The Millennium Declaration and the Millennium Development Goals demonstrated the power of global political will at the highest level with a common purpose: eradicating poverty. The MDGs made it possible to go beyond declarative language and make specific commitments at the national, regional, and global levels for the short, medium, and long terms, with monitoring of progress and follow-up by governments, civil society, the United Nations system, and development partners. This focus on accountability has been an integral part of the MDG agenda and has undoubtedly contributed to the progress made.
The MDGs also made it possible to set guidelines for integrated and synergistic work among sectors and agencies, recognizing that the living conditions of the most vulnerable can only be improved through coordinated efforts based on development strategies that address the issues of nutrition, work and employment, education, and health and sanitation and that involve commitments shared by developed and developing nations. In this sense, the MDGs reinforce PAHO/WHO’s focus on the social determinants of health and the necessity of addressing them with multisectoral interventions. At the same time, by putting health at the center of the development agenda, the MDG framework has raised the visibility and the recognition of health in public policies.
Over the past decade, the Organization has integrated the MDGs into its technical cooperation programs, which already addressed issues such as hunger and malnutrition, gender-based inequality, maternal and child health, infectious and neglected diseases, environmental health, and partnerships for development. The MDGs have advanced and strengthened the efforts of PAHO/WHO and its Member States in these key areas.
At the same time, recognizing the serious income inequality in the Region, PAHO/WHO has emphasized the need to go beyond the MDGs and their official targets to address major disparities that are concealed by national averages. In launching its Faces, Voices, and Places initiative, PAHO/WHO stressed the importance of reaching the most vulnerable and neglected municipalities and territories, reviving the principles of primary health care, and empowering people in their communities. It is not enough for heads of state and government to know and make a commitment to the MDGs. Mayors, local authorities, and residents of the communities themselves must understand that the MDGs are the basic elements of a development agenda based on human rights. By emphasizing this, PAHO/WHO has made a unique contribution through an ethical framework for advancing the MDGs.
The experiences of the Organization in providing technical cooperation to advance the MDGs in Member States have produced lessons that can help accelerate progress toward those goals during the four years that remain before 2015 and shed light on the way forward after 2015.
One clear lesson is the need to give greater attention to the problems of maternal and neonatal mortality, which are two of the MDGs on which the Region has advanced the least, especially in rural areas and areas of vulnerability and poverty. The recent concentration of populations in peri-urban areas poses special challenges in terms of access to health services to reduce maternal and child mortality. The target is also distant regarding chronic malnutrition. . As for access to safe water and basic sanitation, in numerical terms this has become an urban challenge due to demographic trends, but there are still broad segments of the population in poorer rural areas that also lack these development benefits. All these pending issues need to be addressed in a more targeted manner while the comprehensiveness and intersectoral nature of policies, programs, and projects must be reinforced.
At the same time, while there is evidence that poverty has declined, progress has been uneven, and there are still segments of the population that remain vulnerable, particularly as a result of geographic location, cultural identity, and gender. It is therefore essential to continue working to advance the MDGs at the local and municipal levels and among marginalized and disadvantaged groups, even though these disadvantages may be difficult to see with the available evidence. Similarly, although progress has been made in reducing inequality in the Region, promoting equality of opportunities and results remains critical to reduce gaps within countries.
Another important lesson that has been confirmed in recent decades is that there is a virtuous circle in which economic growth and health, together with social development, are mutually reinforcing. It is therefore essential to closely monitor business cycles, because the vulnerability of the poor increases during recessive phases of these cycles, largely because social spending and investment tend to be reduced as part of corrections that are required to overcome crises. The lessons learned from middle-income countries need to be systematized not only to curb economic crises but also to reduce the equity gap and promote sustainable development.
For example, the impact of the 2008-2009 recession has been less profound than in earlier recessions, such as during the 1980s, because the Region’s economies were better prepared and because of social programs that were specifically designed to protect the most vulnerable. This shows the importance of protecting and increasing social spending, especially for social protection programs.
These and other lessons learned from the experiences of PAHO/WHO and its Member States in pursuing the MDGs point to a number of conclusions and recommendations for future efforts, as noted below.
The Millennium Development Goals after 2015
It is essential to constantly generate the evidence necessary for developing policies, plans, programs, and projects. This requires strengthening national health information systems. Evidence is the fundamental basis for decision-making and implementation of effective policies. Only with good-quality data and information can goals be transformed into results. The observatory for the health-related MDGs should be promoted to monitor progress and setbacks at the national and subnational levels and to facilitate appropriate and timely action.
Constant monitoring of public health spending is also necessary, including spending to improve health system performance and to make social protection programs universally available, with emphasis on the most vulnerable sectors and municipalities. This could be achieved through the creation, with the ministries of health, of a program to monitor social spending, with annual reports.
- As long as high levels of poverty and inequality persist in the Region, public spending will need to be increased for the health sector and for social protection programs that imply structural changes. These programs should not only use resources from different sectors but also lead to synergies in processes and results; facilitate empowerment processes and not be limited to assistance to individuals; focus not only on access but on quality; and be monitored for results not only in terms of alleviating extreme poverty but also overcoming it, so that gains are harder to reverse. This requires the countries of the Region to make progress in fiscal reforms that can support increases in and sustainability of social spending.
