There are about 1,000 days to go before the deadline to achieve the current Millennium Development Goals (MDGs) expires in December 2015. The clock is ticking, both to maximize progress on the existing goals and targets, and to ensure that the next set of goals sustain and push forward the successes that the current MDGs have generated.
While there are wide variations within and between countries, it’s clear that remarkable overall progress has been made in the last 15 years on the MDGs. The gains in health have been especially significant, as a recent op-ed in the Lancet co-authored by the World Bank’s Keith Hansen and others points out. The decline in child deaths from almost 12 million a year in 1990 to fewer than 7 million in 2011 is just one example of how a clear, compelling, measurable goal can motivate shared action toward a specific outcome.
At the Bill & Melinda Gates Foundation, we believe that the unfinished agenda of the MDGs of ending extreme poverty should still be our first order of business after 2015. The main purpose of agreeing to successor goals post-2015, we think, should be to extend this agenda through updated, time-bound, measurable, and ambitious but achievable goals.
I see two threads in the post-2015 discussions that could diffuse the power of the MDGs. One is the push to dramatically expand the MDG agenda, which threatens consensus and dilutes the focus on a limited set of joint priorities. The other is a call for visionary goals and targets like “ending all preventable deaths”, which, while laudable, have no hope of achievement by 2030.
The MDGs represented a new kind of global commitment in that they set out to catalyze progress and joint global action towards specific outcomes within a limited period of time. They were not pie-in-the-sky, aspirational and ill-defined targets that UN member states were too often prone to embrace in the past. The MDGs were concrete and at the global level, largely achievable, and as a result, governments felt accountable for achieving them. Purely visionary targets would have been much easier for governments to ignore – and indeed they have routinely been ignored over the decades.
At the recent high-level consultation on health and the post-2015 agenda in Botswana, I argued that we should set ambitious, but technically feasible targets for post-2015 health outcomes. For example, an analysis by the Institute for Health Metrics and Evaluation indicates that reapplying the current maternal mortality rate reduction target of 75 percent to 2030 would require that countries perform to the 95th percentile of those developing countries that achieved the greatest success in the past decade. This kind of goal is likely impossible to achieve for countries that have the most challenging initial conditions, such as high-HIV burden for Sub-Saharan African countries. Just sustaining current rates of reduction would lead to a figure closer to a 50 percent reduction in maternal mortality. An ambitious but achievable goal on this, if we implement scale-up strategies based on local causes of maternal deaths and high-impact interventions, could be in the range of a two-thirds reduction.
Analysis of child mortality by the Child Health Epidemiology Reference Group indicates similar figures, i.e., that a two-third reduction in child mortality by 2030 would be ambitious but possible post-2015. To update MDG 6, setting specific targets for mortality or incidence rate reductions for HIV, malaria, and TB would be a good next step. These figures are illustrative and clearly require much deeper technical analysis and consultation, but they present a starting point for what a meaningful approach to a new set of health MDGs might be. What is most critical is that targets be ambitious but plausible, and provide a clear benchmark for success or failure.
Some changes are clearly warranted given the experience with the current MDG process. For one, while global goals and targets are and should be the focus of this process, targets can also be customized at the national level by each country. The MDG process also tended not to benefit the most marginalized and excluded groups in each country. Reaching them will not be possible without disaggregating data and performance, which many countries are currently not able to do. There is an opportunity for the World Bank to play a critical role here by investing in improvements in data collection and measurement systems. The Bank could also support the development of other core public health functions and public goods, like vital registration systems to accurately record births and cause of death, and national surveillance systems to track disease outbreaks.
With all of its limitations, the last set of MDGs did provide a clear guiding framework for donors and developing country governments to all pull together towards agreed-upon outcomes. In the health sector, we see the evidence in millions of healthier children and families worldwide. By making the goals too broad or visionary, we risk losing the elements that made them work. With smart goal-setting and the right focus, we can ensure that the next fifteen years see even more impressive gains in the fight against poverty around the world.
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