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The Millennium Development Goals: experiences, achievements and what's next
review-article
Publication date (Electronic):
13 February 2014
Journal:
Global Health Action
Publisher:
Co-Action Publishing
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Abstract
The Millennium Development Goals (MDGs) are eight international development goals to be achieved by 2015 addressing poverty, hunger, maternal and child mortality, communicable disease, education, gender inequality, environmental damage and the global partnership. Most activities worldwide have focused on maternal and child health and communicable diseases, while less attention has been paid to environmental sustainability and the development of a global partnership. Up to now, several targets have been at least partially achieved: hunger reduction is on track, poverty has been reduced by half, living conditions of 200 million deprived people enhanced, maternal and child mortality as well as communicable diseases diminished and education improved. Nevertheless, some goals will not be met, particularly in the poorest regions, due to different challenges (e.g. the lack of synergies among the goals, the economic crisis, etc.). The post-2015 agenda is now under discussion. The new targets, whatever they will be called, should reflect today's political situation, health and environmental challenges, and an all-inclusive, intersectoral and accountable approach should be adopted.
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Most cited references56
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Financing of global health: tracking development assistance for health from 1990 to 2007.
Nirmala Ravishankar, Paul Gubbins, Rebecca J Cooley … (2009)
The need for timely and reliable information about global health resource flows to low-income and middle-income countries is widely recognised. We aimed to provide a comprehensive assessment of development assistance for health (DAH) from 1990 to 2007. We defined DAH as all flows for health from public and private institutions whose primary purpose is to provide development assistance to low-income and middle-income countries. We used several data sources to measure the yearly volume of DAH in 2007 US$, and created an integrated project database to examine the composition of this assistance by recipient country. DAH grew from $5.6 billion in 1990 to $21.8 billion in 2007. The proportion of DAH channelled via UN agencies and development banks decreased from 1990 to 2007, whereas the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Global Alliance for Vaccines and Immunization (GAVI), and non-governmental organisations became the conduit for an increasing share of DAH. DAH has risen sharply since 2002 because of increases in public funding, especially from the USA, and on the private side, from increased philanthropic donations and in-kind contributions from corporate donors. Of the $13.8 [corrected] billion DAH in 2007 for which project-level information was available, $4.9 [corrected] billion was for HIV/AIDS, compared with $0.6 [corrected] billion for tuberculosis, $0.7 [corrected] billion for malaria, and $0.9 billion for health-sector support. Total DAH received by low-income and middle-income countries was positively correlated with burden of disease, whereas per head DAH was negatively correlated with per head gross domestic product. This study documents the substantial rise of resources for global health in recent years. Although the rise in DAH has resulted in increased funds for HIV/AIDS, other areas of global health have also expanded. The influx of funds has been accompanied by major changes in the institutional landscape of global health, with global health initiatives such as the Global Fund and GAVI having a central role in mobilising and channelling global health funds. Bill & Melinda Gates Foundation.
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Achieving the health Millennium Development Goals for South Africa: challenges and priorities.
David Sanders, Gavin Churchyard, Rachel Jewkes … (2009)
15 years after liberation from apartheid, South Africans are facing new challenges for which the highest calibre of leadership, vision, and commitment is needed. The effect of the unprecedented HIV/AIDS epidemic has been immense. Substantial increases in mortality and morbidity are threatening to overwhelm the health system and undermine the potential of South Africa to attain the Millennium Development Goals (MDGs). However The Lancet's Series on South Africa has identified several examples of leadership and innovation that point towards a different future scenario. We discuss the type of vision, leadership, and priority actions needed to achieve such a change. We still have time to change the health trajectory of the country, and even meet the MDGs. The South African Government, installed in April, 2009, has the mandate and potential to address the public health emergencies facing the country--will they do so or will another opportunity and many more lives be lost?
