Skip Over Low-Hanging Fruit to Reach the Millennium Development Goals

Leslie Lai, MPA


In 2000, the UN established the Millennium Development Goals (MDGs) to improve the social and economic conditions of the world’s poorest countries by 2015. Of the eight MDGs, two specifically target the reduction of child mortality and the improvement of maternal health. Despite increased aid in the past decade from foundations, bilateral donors, and multilateral organizations, several countries in Sub-Saharan Africa will fail to reach these two goals in the next four years.

The main reason for this is the lack of an equity focus in the planning processes of national health ministries. For economic and political reasons, governments have focused on targeting “low hanging fruit,” or populations that are most easily reached, through the expansion of traditional delivery service mechanisms such as hospitals. While there has been significant progress in health outcomes due to increased international aid, improvements in national averages conceal widening disparities in poverty and worsening health outcomes for the most marginalized populations. Furthermore, the perceived difficulty and economic inefficiency in reaching the poorest hinders donors from targeting technical assistance to those who need the most help.

A practical solution to this challenge is to show evidence that integrating an equity focus into health planning can actually be cost-effective. Organizations such as the United Nations Children’s Fund (UNICEF) has proven this with a bottleneck analysis budgeting software created with the World Bank to assess the marginal costs of scaling up coverage of proven high-impact interventions. The tool incorporates over 186,000 input variables including the building of new facilities, vaccine transport costs, training of community health workers, etc. It also measures the potential number of lives saved per US $1 million invested depending on the mix of health services delivered and to whom.

Using health data from 68 developing countries, UNICEF used the software to show that each of these countries could not only provide essential health services to the most deprived in an economical fashion, but could also potentially achieve the health-related MDGs by 2015. Surprisingly, UNICEF’s analysis also showed that countries ignoring the hardest-to-reach would miss the MDG targets. So just what exactly does a country need to do to reach the MDGs and expand coverage to its hardest-to-reach beneficiaries?

Ethiopia is a successful example of a country that has successfully incorporated the bottleneck analysis tool into its national health plan to expand coverage to its underserved. Ethiopia’s key intervention is the training and deployment of Health Extension Workers (HEWs), young women who provide immunizations and maternal health services to children and women in rural areas. Based on marginal budgeting calculations, Ethiopia could potentially save 68.1 children’s lives per US $1 million spent with the HEW program compared to only 52.9 lives saved without. To achieve this, donors and technical assistance would need to enhance the HEW program or implement similar types of interventions.

Since Ethiopia has historically experienced serious health problems among women and children, it is an ideal model for Sub-Saharan African countries with similar issues. Unfortunately, political matters may obstruct successful implementation in other countries. And in the meantime, the clock is running out…