Bill & Melinda Gates Foundation

Hazardous Road Ahead in Fighting Disease

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September 20, 2013

More than $126 billion in annual financing will be on the table when world leaders and advocates gather at the United Nations on September 25 to kick into high gear what is expected to be a highly contentious, two-year process of negotiations to set international development priorities for a fifteen-year period starting in 2015. The financing comes from diverse sources--ranging from donor governments to multinational institutions like the World Bank to philanthropies such as the Bill and Melinda Gates Foundation.

The danger in the upcoming talks is that an expansive, intellectually coherent but politically unachievable agenda will emerge, fueled by advocates for competing causes, that will undercut current efforts to tackle extreme poverty, hunger, and disease that enjoy widespread political and public support.

The focal point for discussion at the day-long Sept. 25 meeting is the future of the Millennium Development Goals (MDGs), an ambitious set of non-binding milestones set in 2000 by international consensus for achievement by 2015. The MDGs occupy a sweet-spot where progressives and conservatives have found common cause to sharply reduce child and maternal mortality, hunger, and extreme poverty; prevent deadly infectious diseases; greatly expand access to clean drinking water and improved sanitation; and achieve universal access to primary education.

In marketing terms, the MDGs have emerged as a unique and successful "brand"--a brand that needs to be protected and nurtured going forward. The strength of the MDGs is that they offer a limited set of narrowly defined, readily communicated goals that are not only aspirational but also practical, achievable, and measurable using affordable interventions of proven effectiveness. As a brand, the MDGs stand for pragmatic, high-impact investments which make the world a better place. The MDGs' compelling attributes have drawn widespread support from policy makers and funders, and have served as a wedge to generate momentum on a broad variety of fronts related to social development.

But rather than seeking to further strengthen a successful brand, influential development advocates are championing what might be described as a "New Coke" strategy that would scrap the MDGs after 2015 and substitute a new and controversial set of Sustainable Development Goals (SDGs). In a report issued in May of this year, a high-level panel convened by UN Secretary General Ban Ki-moon concluded that the MDGs "fell short by not integrating the economic, social, and environmental aspects of sustainable development..., and by not addressing the need to promote sustainable patterns of consumption and production...We must act now to halt the alarming pace of climate change and environmental degradation.". The high-level panel called for accelerated efforts on the MDGs through 2015. After that date, the politically popular MDGs would be folded into a broader agenda around which there is no consensus on the best way forward.

A second high-level panel, convened by the president of the UN General Assembly, issued its own report earlier this month in which it endorsed the same idea of folding the MDGs into an expansive set of Sustainable Development Goals designed to "overcome the interconnected crises of extreme poverty, economic instability, social inequality, and environmental degradation."

The problem with this approach is that there's no upside to ensnaring the MDGs in divisive arguments over international economic and environmental policies. Indeed, to do so would constitute a serious unforced error, made worse by a fiscal environment in which funding for international development faces significant challenges. A more prudent approach would carve out a "safe space" for the consensus goals embodied in the MDGs, preserving the current equity in the brand while expanding the MDGs' purview incrementally to take account of evolving priorities in social development. The broader economic and environmental goals should be dealt with separately.

The MDGs were derived from a broadly-based Millennium Declaration endorsed by 189 nations in 2000. While the Declaration ranged far and wide--from human rights to environmental protection to curbing inequalities stemming from globalization--the MDGs focused narrowly on social development.

Notably, and smartly, the architects of the MDGs did not pursue the comprehensive approach to development that was embodied in the Declaration. Rather, they took a highly complex set of problems, broke them down into separate manageable components, and identified a limited set of goals where rapid progress was thought to be achievable at the time.

While funding for international development already was rising prior to the MDGs, policy makers and advocates were able to use the new set of consensus goals to harness, intensify, and give direction to existing favorable tailwinds. Health issues of the developing world emerged as a top priority, driven by a combination of high-level political leadership and the availability of effective and affordable interventions. The Institute for Health Metrics and Evaluation at the University of Washington estimates that the annual growth rate of development assistance for health exceeded 11.2 percent between 2001 and 2010, climbing to $28.2 billion, compared to 5.9 percent in the previous decade. U.S investments in global health grew from $1.7 billion in FY2001 to $8.9 billion in FY2012. In a 2012 public opinion poll conducted by the Kaiser Family Foundation, two-thirds of Americans said that the U.S. is spending either too little or about the right amount on global health.

The MDGs are still a work in process. On the one hand, remarkable progress has been achieved, thanks to the combined effects of economic expansion and development assistance. The percentage of people in developing countries living on less than $1.25 per day dropped from 47 percent in 1990 to 22 percent in 2010; under-5 deaths declined in this period by 42 percent; maternal deaths by 47 percent; and the number of undernourished people by 23.2 percent. Between 2000 and 2010, malaria-related deaths fell by 25 percent globally, and by 33 percent in Sub-Saharan Africa, saving more than 1.1 million lives. The spread of HIV/AIDS has been halted and reversed, and 9.7 million HIV-positive people are being successfully treated with antiretroviral drugs. Between 1995 and 2011, 51 million tuberculosis patients were treated, saving 20 million lives.

On the other hand, tremendous variability still exists among regions and individual countries. On the MDGs' key target of reducing extreme poverty by two-thirds, nearly all the reported progress is attributable to just three countries--China, India, and Brazil. And while some African nations have achieved major advances, the region as a whole lags far behind the rest of the world.

Africa, home to 12 percent of the world's population, accounts for half of worldwide deaths among children under the age of five, 56 percent of all maternal deaths, 90 percent of the 330,000 children who contract HIV/AIDS each year, and 91 percent of the world's 655,000 malaria deaths.

In sub-Saharan Africa, about 47 percent of the population still lives in extreme poverty on less than $1.25 per day, despite robust economic growth rates. In 2010, sub-Saharan Africa's share of international development assistance for health was $8.1 billion. Governments of sub-Saharan African nations provided an additional $29.4 billion, 3.6 times the outside assistance. Even with greatly intensified efforts between now and the end of 2015, Africa will need to remain at the core of international development efforts.

Without doubt, the goals and targets of the MDGs are due for an update to incorporate new opportunities and priorities while strengthening ongoing efforts in Sub-Saharan Africa and elsewhere. The process of achieving consensus on a revised set of MDGs will be a thorny enough endeavor without saddling it with divisive struggles that lie ahead over highly contentious economic and environmental policies.

 
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