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      Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs): Addressing Unfinished Agenda and Strengthening Sustainable Development and Partnership

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          Introduction International development agenda has been actively led by the United Nations (UN) and its technical agencies and funds from their inception in the late 1940s. Till 1990s, the approach was fragmented and disjointed initiated by its specialized agencies or funds at various World Summits and Conferences to address three dimensions of development — economic, social, and environmental. The Millennium Declaration and Millennium Development Goals (MDGs) saw the convergence of development agenda of United Nations Development Programme (UNDP); United Nations Environment Programme (UNEP); World health organization (WHO); United Nations Children's Fund (UNICEF); United Nations Educational, Scientific and Cultural Organization (UNESCO); and other development agencies.(1) Recently adopted Sustainable Development Goals (SDGs) reflect further strengthening convergence of the development agenda. The SDGs also strengthen equity, human rights, and nondiscrimination. Progress in MDGs and Build Up to SDGs The MDGs generated new and innovative partnerships, galvanized public opinion, and showed the immense value of setting ambitious goals. By putting people and their immediate needs at the forefront, the MDGs reshaped decision-making in the developed and developing countries alike. It helped to lift more than one billion people out of extreme poverty, to make inroads against hunger, to enable more girls than ever before to attend school, and to protect our planet. Yet inequalities persist and the progress has been uneven. The world's poor remain overwhelmingly concentrated in some parts of the world. Several women continue to die during pregnancy or from childbirth-related complications. Progress tends to bypass women and those who are lowest on the economic ladder or are disadvantaged because of their age, disability, or ethnicity. Disparities between rural and urban areas remain pronounced.(2) India has made a substantial improvement in MDGs but the progress is mixed. The under-five mortality rate (U5MR) has come down from 126 (1990) to estimated 48 not reaching the target of 42 by 2015. However, the estimated child deaths have come down from 3.36 million (1990) to 1.2 million (2015) that translates to 3,300 child lives saved every day! U5MR in India is still above the world average (43), and is higher compared to Sri Lanka (10), Nepal (36), and Bangladesh (38). Infant mortality and neonatal mortality rates have come down to 38 (target 27) and 28 from 88 and 57, respectively.(3) India achieved a maternal mortality rate (MMR) of 167 (2011-2013) and expected to reach 140 in 2015 down from 437 in 1990, which is well above the target of 109.(4) If we go by the latest UN estimates of MMR of 560 in 1990,(5) the target should be 140 and India is on track to achieve this target. The target of safe drinking water has been achieved in rural areas and is likely to be achieved in the urban areas as well. The target of sanitation is likely to be achieved in urban areas and missed in rural areas.(5) The SDGs and Targets To create a new, people-centered, development agenda, a series of global consultations were conducted both online and offline. Civil society organizations, citizens, scientists, academics, and the private sectors from around the world were all actively engaged in the process. The SDGs include 17 goals and 169 targets.(6) Indicators are expected to come out in March 2016. The 17 goals in abridged form are as follows: No poverty; Zero hunger; Good health and well-being; Quality education; Gender equality; Clean water and sanitation; Affordable and clean energy; Decent work and economic growth; Industry, innovation, and infrastructure; Reduce inequality; Sustainable cities and communities; Responsible consumption and production; Climate action; Life under water; Life on land; Peace, justice, and strong institutions; and Partnership for the goals. Detailed goals and indicators are at https://sustainabledevelopment.un.org/?menu=1300. The targets are aspirational and global and that each government will set its own national targets taking into account the national circumstances. The SDGs can be broadly divided into three categories: First, an extension of MDGs that includes the first seven SDGs; second group is inclusiveness (jobs, infrastructure, industrialization, and distribution). It includes goals 8, 9, and 10; and the third group is on sustainability and urbanization that covers the last seven goals: sustainable cities and communities, life below water “consumption and production; climate action; resources and environment; peace and justice; and the means of implementation and global partnership for it”. Health goal The third SDG — “ensure healthy lives and promote well-being for all at all ages” — is wider-ranging compared to the health goals in MDGs that were limited to child and maternal mortality and communicable diseases. The social determinants of health though not spelled as such but are addressed through Goals 1 (poverty), 2 (hunger), 4 (education), 5 (gender equality), 6 (clean water and sanitation), 7 (affordable and clean energy), 8 (decent work and economic growth), 9 (industry innovation and infrastructure), 10 (reduced inequalities), 11 (sustainable cities and communities), 12 (responsible consumption and production), 13 (climate action), and 16 (peace, justice and strong Institutions). Health targets The health goal has nine targets and four subpoints.