The great lesson of the Millennium Development Goals is that women hold the key to development, and the countries that have delivered the greatest gains in education for girls, jobs for women and healthcare for pregnant women and new mothers are the star performers of the MDG era.
When it comes to health, seven of the countries that started with child mortality rates over 100 deaths per 1,000 births and maternal mortality rates over 500 deaths per 100,000 births have achieved both MDGs 4 and 5: Bangladesh, Nepal, East Timor, Bhutan, Cambodia, Eritrea and Rwanda.
These are the All Stars of the MDG era and it’s critical that we understand how their investments in women and girls have driven their success.
Laying the foundations
Countries that can simultaneously provide contraception so that women have the number of children they want, increase female literacy and ensure that economic growth translates into jobs for women can unlock powerful forces for rapid development.
All of the countries that have transformed maternal and child health have also achieved rapid reductions in fertility and strong increases in female literacy and labor force participation. This has created a strong foundation for the kind of development gains that are sustained and irreversible.
While educational gains for women and girls are clearly fundamental with an estimated half of the reduction in child deaths in the last twenty years the result of increases in the education of women of reproductive age, the contribution of contraception should never be overlooked. It’s often a critical first step in development, as women cannot take full advantage of educational and labor market opportunities when they cannot control their own fertility.
There is now strong evidence that alongside declines in child mortality, increases in modern contraceptive use have reduced fertility rates triggering the “demographic dividend” — the economic growth benefit a country receives by lowering birth rates and increasing the proportion of the population that is working— especially in Bangladesh, Cambodia and Nepal.
Building on the foundations
If there’s one other big takeaway from the MDG health success, it’s that the health systems that put the needs of the most vulnerable woman first have achieved the greatest gains.
All of the MDG 4 and 5 All Stars have pushed health care as close to the front door of the most disempowered woman as they can, in most cases by employing massive networks of local women to become community health workers.
These women go door to door in many cases delivering contraception, educating women, diagnosing and treating the leading threats to children on the spot — pneumonia, diarrhea, malaria, malnutrition — referring to hospitals where necessary and generally paying house call after house call, and thus lifting the level of health knowledge and behavior in communities that have no formal health infrastructure. These networks of women health activists have also mobilized the most disempowered women to stand up for their own health and the health of their children and to demand better care.
Critically in the countries that have achieved both MDGs 4 and 5, these community health workers have also been trained and equipped to care for newborns, prescribe antibiotics, engage the private informal health sector and negotiate an often antagonistic public health system on behalf of the most vulnerable woman — to make the entire health system work for her, to regard her needs as sacred and to be a bridge between hospital and community for her.
The great unfinished business of the MDGs is to take these MDG success lessons and apply them to the women and children who have missed out on the MDGs.
The remaining concentrations of maternal and child mortality are in a handful of countries including India, Nigeria, Pakistan, the Democratic Republic of Congo, China, Ethiopia and Indonesia, all which need to accelerate access to contraception and increase female literacy and participation in the labor market as urgent economic priorities. They need to build health systems that reach deeply into the communities where deaths are concentrated and empower local women to transform health outcomes in exactly the same way the MDG 4 and 5 All Stars have done — by delivering integrated packages of care targeting the leading causes of death, door to door if that’s what it takes.
In India and parts of sub-Saharan Africa, particularly, an all-out assault on sanitation and malnutrition will be a necessary condition of future success.
As many of these countries are forecast to grow relatively strongly financing should not be a barrier and as we know from two recent Lancet reports, Global Health 2035 and the New Global Investment Framework for Investing in Women's and Children's Health, countries gain an enormous payoff from investing in health. Other analysis shows clear economic benefits from reducing childhood stunting and improving sanitation.
We have every reason to be optimistic that success is possible under even the most challenging of circumstances, but we also need to stay vigilant against some dark clouds on the horizon that threaten continued advances in women’s and children’s health.
Three forces — rapid population growth, urbanization and continued conflict — could combine to threaten progress and derail gains among the populations of women and children who need them most.
There are now more young men and boys in the world with limited education and job prospects than ever before and their numbers are growing most rapidly in those parts of the world where conflict is brewing and women are most disempowered. As urbanization continues and young men flock to the cities for a better life, the unprecedented pressure on limited resources could be a recipe for more conflict. More than half of all maternal and child deaths are already occurring in fragile settings — especially in Nigeria, Pakistan and the DRC — and should they descend further into crisis, women will face formidable obstacles in their struggle for the freedom to learn, earn and control the number of children they have.
This will be a critical challenge in the Sustainable Development Goal era — how to ensure that the mega trends that will shape our world do not hold back the gains for women and children that are well past due.
Aug. 18, 2014, marked the 500-day milestone until the target date to achieve the Millennium Development Goals. Join Devex, in partnership with the United Nations Foundation, to raise awareness of the progress made through the MDGs and to rally to continue the momentum. Check out our Storify page and tweet us using #MDGmomentum.