What should follow the millennium development goals?BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1193 (Published 28 March 2013) Cite this as: BMJ 2013;346:f1193
- Charles Kenny, senior fellow
- Accepted 14 February 2013
The millennium development goals were an offshoot of the United Nations Millennium Declaration agreed by world leaders at the UN General Assembly in 2000.1 The eight goals that were subsequently adopted in 2001 set targets for progress to reduce poverty and improve outcomes in nutrition, education, health, equality, the environment, and global partnerships by 2015 (box). With that end date fast approaching debate on what should follow them is mounting, and later this year the UN secretary general will set out a draft agenda based on recent consultations. As discussion continues it is important to consider the successes and failures of the goals learnt from the lessons these provide, and look at the desirability and feasibility of new goals that have been suggested.
Millennium development goals
Goal 1: Eradicate extreme poverty and hunger
Halve the proportion of people living on less than $1.25 a day
Achieve decent employment for women, men, and young people
Halve the proportion of people who suffer from hunger
Goal 2: Achieve universal primary education
Ensure that all girls and boys can complete a full course of primary schooling
Goal 3: Promote gender equality and empower women
Eliminate gender disparity in primary and secondary education, preferably by 2005, and at all levels by 2015
Goal 4: Reduce child mortality rates
Reduce by two thirds the mortality rate for children under 5 years
Goal 5: Improve maternal health
Reduce by three quarters the maternal mortality ratio
Achieve universal access to reproductive health
Goal 6: Combat HIV/AIDS, malaria, and other diseases
Have halted and begun to reverse the spread of HIV/AIDS
Achieve universal access to treatment for HIV/AIDS
Have halted and begun to reverse the incidence of malaria and other major diseases
Goal 7: Ensure environmental sustainability
Integrate the principles of sustainable development into country policies and programmes; reverse loss of environmental resources
Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss
Halve the proportion of the population without sustainable access to safe drinking water and basic sanitation
By 2020, achieve a significant improvement in the lives of at least 100 million slum dwellers
Goal 8: Develop a global partnership for development
Develop further an open, rule based, predictable, non-discriminatory trading and financial system
Address the special needs of the least developed countries, landlocked developing countries, and small island developing states
Deal comprehensively with the debt problems of developing countries through national and international measures to make debt sustainable in the long term
In cooperation with pharmaceutical companies, provide access to affordable, essential drugs in developing countries
In cooperation with the private sector, make available the benefits of new technologies, especially information and communications
Setting the development agenda
Soon after they were set, the millennium development goals became a dominant framework for thinking about global development. Seven years ago the phrase “millennium development goals” overtook references to the human development index in the development literature.2 3
The high profile of the goals has not merely been due to the fact that the world’s heads of state signed up to them. It is also because the goals were based on easily understood and self evidently important indicators and included numerical and time bound targets. Furthermore, they said something new (much of the rest of the Millennium Declaration rehashed paragraphs from previous General Assembly statements). In addition, they provided a framework to target development aid and so have been widely cited in strategies for donor programmes.4
What effect have the goals had so far?
Twelve years on, progress towards meeting the goals has been mixed. According to the latest accounting by the United Nations (table⇓) targets for income poverty and access to clean water have been met, but the world is considerably off-track on under 5 mortality and maternal mortality.5
Much of the success we have seen has not been a result of the goals. Progress against global poverty, for example, has stemmed largely from rapid economic growth in China—a country where the goals are not well known and aid has had only a small role in development. On the other hand, the goals may have had a positive effect in some areas—this despite the fact that they were a purely aspirational set of targets.