(6) The first three targets are continuation of MDGs, the next three are on no communicable disease (NCD), and the last three are mixed. Nine health targets and four sub-points are as follows: Reduce the global maternal mortality ratio to below 70/100,000. Reduce neonatal mortality to below 12/1,000 and U5MR to below 25/1,000. End the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases. Reduce by one-third premature mortality from noncommunicable diseases. Strengthen the prevention and treatment of substance abuse. Halve the number of global deaths and injuries from road traffic accidents (by 2020). Ensure universal access to sexual and reproductive health-care services. Achieve universal health coverage. Reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination. Four subpoints are: Strengthen the implementation of the WHO Framework Convention on Tobacco Control. Support the research and development of vaccines and medicines. Substantially increase health financing and the recruitment, development, training, and retention of the health workforce. Strengthen early warning, risk reduction, and management of health risks. Difference Between SDGs and MDGs SDGs benefit from the valuable lessons learned from MDGs. These also carry forward the unfinished agenda of MDGs for continuity and sustain the momentum generated while addressing the additional challenges of inclusiveness, equity, and urbanization and further strengthening global partnership by including CSOs and private sector. They reflect continuity and consolidation of MDGs while making these more sustainable by strengthening environmental goals. There are seven major differences in MDGs and SDGs; MDGs were drawn up by a group of experts in the ‘basement of UN headquarters’ whereas SDGs have evolved after a long and extensive consultative process including 70 Open Working Groups, Civil Society Organizations, thematic consultations, country consultations, participation of general public through face-to-face meetings and online mechanisms and door to door survey; While MDGs were focused with only 8 goals, 21 targets and 63 indicators, SDGs include 17 goals with 169 targets. An expert analyses by noble laureates at Copenhagen consensus, suggest that if the UN concentrates on 19 top targets, it can get $20 to $40 in social benefits per dollar spent, while allocating it evenly across all 169 targets would reduce the figure to less than $10. Being smart about spending could be better than doubling or quadrupling the aid budget;(7) MDGs had a focus on developing countries with funding came from rich countries. All countries, developed or developing, are expected to work towards achieving SDGs; The pillars of human development, human rights and equity are deeply rooted in SDGs and several targets seven explicitly refer to people with disabilities, six to people in vulnerable situations, and two to non-discrimination. These were not even mentioned in the MDGs; (iv) MDGs had 3 direct health goals, 4 targets and 15 indicators with emphasis on child, maternal mortality and communicable diseases. SDGs have one comprehensive goal emphasizing well-being and healthy living including NCDs; MDGs had a time span of 25 years though adopted in 2002 baseline data for the year 1990 was used and some of the baselines were revised subsequently which shifted ‘the goal post’. For the SDGs, the baseline is from 2015 estimates. It may be revised as more recent data becomes available; SDGs include a vision of building vibrant and systematic partnerships with private sector to achieve sustainable development. It builds on, UN Compact which was launched in year 2000 and IMPACT 2030; MDGs had no concrete role for the Civil Society Organizations (CSOs), whereas SDGs have paid attention to this right from the framing stage itself with significant engagement of civil society actors. The CSOs can play an important role to hold governments accountable at the local level. Challenges The four major challenges that need to be addressed for achieving the SDGs are as follows: Some of the SDGs that have been costed show that the cost of the SDGs is huge. The rough calculations have put the cost of providing a social safety net to eradicate extreme poverty at about $66 bn a year,(8) while annual investments in improving infrastructure (water, agriculture, transport, and power) could be up to a total of $7 tn globally. A major conference on financing for the SDGs, held in the Ethiopian capital Addis Ababa in July, failed to ease concerns that there will not be enough funds to meet the aspirational nature of the goals. It included a recommitment to the UN target on aid spending 0.7% of gross national income (GNI) set more than 40 years ago. Multilateral banks committed $400 bn;(9) Maintaining peace is essential for development. A threat to international peace and stability by nonstate actors is emerging as a major factor for both developed and developing countries. The recent crisis in Syria has forced 12 million people to leave their homes and made them refuges. Measuring progress: A number of targets in the SDGs are not quantified. The indicators for measuring progress have not yet been identified. Even if they limit to two indicators per target there will be 338 indicators to monitor and report. “Having 169 targets is like having no targets at all.”