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Tools and approaches to operationalize the commitment to equity, gender and human rights: towards leaving no one behind in the Sustainable Development Goals
other
Author(s):
Gerardo Zamora ,
Theadora Swift Koller ,
Rebekah Thomas ,
Mary Manandhar ,
Eva Lustigova ,
Adama Diop ,
Veronica Magar
Publication date (Electronic):
29 May 2018
Journal:
Global Health Action
Publisher:
Taylor & Francis
Read this article at
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ABSTRACT
The objective of this article is to present specific resources developed by the World Health Organization on equity, gender and human rights in order to support Member States in operationalizing their commitment to leave no one behind in the health Sustainable Development Goals (SDGs), and other health-related goals and targets. The resources cover: (i) health inequality monitoring; (ii) barrier analysis using mixed methods; (iii) human rights monitoring; (iv) leaving no one behind in national and subnational health sector planning; and (v) equity, gender and human rights in national health programme reviews. Examples of the application of the tools in a range of country contexts are provided for each resource.
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Most cited references16
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Health service coverage and its evaluation.
T Tanahashi (1978)
Health service coverage is considered as a concept expressing the extent of interaction between the service and the people for whom it is intended, this interaction not being limited to a particular aspect of service provision but ranging over the whole process from resource allocation to achievement of the desired objective. For the measurement of coverage, several key stages are first identified, each of them involving the realization of an important condition for providing the service; a coverage measure is then defined for each stage, namely the ratio between the number of people for whom the condition is met and the target population, so that a set of these measures represents the interaction between the service and the target population. This definition of coverage allows for variations, which are called "specific coverage", by limiting the target population to specific subgroups differentiated by certain conditions related to service provision or by demographic or socioeconomic factors.The evaluation of coverage on the basis of these concepts enables management to identify bottlenecks in the operation of the service, to analyse the constraining factors responsible for such bottlenecks, and to select effective measures for service development.
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Income-related inequalities and inequities in health care services utilisation in 18 selected OECD countries.
Marion Devaux (2015)
A key policy objective in OECD countries is to achieve adequate access to health care for all people on the basis of need. Previous studies have shown that there are inequities in health care services utilisation (HCSU) in the OECD area. In recent years, measures have been taken to enhance health care access. This paper re-examines income-related inequities in doctor visits among 18 selected OECD countries, updating previous results for 12 countries with 2006-2009 data, and including six new countries. Inequalities in preventive care services are also considered for the first time. The indirect standardisation procedure is used to estimate the need-adjusted HCSU and concentration indexes are derived to gauge inequalities and inequities. Overall, inequities in HCSU remain present in OECD countries. In most countries, for the same health care needs, people with higher incomes are more likely to consult a doctor than those with lower incomes. Pro-rich inequalities in dental visits and cancer screening uptake are also found in nearly all countries, although the magnitude of these varies among countries. These findings suggest that further monitoring of inequalities is essential in order to assess whether country policy objectives are achieved on a regular basis.
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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): ZGHA
Journal ID (publisher-id): zgha20
Title:
Global Health Action
Publisher:
Taylor & Francis
ISSN
(Print):
1654-9716
ISSN
(Electronic):
1654-9880
Publication date Collection: 2018
Publication date
(Electronic):
29
May
2018
Volume: 11
Issue: Suppl 1
,
Monitoring Health Inequality in Indonesia
Electronic Location Identifier: 1463657
Affiliations
Author notes
CONTACT Gerardo Zamora
zamorag@
123456who.int
Gender, Equity and Human Rights Team, World Health Organization , 20 Avenue Appia,
Geneva1211, Switzerland
Author information
Gerardo Zamora
http://orcid.org/0000-0002-8695-8249
Theadora Swift Koller
http://orcid.org/0000-0001-5655-7690
Rebekah Thomas
http://orcid.org/0000-0001-7416-4401
Mary Manandhar
http://orcid.org/0000-0001-9189-7762
Adama Diop
http://orcid.org/0000-0002-1788-8830
Article
Publisher ID: 1463657DOI: 10.1080/16549716.2018.1463657
PMC ID: 5974708
PubMed ID: 29808773
SO-VID: aeb4f555-2c14-4de9-a878-de7fc55f1027
Copyright © © 2018 WHO. Published by Informa UK Limited, trading as Taylor & Francis Group.
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This is an Open Access article distributed under the terms of the Creative Commons Attribution IGO License ( http://creativecommons.org/licenses/by/3.0/igo/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. There should be no suggestion that the WHO endorses any specific organization, products or services. This notice should be preserved along with the article’s original URL.
History
Date
received
: 22
September
2017
Date
accepted
: 05
April
2018
Page count
Figures: 1,
Tables: 1,
References: 47,
Pages: 8
Funding
None.
Categories
Subject:
Current Debate
ScienceOpen disciplines: Health & Social care