Health-dedicated Millennium Development Goals: What has been Done Wrong?

INTRODUCTION

The United Nations Millennium Declaration, signed in September 2000, commits world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. The Millennium Development Goals (MDGs) are derived from this declaration. Each MDG has targets set for 2015 and indicators to monitor progress from 1990 levels. Several of these that relate directly to health are shown in Table 1, together with targets and achievements.¹

MILLENNIUM DEVELOPMENT GOALS: SUCCESS STORY OR DISASTER?

In the Millennium Development Goals report from 2015, it has been pointed out that “Despite many successes, the poorest and most vulnerable people are being left behind. Gender inequality persists. Big gaps exist between the poorest and richest households, and between rural and urban areas. Climate change and environmental degradation undermine progress achieved, and poor people suffer the most. Conflicts remain the biggest threat to human development. Millions of poor people still live in poverty and hunger, without access to basic services.”² However, there have been stories published on maternal and child health improvements from different parts of the world, which seem to be worth sharing.

The data from India on infant, under-five, and maternal mortality rates have been published recently on the example of metropolitan city of Mumbai in which infant mortality decreased in the 5-year period (2011–2015) from 29.53 to 26.72 per 1,000 livebirths, whereas maternal mortality increased from 80.57 to 8 per 100,000 livebirths.³ The authors were very satisfied with those data pointing out in the conclusions that mechanism for intersectoral coordination, information technology support, surveillance, and tracking of pregnant mothers needs to be developed. The linkage of maternal and child health services with developmental programs is needed.

The data from Ethiopia revealed that most of the MDGs have been achieved. They claim that there was a 90% decline in HIV infections, 73% decrease in malaria-related deaths, 71% reduction in maternal mortality rate, 67% reduction in under-five mortality, and 50% decline in mortality due to tuberculosis. Authors of the study from Ethiopia concluded that meeting most of the targets of the health-related MDGs could be explained by multisectoral and comprehensive approach.⁴

In one study comparing the progress of MDGs in other regions and sub-Saharan Africa, it was revealed that significantly faster progress of MDGs 4 and 5 of other regions compared to sub-Saharan countries, reported previously by a number of studies, was attributable to the substantial achievement already accomplished prior to the MDGs campaign. It is time to learn from the success stories of the sub-Saharan African countries.⁵

In the study from Muslim majority countries, the authors proved that unfavorable social conditions, such as war, terrorism, refuge status, total literacy and female literacy rate, and greater female to male enrolment in secondary school, had major impact on the results on under-five mortality rate in those countries.⁶ Very similar conclusions have been driven in the study from Afghanistan proving the associations between conflict and maternal and child health, differed by health care intervention and delivery domain, with several key indicators lagging behind in areas with higher-intensity conflict.⁷

In Kenya, the authors concluded that country was faced with wide inequities for several health-system-based interventions with the predictors of change in family planning, skilled birth assistance, and full vaccination suggesting that maternal literacy and family size are important drivers of positive change in key interventions across the continuum of maternal and infant care.⁸

In a very important study published in Lancet on universal coverage for reproductive, maternal, newborn, and child health (RMNCH), the conclusions were as follows:⁹

• “Even though strong progress was made in the coverage of many essential RMNCH interventions during the past decade, many countries are still a long way from universal coverage for most essential interventions. Furthermore, a growing body of evidence suggests that available services in many countries are of poor quality, limiting the potential effect on RMNCH outcomes.
• Within-country inequalities in intervention coverage are reducing in most countries (and are now almost nonexistent in a few countries), but the pace is too slow.
• Health-sector (e.g., weak country health systems) and nonhealth-sector drivers (e.g., conflict settings) are major impediments to delivering high-quality services to all populations. Although more data for RMNCH interventions are available now, major data gaps still preclude the use of evidence to drive decision-making and accountability.”

DEVELOPMENT OF SUSTAINABLE DEVELOPMENT GOALS

When almost 20 years ago United Nations General Assembly (UNGA) launched MDGs, there was a hope that inequalities in the world will be decreasing. Among the MDGs, there were goals 4 and 5 dedicated to the child and maternal health, mostly treating maternal, neonatal, and under-five mortality rates. The analysis of the achievement of MDGs revealed that time for developing countries to reach the same chance of neonatal survival as in 2012 for newborn babies in high-income countries, based on average annual rate of reduction from 2000 to 2012, is for sub-Saharan Africa 110 years and for South Asia 99 years.¹⁰ These distressing data urged world leaders at United Nations Conference on Sustainable Development (Rio +20 Conference in 2012) to launch 17 Sustainable Development Goals (SDGs) to be implemented till 2030.¹¹ Sustainable Development Goals differ from MDG because they cover all aspects of human life and development, such as environment, peace, justice, security, equality, education, and health, and SDGs apply to all countries not just to developing world.¹¹

Most of the SDGs carry forward the matters not solved by the MDGs.¹¹ In contrast to the MDGs, SDGs have been brought together within one framework as universal whole, with the interactions among them, which are brought into focus in the 2030 Agenda.¹¹ The 2030 Agenda defined 17 SDGs and 169 targets, with 232 indicators in the global framework.¹¹ Depending on the availability of the data, accuracy of the definition, and the level of methodological development, the indicators have been classified into three tiers. Tier I and II indicators are well defined, and they differ on the data availability at the country level.¹¹ For the tier I indicators, the data are available and collected regularly at the country level, while for the tier II indicators the data are not available, thus not regularly collected at the country level.¹¹ For the tier III indicator definitions, methodologies and standards are under development. According to the data from May 2019, 104 out of 232 indicators were in tier I, 88 were in tier II, 34 in tier III, whereas 6 were in multiple tiers.¹¹ The process of moving the indicators between the tiers is very dynamic and changeable. Advancement in the implementation of SDGs targets by the country will enable to make the comparisons between the countries, regions, and the world as a whole.

