SCN News, No. , Gva., 20..
1. I have, for long, been on record to be very ambiguous about goals and targets in health and nutrition work (1).
2. What I keep reading in the literature is a mixture of a ‘praise for having (a) goal(s) to strive for now’, and ‘active steps being taken to get there in many countries thus (for the first time) building a united front’. In this context though, one should not and cannot forget how many sets of these development goals have come and gone without sorrow or glory…! We simply have no assurances that the new set of goals will mobilize leaders any more than before. This, because MDGs do (and have) not automatically translate(d) into greater advocacy, action and donor resources for launching the processes that are really important. Also here, keep in mind that setting these international goals is the result of a process in which public admission of dissent is difficult (these days, being against the MDGs is like being against motherhood). Therefore, countries pledge, but do not really embark or comply.
3. I have read that ‘colleagues feel disappointed that ordinary people do not have a clue about the Millennium Development Goals (MDGs)’: does anybody really think it would make much of a difference given the almost nil power ordinary people have to change things? A better question would certainly be: why were ‘ordinary people’ not invited to set the MDGs to begin with??
4. We are told ‘MDGs are within reach’ – if only guidance (top-down?) is given on how to accomplish each of them; yes, but are they really within reach – with or without guidance?, or are we setting ourselves up for failure?
Here is a further sample of the type of things I get to read:
5. In General:
i.- That, in many developing countries, the quality of life over the past 20 years (measured as child deaths) has dropped; yes, but – ten years from the deadline – do we have any indication the trend has changed for the better indicating some realistic hope?, or
ii.- that the various already existing MDG Progress Reports assert little if any progress, but that, by 2015 there will be a decrease in preventable ill-health, malnutrition and poverty; yes, but by what wonderful quantum leap forward?
iii.- That MDGs have renewed ‘our sense of urgency’; yes, but have they really and, if so, of whom?
iv.- That MDGs have given us a new sense of direction; yes, but have they really given as a ‘new’ sense and, if so, which?
v.- That new policies under consideration (or under implementation) will go a long way to achieve the MDGs; yes, but are they really going ‘a long way’?
vi.- That accountable governments will make sure these policies are enacted; yes, but how many objective signs are there of this?, or
vii.- that many governments have demonstrated renewed commitment to the MDGs; yes but do the deeds also show measurable signs of this ‘renewed commitment’?, or
viii.- that renewed political commitment has translated into ad-hoc funding and the provision of more and better essential services; yes, but has it really?
ix.- That countries have indeed shown progress in achieving MDGs; yes, but has there really been measurable progress commensurate to the MDGs promise, e.g., in health, nutrition, water and sanitation, community-based programs, women’s income generation activities?
x.- That – in an effort in the same direction – Poverty Reduction Strategy Papers (PRSPs) can, in many countries, create thousands of jobs annually, as well as raising the GDP/capita substantially and keeping inflation rates low; yes, but, so far, have they really?
6. Perhaps, even if not exhaustively, breaking what I read down by sector, I can illustrate further what I mean:
7. In Health, I read:
i.- That, overall, more prevention will result in improved quality of life; yes, but has there really been a new emphasis on the preventive over the curative – and is a greater preventive focus enough to reach the health MDGs?
ii.- That ministries of health around the world have set up several programs to address the reproductive health needs of women; yes, but have these performed up to MDG-expected standards and speed?
iii.- That the political commitment towards, HIV/AIDS, tuberculosis and malaria has increased; yes, but has this had any measurable effects?, or
iv.- that national HIV, TB and malaria strategies will measurably reduce morbi-mortality from these diseases; yes, but have they really?
8. In Nutrition, I read:
i.- That, before 2010, Vitamin A deficiency will be eliminated in many countries through the production and consumption of micronutrient-rich foods; yes, but are we really seeing this happening?
ii.- That nutrition is (or is about to become) a key component of development; yes, but have the new programs incorporating nutrition performed on the scale needed? (In this context, has anything happened beyond ‘proposed’ new policies?).
iii.- That food production is now better addressing population needs; yes, but has it really?
iv.- That nutrition ‘empowers individuals and communities and leads to poverty reduction’; yes, but through what magic automatic mechanism(s)? (Not trying to be facetious here, but just saying that most strategies should be at the community level is like shifting the responsibility to the community itself – “so they better deal with it”).
9. In Child Welfare, I read:
i.- That child labor will be reduced; yes, but has it really?
10. In Education, I read:
i.- That educational policies should strive for attaining universal access to primary education; yes, but have these policies been implemented objectively increasing access to near these levels?
ii.- That repetition and drop-out rates will decrease; yes, but have they really?
iii.- That free school feeding will be given to children in poor areas; yes, but have these poor children really been receiving these breakfasts and lunches?
11. In Gender, I read:
i.- That gender equality still needs implementation….an honest exception here since women do really need to (and have not yet) take(n) up leadership positions and participate(d) in all debates affecting their lives and the lives of their children…,
ii.- but…that many governments have committed themselves to mainstreaming gender issues; yes, but have they really or is it only more of the same lip-service?
12. I do not know (nor do I claim to know) if all my ‘yes, but’ questions (and there are many more!) are justified and/or exposing broken promises. But, already being half through 2005, my point is that we have to get to the deeds: Enough of grandiose pronouncements and empty promises, lest the MDGs become one more crutch to delay or fake needed action. If we do not change course, I can see, for instance, nutrition being relegated to simply ‘an indicator of the attainment of the MDGs’ rather than an essential foundation for their attainment.
