MDG4 Lessons Could Save More Children’s Lives After 2015

By Carmel Williams, Executive Editor, Health and Human Rights Journal

If human rights-based approaches to child health had informed the Millennium Development Goal addressing child survival, the already impressive reduction in child mortality since 1990 could have been even greater. Elisa Diaz-Martinez and Elizabeth Gibbons argue that the narrow framing of MDG4 created a rupture from the previous 25 years’ worth of global endeavors to advance child survival in tandem with child health, and brought prior “efforts to embed human rights standards and principles into global goals for children” to an abrupt halt.1

Diaz-Martinez and Gibbons are critical of MDG4’s indicators for not being accurately aligned with the major causes of child death in 2000. For example, measles was selected as an indicator even though it was responsible for only 4% of child deaths, while there were no indicators for pneumonia (causing 19% of deaths in children aged one to 59 months), diarrhea (17%), or malaria (8%).

Pneumonia and diarrhea remain major contributors to child deaths, and are closely associated with poverty, poor environments, under-nutrition, and weak health systems. However, the authors claim that these two diseases were not selected as indicators of MDG progress because they could not be quickly addressed. Consequently, global political attention and resources were not directed toward the very conditions that cause children to die. Although the number of children dying before age five almost halved from 12 million in 1990 to 6.6 million in 2012, the authors state that selection of well-aligned indicators to causes of death could have reduced the number even further.

This paper was first conceived as part of a Harvard University and New School Working Paper Series: The power of numbers. A critical review of each MDG revealed

many unfortunate, largely unintended, consequences of simplification which framed development as a process of delivering concrete and measurable outcomes. During the 1990s, much of development economics research concluded that poverty reduction was a process requiring social change, including shifts in power relations. Several studies found a shift in development thinking during the decade of the 2000s, which trended towards meeting basic needs, with strengthened financial support for vertical and technocratic strategies that represented a reversion to 1980’s thinking.2

The simplifications and unintended consequences of MDG4 included inter-government processes lacking local participation; a one-size-fits-all goal that did not respond to local circumstances or resources; and use of global data that neither addressed nor reduced inequities in a country, such that the poorest children ultimately fared the worst.

Implementation of standardized targets and indicators generated various distortions, even making some regions look successful when their rates of improvement have slowed, and others look like failures when their rates of improvement have been higher than those of ‘successful’ regions. Because no mechanism exists to measure variations within countries, changes in equity are not compiled. Such distortions can then make matters even worse:

When the global measurement of success takes no account of absolute change in child mortality, or of the speed of change, both political will and resource mobilization seem to suffer. Unfair treatment against the regions with the highest burden of children mortality has been an unintended consequence of MDG4’s method of measurement.

Fortunately, the international public health system identified and subsequently addressed some of these consequences in the mid-2000s. This collective effort contributes to the Post-2015 Development Agenda and advocates for a more holistic, rights-based approach. Diaz-Martinez and Gibbons use UNICEF data to emphasize the interconnections between MDGs1-4: children of mothers with no education are three times more likely to die before their fifth birthday than those whose mothers attended secondary school; the poorest children’s risk of mortality is twice that of the richest, and rural children are also two times more likely to die than urban children.

The authors recommend that the post-2015 agenda include sub-targets for improving child health within the overall approach to monitoring child survival. They call for a new agenda that will build national health information systems, strengthen national and global accountability, and adopt a more inclusive, participatory approach to development that also addresses equity. In particular, they advocate the principle of non-discrimination in practice in order to specifically monitor progress for the most marginalized children.


1. Elisa Diaz-Martinez and Elizabeth Gibbons, The questionable power of the Millennium Development Goal to reduce child mortality, Journal of Human Development and Capabilities (2014).

2. Sakiko Fukuda-Parr and Alicia Ely Yamin, The power of numbers: A critical review of MDG targets for human development and human rights. (Boston, USA: Harvard University FXB Center for Health and Human Rights; The New School, 2013).