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The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015
Jeff Waage, Rukmini Banerji, Oona Campbell … (2010)
Executive summary The Millennium Development Goals (MDGs) represent an unprecedented global consensus about measures to reduce poverty. The eight goals address targets to increase incomes; reduce hunger; achieve universal primary education; eliminate gender inequality; reduce maternal and child mortality; reverse the spread of HIV/AIDS, tuberculosis, and malaria; reverse the loss of natural resources and biodiversity; improve access to water, sanitation, and good housing; and establish effective global partnerships. Progress in some goals has been impressive; however, global targets will not be met in some regions, particularly sub-Saharan Africa and south Asia. As we approach the 2015 target date, there is considerable interest in assessment of the present goals and in consideration of the future of development goals after 2015. This Commission has brought together sectoral experts on different MDGs from the London International Development Centre to identify cross-cutting challenges that have emerged from MDG implementation so far. This interdisciplinary approach differs from previous MDG studies that have either examined individual goals or made broad sociopolitical assessments of the MDGs as a development mechanism. We used our analysis of cross-cutting challenges as the basis to identify a set of principles for future goal development, after 2015. We emphasise that this report is not an assessment of the MDGs; we focus deliberately on challenges with the implementation of the MDGs so as to inform future goal setting. The MDGs are an assembly of sector-specific and often quite narrowly focused targets that have their various origins in development ideas and campaigns of the 1980s and 1990s. They were not derived from an inclusive analysis and prioritisation of development needs, and this is reflected in the absence from them of a range of key development issues. The variable progress recorded with goals and targets partly indicates a tendency over time to focus on a subset of targets that have proven easier to implement and monitor, or which have stronger ownership by international or national institutions, or both. Complexity and lack of ownership have been particular problems for new targets added later in the MDG process. We provide short analyses of each MDG for those seeking more depth and to set out the evidence for a cross-MDG analysis (webappendix). Clearly the MDGs have had notable success in encouraging global political consensus, providing a focus for advocacy, improving the targeting and flow of aid, and improving the monitoring of development projects. However, MDGs have also encountered a range of common challenges. Challenges with the conceptualisation and execution of the MDGs arise at the three discrete levels on which they are constructed: goals, targets, and indicators. The very specific nature of many goals, reflecting their diverse, independent origins, leaves considerable gaps in coverage and fails to realise synergies that could arise across their implementation; we draw attention to particular synergies between education, health, poverty, and gender. In some cases, targets present a measure of goal achievement that is too narrow, or might not identify a clear means of delivery. Other challenges encountered by several MDGs include a lack of clear ownership and leadership internationally and nationally, and a problem with equity in particular. Issues of equity arise because many goals target attainment of a specific minimum standard—eg, of income, education, or maternal or child survival. To bring people above this threshold might mean a focus on those for whom least effort is required, neglecting groups that, for geographical, ethnic, or other reasons, are more difficult to reach, thereby increasing inequity. From our cross-sectoral analysis, we conclude that future goals should be built on a shared vision of development, and not on the bundling together of a set of independent development targets. By means of example, we conceptualise development as a dynamic process involving sustainable and equitable access to improved wellbeing, which is achieved by expansion of access to services that deliver the different elements of wellbeing. These elements can be defined in many ways, and would include those addressed in the MDGs. Instead of proposing a set of elements, and hence a new set of MDGs, we suggest a set of five principles by which development should be achieved. A holistic approach is needed to avoid gaps in the development agenda and ensure synergy between its interlinked components, each of which should address elements of human, social, and environmental development. Elements of wellbeing should be delivered to ensure equity of opportunity and outcome, recognising its complex and local nature, and addressing all communities while taking a deliberately pro-poor approach. This equity is a key feature of sustainability, as is a clear commitment to focusing productivity growth where it is needed. A broad development agenda arising from this process should be agreed internationally, but developed locally, to ensure ownership of goals and their monitoring across society nationally, regionally, and globally. This agenda should be based on a strong global obligation supported by effective international institutional frameworks. Finally, we show how such principles can be applied to the development of future goals by selecting one element of wellbeing, health, and exploring the implications of each principle for its future improvement. Part 1: a review of the MDGs—origin, implementation, and progress Introduction The eight Millennium Development Goals (MDGs) emerged from the United Nations (UN) Millennium Declaration in 2000, and are arguably the most politically important pact ever made for international development. 