembly and by the G8. In 5 years, access to antiretroviral therapy in sub-Saharan Africa has increased from under 1% to current levels of 28%. Source: Forman, 2007