Count down to MDGs Correcting mistaken targets vital
The count down for the Millennium Development Goals has begun. With only five years remaining, can Nepal achieve the health-related MDGs? That question is being asked both within Nepal and outside her borders. Nepal is closely observed by the international community as one of the few “least developed” countries with potential to answer in the affirmative. It is high time we take stock of our own progress and achieve clarity about the issues involved.
For MDG4, related to child health, all the three target indicators (infant mortality rate (IMR) of 34/1000 live births or less; under-five mortality rate (U5MR) of 54/1000 live births or less; measles vaccination coverage of 90% or more) are expected to be met on time. The findings of the Nepal Demographic Health Survey (2006 DHS) are suggestive of even faster decline for U5MR and IMR. The measles vaccination status, however, is showing some instability. It has not crossed the high mark of 85%, a figure which Nepal had already achieved in the year 2005. The decline in vaccination coverage has been observed, paradoxically, often in areas where public health action is otherwise more effective. Could such decline be due to inflated targets, diminished efforts, or both?
Such findings, together with the dramatically reduced fertility rate reported by the 2006 DHS, led the previous government to commission a revision of expected birth estimates in accordance with the fast fertility decline scenario. Targets are less likely to be met with inflated estimates.
The key point, and one that should guide policy makers, is that progress
can be effectively assessed only by keeping ourselves abreast of the real situation. We may make mistakes. One classic example is the Health Sector Strategy (HSS, 2004) one of the landmark documents, which laid the basis for Nepal Health Sector Program -Implementation Plan (NHSP-IP, 2004-9). It had mistakenly proposed, among others, a target for U5MR of 30 (per 1000 live births). That target was endorsed by a cabinet decision of the Nepal government. However, that mistake was quickly rectified in another landmark document, the Nepal MDG Document 2005, which revised the target to 54. What was the mistake committed by the experts who prepared the Health Sector Strategy (HSS) document?
To meet MDG4 in child health one of the targets is a two-thirds reduction of the U5MR by 2015, taking the 1990 rates as the baseline. The HSS document took 2001 MMR of 91 as the baseline for setting the MDG4 target. The Nepal MDG Document 2005 corrected that error by taking the 1990 U5MR of 162 as the baseline, setting the target for 54. Now we may ask ourselves and our learned experts from abroad: Could we claim to be on track for meeting MDG4 if we had to reduce U5MR to 30 by the year 2015?
For meeting MDG5, a three-quarters (3/4) reduction in the MMR, taking
the 1990 MMR as the baseline, must be achieved.
Instead of taking 1990 baseline figures the HSS document took 1996 MMR of
539 (per 100,000 live birth) as baseline hence set the target as 134. In contrast, the Nepal MDG document has taken 1990 figure of
850 as baseline and 213 as target for trend analysis and measuring progress in reduction of maternal mortality. The government, the external development partners and academia should have taken a cue from that report and established a single target of 213 by sticking to 1990 baseline. It should be mentioned here that there were two conflicting figures for the 1990 MMR (per 100000 live birth) baseline: 850 and 515 reported from different studies. For corrective action to be taken one had to decide which figure is most plausible.
If there is a the question of which figure is more likely for 1990 - 850 or 515 we may pose a counter question: Who would believe that Nepal had an MMR of 515 in 1990 if it had 539 in 1996? Even the figure of 539 was considered an underestimate by WHO and UN
agencies who had preferred to adjust it upward to a figure of 740. In Nepal there are issues concerning the accuracy of statistical data, and especially so for a period two or three decades in the past. In this article, for the sake of simplicity, confidence intervals have not been discussed.
There are only two choices for us. We should either stick to the 1996 figures or the 1990 figures for establishing our MDG baselines. But in fact there is no choice to be made at all. Why should we go for 1996 when the MDG concept is based on the using 1990 as the baseline? But if the present policy makers and EDPs want to go ahead using a 1996 baseline, and effectively killing Nepal’s chance to meet MDG5, the same standard should apply to U5MR and IMR also, which would effectively derail the status of “on track” for MDG4.
For all the above mentioned reasons, the MMR reduction target for the year 2015 should be set at 213 and not 134. In the past, we have corrected our mistakes and moved forward. Let us do so again now, without delay, since if we do not learn from our mistakes, we are condemned to repeat them again.