1 They identify specific development priorities across a very broad range, including poverty, education, gender, health, environment, and international partnerships. These goals have substantially shaped development dialogue and investment; some development agencies judge all their activities on the contribution to achievement of the MDGs. 2 Overall, progress towards the MDGs has been described as “patchy” 3 and “uneven”. 4 The broad conclusion is that few goals are entirely on track globally, and those that are show substantial variation, with least progress in Africa and often south Asia. Whereas MDG 1 (eradication of extreme poverty and hunger) is on course to be achieved and “remarkable improvements” have been made regarding aspects of MDG 6 (combating of HIV/AIDS, malaria, and other diseases), insufficient progress has been made towards achievement of MDG 2 (provision of universal primary education), MDG 4 (reduction of child mortality), and MDG 5 (reduction of maternal mortality).4, 5 Steps towards MDG 3 (promotion of gender equality and empowerment of women) have been labelled “sluggish”; “alarmingly high” rates of deforestation are hampering MDG 7 (ensuring of environmental sustainability); and Africa is “short-changed” by the aid flows included under MDG 8 (development of a global partnership for development). 4 Moreover, the global economic crisis has accentuated the urgency of the discussion, and progress is being jeopardised because of new financial constraints. 6 As we approach the two-thirds mark for the achievement of these goals in 2015, attention is focused on acceleration of progress, and on whether these goals are the right model for international development after 2015. So far, analysis of the MDGs as models for international development has taken two forms. The first involves sector-specific assessment of progress towards individual MDGs, largely by sectoral experts.7, 8, 9, 10, 11 The second involves broader analysis of the MDGs as instruments of development, largely by international development specialists.3, 12, 13 We believe that an understanding of the MDGs and future improvements in goal setting benefits from consideration of all goals together, because they are so interconnected and because their individual implementation has identified many common issues. The purpose of this report is to identify challenges that have emerged in delivery of the MDGs that are common to different goals and to suggest how future goal setting can be improved to avoid these difficulties. We do not undertake to present a verdict on the MDGs, or a balanced assessment weighing advantages and disadvantages. We focus deliberately on problems with the MDGs to identify better future approaches. We will not propose specific changes in MDGs after 2015, but will suggest a set of principles that might guide future goal development. This Commission is intended for a broad readership interested in all MDGs and for a more health-focused readership, who we hope will gain an improved understanding of the important relations between health and other MDG targets. We begin part 1 of our report with a brief introduction to the MDGs, which is accompanied by a webappendix presenting analyses of the development and implementation of each MDG. In part 2, we present a cross-cutting comparison and analysis of MDGs 1–7. We restrict our analysis to these seven MDGs because they share a focus, across very different sectors, on action in and by developing countries, whereas MDG 8 is focused more on actions by wealthy countries. We derive from this analysis the common challenges facing the MDGs. In part 3, we use these challenges to develop and illustrate five principles for future development goal setting, with health as a theme. Methods This Commission was undertaken at the request of The Lancet by the London International Development Centre (LIDC)—a consortium of six University of London colleges (Birkbeck, Institute of Education, London School of Hygiene and Tropical Medicine, School of Oriental and African Studies, Royal Veterinary College, and the School of Pharmacy). LIDC is dedicated to novel, intersectoral, and interdisciplinary approaches to international development. The Commission was co-designed with The Lancet, coordinated by LIDC, and prepared by experts in three LIDC member institutions: the London School of Hygiene and Tropical Medicine, Institute of Education, and School of Oriental and African Studies, and their research partners in South Africa, Zambia, Malawi, India, and Thailand. This team brought specific, individual expertise with MDGs 1–7, from different development perspectives and backgrounds. To build a team approach, each expert was asked with her or his partners to write a critique of their MDG and to contribute ideas arising from this analysis towards the design of future development goals. All participants read these papers as preparation for a 2-day facilitated workshop that identified issues and challenges that cut across the MDGs and built a consensus about future development goal setting. During four subsequent, smaller workshops, this consensus was developed into a final document. Although overseas partners could participate only in the first main workshop, all contributed towards subsequent development and have made contributions to the final version, including specific case studies. Analyses of individual MDGs are provided (webappendix) for readers interested in more detail. They provide the evidence base for the cross-cutting analysis. Background to the MDGs The MDGs comprise a set of eight goals and associated targets and indicators. They represent the latest effort in a long process of development goal setting which had antecedents in the Universal Declaration of Human Rights, the Development Decade of the 1960s, and the many UN summits of the second half of the 20th century that set specific goals to reduce hunger, improve health, eradicate diseases, and school children. 