Millennium Development Goals

Here is article recently published in the economist... I live just a few kilometers from one of the MDC villages and Segou has recently been choosen as an MDC city (not sure exactly what that means and what it will entail yet).

Enjoy and let me know what you think!

The eight commandments
Jul 5th 2007 | DHAKA, KOLKATA AND TIMBUKTU
From The Economist print edition


Panos












In 2000 the world set itself goals to cut poverty, disease and illiteracy. It will take more than aid to meet them

RICK JOHNSTON carries his “Arsenator” with him whenever he leaves his office at the United Nations Children's Fund (UNICEF) in Dhaka to check on the handpumps, standpipes and ringwells of rural Bangladesh. This device, a sort of portable chemistry set, can detect whether village groundwater is laced with dangerous concentrations of arsenic. If it finds its way into a person's organs the poison can accumulate, causing black lesions and terminal cancers.

Arsenic has contaminated over 90% of the shallow tubewells in Muradnagar, a subdistrict three hours from Dhaka. Drilling deeper is not an option: the low-lying aquifer is too salty. The households in this corner of the subdistrict rely instead on a gift from the United Nations Foundation: a $4,000-filtration plant, which can strip arsenic and iron from up to 2,000 litres of water a day. A small crowd gathers to watch Mr Johnston mix water from the plant with the chemical reagent in his kit. The Arsenator will take 20 minutes to deliver its verdict.

In 1990 more than one person in four lacked access to safe water, according to the United Nations. By 2015 that scandal will be only half as large—if the world's leaders keep the grand promises they made at the UN's New York headquarters in September 2000. The pledges, which also include halving poverty and hunger, schooling the world's children, arresting disease and rescuing mothers and their infants from untimely deaths, have been translated into eight “Millennium Development Goals” (MDGs). July 7th is officially the halfway point between setting the goals and reaching the 2015 deadline.

Sadly, the UN family is better at making goals than meeting them. In 1977 in Mar del Plata, Argentina, the world urged itself to provide safe water and sanitation for all by the end of the 1980s. In 1990 the UN renewed the call, extending the deadline to the end of the century. In 1978 in what is now Almaty, Kazakhstan, governments promised “health for all” by 2000. In 1990 in Jomtien, Thailand, they called for universal primary schooling by 2000, a goal pushed back to 2015 ten years later. Kevin Watkins, the lead author of the UN's yearly Human Development Report, worries that the pledges the UN mints so readily may become a “debased currency”. In the summer of 2005, at the height of a campaign to “make poverty history”, only 3% of Britons thought the world would meet the 2015 goal of halving poverty, defined as the proportion of people who live on less than the equivalent of a dollar a day.

Such fatalism is as unwarranted as complacency. The world is making unprecedented progress against poverty. Thanks to miraculous growth in China and India, the first MDG target should be met. Almost 32% of people in the developing world lived on less than a dollar a day in 1990. In 2004 that figure was 19.2%. It should fall below 16% by 2015 (see chart 2).

But if such progress inspires optimism, the goals themselves provoke scepticism. They are meant to convert worthy aspirations into quantifiable commitments, against which governments can be judged. But only 57 out of 163 developing countries have counted the poor more than once since 1990. Ninety-two have not counted them at all.

The world has promised to halt the spread of malaria by 2015. But the disease's death toll is unknown. To monitor its fourth and fifth goals, cutting infant and maternal mortality, the UN would like to cull data from death certificates. But many places lack hospitals, let alone hospital records. The UN relies instead on surveys, which net 5,000-30,000 people in a country once every five years or so. These ask siblings whether they have lost any sisters to childbirth. But these estimates are too vague to track trends over time or to make meaningful comparisons between countries, the UN laments.

The numerical targets are also arbitrary. They are not a global totting up of what might be doable country by country. Far from it. China, for example, had more or less halved poverty from its 1990 level by the time that goal was set in 2000. Sub-Saharan Africa, by contrast, will not meet any of the goals. They remain too distant even to serve as beacons to steer by.

Although the extreme-poverty rate in Africa has fallen from an estimated 46% in 1999 to 41% in 2004, that is still way off the 2015 target of 22%. Hunger and malnutrition still gnaw at the region: the proportion of under-fives who are underweight has declined only marginally, from 33% in 1990 to 29% in 2005. Despite dramatic gains, Africa will not meet the goal of universal primary enrolment either; the rate is up from 57% in 1999 to 70% in 2005.