(10) Measurability will depend on the availability of data and capacity to measure them. Accountability: There was a lack of accountability for inputs into MDGs at all levels. This challenge needs to be addressed in SDGs. At the international level, most of the developed countries have not met the target of allocating 0.7% of GNI to international aid in the last 40 years. The lack of priority in funds allocation within country budget has also been a problem during MDGs. Similar lack of accountability exists at ministry, state, and local administration level. If we take SDGs seriously the accountability needs to be strengthened at all levels. India and SDGs The momentum created by MDGs in India needs to be sustained with focus on completing the unfinished task of MDGs. India-specific goals, targets, and indicators along with the roadmap to achieve these should be drawn up by the concerned ministry and states and union territories (UTs). One major challenge will be to fund these goals. It is also important to estimate the budget required and to find out from where these funds will come. The preliminary estimates from global meetings suggest mobilizing required resources is going to be a major challenge. The need to establish a system of collecting relevant data to monitor the progress is vital to achieve these goals, targets, and indicators that are much larger in numbers compared to MDGs. The reliance on data from surveys needs to be minimized. The health goal will need a major effort in addressing noncommunicable diseases and accidents and injuries while sustaining efforts to address maternal and child health and nutrition. Conclusion MDGs helped in mobilizing international community, leaders, politicians, civil society and sectoral ministries, and departments to focus on achieving these time-bound and measurably goals. We may not have achieved all these goals but have made a substantial progress in saving lives and improving quality of lives of millions of people within the country and globally. India has not made progress commensurate with its economic and technological might and needs to do more. MDGs have been easy to relate, understand, communicate, implement, and monitor, whereas SDGs, though to some extent, are a continuation of MDGs, yet suffer from the weakness of being too many and unwieldy to implement and monitor. This has probably resulted from large consultative process where everyone wants to see their areas of interest included. Providing required funding to these a reality remains a challenge. There is a need to improve accountability from international level to local level. The next 15 years is likely to see unprecedented mobilization of resources and efforts to make the world a better place to live for “we the people”, especially the marginalized and disadvantaged groups.

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              Health in International Development Agenda: Present, Past and Future

              Introduction International development agenda has been actively led by the United Nations (UN) and its technical agencies since their inception in 1940s. It brings together global political leaders to discuss common concerns related to peace, security, and development in line with the international charters and treaties. The development goals are built on the principle of consensus building. The Millennium Development Goals (MDGs) have been unique rallying point to bring the member states, civil society organizations and donors together to address development issues. The Past The UN and its technical agencies have spearheaded the initiatives related to development, health, and sustainable development. The UN has addressed development issues through its Development Decades and related initiatives which called for measures to eliminate illiteracy, hunger, disease, mortality and poverty, and a minimum of 0.7% of the GDP by developed countries to development assistance, for developing countries to achieve a GDP growth rate of 7.5%, etc., The UN organized a number of conferences to address problems of Social Development and declared 1996 as an International Year against Poverty and UN Decade for the Eradication of Poverty (1997-2006). The global initiatives on the health issues were led by the World Health Assembly (WHA) and mostly related to the eradication of diseases. Some of the major health issues addressed by the global community, at the WHA, include: Malaria Eradication (1955); Small Pox eradication (1958 and 1966); Guinea worm eradication (1981); EPI (1974) and UCI (1985); Polio eradication (1988); Leprosy eradication (1991). UNICEF’s Growth Monitoring, Oral rehydration, Breastfeeding and Immunization (GOBI) initiative contributed to the "First Child Survival Revolution" in 1980s.