14 The immediate antecedent of the MDGs was the Millennium Declaration, presented in 2000 at the UN Millennium Summit. 15 The Millennium Declaration presented six values that were considered to be fundamental to international relations in the 21st century: freedom, equality, solidarity, tolerance, respect for nature, and shared responsibility. Seven key objectives were identified to translate these shared values into actions: peace, security, and disarmament; development and poverty eradication; protection of our common environment; human rights, democracy, and good governance; protection of vulnerable people; meeting of the special needs of Africa; and strengthening of the UN. The second objective, development and poverty eradication, was translated into eleven resolutions, presented as development targets. Many of these targets had legacies that predated the Millennium Declaration and had arisen from sector-specific UN-sponsored and other world conferences and summits during the previous decades. Most had appeared as international development targets in the report of the Development Assistance Committee (DAC) of the Organisation for Economic Co-operation and Development (OECD) Shaping the 21st century: the contribution of development cooperation. 16 The OECD's international development targets were particularly influential in the determination of the relevant text of the Millennium Declaration. With the addition of a few more targets, particularly for environmental sustainability, these became the MDGs. In turn these targets were linked post hoc with indicators, for the purposes of measurement, and with goals, for the purpose of conceptual simplicity. By 2001 the MDG framework comprised eight goals, 18 targets, and 48 indicators. 17 A few more targets and indicators were added later, creating the set presented in panel 1 . Panel 1 The Millennium Development Goals18 Goal 1: eradicate extreme poverty and hunger • Target 1A: halve, between 1990 and 2015, the proportion of people whose income is less than US$1 a day • Indicator 1.1: proportion of population below $1PPP per day • Indicator 1.2: poverty gap ratio • Indicator 1.3: share of poorest quintile in national consumption • Target 1B: achieve full and productive employment and decent work for all, including women and young people • Indicator 1.4: growth rate of GDP per person employed • Indicator 1.5: employment-to-population ratio • Indicator 1.6: proportion of employed people living below $1 PPP per day • Indicator 1.7: proportion of own-account and contributing family workers in total employment • Target 1C: halve, between 1990 and 2015, the proportion of people who suffer from hunger • Indicator 1.8: prevalence of underweight children younger than 5 years • Indicator 1.9: proportion of population below minimum level of dietary energy consumption Goal 2: achieve universal primary education • Target 2A: ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling • Indicator 2.1: net enrolment ratio in primary education • Indicator 2.2: proportion of pupils starting grade 1 who reach last grade of primary • Indicator 2.3: literacy rate of 15–24-year-olds, women, and men Goal 3: promote gender equality and empower women • Target 3A: eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015 • Indicator 3.1: ratios of girls to boys in primary, secondary, and tertiary education • Indicator 3.2: share of women in wage employment in the non-agricultural sector • Indicator 3.3: proportion of seats held by women in national parliament Goal 4: reduce child mortality • Target 4A: reduce by two-thirds, between 1990 and 2015, the mortality rate in children younger than 5 years • Indicator 4.1: mortality rate in children younger than 5 years • Indicator 4.2: infant mortality rate • Indicator 4.3: proportion of 1-year-old children immunised against measles Goal 5: improve maternal health • Target 5A: reduce by three quarters, between 1990 and 2015, the maternal mortality ratio • Indicator 5.1: maternal mortality ratio • Indicator 5.2: proportion of births attended by skilled health personnel • Target 5B: achieve, by 2015, universal access to reproductive health • Indicator 5.3: contraceptive prevalence rate • Indicator 5.4: adolescent birth rate • Indicator 5.5: antenatal care coverage (at least one visit and at least four visits) • Indicator 5.6: unmet need for family planning Goal 6: combat HIV/AIDS, malaria, and other diseases • Target 6A: have halted by 2015 and begun to reverse the spread of HIV/AIDS • Indicator 6.1: HIV prevalence among population aged 15–24 years • Indicator 6.2: condom use at last high-risk sex • Indicator 6.3: proportion of population aged 15–24 years with comprehensive correct knowledge of HIV/AIDS • Indicator 6.4: ratio of school attendance of orphans to school attendance of non-orphans aged 10–14 years • Target 6B: achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it • Indicator 6.5: proportion of population with advanced HIV infection with access to antiretroviral drugs • Target 6C: have halted by 2015 and begun to reverse the incidence of malaria and other major diseases • Indicator 6.6: incidence and death rates associated with malaria • Indicator 6.7: proportion of children younger than 5 years sleeping under insecticide-treated bednets • Indicator 6.8: proportion of children younger than 5 years with fever who are treated with appropriate antimalarial drugs • Indicator 6.9: incidence, prevalence, and death rates associated with tuberculosis • Indicator 6.10: proportion of tuberculosis cases detected and cured under directly observed treatment short course Goal 7: ensure environmental sustainability • Target 7A: integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources • Indicator 7.1: proportion of land area covered by forest • Indicator 7.2: CO2 emissions, total, per head and per $1 GDP (PPP) • Indicator 7.3: consumption of ozone-depleting substances • Indicator 7.4: proportion of fish stocks within safe biological limits • Indicator 7.5: proportion of total water resources used • Target 7B: reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss • Indicator 7.6: proportion of terrestrial and marine areas protected • Indicator 7.7: proportion of species threatened with extinction • Target 7C: halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation • Indicator 7.8: proportion of population using an improved drinking water source • Indicator 7.9: proportion of population using an improved sanitation facility • Target 7D: by 2020, to have achieved a significant improvement in the lives of at least 100 million slum dwellers • Indicator 7.10: proportion of urban population living in slums Goal 8: develop a global partnership for development • Target 8A: develop further an open, rule-based, predictable, non-discriminatory trading and financial system (includes a commitment to good governance, development, and poverty reduction, both nationally and internationally) • Target 8B: address the special needs of the least developed countries (includes: tariff and quota free access for the least developed countries' exports; enhanced programme of debt relief for HIPC and cancellation of official bilateral debt; and more generous ODA for countries committed to poverty reduction) • Target 8C: address the special needs of landlocked developing countries and small island developing States (through the Programme of Action for the Sustainable Development of Small Island Developing States and the outcome of the 22nd special session of the General Assembly) • Target 8D: deal comprehensively with the debt problems of developing countries through national and international measures in order to make debt sustainable in the long term Official development assistance* : • Indicator 8.1: net ODA, total and to the least developed countries, as percentage of OECD/DAC donors' gross national income • Indicator 8.2: proportion of total bilateral, sector-allocable ODA of OECD/DAC donors to basic social services (basic education, primary health care, nutrition, safe water, and sanitation) • Indicator 8.3: proportion of bilateral official development assistance of OECD/DAC donors that is untied • Indicator 8.4: ODA received in landlocked developing countries as a proportion of their gross national incomes • Indicator 8.5: ODA received in small island developing States as a proportion of their gross national incomes Market access: • Indicator 8.6: proportion of total developed country imports (by value and excluding arms) from developing countries and least developed countries, admitted free of duty • Indicator 8.7: average tariffs imposed by developed countries on agricultural products and textiles and clothing from developing countries • Indicator 8.8: agricultural support estimate for OECD countries as a percentage of their gross domestic product • Indicator 8.9: proportion of ODA provided to help build trade capacity Debt sustainability: • Indicator 8.10: total number of countries that have reached their HIPC decision points and number that have reached their HIPC completion points (cumulative) • Indicator 8.11: debt relief committed under HIPC and MDRI initiatives • Indicator 8.12: debt service as a percentage of exports of goods and services • Target 8E: in cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries • Indicator 8.13: proportion of population with access to affordable essential drugs on a sustainable basis • Target 8F: in cooperation with the private sector, make available the benefits of new technologies, especially information and communications • Indicator 8.14: telephone lines per 100 population • Indicator 8.15: cellular subscribers per 100 population • Indicator 8.16: internet users per 100 population To understand the MDGs, the political context in which they arose has to be appreciated. Several recent analyses have provided a useful insight into how the MDGs represent an integration of different international development strategies and initiatives emerging over recent decades. Hulme, 19 for instance, suggests that the MDGs developed through an interaction between, on the one hand, a US-led, neo-liberal ideology (one that promotes economic growth based on free trade and markets) linked to results-based management and, on the other hand, a development approach of some other wealthy countries, multilaterals, and non-governmental organisation (NGOs) that focused on multidimensional human development—eg, health, education, and gender equity, treating these as both development goals