Africa lags behind partly because its population is growing so rapidly. In rural areas, mothers are giving birth to at least six children on average, doubling the population every generation. As a result, Africa's top-line numbers are improving more than its ratios. Millions more African children are going to school, but the denominator is also increasing. According to the UN, in 1990 there were 237m Africans under 14; today, that figure is 348m, and by 2015 it is expected to top 400m. What price the goal of universal schooling at that pace of population growth?

Start where you're ATT

Yet it is still possible to get things done, even if not at the pace that the MDGs demand. Take Mali, for instance. This landlocked country, straddling the Sahel region and the Sahara desert, should be one of the least promising countries for development on earth. It is ranked third from bottom (in 175th place) in the UN's human-development index, just shutting out its neighbour Niger and poor Sierra Leone. Yet Western governments and aid agencies, to say nothing of Libya, the Islamic Development Bank and the Chinese, are all flocking to Mali with both great expectations and lots of money.

Why has Mali generated so much hope, whereas nearby Nigeria and Guinea, for example, provoke merely exasperation? Mali has a government, led by Amadou Toumani Touré (“ATT” to Malians) that devotes most of its limited resources to what it calls the “Struggle against Poverty” rather then squandering them on the baubles of office. Mr Touré's commitment is acknowledged by Malians, who have just re-elected him for a second term. It has also been rewarded by donors. Mali is one of only five African countries to have fully qualified for America's Millennium Challenge Account (MCA), with its stringent criteria for good governance; that alone will bring in $460m over the next five years, a huge amount in a country with a government budget of only about $1.5 billion.

How will Mr Touré spend this money? Mali's government has made agriculture and infrastructure a priority. The head of its poverty-reduction programme, Sékouba Diarra, argues that rather than depending on aid, his government wants to raise growth to lift people out of poverty. With greater mechanisation and irrigation, the country's 3.5m farmers will, he hopes, become self-supporting, growing much more than the traditional crop of cotton. Donors have been persuaded to give large sums to support this; the MCA, for example, is funding a 16,000-hectare (40,000-acre) irrigation project at Alatona, which represents almost a 20% increase in the country's drought-proof cropland.

In a desert country, irrigation is probably the most important anti-poverty tool of all, and the results can be seen in the remote villages around the desert town of Timbuktu. In recent years villagers have been shown how to build irrigation canals to capture the flood-waters of the huge Niger river, which winds its way through most of the country. This week, with the rains just about to arrive, the people of one of the villages, Adina Koira, are coming to the end of a three-month communal slog to build up their 5km of irrigation canals. On the irrigated lands they have been able to grow traditional crops such as cotton and rice, as well as new ones such as tomatoes and onions. At the moment they can buy aid-subsidised fertiliser and seeds to do this.

So successful has some of this irrigation work been that the villagers have even reversed the usual patterns of immigration. People are coming back to the villages, from the capital Bamako, or from other nearby countries such as Côte d'Ivoire and Niger, to share in the new sense of endeavour, if not actual prosperity. One man, reflecting the experience of many villagers of the Sahel, says that without the irrigation schemes “none of us would be here today.”

The hope eventually is that Mali, using the waters of the Niger, will become the bread-basket of west Africa. It would also be nice to have better access to European and American markets. But for any of that to happen, Mali needs roads and transport. The country has excellent beef, for instance. But as one UN official says, “You can't have the cattle walk 2,000km to market—they become skeletons.” During the four-month rainy season, villages just 20km or 30km apart can become cut off from trading with each other. Thus donors such as the European Union and China are building roads and the Americans are re-developing the international airport.

Donors now contribute about a fifth of the government's budget. Foreigners are happy to help out because they are confident that the funds they provide will not be misused. The institutional framework for reducing poverty seems entrenched and irreversible, whatever happens to ATT. Mr Diarra is confident that even Mali will reach the goal of halving poverty in the end. Not by 2015, but perhaps by 2025.

Goal-hanging

Such incremental progress pleases, but does not satisfy, the custodians of the MDGs, such as Jeffrey Sachs, the UN's special adviser and a tireless advocate for the goals. They are reluctant to lower their sights, arguing that the goals are akin to human rights, solemn obligations that brook no compromise. By this reckoning, the developing world's needs can be counted, the cheapest fixes can be costed, and the resulting bill can be calculated. All that remains is for the rich world to pick up the tab, so that a poor country's health and education ministries can get the job done.

