Moving beyond MDG Silos

The UN High-Level Summit concluded yesterday. The main headline is the $40 billion in commitments over the next five years for the Global Strategy for Women and Child Health. The real test will be whether donors deliver on these commitments, and are flexible enough in their definition of improving “women and child health” to take into consideration significant broader determinants such as education.

A key strength of the MDGs has been their simplicity and scope. The flip side of the coin is a tendency towards a ‘silo model’ of interpretation. Each MDG has its own cluster of experts, advocates, and donors, and recent economic modelling exercises have attempted to order MDG priorities on a cost-benefit basis. The result is a tendency towards a fragmented interpretation of the MDG framework in public policy discourse.

This mindset has real consequences. What we see in global health are various initiatives competing for a limited pot of funds, drawing on links about how their cause will contribute to progress towards MDGs, most recently MDGs 4 and 5. The more important question is whether there is more money overall targeting the largest causes of morbidity and mortality and the social determinants of better health.

The strong links between women’s education and better health outcomes have been long recognized. It is strongly associated through productivity, income-generation and wider effects to nutritional status. Similarly, levels of education are positively associated with a wide-range of practices – late marriage, ante-natal care, skilled attendance during delivery, recourse to health treatment and so one – which are known sources of risk reduction.

A new Lancet study by Professor Emmanuela Gakidou and colleagues from IHME provides compelling longitudinal evidence of what this relationship looks like across the world. The study found that 4.2 million fewer children died in 2009 because women received more years of schooling. Between 1970 and 2009, mortality in children under age 5 dropped from 16 million to 7.8 million annually, and the study estimates that 51% of the reduction can be linked to increased education among women of reproductive age.

The evidence is clear. It is difficult to look at the evidence without reaching the conclusion that sustained and accelerated progress towards the MDGs on child and maternal health depends in large measure on progress in education. Just look at these graphs from IHME on regional and country-level trends.

Potential pathways of influence from education to improved child health outcomes are often difficult to extrapolate. Broadly, however, education equips people with knowledge about nutrition, illness prevention and treatment, and service provision, and it empowers people to demand their entitlements. Of course, education also does much more than this. Under the right conditions, it can facilitate the development of more secure and diversified livelihoods, strengthen equity, and enhance the voice of poor people in political processes.

To return to my initial argument, one of the strongest illustrations of the problem with the MDG ‘silo mentality’ is the interface between education and child nutrition. Specialised education agencies tend to focus on headcount indicators of progress, defined in terms of net intake or enrolment rates or school completion. Less attention has been directed towards the health and nutritional status of children entering school.

Undernutrition is close to my heart- perhaps this is why I bring it up so often. But what does it mean for progress towards education-for-all, when one-in-three of the children entering primary school have experienced malnutrition? There is compelling evidence that the damage resulting from under-nutrition and micronutrient deficiency in the first two years of life is irreversible.

Against this backdrop, improving child and maternal health has much to do with women’s education and malnutrition. What were the commitments at the UN summit to education? The World Bank committed to increase its support by $750 million for zero-interest and grant investment in basic education, and Dell committed $10 million towards education technology initiatives. These pale in comparison to the commitments for the Global Strategy for Women and Child Health which is why I really hope that a broader approach will be taken involving relevant sectors.

Devi Sridhar (I am greatly indebted to conversations with Dr. Kevin Watkins for the ideas in this post).