and development means. The emerging goals are biased towards a human development approach—“five and a half of the eight MDGs are about enhancing human capabilities” 19 —and there is a strong emphasis on basic needs. However, they also incorporate neo-liberal thinking about economic growth into their important poverty goal (MDG 1), and their overall results-based framework focused greatly on international development partnerships. Manning 3 observes how the early neo-liberal leanings of the goals were tempered by recognition of the need for buy-in by developing countries and by NGOs, leading to the inclusion of goals more focused on human welfare and development, such as health and education. In addition to their integration of different development challenges and approaches, the MDGs also provided a novel, target-oriented framework for the international development community. Gore 13 suggests that in tempering earlier neo-liberal approaches to development with human development objectives, the MDGs represent a switch from a “procedural conception of international society” to a “purposive conception”. The former involves “an association of States joined together through their common respect for a set of rules, norms and standard practices which govern the relationships between them” whereas the latter involves “an association of States joined together in a cooperative venture to promote common ends”. 13 With this target focus came an important shift from maximalist views of development (in which development involves poorer countries achieving aspirations of equality with richer countries) to minimalist standards (of proportions of people crossing poverty thresholds or accessing particular services or avoiding mortality or morbidity); and from societal and national change to changes for individuals within nation states. The emphasis on specific and minimalist targets, and the way in which it narrowed the development agenda and placed particular responsibilities on developing country governments, has generated many of the challenges facing implementation of the MDGs. Our study is based on the comparison of experiences across the different MDGs. To facilitate this comparison, we provide analyses of each MDG: how it was developed, how it has been implemented, and what this information tells us about its success so far. This analysis is provided in the webappendix, which we recommend readers consult for a deeper understanding of MDG performance. We use the analyses of MDGs 1–7 as the evidence base for our analysis in part 2 of this Commission. These MDG analyses show that the MDGs and their targets all have their origins in development initiatives that predate the Millennium Declaration. For the most part, the MDGs constitute an assembly of often very narrowly focused and sector-specific development ideas and campaigns from the 1980s and 1990s. Their targets are often so narrow as to neglect important development issues in the same sector—eg, tertiary education, reproductive health, and a range of gender issues. At their conception, therefore, the MDGs were not a plan derived bottom-up from a broad, intersectoral conceptualisation of development and prioritisation of development needs, although superficially they might seem to have been. These summaries also show that progress has varied between goals and between targets. Although some goals were set up with a range of targets and indicators, subsequent attention and monitoring for any goal has usually focused on a subset of these targets and indicators, sometimes only one. This narrowing process could be an indication of differences in ease of target implementation and monitoring, and in the level of ownership by international and other institutions, with little ownership or overlap in ownership reducing progress. Generally, efforts to improve MDGs by adding new targets at a later date have not been very successful, owing to the complexity of these targets and their indicators or to limited ownership, or both. Part 2: a cross-cutting analysis of the MDGs Positive contributions of the MDGs In this section, we use our studies of individual MDGs as the evidence base from which we build a cross-cutting analysis. When appropriate, we relate our conclusions to other reviews of the MDGs that have used a range of approaches.2, 3, 12, 13, 15, 20, 21, 22, 23, 24 The performance of individual MDGs so far suggests that they have made four important positive contributions: encouraging global political consensus, providing a focus for advocacy, improving the targeting and flow of aid, and improving the monitoring of development projects. Endorsed by 189 governments, the MDGs represent an unprecedented consensus on international development. In this context, they have been more successful than have some of the UN's earlier development initiatives, such as the Development Decades of the 1960–90s or the resolutions about Least Developed Countries and Small Island Developing States. 3 In a 2005 survey of 118 countries, 86% had reportedly acted in response to the MDGs. 25 The MDGs are claimed to be “the first global development vision that combines a global political endorsement with a clear focus on, and means to engage directly with, the world's poor people”. 