This MDG-think is seductive. It is a potent mix of inspiration (saving lives and educating minds is eminently doable) and accusation (why, then, is the rich world not doing it?). But this thinking is also misleading. However laudable, the goals wrongly invite people to think of development as akin to an “engineering problem”, as Lant Pritchett, now of Harvard University, and Michael Woolcock of the World Bank have argued. The task is to pour money in one end of the MDG pipeline and then count the tubewells and school enrolments emerging from the other.

Some of the duties of government can indeed be left to the technocrats. Repealing tariffs or preserving the value of the currency are tasks best handled by “ten smart people”, the two authors point out. Mr Sachs was one such person, stopping Bolivia's hyperinflation in its tracks in 1985-86, the triumph that first made his name. In Africa, such monetary mayhem is now confined to Zimbabwe. Elsewhere, inflation has fallen from an average of 17% in 2000 to 7% last year.

Other tasks, such as laying a road or delivering a measles jab, rely on the efforts of many more people. But these legionaries need not exercise much judgment or discretion, and their output (a mile of road, a shot in the arm) can be easily counted. Thus immunisation drives and road-building campaigns lend themselves to routinised programmes that can be rolled out and “scaled up”, often with the help of foreign funds. International efforts against measles have helped cut the disease's death toll in Africa from 506,000 in 1999 to 126,000 in 2005.

Most of the MDGs, however, do not play to these strengths. If a country is to educate every child and spare its infants and mothers an early death, it must enlist the efforts of thousands of teachers, nurses and midwives, all of whom must exercise care, diligence and judgment. That conscientiousness is not easy to buy or import, except in showcase communities such as Mr Sachs's Millennium Villages, of which there are several very impressive examples in Mali. For these services, the link between spending and results is notoriously weak.

Ultimate success depends not so much on field-marshals like Mr Sachs, but on footsoldiers like Rita Dana, an auxiliary nurse and midwife in the Bardhaman district of West Bengal, who patiently examines over 60 pregnant mothers in a day. They arrive from up to 3km away, complaining of abdominal pain, vomiting or swollen feet—a possible sign of dangerously high blood pressure. Some of these workers show up even when floodwater is “up to the knee”, says Mohammed Hossain, a consultant to UNICEF. But perhaps a quarter of the centres, he adds, will not be open when they should be.

The more qualified the doctor, the more likely he is to take flight. The district hospital in Matlab, Bangladesh, boasts an operating table, lamp, oxygen cylinder and anaesthetic machine, all carrying the EU's gift tag. They gleam, partly because they are unused. Several surgeons and anaesthetists have been trained, but none so far retained. “Other than holding a gun to their head, doctors do not stay here,” comments Shams Arifeen, a researcher in the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). Doubling their pay is not the answer, because they can earn five or ten times as much in private practice. Besides, specialists want to educate their children in Dhaka, not in Bangladesh's backwaters.

One response is to turn the doctor's arts into a routine programme. Outside a hut not far from the hospital, a young woman examines a child suffering from pneumonia and diarrhoea, with blood in his stool. Her diagnosis is guided by a flow-chart that leaves little room for discretion. She is one of about 4,500 villagers who have been given 11 days' training under a scheme called Integrated Management of Childhood Illness (IMCI). The IMCI protocols are a great leveller: Bangladeshi social workers can adhere to them as faithfully as qualified Brazilian physicians, and reach similar medical conclusions.

Doctors and paramedics pose one set of problems, patients and clients another. The IMCI workers cannot count on everybody taking the advice they offer, for example. Farida Yesmin advises a young mother, expecting her fourth child, of the need to rest and avoid lifting heavy pots of water. The mother's neighbour, sticking her nose in through the window, offers a second opinion: work never did me any harm, she insists.

The customer is not always right

Villagers think a labour of three or even four days is normal for a first-born, Ms Yesmin says; a few will also blame headaches and convulsions on evil spirits. A study published by the ICDDR,B provides an alarming catalogue of such misconceptions. Pregnant women are sometimes told to eat less than normal because an empty stomach supposedly leaves room for the baby to grow. By tradition, midwives might kick the mother's waist or break snails over her head to speed up the delivery.

Superstition is not the only source of competition. Well-stocked quacks in the private sector are adept at giving people what they want—drugs, principally—if not always what they need. One government paramedic, his desk standing in the rainwater that leaks through the roof, confesses that he sometimes prescribes vitamin pills for the sake of it, because his patients do not expect to leave his clinic empty-handed.

