Millennium Development goals (MDGs)

I have been hearing about MDGs since my first year in medical school about 9 years ago. I had never thought to question these that had been handed down to me with such firmness and seriousness focussing especially on the goals directly linked to health.(MDG 4,5 and 6). Our last class was particularly interesting because for the first time, I questioned.

As 2015 draws near(the time limit set for the goals), re-evaluation is critical. Not just as to whether the goals have been achieved or not but also whether they were good goals in the first place: were the targets realistic, not merely politically biased and were the indicators appropriate?

These were my highlights from our class conversation. They shall be summarized broadly as Pros and Cons of the MDGs.
Pros:
1. They improved domestic and international co-ordination of programmes by providing direction as to where efforts were being focussed.
2. Wealthier countries exhibited increased moral responsibility for poverty around the world.
Cons/ Criticism against them:
1. They did not address means on developing capacity within low income countries. Many of them continually heavily rely on donor funds to meet these goals.
2. There were conditions which were excluded: Non-communicable diseases which in some poorer economies such as in the Pacific Islands (obesity) are more pertinent issues.Also injury wasn't addressed as well as mental health and disabilities.
3. Indicators used e.g extreme poverty referring to income below $1.25. This may not be realistic even the rises in food prices and depending on the countries, someone with a daily income of income of $2 can be 'poorer' than one who earns $1 depending on cost of living and value of a dollar in that economy. Also measuring women empowerment by number of girls in school may not give a representative picture as that does not mean that they are learning or even that they are incorporated into the workforce. For example,  Saudi Arabia has large numbers of educated women but there are no jobs for them in the labour force.
4. What about the poor in rich countries where large inequality gaps exist?
5. The goals generally focussed on poverty/ disease eradication and not development which is much broader.

The question that has to be asked is WHAT NEXT?
This is an area that is under discussion through different forums. Research is on going in a number of countries to find out what the people would like addressed in whatever is decided as the next course of action.

• There was a consultation meeting held in Botswana (Lancet April 2013) which addressed a couple of questions. I found these particularly interesting in Panel 1:

- What are the best indicators and targets for health?
- How can it be ensured that the process and outcomes are relevant to the key stake holders?
Not all the members present agreed on the answers to these questions.

They also however proposed:(There was more convergence here) Panel 2:
1. Accelerating the progress of the MDGs
2. Reducing the burden of Non-communicable diseases (Yes, the world has changed a lot since 2000 when he MDGs were formulated.)
3. Ensuring Universal Health acess

Universal Health Coverage:(UHC)
This has been discussed by Yates R.(2009) and Sachs J(2012) sighting the that UHC improves access to health services without marginalising the poor. The benefits of this system have been seen in countries like Uganda however the main challenge for the how income countries is how they will be able to raise the money required to cater for the population(Sach estimated the cost at 40-60 USD per person)

Cost sharing was abolished in Uganda a few days before the 2001 presidential election. Burnham et al (2004) who did a follow up study for 21 months in 78 health facilities across 10 districts of Uganda. They found that there was resulting increased attendance by 53.3%. Also there were increased rates of use of services which were even free prior to introduction of UHC such as: family planning services, immunisation and  Antenatal care. However, also noted was the displeasure of health workers concerning loss of salary benefits and decreased availability of essential drugs.

This article shows some of the existing challenges in Uganda: corruption and questions concerning the priorities of the government. I wonder if it is practical to expect such a system to effectively implement Universal Health Coverage. According to the Lancet 2012:
"...universal health coverage in isolation is no guarantee of efficient and effective care. In addition to political will, UHC requires sufficient numbers of well-trained and motivated staff with adequate resources for prevention, diagnosis, treatment, and professional development, and—to thrive—a culture of good governance and aspirational attitudes. In this way, the spiral of impoverishment from disease can be replaced by one of prosperity driven by health."

From my experience working as a doctor in some of the rural hospitals in Uganda, I am convinced that abolishing the cost- sharing system in Uganda has done more harm than good. This is because of the inadequate drugs and supplies at the facilities as well as the underpaid and disgruntled staff who many times impose 'unofficial' prices on patients- most of which are off-record. Maybe now, after more than 10 years of implementing UHC in Uganda, there may be additional value of re-evaluating the programme: Merits and Demerits across the various regions of Uganda.