(1) There were 21 World Summits and conferences starting with Alma Ata Primary Health Care (1978) which provided the foundation for MDGs. The Sustainable Development has received attention since 1972 with the UN Conference on Human Environment at Stockholm. World Commission on Environment Development brought out its report "Our Common Future" in 1987. UN Conference on Environment and Development referred to as Earth Summit was held in 1992 and developed the UN Framework Convention on Climate Change, Convention on Biological Diversity and Statement of Forest Principles. Most recent conference was the Rio + 20 in 2012, which has provided inputs for the Post 2015 Development Agenda. The Present: Un Millennium Declaration and Millennium Development Goals One hundred and eighty-nine member states of the UN met at UN headquarters in Sept 2000 and set development agenda for the 21st century and adopted the UN Millennium Declaration. The road map toward its implementation is known as the MDGs. The MDGs introduced targeted approach for development. "The health-related MDGs do not cover all the health issues that matter to poor people and poor countries. But they do serve as markers of the most basic challenges ahead: to stop women dying during pregnancy and childbirth; to protect young children from ill health and death; and to tackle the major communicable diseases, in particular HIV/AIDS. Unless we can deal with these fundamental issues, what hope is there for us to succeed in other, equally important areas of health?(2)" Monitoring progress of MDGs An Inter-Agency Expert Group (IAEG) led by Department of Economic and Social Affairs, UN Secretariat was formed to report to the General Assembly (UNGA). Progress toward the eight MDGs is measured through 21 targets and 60 indicators. Data for monitoring of achievements are provided by the governments. To fill data gaps, IAEG uses surveys i.e., Multiple Indicator Cluster Surveys and Demographic Health Surveys. Data at individual countries often differ from IAEG data because: Some countries may have more recent data than what they reported to the UN, the IAEG estimates the missing values, and adjustments are often needed to ensure international comparability. The UN Statistics Division maintains an official website of the IAEG and its database (http://mdgs.un.org).(3) Frequency of reporting by member states is flexible and usually varies between 3 and 5 years. The Secretary General (UNSG) presents an annual report to the UNGA. The progress made in MDGs In the words of UN SG Ban Ki Moon, "Between now and 2015, we must make sure that promises made become promises kept. The consequences of doing otherwise are profound: Death, illnesses and despair, needless suffering, lost opportunities for millions upon millions of people."(4) The news from the recent MDG report(5) is summarized below. Good news The proportion of people living on < $1.25 a day fell (47% in 1990 to 24% in 2008). In terms of numbers it has declined from over 2 billion to less than 1.4 billion. The target of halving the proportion of people who lack access to improved sources of drinking water has been met. Conditions for more than 200 million people living in slums ameliorated which is double the 2020 target. Primary school enrolment of girls equaled that of boys. There has been 41% reduction in U5MR from 87 to 51 and the number of child deaths has come down from 12 to 7 million or 14,000 child lives saved every day. Not so good news In 2015, more than 600 million people will still be using unimproved water sources and almost one billion will be living on an income of less than $1.25 per day. A large number of mothers and children continue to die from preventable causes. Hunger remains a global challenge. Ensuring that all children complete primary education remains unfulfilled. Lack of sanitation is hampering progress in health and nutrition. Biodiversity loss and greenhouse gas emissions continue to pose a major threat to people and ecosystem. Progress in India According to the India Statistical Year Book 2013,(6) gender parity was achieved in primary education in 2007-08 and the disparity in secondary education is set to disappear by 2015. The country is well set to achieve 100% primary education ahead of 2015. Poverty ratio is likely to be 26.7% against target of 23.9% by 2015. Under five mortality rate would be around 52 against target of 42/1,000 by 2015. Maternal Mortality Rate would decline to 139/100000 against the goal of 109 by 2015 (437 in 1990). Proportion of underweight children is expected to decline to 33% against the target of 26% (52% in 1990). The future: Post 2015 agenda Post 2015 agenda builds on the experience of MDGs. It used an open and consultative process which was lacking in the development of the MDGs. The Secretary General of the UN constituted a High-level group in 2010 to make recommendations to advance the UN development agenda beyond 2015. UN System task team report 2012, Realizing the Future We Want,(7) was based on member states led consultation process, lessons learned from MDGs, decisions taken at Rio + 20 (June 2012) and global thematic consultations on inequalities, health, education, growth and employment, population dynamics, governance, conflict and fragility, environmental sustainability, food security, and nutrition and national consultations organized through UN Development Group. The major recommendations from these are summarized below. Post-2015 agenda should be universal. It should address global challenges such as sustainability, climate change, inequality on development and