After the Millennium Declaration was signed in 2000, overseas development assistance increased—climbing by more than $50bn (£33bn; €38bn) over the following decade, and more aid was provided for health and education. There is also evidence that progress in social sectors has been more rapid than would be expected from historical trends. For example, it is estimated that the proportion of children completing primary education in the developing world would have been expected to reach 76% in 2010. In fact, the completion rate reached 81% in that year.2 The number of girls enrolled in primary school as a percentage of boys was predicted to be 96%, but it reached 98%. The maternal mortality rate in 2010 was 203/100 000 births compared with a predicted value of 221/100 000; the child mortality rate was 5.1% rather than the expected 5.4%.2
Criticisms of the goals
Despite their widespread adoption in the discourse around development the goals have faced criticism. Firstly, what were originally seen as global targets were rapidly interpreted to apply at the regional and country level. A target for the average country to reduce child mortality by two thirds became a target for all countries to reduce mortality by that amount.6 This created a cottage industry of national report writing to create country programmes designed to meet the goals, with funding requests attached.
Secondly, once the global goals were “reborn” as country goals they often called for unrealistically fast progress. Progress reports suggested countries were failing, or off-track, despite the fact they were making incredibly rapid progress on the basis of any historical norm.7 Burkina Faso, for example, increased the proportion of children completing primary school from 24% to 45% between 2000 and 2010—an impressive performance. But it is still clearly off track for 100% completion by 2015.
Thirdly, some goals were wrongly targeted, inadequate, or simply missing. The education goal for example, has been widely criticised for measuring inputs (presence in school) rather than outputs (learning). India’s experience shows the extent to which this is a major concern. While grade eight enrolment increased from 82% to 87% between 2006 and 2011, national tests suggest that the proportion of grade eight children who could do division actually fell from 70% to 57%.8
The imbalance between different elements of development has also been criticised. There were three and a half health goals (covering child mortality, maternal mortality, infectious disease, and water and sanitation) as well as a goal 8 commitment to access to affordable essential medicines but no attention was given to roads or energy. And the gender equality goal focused only on school enrolment. Other key concerns including income equality, national governance, violence, and climate change were not mentioned.
In addition, the goals are heavily focused towards progress in the least developed countries. This has let middle and high income countries off the hook since many of these had already achieved universal primary school enrolment and gender equity in access to secondary education and had seen absolute poverty or stunting reduced to near zero.
Current ideas on the post-2015 development agenda
The UN secretary general has set up a high level panel on the post-2015 development agenda, co-chaired by the heads of state of Liberia, Indonesia, and the United Kingdom. The panel, made up of politicians, academics, and civil society representatives from a range of countries, will issue a report to the secretary general in the middle of 2013. Meanwhile, the closing declaration of the UN Rio summit last year called for the creation of an open working group of UN member states to discuss the creation of sustainable development goals, and this group, made up of 30 UN member countries, was launched in January.
UN agencies have produced a joint paper Realizing the Future We Want for All as an input to the deliberations.9 and the UN Development Programme conducted a series of consultations under the banner of “The World We Want.”10
Current debate centres not only on what the post-2015 goals should be but what they are for, and who should be involved in drawing them up. To add to the challenge it is evident that there is some disagreement within the UN about framing new development goals, with both the secretary general’s high level panel and the UN’s sustainable development goals open working group charged with coming up with a set of new global goals.
Although it is widely agreed that the post-2015 agenda should remain focused on the world’s poorest and most disadvantaged people, some commentators argue that a declaration of where we want to be in 2030, signed by all of the world’s leaders, should speak to the concerns of rich and poor alike. Some also suggest the most useful contribution of a UN document of global aspirations would be to focus on the global “commons”—issues like climate change, loss of biodiversity, and communicable disease.11
What has been agreed is that the post-2015 agenda should stretch “beyond aid.” Although financial aid is a powerful way of improving quality of life in poor countries, its contribution is declining as developing countries become richer. China, Brazil, Russia, and Mexico are all now richer than Italy was when it joined the Organisation for Economic Cooperation and Development’s development assistance committee in 1960.12 And even in low income countries trade, money sent home by migrants, and private investment often dwarf official assistance. According to World Bank data, foreign direct investment and portfolio equity flows to developing countries were worth $444bn in 2009 compared with $120bn in overseas development assistance.
With world trade talks moribund, increased opposition to migration and financial integration from recession hit citizens in the West, and talks on financing measures to combat climate change stalled, it may seem optimistic to think that we can achieve a post-2015 declaration with strong, measurable commitments on global cooperation.
