Millennium Development Goals: background.

To cite: Chopra M, Mason E. Arch Dis Child 2015;100(Suppl 1):s2–s4. INTRODUCTION The Millennium Development Goals (MDG) arose from one of the largest ever gathering of world leaders in New York in September 2000. Collectively, 189 countries adopted the United Nations Millennium Declaration, which evolved into the MDG. These ambitious targets—ranging from halving extreme poverty and reducing maternal mortality by three-quarters to achieving universal primary schooling and halting (and beginning to reverse) the spread of HIV/AIDS—are supposed to be met by the end of 2015. The Millennium Declaration represented an important break with previous efforts to rally the world around global development. The articulation of specific goals and targets with a heavy focus on social development such as education, health, nutrition and water and sanitation was a distinctive move away from the monolithic focus upon macroeconomic growth. The setting of goals and targets and the establishment of monitoring and accountability frameworks was another important shift. The process of formulating the MDG must be seen in the context of widespread criticism of the United Nations (UN) during the two decades prior to 2000. The lack of a common development framework alongside declining global aid—for example, the foreign aid budget of the USA hit an all-time low in 1997, at 0.09% of gross national income—allowed global financial institutions such as the World Bank and International Monetary Fund to dominate development priorities. Not surprisingly, given the ruling paradigm of achieving economic growth by cutting social expenditures and reducing the role of the state, there was insufficient progress in reducing preventable child deaths, especially for those countries in Africa, South Asia and Latin America. There remains an active debate as to what extent the setting of a limited number of goals and targets has helped or hindered broad and inclusive development across the world. A study by Charles Kenny and Andy Sumner suggests that the MDG boosted aid flows and redirected them towards smaller, poorer countries and towards targeted areas such as education and public health. There is good evidence that this has translated in many parts of the world into accelerated progress. Particularly important have been the access to free primary education and free healthcare for children aged <5 years and pregnant women in many low-income countries. Perhaps, the greatest MDG successes concern health especially the progress made in reducing child mortality (MDG 4) and HIV/AIDS, malaria and tuberculosis (TB) (MDG 6) and more latterly maternal mortality (MDG 5a). The MDG formed the basis for the formation of multilateral global health institutions, such as the GAVI Alliance and Global Fund for HIV/AIDS, malaria and TB. The private sector plays a central part in both the institutions with representation at the Board level, active engagement in the governance committees and collaboration in implementation—another clear break with previous paradigms that had tended to ignore the role of the private sector in social development. The combined results have been remarkable. For example, the most recent UN report on levels and trends in child mortality documents the almost halving of child mortality rates since 1990, dropping from 90 to 46 deaths per 1000 live births in 2013. The absolute number of under-five deaths was cut in half during the same period, from 12.7 million to 6.3 million, saving 17 000 lives every day. Furthermore, the under-five mortality is falling faster than at any other time during the past two decades. Globally, the annual rate of reduction has more than tripled since the early 1990s. Eastern and Southern Africa currently has the highest annual rate of reduction in the world with the exception of East Asia and the Pacific. Analysis undertaken in the 2014 ‘A Promise Renewed’ report shows that in sub-Saharan Africa, a continent that the MDG were meant to draw focus upon, more than 90% of countries have seen the decline in child deaths accelerate compared with 1996–2001. Nonetheless, there remains wide inequities within countries, particularly the urban–rural divide with studies demonstrating that the poorer quintiles of the population have less access to healthcare services and higher mortality rates. Of course one question that immediately arises is how much of this would have been achieved even without the MDG process? In a recent analysis, Baker creates a counterfactual of progress in reductions in child mortality rates continuing at the same rate as the 10 years before the Millennium Declaration in 2000. He finds that if the trend for the whole of the 1990s is extrapolated to 2013, 8.2 m children aged <5 years would have died globally last year; the cumulative total of lives ‘saved’ since 2001 is 13.6 m. These findings do not prove that setting the MDG caused child deaths to fall, merely that something improved in the years that followed, nor does the fact that the biggest improvements came in poorer countries that were the main focus of MDG-inspired policies, lobbying, education and aid. Perhaps all this would have happened anyway. As the Economist concludes, ‘On balance though, there is good circumstantial evidence that setting the child-mortality MDG helped save millions of young lives.’ Success of course is variable, both across the different MDG, across different countries and within countries. What have we learnt about success? One measure of success is the commitments both