MAIN DRAWBACKS OF THE IMPLEMENTATION OF SUSTAINABLE DEVELOPMENT GOALS INEQUALITY AND INEQUITY

Economic development of the country is influencing the accomplishment of SDGs. As there is huge inequality within the world, some of them should be pointed out to better understand the diversity in the implementation of the SDGs.¹¹ The least developed countries have 12% of the global population, while they account for 2% of global gross domestic product (GDP), and 1% of global trade.¹¹ The projection growth of their GDP in 2020 is 5.7%, while 7% GDP growth was called for in the Agenda 2030.¹¹ The incomes of the poorest 50% of the world population rise significantly, but they received a 12% share of global gains, while the richest 1% of the world population received 27%.¹¹ The richest 1% of the world population in the 1980s had 28% of total wealth, while in 2017 they had 33%.¹¹

In 2017, the access to the electricity was only 51%, while the global rate was 88.8%.¹¹ They have access to a basic handwashing facility at home in 34%, while the global rate is 60%.¹¹

The least developed countries have higher rates of neglected tropical diseases, lower number of medical personnel and women at management positions, and lower rates of Internet access and access to preprimary education.¹¹

CONCLUSION

Importance of interactions between SDGs came out of the understanding of the Earth as a complicated environmental system which sustainability is dependent on human activities threatening the nature and natural laws.¹¹ Sustainable development was adopted by the UN GA in September 2015, with the first forum of ministers and/or country high representatives held in 2016 about their tasks on the realization of the SDGs.¹¹ They decided that annual progress report on the SDGs to be prepared by the UN Secretary General, while global sustainable development report should be prepared quadrennial, providing with deeper scientific analysis to strengthen science–policy interface.¹¹ This report should not only consider implementation of individual goals and targets but also explore interlinkages between the goals with special emphasis on resultant cobenefits and trade-offs.¹¹ Such a comprehensive approach will prevent possible unintended and/or unpredictable short- or long-term consequences of any intervention after implementation of just one goal and its targets in contemporary globalized and hyperconnected world.¹¹ Rather, to identify the transformative potentials of the 2030 Agenda, the intervention in other sectors and distant places should increase the chances of progress on one goal with all its interactions, cobenefits, and transformations toward sustainable development.¹¹

REFERENCES

1. World Health Organization. Millennium Development Goals. https://www.who.int/en/news-room/fact-sheets/detail/millennium-development-goals-(mdgs) ,Accessed January 2, 2020.

2. United Nations. Millennium Development Goals Report, 2015. United Nations:New York, 2015. https://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf ,Accessed Jan 04, 2020.

3. Mohapatra A, Gomare M. A critical appraisal of the maternal and child health scenario in a metropolitan city in India with reference to achievements of millennium development goals. J Family Med Prim Care 2019;8(3):995–1001. DOI: 10.4103/jfmpc.jfmpc_379_18.

4. Assefa Y, Damme WV, Williams OD, et al. Successes and challenges of the millennium development goals in Ethiopia: lessons for the sustainable development goals. BMJ Glob Health 2017;2(2): e000318. DOI: 10.1136/bmjgh-2017-000318.

5. Cha S. The impact of the worldwide Millennium Development Goals campaign on maternal and under-five child mortality reduction: “Where did the worldwide campaign work most effectively?” Glob Health Action 2017;10(1): 1267961. DOI: 10.1080/16549716.2017.1267961.

6. Akseer N, Kamali M, Bakhache N, et al. Status and drivers of maternal, newborn, child and adolescent health in the Islamic world: a comparative analysis. Lancet 2018;391(10129):1493–1512. DOI: 10.1016/S0140-6736(18)30183-1.

7. Akseer N, Rizvi A, Bhatti Z, et al. Association of exposure to civil conflict with maternal resilience and maternal and child health and health system performance in Afghanistan. JAMA Netw Open 2019;2(11): e1914819. DOI: 10.1001/jamanetworkopen.2019.14819.

8. Keats EC, Ngugi A, Macharia W, et al. Progress and priorities for reproductive, maternal, newborn, and child health in Kenya: a countdown to 2015 country case study. Lancet Glob Health 2017;5(8):e782–e795. DOI: 10.1016/S2214-109X(17)30246-2.

9. Countdown to 2030 Collaboration. Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. Lancet 2018;391(10129):1538–1548. DOI: 10.1016/S0140-6736(18)30104-1.

10. Lawn JE, Blencowe H, Oza S, et al. Every newborn: progress, priorities, and potential beyond survival. Lancet 2014;384(9938):189–205. DOI: 10.1016/S0140-6736(14)60496-7.

11. Independent Group of Scientists appointed by the Secretary-General. Global Sustainable Development Report 2019: The Future is Now – Science for Achieving Sustainable Development. United Nations:New York; 2019. https://sustainabledevelopment.un.org/content/documents/24797GSDR_report_2019.pdf ,Accessed January 3, 2020).