The Millennium Development declaration was a visionary document, which sought partnership between rich and poor nations to make globalisation a force for good. Its signatories agreed to explicit goals on a specific timeline. The Millennium Development Goals (MDGs) set ambitious targets for reducing hunger, poverty, infant and maternal mortality, for reversing the spread of AIDS, tuberculosis and malaria and giving children basic education by 2015. These also included gender equality, environmental sustainability and multisectoral and international partnerships.
The 10th anniversary of the declaration was used to review progress and suggest course corrections to meet the 2015 deadline. The glittering banquets, the power lunches and the rhetoric at the formal meetings, attended by many celebrities, ambassadors of different nations, international charities and the media, in New York belied the stark reality in many poor countries. While the declaration and the MDGs were a clarion call and mobilised many governments into concerted action, a review of the achievements to date and projections for 2015 suggest some success and much failure. Most rich nations failed to meet the targets on promised aid. While progress has been made, much more needs to be done.
Government's claims
The Government of India claims that the country is on track to meet the MDG targets by 2015. It argues that the number of people living below the poverty line has reduced. It claims that child and maternal mortality rates are reducing at a pace commensurate with its plans. It maintains that many government-sponsored schemes have increased public resources in several key sectors. The Mahatma Gandhi National Rural Employment Guarantee Scheme has increased rural employment. The Sarva Shiksha Abhiyan, a national policy to universalise primary education, has increased enrolment in schools. The Reproductive and Child Health Programme II, the Integrated Child Development Services and the National Rural Health Mission have resulted in massive inputs in the health sector. It states HIV rates are low and that deaths due to tuberculosis and malaria show downward trends. It asserts that the Rajiv Gandhi National Drinking Water Mission and the Total Sanitation Campaign address crucial MDGs.
It is, however, difficult to endorse the government's confidence and optimism. Experts argue that the poverty reduction claims are the result of a sleight of hand, which employs debatable measurements and methods for assessment. The existing rates of malnutrition, affecting half of all children under 5, do not support the claims of hunger reduction.
While many agree with the figures for reduction in maternal mortality, they feel the target set is unachievable, as are those for reduction of child mortality and for universal primary education. Gender equality remains elusive. The emergence of an extremely drug-resistant tuberculosis and the high incidence of malaria in certain regions are worrying.
The impressive growth and the creation of wealth with economic liberalisation have not resulted in social development, what with stagnation in key social indicators, particularly among the disadvantaged. There has been an uneven expansion of social and economic opportunities with growing disparities across regions, castes and gender. While India's Gross Domestic Product argues for its middle-income nation status, it also hides massive poverty and much inequity. The challenge to convert India's commitments and resources into measurable results for all its citizens, especially those belonging to socially disadvantaged and marginalised communities, remains gigantic and unmet.
Illusory measurements
The Millennium Declaration, unlike many other documents, set out measurable aims instead of the usual vague platitudes of many international agreements. The MDGs focus on specific and measurable outcomes. However, employing proxy and surrogate variables to measure the country's success may not reflect actual progress. The focus on the massive inputs related to the National Rural Health Mission (NRHM) while discussing child and maternal mortality, for instance. Most NRHM documents describe in detail particulars of the increased funding, new infrastructure, additional health personnel and the many new initiatives. However, they are silent on their impact on the health of people. The Janani Suraksha Yojana (JSY), a conditional cash transfer scheme for safe motherhood, is operative and is part of the drive to increase institutional deliveries. The impressive number of women who have given birth to children in hospitals and the amounts utilised under the scheme measure its success. However, the system does not collect and collate data on the number of safe deliveries, the number of live births and measures of the health of mothers and babies. Data on the person who actually conducted the delivery, post-delivery complications, duration of stay at health centres and the status of the mother and child are not available. System failures related to transport, functioning of facilities, referral and emergency obstetric care are not rare but go undocumented.
While there is no doubt that the NRHM has made a positive impact on primary and secondary health systems, we need proof of improved functioning in addition to evidence of enhanced infrastructure and increased personnel. Specific measurements of outcomes will allow for course corrections and targeted inputs.
Similarly, while enrolment rates have improved, the question of retention of girls in primary education is yet to be established, posing a threat to meeting the targets for universal education. While the figures for hunger reduction look better, those for malnutrition in children suggest otherwise. The figures for poverty reduction are contested. Patriarchy is firmly established and shows little signs of change, especially in rural India, making gender equality and justice elusive. Many reports suggest that environmental sustainability of many development projects is not adequately evaluated.
While there are many gains, the question to be answered is: “Is India on track to meet the MDGs in 2015?” Its vast population, its diversity, the variability of services and the differing baselines across regions complicate the achievement of the MDGs. There is evidence that while some States are on track, many others lag behind and will lower the country's overall achievement. This demands a more detailed assessment of the impact of the many schemes introduced rather than the use of only input variables to predict MDG outputs.
Rhetoric-reality divide
India's vast geography and its diversity are major reasons for significant variations across regions. They mandate the need for separate targets, governance, a focus on public health and changes in social structures. The variability across regions mandates dedicated goals and specific targets tailored to regional baseline rates, for both specific regions and marginalised populations. Periodic assessments of specific outputs required to meet the MDGs are necessary rather than highlighting of new inputs. The many new schemes need to audit their actual, rather than their presumed, impact.
Any survey of regional data clearly documents that poor outcomes are in regions with poor governance. While the NRHM divides the country into high-focus and non-high focus States, the inputs to improve the situation are not directed at improving governance. The federal structure means that improving local governance is the responsibility of individual States. Many States have not fully exploited the increased funding and the newer schemes. Good governance is an effect multiplier and will have a much greater impact on the country's MDGs than just increases in finance, infrastructure and health personnel. Corruption is a deadlier disease which needs urgent attention than most of the medical conditions affecting the people.
The focus on improvement in health continues to employ perspectives of curative medicine rather than concentrate on public health approaches. Clean water, sanitation, nutrition, housing, education, employment and social determinants seem to receive a lower priority despite their known impact on the health of populations.
Feudal social structures continue to oppress millions of people. Health and economic indices of the Scheduled Castes and Tribes show much lower rates of health and greater poverty. Patriarchal society places much burden on girls and women, especially in rural India. Without changes in social structures, improvements in health and economic status will remain a distant dream for the many millions who live on the margins of a resurgent India.
The 10th anniversary assessment of the MDGs and its rhetoric left many wondering if they were just warm words, business as usual. Millions live in poverty, hunger is common, half the children under-five are malnourished, maternal mortality is unacceptably high, and a significant number of girls will not receive primary education. The sense of urgency, born of the moral conviction that extreme poverty is unacceptable in our inter-connected world, should not be lost. The time for action is now.
(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)