1 The survey of individual MDGs (webappendix) shows how the MDGs have helped advocacy of particular development agendas. For popular agendas, such as those to reduce poverty (MDG 1) and infectious diseases (MDG 6), MDGs provided additional leverage, whereas for relatively neglected agendas such as child survival (MDG 4) and gender (MDG 3), their effect was to reinvigorate these campaigns. In the case of gender, for example, the Fourth World Conference on Women in Beijing in 1995 had led to the establishment of gender mechanisms and approaches to mainstreaming of gender issues within several ministries. Their achievements were fragile,26, 27 until the MDGs stimulated donors to include gender equity in aid packages.28, 29, 30 The MDGs are generally thought to have improved the targeting and flow of aid and other investments, supported by the way in which donors have linked the MDGs to their strategies for aid provision 6 and by evidence of an increase in resource mobilisation. 21 According to OECD figures, between 2000, when the Millennium Declaration was adopted, and 2006, total development assistance for health has more than doubled from US$6·8 billion to $16·7 billion, most of it focused on infectious diseases (MDG 6). 31 Large increases in donors' financial commitments to education, which can fairly transparently be linked to MDG 2, were recorded after 2000. However, the cases of health and education also show how difficult it is to establish a cause and effect relationship between the MDGs and an increase in aid. The late 1990s and early 2000s saw the conceptualisation and creation of several independent initiatives in health and education, including the International Finance Facility for Immunisation; the Global Fund to Fight AIDS, Tuberculosis and Malaria; Business Alliance Against Chronic Hunger; and the initiatives following the Education for All conferences in Jomtien (1990) and Dakar (2000), whose objectives overlapped with those adopted subsequently in MDG 6 and MDG 2. The contribution of the MDGs, in these cases, might best be viewed as reinforcing, rather than driving, the targeting and mobilisation of resources. Finally, the MDGs have stimulated an improvement in monitoring development programmes through data collection and analysis: “Once the MDGs gained currency, a cascade of statistical and analytical work got underway”. 23 Although we have noted that across the MDGs there are profound questions about the quality of the data obtained from such monitoring, few would disagree that it has been beneficial to evaluation, and probably to investment. Challenges posed by the MDGs Set against these positive contributions are several shortcomings that emerge consistently across our analysis of individual MDGs. Characteristically, most of these weaknesses present themselves as the flip side of the MDGs' more positive elements. Thus, the parsimony of the MDGs, which has probably facilitated their acceptance and use, makes them at the same time limited in scope, whereas their quantitative targets and precise indicators, for all their value in providing measurable outcomes, often fail to capture some crucial elements of goal achievement. We have to accept that all goal setting involves such trade-offs. However, the value of focusing on shortcomings of the MDGs lies in our potential to improve them, or replace them with something better. Ineffective MDGs pose two risks: they might not achieve their intended effect, and they could lead to negative effects by ignoring or impeding more effective development and poverty reduction. Our analysis identifies challenges with the MDGs in four areas: conceptualisation, execution, ownership, and equity. Other studies have also identified cross-cutting issues,12, 22 which we will discuss as appropriate. Conceptualisation and execution We consider first how well the MDGs have been developed at different levels—goal, target, and indicator—which has obvious consequences for how well they have been executed at each level. For instance, an indicator for which accurate data cannot be obtained is poorly conceived and prevents execution of the target. In table 1 we show some difficulties relating to conceptualisation and execution, drawn from our individual analyses of the MDGs presented in the webappendix. This list is illustrative and not meant to be comprehensive. Table 1 Goals and targets for MDGs 1–7, with observations on difficulties with conceptualisation and execution Problems with goals Problems with targets delivering goals Problems with indicators delivering targets Goal 1: halve hunger and poverty Poverty too narrowly conceived as income-based .. .. Target 1A: halve, between 1990 and 2015, the proportion of people whose income is
Author and article information
Journal
Journal ID (nlm-ta): Glob Health Action
Journal ID (iso-abbrev): Glob Health Action
Journal ID (publisher-id): GHA
Title:
Global Health Action
Publisher:
Co-Action Publishing
ISSN
(Print):
1654-9716
ISSN
(Electronic):
1654-9880
Publication date
(Electronic):
13
February
2014
Publication date Collection: 2014
Volume: 7
Electronic Location Identifier: 10.3402/gha.v7.23695
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Author notes
[*
]Correspondence to: Marta Lomazzi, World Federation of Public Health Associations &
Institute of Global Health, University of Geneva, rue Michel Servet 1, CH-1211 Geneva,
Switzerland, Email:
marta.lomazzi@
123456unige.ch
Article
Publisher ID: 23695DOI: 10.3402/gha.v7.23695
PMC ID: 3926985
PubMed ID: 24560268
SO-VID: 5bf4d082-0aba-419a-9bef-fbb5448e58bc
Copyright © © 2014 Marta Lomazzi et al.
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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
History
Date
received
: 05
September
2013
Date
revision received
: 28
November
2013
Date
accepted
: 18
December
2013
Categories
Subject:
Review Article
ScienceOpen disciplines: Health & Social care
Data availability:
ScienceOpen disciplines: Health & Social care