6 thoughts on “Moving beyond MDG Silos

  1. This report meeirprssents the MDGs and takes a very Eurocentric view of the development enterprise. First, the report states that the MDGs are too narrowly defined. Yet, they represent a far more comprehensive agenda than the growth-driven doctrine that previously prevailed. Going further than this and aiming at a universal political blue print of how development should be managed would be a bridge too far. We live in a world of sovereign states and poor though they may be developing countries will undertandably resist the unabashed political conditionality that you are advocating. Second, the paper states that the MDGs confuse means and ends. This is absolutely not the case and ironically it is a main drawback of your own report. Conversely, a notable strength of the MDGs is that they emphatically stay away from specifying the means to achieve the goals and indicators it lays out to track development progress. achieved. Indeed, the Monterrey compact makes it abundantly clear that individual countries are in the driver seat of the poverty reduction agenda. This is the purpose of the Poverty Reduction Stragegy Process. While it studiously stays away from domestic politics, it stresses the need for a holistic development vision and lays out ownership, partnership and result orientation as fundamental principles of engagement. Third, the report does not address the legitimacy issue. The MDGs are grounded in the work of several UN conferences to which all countries of the world have participated. They were endorsed by all UN members at the highest level (except for Cuba) following intensive debate and negotiations that involved all major stakeholders. By contrast the fragility concepts that te report uses to buttress its narrative are not broadly accepted. Indeed, they are resented by countries thus categorized by the rich countries’ club. Following the recent financial crisis it now appears that many OECD countries are exhibiting signs of fragility while emerging market economies that do not comply with the governance tenets proposed by International Alert have become the engine of the global economy. Nor is it accurate to state that India and China did not benefit from aid. For decades they were the largest World Bank Group borrowers and they have made shrewd use of the economic management advice proferred to them. Fourth, the report is grounded on intellectual premises that need revisiting in the wake of the unfolding financial crisis. The rules of the game of the global system more than the MDGs need revisiting in the common interest. The International Alert report does not address issues of trade, migration, foreign direct investment, environment that underlie the current global malaise and hamper development in the poorest regions of the world. Here again, the report fails to notice the value of the MDGs: MDG#8 does address (however tentatively) the need to level the playing field of the international economic system. Fifth, the hard reality is that achieving a shared understanding of what human progress looks like is a missionary and aspirational goal which can only be reached (if it can be reached at all at the global level) through public debate, broad based participation and shrewd international diplomacy.From this perspective, the template proposed by the report is polemical and it would be dead on arrival in the international diplomatic arena. Indeed, the Douglass North view you are promoting is not all that different from the end of history model proposed by Francis Fukuyama in the wake of the Soviet Union implosion. This big picture model of the world no longer fits. Indeed, Fukuyama has since clarified his position and his more recent state building doctrine is far more nuanced, agnostic and convincing. Paradoxically the liberal, pluralistic, civil society centred approach that you are advocating (and that I personally subscribe to) is precisely the model that the United Nations agencies (especially the UNDP) has quietly promoted alongside the MDGs. But it is now being shunned by many developing countries. This is not surprising: many western countries that comply with its tenets are teetering on the brink of financial ruin. By contrast, a number of development states (China, Vietnam, etc.) have broken many of its rules and yet (whether we in the west like it or not) have so far proven remarkably resilient to global economic downturns. Indeed, over the past decades they have experienced high growth rates, reduced poverty and accumulated vast reserves of foreign currency. A corollary of this unexpected outcome is that it is bringing back to the fore basic apolitical Washington consensus rules about sound economic management that the western states have ignored in the exuberance of their debt driven economic strategies and that developmental states able to connect to the global market and to achieve internal security have studiously observed with excellent results at the macroeconomic level. The unpalatable fact is that the authoritarian capitalist state model while unappetizing to western electorates has many adherents in the zones of turmoil and transition (witness Rwanda) for one simple reason: it offers stability and security for the bulk of the population. This is where big bang economic reform strategies pushed by the international financial institutions in post conflict states have lacked savvy. Fifth, given these trends, it is unhelpful for your paper to ignore the Human Development paradigm (and the Amartya Sen perspective that it embodies). This broad based development consensus is in fact not inconsistent with what you are suggesting and it is surprising that your paper does not examine it. Nor do you give credit to the efforts of the previous Secretary General to connect security and development through the Commission for Human Security and the In Larger Freedom report. It failed to secure broad based support but was nevertheless the right doctrine for the times and it is one that may yet prevail.

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