By: Ian Matthews, GBCHealth
The unfinished business of the MDGs…
Leave no one behind…
Introduction: The moral foundation of the SDGs
These phrases are uttered almost daily by development practitioners across the globe. In many ways, they have collectively come to represent the moral foundation of the SDGs. However, we are only just starting to understand how these principles will be translated into action between now and 2030.
The phrases are interconnected of course. Much of the work that remains from the MDGs is in communities that have been largely left behind. As we embark on this new era in development, it is imperative we not overlook the lessons of our past.
The SDGs have attempted to reckon with the major challenges of the MDG era – namely selectivity, sectorization, and top-down implementation – by emphasizing country ownership and integration. The Inter-agency and Expert Group on SDG Indicators (IAEG) tasked with setting indicators encompassed an economically and geographically diverse group of more than 25 Member States. This diversity produced the current framework – an overlapping set of 17 goals and 169 targets – with the ambition to develop fully-integrated systems at the national level to support widespread human, social and environmental progress. The hope is that these systems will eventually extend to reach those previously left behind with sustainable services and economic opportunities.
What will this integration look like?
Integrating development – agenda, sectors and actors – implies a new approach, that links design, delivery, funding and evaluation of multiple development projects to amplify impact. Integration can happen at the national level through a comprehensive approach to delivering multiple services simultaneously or at the community level through the explicit coordination of programs focused on different sectors, such as water, agriculture and health or on cross-cutting issues like One Health. On a more fundamental level, integration can happen within organizations implementing complex programs by tapping expertise across departments and creating robust measurement frameworks that take indirect causes of interventions into account.
At the global level, integration is already forcing diverse partners together to reconcile disparate agendas for development. For example, there have been significant overtures made to the private sector through the UN’s SDG Business Forum and Global Compact. While overly focused on financing to date, the dialogue has started to shift into the realm of genuine partnership. Less visible are the ways the World Bank and the UN have begun to collaborate more closely on matters beyond conflict and violence. Integrated frameworks, such as the African Union’s focus on Demographic Dividend to unite health, education and economic empowerment work on key adolescent populations under a single banner, are also necessary.
Yet, despite the unique circumstances of the world today, it is important to note that the notion of integrated development is not a new one. In fact, it has been with the development community since the beginning.
The first major post-WWII development agenda, the Marshall Plan, endeavored to rebuild Europe through a mixture of food aid, agricultural improvements and revitalized housing stock, while simultaneously transferring capital to stimulate large-scale industrialization. Twenty years later, the World Bank and other donor agencies began experimenting with Integrated Rural Development (IRD).
IRD programs sought to professionalize smallholder agricultural systems and strengthen rural-based human capital as key drivers of development. Further evidence accumulated over this period suggested that investing in social programs including health and political empowerment led to increased productivity and better alignment between community and donor goals.
During the 1978 Alma Ata Conference, the WHO and health workers around the world agreed to prioritize investing in Primary Health Care (PHC) systems, which required an integrated case management approach to newborn and child health at the national level. Almost immediately, the credit crisis of the 1980s and the election of conservative governments in the United States and the UK, shifted donor focus from empowering communities to enforcing structural adjustment. Beyond these political pressures, comprehensive PHC proved difficult to enforce. The education of health personnel, the challenges of involving community participation and the economic costs of PHC were never clear before 1980.
As a result of these challenges, broad PHC was shelved in favor of a more specialized primarily health care (SPHC) approach. SPHC focused on four main areas: growth (i.e. nutrition), oral rehydration for diarrhea, breastfeeding, and immunization. Despite positive results in each area, growth, breastfeeding and Oral Rehydration all proved difficult to institute without first dealing with the broader structural issues that limited earlier comprehensive efforts. Immunization however achieved remarkable results due to its focus on community mobilization and education; and its less-rigid design. By 1989, over half of the children of the developing world received priority immunizations each year. In addition, smallpox was eliminated from the globe and polio was controlled in several regions of the world during the 1980s.
MDGs: Sectoral development
While the Millennium Development Goals (MDGs) weren’t exactly drafted by a handful experts in a UN conference room, as some have contended, they were often criticized for emphasizing donor priorities over domestic ones. This approach was remarkably efficient for setting clear and ambitious global targets, but did not necessarily encourage the participation of the very governments required to carry out the programs.
As a result, some donors took to investing in specific sectors such as health, education or water while others became even more surgical – investing only in specific disease areas. Similar to the experience of the 1980s, this sectoral or siloed approach worked well in areas like universal immunization for measles – an intervention that requires vertical cold-chain supply and community education — and fared worse in areas with more complex, systemic factors such as maternal health or sanitation. This led to uneven progress from 1990 to 2015. For example, the targets for MDG 6, which focused on HIV/AIDS, malaria and TB, were surpassed, while other health indicators beyond the scope of the MDGs like childhood obesity and Hepatitis B experienced minimal improvements or got significantly worse over the same period.
Conclusion: SDGs learning from the past
Re-integrating development after the sectorization of the MDG period is central to the success of the Agenda 2030. To learn from the full historical experience of development, integration during the SDG period must seek to:
- Shift accountability downward – away from donors and toward communities.
- Map complex systems – acknowledge the web of implementing partners and local power dynamics that affect how programs are designed and who receives benefits.
- Consult communities from the start – ensure that communities have platforms for their voices to be heard, are organized, informed and empowered.
- Make financing more flexible – allow for iteration and adaptation of programs to respond to changes on the ground. Utilize data, technology and direct feedback to drive program activities.
- Partner with all sectors from the design stage – treat non-governmental sectors, especially the private sector, as a development partner with particular expertise and experience – not just as a funder.
By focusing on the multidimensional nature of complex systems, practitioners cannot help but consider local political actors, community power dynamics and family/individual motivations as the key drivers of development. This is particularly true in the health space where healthcare seeking behavior and private/public competition for patients drive outcomes.
A single actor cannot create sustainable impact on their own or through a one-size fits all approach. Ultimately, to match the dynamic spirit of the SDGs and satisfy their moral foundation of leaving no one behind, a re-integrated agenda, mindful of past missteps, is a good place to start.
Ian Matthews is Director of Strategy and Communications at GBCHealth. He has worked for almost 15 years in the development and private health sectors. Ian writes on a range of international development issues including global health policy, conflict, development financing, and public-private partnerships.