Global Health 101: Millennium Development Goals

If you're working on a major global problem like poverty, it's important to have goals to work towards. Back in 2000, world leaders came together and adopted the United Nations Millennium Declaration, which commits to reducing extreme poverty and sets out a series of goals to be reached by 2015. Each of the eight Millennium Development Goals, as they've come to be known, has between one and five specific targets, many of which involve reducing the proportion (by half, two-thirds, etc.) of people who suffer from a particular condition or lack access to an essential resource like clean drinking water or basic sanitation. The goals are:

Goal 1: Eradicate extreme poverty and hunger

Target 1: Halve, between 1990 and 2015, the proportion of people whose income is less than $1 a day
Target 2: Achieve full and productive employment and decent work for all, including women and young people
Target 3: Halve, between 1990 and 2015, the proportion of people who suffer from hunger

Goal 2: Achieve universal primary education

Target 1: Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling

Goal 3: Promote gender equality and empower women

Target 1: Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015

Goal 4: Reduce child mortality

Target 1: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate

Goal 5: Improve maternal health

Target 1: Reduce by three quarters the maternal mortality ratio
Target 2: Achieve universal access to reproductive health

Goal 6: Combat HIV/AIDS, malaria and other diseases

Target 1: Have halted by 2015 and begun to reverse the spread of HIV/AIDS
Target 2: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it
Target 3: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases

Goal 7: Ensure Environmental Sustainability

Target 1: Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources
Target 2: Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss
Target 3: Halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation
Target 4: By 2020, to have achieved a significant improvement in the lives of at least 100 million slum dwellers

Goal 8: Develop a global partnership for development

Target 1: Address the special needs of least developed countries, landlocked countries and small island developing states
Target 2: Develop further an open, rule-based, predictable, non-discriminatory trading and financial system
Target 3: Deal comprehensively with developing countries' debt
Target 4:In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries
Target 5: In cooperation with the private sector, make available benefits of new technologies, especially information and communications

Uneven Progress
This week, a UN summit on the MDGs is taking place in New York. The New York Times' Neil McFarquhar reports that there hasn't been enough progress to put the world on track to achieving the targets:

Yet despite broad if sporadic progress, the United Nations acknowledges that only two of the many targets might actually be met: cutting in half the number of people who lack safe drinking water and halving the number of people who live on $1.25 or less daily.

Any progress is widely welcomed, of course, but experts warn that even those achievements may disguise the fact that some of the poorest countries are making considerably less headway, or even becoming worse off.

Because the goals concentrate on global averages, China skews the statistics on earnings because its roaring economy has lifted millions out of poverty since 1990, the baseline year on which all the goals are set.

Looking at nations individually makes for a much more complicated portrait. In Nigeria, the ranks of people living on less than $1.25 a day jumped to 77 percent of the population in 2008 from 49 percent in 1990, for example, while in Ethiopia it was reduced to 16 percent from 60 percent, according to a new report from the Overseas Development Institute, a British research group.

Similarly, Ghana cut hunger by 75 percent by 2004, but the problem more than doubled in the Democratic Republic of Congo in the same period.

A UN Development Programme assessment published in June puts more emphasis on what's been achieved, but also describes the unevenness of progress:

There have been noticeable reductions in poverty globally. Significant improvements have been made in enrolment and gender parity in schools. Progress is evident in reducing child and maternal mortality; increasing HIV treatments and ensuring environmental sustainability. While there are welcome developments in the global partnership, where some countries have met their commitments, others can do more.

At the same time that the share of poor people is declining, the absolute number of the poor in South Asia and sub-Saharan Africa is increasing. Countries that achieved rapid reductions in income poverty are not necessarily making the same progress in gender equality and environmental sustainability. Lack of progress in reducing HIV is curtailing improvements in both maternal and child mortality. Moreover, attention to the quality of education and health services may have suffered in the rush to extend coverage.

One of the benefits of measuring global progress toward specific MDG targets is that it allows for comparisons between countries' strategies and results. (Although the assessments aren't as rigorous as some would wish - McFarquhar quotes MIT's Esther Duflo criticizing a lack of understanding of what works.) The UNDP assessment highlights some successful strategies, including large-scale immunization campaigns and conditional cash transfer programs (see this recent Economist report for more on CCTs). It also notes that locally developed strategies that are based on a broad national consensus and take into account the voices of the poorest and most marginalized are most likely to lead to sustainable achievements.

At the same time, the assessment suggests that progress on hunger will remain inadequate if we can't improve global agricultural productivity and address (Der Spiegel has a special report on this topic), and we urgently need to strengthen climate-change adaptation and risk-reduction capacities in countries exposed to national disasters.

The Importance of Equality
While all of the targets interact with one another to some degree, the UNDP assessment reports that improving gender equality has a strong multiplier effect. While the world hasn't managed to eliminate gender disparity in education in primary and secondary schools (the sole target for Goal 3), by 2008 there were 96 girls per 100 boys enrolled in schools, up from 91 in 1999. This is likely to have a positive impact on several other MDG targets:

Ensuring girls have unfettered access to health, education and productive assets helps progress across the MDGs. Increased female school enrolment is associated with better health and nutritional intake of families. Enhancing reproductive and maternal health contributes across the MDG goals. Equitable provision of land and agricultural inputs significantly increases output and ensures food security. Constitutional and legal reforms enhance women's empowerment and increase their political participation. Providing infrastructure to households with energy sources and water reduces the burden of domestic activities and frees girls to attend school, engage in self employment or participate in labour markets.

And:

In many countries, transactional sex, social norms that disempower women and domestic violence are among the causes of HIV infection. Birth rates are likely to be lower in households where women are empowered, which, in turn, is associated with better health and education for children.

The push for gender equality may get a boost with the recent creation of the UN Entity for Gender Equality and the Empowerment of Women; last week, UN Secretary-General Ban Ki-moon announced the appointment of Michelle Bachelet, former president of Chile, to head it.

Gender isn't the only source of inequality, of course, and UNICEF has urged a greater focus on the most disadvantaged children over the next five years. In their Narrowing the Gap to Meet the Goals report, UNICEF provides evidence that such a focus is not only right in principle, but could allow for more lives to be saved per million spent. UNICEF's equity-focused approach model includes three key measures: upgrading selected facilities (especially for maternal and newborn care), and expanding maternity services; overcoming barriers (like user charges) that prevent the poorest from using already-available services; and increasing the use of community outreach and involvement, such as using more community health workers to deliver basic services outside of facilities.

Financial Commitments
Earlier today, Secretary-General Ban urged heads of state attending the UN summit to "provide the necessary investment, aid and political will to end extreme poverty." From the news release, it looks like he focused on urging countries to honor their previous commitments on development assistance, rather than asking for increased commitments. French President Nicolas Sarkozy, however, has already announced that his country will boost its aid contributions by 20% over the next three years (France currently donates 10 billion euros per year), and he also proposed a small international tax on financial transactions to fund development efforts.

I can't find anything recent on the White House website about the US involvement in the summit or the broader MDG effort, but I hope President Obama will soon make an announcement about how the US will support the global effort to meet MDG targets.