Efforts to tackle the plight of the poor do not always win their favour. The needy make their own judgments about outside schemes to improve their lot. In 1980, for example, the UN proclaimed that the next ten years would be the “sanitation decade”. In India the government set about improving sanitation in villages where people still defecated by rivers and under trees. The need was glaring: contaminated water was responsible for countless deaths from diarrhoea. The solution seemed obvious: a toilet with a brick cubicle, squatting slab and two pits. The government set its budget and began building.

Unfortunately, the villagers themselves had not signed up to the UN's proclamations. They preferred to defecate a prudent distance from the place where they ate and slept. Besides, a walk helped to clear the bowels. So the government's construction programme failed abjectly as a sanitation programme. As the only pukka concrete structure in many homes, the toilets were often used for storing grain, keeping hens or even displaying deities, says Chandi Dey of the Ramakrishna Mission, a charity based in Kolkata.

In the late 1980s, his mission and UNICEF realised they could not tackle the sanitation need until they first drummed up demand. Songs, slogans and slideshows spread the message. Public meetings pressed it home. Mr Dey describes how they would put a drop of faecal matter into a glass of water. When people refused to drink from it, the mission would point out that they imbibed such water every day from ponds and rivers where some people defecated, even as others bathed their bodies and rinsed their mouths.

Non-governmental organisations, accustomed to the role of good Samaritans, had to learn the art of marketing. They offered people a commission for persuading their neighbours to buy a toilet. One paid 13 visits to a potential client before closing the deal. Proceeds from the sales helped meet the running costs of “rural sanitary marts”, which employed poor people as toilet-masons making a range of affordable models (mosaic or ceramic bowls; bamboo or brick walls; single pits or twin pits). Now, says one mission-member, “It is not a programme, it is a movement.”

The government soon latched on to this campaign, adding a small subsidy in 1993-94 and a presidential prize in 2003 for villages and districts that can show they are nirmal or unsullied. In West Bengal, where it began, more than two-thirds of rural households now have access to a toilet. But some districts still lag. M.N. Roy, a top civil servant, puts this down to the “low equilibrium” of poor expectations and apathetic politicians.

Parish-pump politics

The trick is to sharpen the elbows and strengthen the hands of poor people so that they demand what they need and get what they demand. For example, a recent report on the MDGs by the World Bank's Bangladesh office lavishes praise on the efforts of Gonoshasthaya Kendra (GK), a health charity, which began life as a battlefield clinic, treating the casualties of Bangladesh's war of independence. Born in battle, the group still sees a place for “creative tension” between the poor and the people who are supposed to serve them. Whenever someone dies in a village, it holds a public post-mortem. The aim is not to blame or indict per se—bare-knuckled confrontation would alienate the government—but to remind public servants that someone is watching them, and that the negligent will be named and shamed.

Promises, promises
EPA
But is this brand of feisty local politics something donors can cultivate? Aid proposals are now replete with mentions of the word “community”. Sceptics argue that donors will conjure up “communities” to fit their projects and their timetables, even if no such organic political unit exists. They also worry that ceding control to the grassroots may simply put aid in the hands of the local mafia.

Perhaps all donors can do is pray for a more productive politics to evolve, then support it when it does. Mali, for example, has gone further than any other African country in decentralising its government. In 1991 it had 18 local communes, now it has 702. In many communes the people now actually pay local taxes and can see the tangible results of the money that they hand over in a school or a health centre. Alexander Newton, the head of USAID in Mali, which helps train the new layer of local administrators in 155 of the communes, argues that “local management of money tends to be much better.”

Likewise, in Bangladesh, households are often asked to pay something towards the filters that strip their water of arsenic. These charges are not mean-spirited. They aim instead to turn victims into proprietors. A financial contribution is proof of a household's commitment to a scheme, which helps to ensure a filter's upkeep. Halima paid 300 takas ($4.30) for her filter. Now she wouldn't part with it for 5,000.

Across the border in West Bengal, villages are going a step further. For each well or pump, they are convening a water committee. The committees collect dues to pay for regular water-quality tests by laboratories set up in the sanitary marts. Elsewhere, such committees have not always lasted; everyone would rather someone else paid to maintain their well. But without them, villages will remain forever dependent on outside professionals from the government, UNICEF and the like.

After 20 minutes, Mr Johnston's arsenic reading is ready. The test paper has turned an ominous shade of ochre, suggesting arsenic up to four times the allowable limit. He is phlegmatic. The filter's granules have probably reached the end of their natural life. Once informed, the company can fix it within days, and it takes years of exposure at these concentrations to suffer much harm. But as schoolchildren busily fill their kolshi pitchers with contaminated water, the easy promises of seven years ago feel a long way from fulfilment.