Revisiting the discourse on accomplishing MDG-4

On 8 September 2000, the heads of state from 147 countries participating in the United Nations Millennium Summit agreed to accelerate efforts to achieve a series of human development goals, which since 2001 have been referred to as the Millennium Development Goals (MDG). Eight goals were established encompassing 18 targets and 48 indicators. The fourth goal (MDG4, target 5) was ‘to reduce by two thirds, between 1990 and 2015, the under-five mortality rate’ (U5MR), also referred to as the child mortality rate. Given its importance, considerable resources and efforts have gone into assessing the progress towards achieving MDG-4 along with determining what interventions are needed to accomplish this goal. With less than 1000 days remaining until the 2015 deadline for accomplishing the MDG, there has been renewed visibility around the success (or not) of meeting these targets. In this issue of IJE, an editorial raises an important issue that is central to measuring progress towards MDG-4, and an article presents an interesting analysis of the type of efforts required to accomplish MDG-4. Oestergaard and colleagues argue that annual assessments of a country’s progress towards MDG-4 are problematic as the targets are not constant, and any reliable knowledge of progress (or lack thereof) will only be possible well after 2015. In the case of MDG-4, the UN Inter-agency Group on Child Mortality Estimation (UN-IGME) uses the annual rate of change in U5MR to assess whether countries are on track to achieve MDG-4. Thus, the MDG targets are ‘moving’ in the sense that with each new release of estimates from UN-IGME, the required rate of change, and thus a country’s target pace to achieve MDG-4, will likely be different. The issue is further complicated by uncertainties around estimation of the baseline rates of U5MR in 1990 in several countries. Whereas the annual rate of change is important in determining a country’s current trajectory toward MDG-4, it does not have much relevance for the ultimate determination as to whether a two-thirds reduction in U5MR will be reached by 2015. As Oestergaard and colleagues argue, tracking of the progress towards MDG-4 could be strengthened both by a direct comparison of whether a country’s annual rate of change is statistically different from the required rate to achieve MDG-4 in a given year, along with an estimate of the probability that a country is on target. At the same time, it seems that the issue raised by Oestergraad and colleagues is technical. Simple and effective tracking of the progress towards MDG-4 can be easily accomplished by maintaining the focus on the absolute level of U5MR, as opposed to solely relying on the rate of change. Meanwhile the article by Amudhan and colleagues examines the effects on rates of institutional deliveries following sequential interventions of a conditional cash transfer scheme and strengthening of primary health centres to provide 24-h access to obstetric care in a rural north Indian setting. Their findings suggest that improvements to service delivery are most effective in a population where demand has been strengthened through conditional cash transfer. These two papers provide a useful segue to broadly discuss and deliberate whether the discourse on, and efforts to, accomplish MDG-4 need to be altered since it is clear that many countries are not on course to meet their targets. At the outset, although MDG targets are framed at the global level, action or strategies to meet targets need to be focused within local or country contexts. In this editorial, we use India as an example to highlight four critical issues in the context of MDG-4 target-setting as well as efforts to achieve a two-thirds reduction by 2015. It is worth noting that there has been a secular decline in rates Published by Oxford University Press on behalf of the International Epidemiological Association