Original article found on: Brookings
By John McArthur
Over the past decade, the Millennium Development Goals (hereafter MDGs or “Goals”) have become a central framework in organizing global health efforts. Many developing countries have made significant progress toward the official targets, including Goal 4, which is to achieve a two-thirds reduction in under-5 mortality rates (U5MR) by 2015 compared to 1990. According to the United Nations’ latest estimates, the developing world’s 2013 aggregate U5MR had declined 40 percent since 2000, and 50 percent since 1990.
But progress toward the Goals is not the same as progress because of the Goals. Nor can the mere setting of targets be considered the full scope of what might be called the “MDG agenda.” The broader agenda includes policy, organizational, and advocacy efforts to mobilize targeted resources in the practical pursuit of goals. It also includes the consolidation of common global reference points across diverse public, private, and non-profit actors, which might in turn have prompted incremental efforts toward results. As Manning (2009) has pointed out, “it is intrinsically difficult to distinguish the impact of the MDG framework itself from the strands of thinking that helped to create it.”
Although causal pathways are difficult to discern in aggregate, one highly correlated trend since the launch of the MDGs is a significant expansion in global health budgets. The Institute for Health Metrics and Evaluation (2014) estimates that total development assistance for health nearly tripled, from U.S. $10.9 billion in 2000 to more than $30 billion in each of 2011, 2012 and 2013 (all in constant $2011). These resources have helped to launch and expand important new international institutions, including the GAVI Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the U.S. presidential initiatives for both AIDS and malaria, all of which have helped to expand dramatically the country-level coverage of preventive and therapeutic health interventions.
Skeptics tend to question the MDGs based on four categories of critiques. One focuses on shortfalls in results. Many countries are not on course to achieve individual Goals, either because policy efforts or resources are inadequate. A second criticizes the establishment of political targets considered too ambitious to begin with. A third asserts that the developing world was making advances prior to the establishment of the MDGs, so the Goals should not be given credit for progress that would have been made in any case. A fourth argues that global aggregates might reflect success, but these are driven by results in the most populous developing countries, China and India, which made progress independently of the MDGs.
With these questions in mind, and as the international community considers the next generation of intergovernmental targets beyond the 2015 deadline, it is an appropriate juncture to examine the overarching “macro” hypothesis that the establishment of the MDGs and related efforts to support their achievement have been associated with accelerated progress on intended development outcomes. This paper does so with specific focus on MDG 4 for reducing under-5 mortality. The analysis focuses only on discerning long-term variations in outcomes that coincide with the establishment of the Goals. This is distinct from an investigation of “micro” hypotheses regarding how the MDGs might have been linked to variations in U5MR outcomes within countries.
The results are striking. They show that the period since the establishment of the MDGs has seen unprecedented rates of progress among the poorest countries, even when they are not on a path to achieve the formal MDG targets. As of the end of 2013, at least 7.5 million more children’s lives have been saved compared to the trajectory of progress as of 2001. The majority of these lives have been saved in sub-Saharan Africa. Moreover, the period since the turn of the millennium appears to show convergent rates of progress across developing regions. At a minimum, the period from 2002 to 2012 was the first to show a clear break in the previous long-run trend whereby countries with higher U5MR saw systematically slower rates of U5MR decline.
The paper is divided into ten sections. Following this introduction, the second section describes the core hypotheses used to test MDG performance. The third section describes the data used in the analysis. The fourth section describes key methodological assumptions, including the definition of pre-MDG reference periods and the distinction between On Track versus Off Track countries at the outset of the MDG period. The fifth section describes the results for the three key tests of MDG performance, including variations by region and country income group. Section 6 then considers whether U5MR reduction trends have been subject to deeper structural shifts. Section 7 presents longer-term regression results evaluating trends over more than five decades. The results suggest a structural change in global trends since the onset of the MDGs, so Section 8 estimates the number of children’s lives saved that could be plausibly linked to the MDGs. Section 9 considers future implications for new targets to 2030. A final section concludes.
Full paper can be found or downloaded here.
Original article can be read at: Brookings