health. Some of the MDGs were “too narrow” and needed to be re-examined. "One size does not fit all", hence national goals should be determined nationally, in line with global principles and goals and focus on macroeconomic, political (democratic rights and participation) and social policies, as well as a supportive international environment (internally driven development, technology transfer, aid and labor mobility), and stronger global governance (regulation of trade and finance) to provide an enabling environment. Preserving the catalytic power of clear and simple MDG framework to build political momentum, ensure feasibility of implementation, strengthen measurability and accountability and the need to avoid an overload, while still ensuring an open and inclusive process of consultations. All the recommendations from the consultative processes have fed into the report of the High Level Panel of Eminent Persons on the Post-2015 Development Agenda. The Panel with 27 eminent members was co-chaired by the Presidents of Indonesia, and Liberia and Prime Minister of UK. The report builds upon the historic advances of the MDGs. The Panel interacted with more than 5000 civil society groups from 121 countries in developing its recommendations. The report was presented to the UNSG on May 30, 2013.(8) The report calls for the new post-2015 agenda to drive five big transformative shifts: (a) Leave No One Behind which recommends ending extreme poverty and equity; (b) Put Sustainable Development at the core, to integrate the social, economic and environmental dimensions of sustainability; (c) Transform Economies for Jobs and Inclusive Growth to end extreme poverty and improve livelihoods; (d) Build Peace and Effective, Open and Accountable Institutions for All to recognize peace and good governance as core element of wellbeing, not an optional extra; and (e) Forge a New Global Partnership in a spirit of solidarity, cooperation, and mutual accountability based on a common understanding of our shared humanity, based on mutual respect and mutual benefit. The report includes 12 illustrative candidate goals to be achieved by 2030 which are: End poverty Empower girls and women and achieve gender equality Provide quality education and lifelong learning Ensure healthy lives Ensure food security and good nutrition Achieve universal access to water and sanitation Secure sustainable energy Create jobs, sustainable livelihoods, and equitable growth Manage natural resource assets sustainably Ensure good governance and effective institutions Ensure stable and peaceful societies Create a global enabling environment and catalyze long-term finance. In the proposed goals, goal 4 is about health, food security, and nutrition is goal 5 and universal access to water and sanitation is goal 6, and other goals contribute to health. In the goals, non-communicable diseases and universal health care do not figure, though strongly recommended in the health sector report for Post-2015 agenda.(9) The UNSG will present the Post-2015 development agenda based on the High level panel report to the GA to move forward in September 2013. Conclusion Emphasis on human development has shifted policy attention beyond economic growth that dominated previous agenda. Major strength of MDGs is its focus on a limited set of concrete, common human development goals, and targets. It mainstreams stronger health and climate issues into development agenda. MDGs brought together governments, development partners, UN agencies and NGOs to achieve the goals. There is a need to accelerate efforts to achieve goals in the remaining time by developing a sense of urgency. The Post-2015 agenda in universal as it includes development issues in middle and high income countries and is being developed in an open and consultative manner building upon, providing continuity while addressing the weaknesses of the MDGs.
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                Author and article information

                Journal
                Indian J Community Med
                Indian J Community Med
                IJCM
                Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine
                Medknow Publications & Media Pvt Ltd (India )
                0970-0218
                1998-3581
                Jan-Mar 2016
                : 41
                : 1
                : 1-4
                Affiliations
                [1]National Health Systems Resource Centre, Ministry of Health and Family Welfare, New Delhi, India
                [1 ]Department of Pathology, Jamia Milia Islamia, New Delhi, India
                [2 ]Department of Community Health Administration, National Institute of Health and Family Welfare, NIHFW Campus, New Delhi, India
                Author notes
                Address for Correspondence: Dr. Sanjiv Kumar, National Health Systems Resource Centre, Ministry of Health and Family Welfare, NIHFW Campus, Baba Gangnath Marg, New Delhi - 110 067, India. E-mail: sanjiv.kumar@ 123456nhsrcindia.org
                Article
                IJCM-41-1
                10.4103/0970-0218.170955
                4746946
                26917865
                45d66dc0-493c-422e-b182-8bb9e4b60ea6
                Copyright: © 2016 Indian Journal of Community Medicine

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