But this has not deterred international agencies and organisations from putting forward a raft of ideas for new global goals, including those aimed at improving employment rates and reducing income equality; learning (literacy and numeracy targets); global greenhouse gas emissions, forestry, and biodiversity; governance; and rates of violence.10 Producing easily understood and self evidently important indicators with numerical and time bound targets in some of these areas is a challenge—as is the fact that they also have to be agreed by consensus in the UN General Assembly.13
With respect to health, the World Health Organization has proposed universal health coverage and healthy life years as the anchors for post-2015 health goals and completed a consultation process around that proposal.12 14 While healthy life years pose statistical difficulties (because good data are sparse for many of the world’s poorest countries) and it may be hard to define a realistic goal for progress by 2030, the metric does have the merit of being easily understood.
More problematic is the idea of a goal to achieve universal health coverage. Just as presence in school does not guarantee learning, access to health professionals by no means guarantees wellness. It is a repeated finding, for example, that the number of doctors and nurses or hospital beds per capita is not correlated with life expectancy or child mortality outcomes at the country level.15 The quality of healthcare remains an ongoing concern. A recent World Bank survey suggested that doctors in Tanzania took fewer than a quarter of the diagnostic steps needed to confirm malaria in patients showing symptoms.16 A study in India found that the average number of questions in an interaction with a public sector doctor in India was one (usually “What’s wrong with you?”).16 Universal healthcare might, some argue, be seen as a goal of institutional development (much like the primary education goal) that could result in (primarily) dysfunctional institutional expansion rather than improved health.
Aiming for universal health coverage also risks downplaying the huge importance of the wider determinants of health, including socioeconomic status and health literacy ( where knowledge of good practice from hand washing and safe care of the newborn to sanitation, sound nutrition, and the adverse impact of smoking and drinking on health is important.) It also has no clear definition. What constitutes a plausible package of health coverage available to all depends on a country’s economic circumstances so it is hard to craft and agree on a universal global goal that is easy to understand and measure, especially if universal coverage were to includes interventions outside the health sector—for example, the provision of water and sanitation and financial risk protection.17
Setting targets will be important
Whatever indicators are eventually chosen, those who frame the post-2015 agenda will have to set targets for progress. A recent study using country projections for a range of potential goals suggests that the targets might plausibly include
To reduce the proportion of the world’s people whose income is less than $2 a day or that is undernourished to below 1 in 10
To increase global completion of secondary schooling in the population aged ≥25 by 50%
To increase global average life expectancy to 75 years
To reduce global maternal mortality to below 1/1000 births
To reduce global mortality among children under 5 to half its level in 2010
To halt, and have begun to reverse, trends towards greater population disparities in the number of girls and boys at age 5 in every country where such trends have been manifest
To have reversed the global trend towards deforestation.13
The idea of “getting to zero’” on a range of indicators has gained political traction, and our forecasts suggest that, for absolute poverty at the level of $1.25 a day, effectively wiping out poverty is achievable.13 However, in some areas where a zero goal has been proposed (no children failing to complete secondary education, for example) this would require a historically unprecedented rate of progress in many countries and, once again, result in some countries (especially in Africa) being branded as development failures, even were they to make giant strides in enrolling students.
Despite the limitations of the millennium development goals and the challenges of developing a post-2015 agenda one thing is worth bearing in mind. The past 20 years have seen immense and ubiquitous progress on development across a wide range of measures from income through health and education to civil and political rights and security. While the credit for this must largely go to the people and institutions of the developing world, the international community has played a part. If a post-2015 development framework can be agreed and the UN can muster the motivation to continue and strengthen its supporting role, a new set of goals could deliver worthwhile dividends.
Cite this as: BMJ 2013;346:f1193
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Contributors and sources: CK has 18 years of experience researching and writing about development as well as managing aid projects at the World Bank and the Center for Global Development.
Provenance and peer review: Not commissioned; externally peer reviewed.