- Technical cooperation focused on geographical areas—including poverty zones in urban municipalities, hard-to-reach communities, and transnational territories— will continue to be critical to accelerating progress toward the MDGs. The Faces, Voices, and Places initiative has helped call attention to the unfinished agenda and inequity within countries. This agenda must maintain a high profile, and its political, technical, and financing dimensions must be addressed, so that policies and resource allocation do not end up once again neglecting these areas.
- To ensure a multisectoral and multidimensional approach, inventories of national policies are needed to facilitate evaluation and to concretely promote “health in all policies.” This is the only way to make achievements sustainable and to guarantee effective action on the social and environmental determinants of health.
- It is also important to complement harmonization of international cooperation with efforts to enhance governance and the coordinating capacity of national authorities. This means mobilizing, harmonizing, and aligning international cooperation for achieving the MDGs and addressing national health and development priorities.
- Large-scale projects that require significant resources, such as infrastructure for drinking water supply and basic sanitation, require support from multilateral financial institutions. To guarantee quality services and to ensure their sustainability, the efforts of international financial entities and other agencies devoted to achieving these goals must be coordinated; and relationships with development banks and United Nations agencies must be strengthened to address national priorities. As noted above, a series of partnerships have been launched during the past 11 years that exemplify integrated work toward a common goal.
- Finally, the fact that the Latin American and Caribbean countries have been able to meet many of the MDG targets implies a responsibility to share their cumulative experience with other developing regions. With this in mind, PAHO will continue to share its experience, promote South-South cooperation, and organize efforts for cooperation and knowledge transfer between countries with support from donors and member governments, as well as WHO and other specialized United Nations entities.
The goal of reducing poverty and improving quality of life will not be fully achieved in 2015—either in the Region of the Americas or in the rest of the world—despite the substantial progress made. It will be necessary to continue pursuing the ethical imperative established in the MDGs using an approach informed by an analysis of experiences to date. Among the considerations that should be incorporated into this approach are the following:
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The commitment should be global, but goals, targets, and indicators should be adapted to the regional level to take into account relevant differences. For our Region, this implies higher targets that are focused on excluded populations, indigenous peoples, and African descendants, as well as women, children, and the elderly. Only with differentiated targets can the core of inequality be breached.
- The MDG agenda must go beyond the national level and exert a decentralizing influence to encourage subnational analyses and actions within communities. Given the unequal distribution of capacities, efforts to create human capital at the local level must be emphasized.
- Lessons learned during the past 15 years can be used to develop regional, national, and subnational baselines and to systematize evidence, making it possible to adjust action and clear the way for progress. This will give rise to processes to accelerate progress toward achieving the MDGs, supported by national policies, local action, and public awareness efforts.
- The development agenda set by the MDGs in 2000 must be enriched with sustainable development models that address the challenges of climate change as well as the positions taken at the Rio+20 Summit. Poverty and inequality must be at the heart of the discussions at the Earth Summit. The most vulnerable are the ones who are suffering the most from the effects of climate change, so this is where efforts to prepare for disasters and mitigate the consequences of climate change should begin.
- At the same time, the Region’s demographic transition, together with its inhabitants’ consumption habits, has created a new and greater challenge that was not part of the MDG agenda. Although considerable progress has been made in controlling infectious diseases in the Americas, the epidemic of chronic diseases is growing. It affects rich and poor countries and individuals alike, to such an extent that health and development targets for Latin America and the Caribbean after 2015 should assign the same or higher priority to noncommunicable diseases, which have harmful consequences for vulnerable populations and whose treatment is more complex and expensive. Health promotion must play a key role in creating good habits and turning urban settings into healthy settings, while raising awareness about new, healthier ways of living.
- The issues of productivity and employment will become more important in the second-generation MDGs, with emphasis on young people and work skills development. Efforts to reduce poverty will not be sustainable unless economic growth and productivity are prioritized and forms of dignified and healthy employment are created in both the formal and informal sectors. Occupational health and safety, linked to social protection, health insurance, and pensions programs, make it possible to maintain quality of life, not only during the economically active years but also during retirement. Creative alternatives are also needed to ensure that workers in the informal sector have retirement funds that are sufficient for a decent life.
- The priorities of the second-generation MDGs should be centered on multidimensional development with a human face and within an ethical framework based on human rights and peace. In addition to economic and social development, other challenges must be tackled because they have a major impact on daily life, especially—in the Region of the Americas—violence and insecurity. This will require targets and indicators on public safety to respond to organized crime and policy reforms in the justice sector to end impunity. A new era of human security in which the health sector plays a key role is yet to come.
- Finally, to continue along this path, strengthening partnerships among different development actors will remain critical. International solidarity must continue but must also make adjustments to become more effective. The complex situation of middle-income countries must be recognized, and international support must become more harmonized and less fragmented, must be based on a systemic vision, and must be directed more toward strengthening country capabilities and autonomy, while recognizing and strengthening national leadership. These characteristics would make it possible to consolidate achievements, address shortcomings, and continue to face the development challenges of the decades to come.