Updated: September 28, 2015 6:31:26 am
September 8 marked 15 years to the day since the United Nations adopted the millennium development goals (MDGs). Soon the world will adopt a new regime in global milestones, the sustainable development goals (SDGs) that extend for the next 15 years, from 2015 to 2030. Given the way the MDGs captured the imagination of the developing world, it is perhaps safe to say that the SDGs will be a similar rallying point on a series of development issues.
Of the eight MDGs, three relate directly to health. The first goal was to reduce mortality among children under the age of five; this is only moderately on-track. The second goal was to reduce maternal mortality. On this India is off-track. India is on-track for the third goal, which was to halt and reverse the spread of HIV/AIDS, and only moderately on-track on the fourth goal, which was to halt and reverse the spread of malaria and other major diseases. In short, we have achieved only one out of four targets. Globally, this is a worry, because if India does not achieve the MDGs, given its size, neither will the world.
Are the SDGs any different from the MDGs? For one thing, only one SDG addresses health, as compared to three MDGs. On maternal and child health, the SDGs extend the MDGs, since they have largely not been met in many developing countries. Non-communicable diseases have been included, reflecting concern for the growing incidence of non-communicable disease even among the poor. Alcohol abuse and tobacco have also been targeted.
Interestingly, the targets that have a specific timeline mentioned are those for which cost-effective interventions have been identified — for example, institutional delivery to reduce maternal mortality. It raises the question: Are we adopting goals that have the “right” cost-effective interventions, rather than discovering cost-effective interventions for the right goals? For instance, mental illness is one of the most prevalent morbidities in India, and suicide is the leading cause of death among people between 15 and 29. There is only a passing mention of this in the SDGs. Perhaps because there is no cost-effective intervention against mental illness and suicide?
If the SDGs are seeking to complete and extend the task of the MDGs, they should learn from the experience of the last 15 years. The failure of the MDGs has been blamed on a lack of adequate financing and governance failure. This seems to be a simplistic answer. The critique should look also at the way the MDGs were structured. First, the goals and targets were interpreted too literally, without reference to the starting point from which different countries began the journey. Second, the cost-effectiveness analysis focused on addressing the biological causes of disease, with little recognition of the social determinants of health. It was this biological agent that was the target of the cost-effective intervention, maybe because biological causes are easier to tackle.
Let us consider one of the key goals that India has failed to achieve — reduction in maternal mortality. Institutional delivery was the solution chosen to achieve this goal. Strengthening health infrastructure, training manpower and incentivising women who would otherwise have given birth at home to come to an institution for their delivery have been the goals of the health system since 2005. Yet we did not achieve the MDG for maternal mortality reduction. Why? The answer lies outside the health system: Poor women in rural areas face tremendous challenges in reaching an institution for delivery, despite government subsidies. There is evidence that skilled birth attendance inside the home can be just as safe. Many women find it more comfortable, less socially intimidating, and certainly less expensive. But it takes time and sustained effort to ensure the quality of care that will make it a credible choice.
This should teach us that the goals we set should be informed by the realisation that health issues cannot be seen in isolation from the social context. Can we put in place strategies that may not bring quick wins, but over a period of time will ensure better health equity? Can we
liberate ourselves from time-bound targets? We need to recognise the flaws in the design of these targets and reflect on ways to address them if we are to fare any better in the next 15 years than we did the previous 15.
The writer is professor of health and nutrition at Azim Premji University, Bangalore.
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