13. Knowing and getting where we want to go (i.e. MDGs) is OK. But we need concrete advice not only on finish lines, but also on direction, i.e., the processes involved to get there are even more important. It is processes that carry the seed of sustainability. But let us face it: most of us fear prescribing the more radical processes needed; we even fear discrediting processes that we know do not work! On the other hand, we do not emphasize (or have good?) indicators that can measure ‘sustainable-progress-in-processes’ such as participation, social mobilization and empowerment (3). Instead, we have spent time and money choosing and monitoring outcome goals, and worst of all… over-medicalizing some of the key health and nutrition ones.
14. I just keep, again and again, reading the clauses ‘the government should’ or ‘policies are needed’…well, that is not good enough for the MDGs to get there by 2015! Most governments simply do not have the will and the commitment – and we better begin accepting this. [It is actually not a lack of political will. It is a political choice. Internal and external resources allocated have thus remained a pittance, unmatched to the challenge]. There is nothing in sight that tells me this will change soon.
15. [Actually, the best thing about this “yes, but” approach is that it invites for a yearly follow-up essay along the same lines, because SOMEBODY has to keep asking every year from now to 2015: Where are we beyond pronouncements and promises? Would any of our readers take up the challenge? You can continue calling those future essays: “Towards the Millennium Development Goals: Yes, but… and add the year in which the review is done].
16. Given the growing and urgent call for wider application of a Human Rights-based approach to development, sustainable development work is to contribute, not only primarily to achieve goals (e.g., MDGs), but also primarily contribute to the process of developing the capacities of duty-bearers to meet their obligations and of claim-holders to claim their rights. So what has to be noted is that the outcome dimension is determined by Human Rights standards while the processes must adhere to Human Rights principles (non-discrimination, inclusion participation, etc.) (4). [Actually, goals and targets are, per-se, antithetical to the HR paradigm; in the HR-based approach, we cannot rest until the rights of all are instated].
17. I urge you to understand that there is nothing inherently wrong with MDGs; they may even be laudable if we go about them doing ‘the needed’ to achieve them. But MDGs were (are) imposed top-down and are overwhelmingly tackling immediate and underlying, and not the basic (structural) causes of the poverty that is sustaining ill-health and malnutrition. What we actually need to do is to de-medicalize MDGs and focus more on structural processes than on ill-health or malnutrition themselves, because the latter two are outcomes not of biological disease, but of a widespread social disease!
18. Therefore, do we want to continue to be undemocratic? We have already failed those whose rights are being violated day-in, day-out. As long as we consider the strategies needed to tackle the basic causes of poverty to be outside the realm of our professional scope of work, we should consider ourselves part of the problem and not the solution. Simply put, acting at the upper causal levels is necessary but not sufficient.
19. Take for example health: Many of the currently proposed approaches to resolve health problems (and for which there are respective MDGs) focus on targeting; as if targeting were an alternative to Primary Health Care as originally conceived in Alma Ata 25 years ago. Individual targeting – on which much of the current strategies to achieve the MDGs are based on – is equivalent to the discredited Selective PHC Approach, i.e., “go for the worst cases, fix them, and improve the statistics”. But where are the sustainable changes – those that avoid the recurrence of the same problems generation after generation – to be seen? Targeting keeps a semblance of equity; targeting can and does stigmatize the poor creating ‘second-class citizens’ that can be manipulated. It tacitly blames the most vulnerable for being where they are and tends them a rescuing hand. Individual targeting is not a substitute for a more redistributive public policy. (Conversely, geographic targeting may have more equity potential). Starting with individual targeting interventions as the central thrust to achieve equity is the wrong approach; it pursues what is rather a ‘mirage of equity’. [As a matter of fact, vehemently pursuing the MDGs has an important potential risk: it can push us to implement interventions amongst the-easier-to-reach-near-poor, eventually leading us to achieve the target on schedule, BUT at the cost of exacerbating inequity].
Epilogue:
20. Probably related to the above, have you noticed that no actual development strategies are announced anymore? Only ‘goals’! But goals are not strategies! They are statistical objectives. You can only achieve a goal if the path to it is described – and this means preparing down-to-earth participatory action plans. (A mere number reflecting how far one is from achieving the goal is simply misleading).
21. The take-home message here is that there is probably no such a thing as across-the-board realistic goals; at most, they are being proposed on some technical grounds.
22. In contrast to all the above, the way I see it is: Let us (who read papers like this) not even try to unilaterally decide what is needed. Let inputs on ways out of non-equity-redressing schemes and the provision of needed services come from the more directly affected themselves; devoting our energies to facilitate such a process will be a big leap forward for all of us.
23. Bottom line, I contend that the Millennium Development Goals are primarily a rhetorical device – useful as it might be if…. You disagree? Then, consider for a moment that – for the specific poverty reduction MDG – even those who we manage to push above the $1/day mark by 2015 may still stay between 1-2 dollars a day…forever. (2)
24. There simply are no short-cuts: Goals or no goals, for people to gain control over the resources they need to overcome all aspects of the deprivation of entitlements they are subjected to remains the key…. from now till way past 2015.
Claudio Schuftan MD
People’s Health Movement,
Ho Chi Minh City
schuftan@gmail.com
References:
(1): Schuftan, C., Aiming at the target: What’s left for the devil to advocate?, SCN News No. 22, pp. 17-19, Standing Committee on Nutrition, UN, Geneva, July, 2001.
(2):Boughton, J. and Qureshi, Z., Staying on track: A framework for monitoring progress toward the MDGs, F+D (Finance and Development), 40:3, pp 46-47, IMF, Washington DC, September, 2003.
(3): Schuftan, C., The community development dilemma: what is really empowering?, Community Development Journal, 31:3, pp.260-264, July 1996.
(4) Urban Jonsson, UNICEF adviser on Human Rights, personal communication.