What can we learn about making progress on women’s and children’s health?
Blog by Professor David Bishai, Johns Hopkins Bloomberg School of Public Health
Better Indicators of Progress in Health Will Lead to Better Progress: How to Make Better Goals
David Bishai, MD, MPH, PhD, Professor, Johns Hopkins Bloomberg School of Public Health
21 September 2013
Millennium Development Goals (MDGs) 4 and 5 resolve to reduce under-five child mortality by two thirds and to reduce maternal mortality by three quarters by 2015. These aspirational goals have spurred commitment to achieve these goals in some of the poorest places on earth. Thanks to the MDGs, people have done their very best to make life better. That inspiration should carry us forward as we design a post-2015 agenda. We can all do better. We should especially do better at finding a compromise between aspirations and accountability in the post 2015 . When aspirations are unreasonably high—nobody feels accountable. When one only needs to be accountable for mediocrity there is no aspiration.
Improving the health of populations is something that never happened until 150 years ago. Nobody expected health to get better from 1000 to 1015 AD and a millennium declaration signed in 1000 could not possibly have made it happened. The passage of 15 years doesn’t automatically save lives, nor does a signed piece of paper. What is different about this millennium is that there are far more resources to devote to the problem and a lot more international cooperation to solve hard problems in public health. The essential ingredients are having resources and the commitment to use them to make life better.
An important way to enforce commitments is to check on progress, and that is an area where I think the post 2015 agenda can do better than the year 2000 MDGs did. After 2000 a series of Countdown checks applied the global MDGs as benchmarks to every single country under the pretense that in 15 years every country no matter how poor or how sick could achieve the exact same percent reductions in child and maternal mortality. Most countries in Africa were diagnosed as “not on track”. This was artificial. Accountability means being accountable for the resources that one has. The 2/3 or 3/4 mortality reduction benchmarks bore no adjustment for a country’s prior health status or its GDP. It was just too easy for a politician to shrug off being held accountable for standards that had been applied with no attention to the particular situation of their country.
Going forward it would be much better to check accountability by developing standards that pay attention to what could reasonably be expected given a country’s GDP and current disease burden. This year I led a team of researchers from Johns Hopkins Bloomberg School of Public Health and the World Health Organization in developing a set of country-specific targets. Our minimum performance target predicted for each country what the child mortality and maternal mortality rates would be given each country’s levels of mortality from 1990 to 2000 and given each country’s GDP growth rate. Our high performance target predicted what would be possible if each country implemented the best set of practices that leaders in its region had achieved for things like clean water, girl’s schooling, vaccination coverage, and health service availability.
Our minimal performance standard shows that 27 sub-Saharan African countries are not on track for improvements in child mortality. Given the GDP growth and accounting for their prior burden of disease (including HIV) they should be doing better. Politicians and civil society in those countries should be concerned that opportunities to use the GDP growth to make life better are being missed. What should they do? Our high performance target offers a clue. We found four African countries that exceeded our high performance target: Botswana, Liberia, Niger, and Rwanda. Paying attention to these regional leaders and other high performers can offer new strategic insights. None of these countries had a magic bullet that made life better. Some had the good fortune that their head of state was committed to improving the health of the people. Some had charismatic and effective health officials. A common denominator is country ownership and participation in decision making.
I believe that if the people of Africa could have a valid set of expectations they could hold their own leaders accountable. Right now a leader can say the MDGs are wild aspirations. In contrast, I think that the leaders of the countries that failed to meet our minimum performance target should be asked why GDP growth did not lead to the expected improvements in the lives of the children and mothers. An ongoing dialogue between a people who know what to expect and leaders who get support in how to deliver it is the engine of progress in public health. Better indicators of progress are fuel for this engine.