Country processes

The core challenge of the Goals lies in financing and implementing the interventions at scale—for two reasons. One is the sheer range of interventions that should be implemented simultaneously to reach the Goals. The second is the need to reach large proportions of the population. National scale-up is the process of bringing essential MDG-based investments and services to most or all of the population, on an equitable basis, by 2015.

Scale-up needs to be carefully planned and overseen to ensure successful and sustainable implementation. The level of planning is much more complex than for any single project. Scaling up for the Goals requires a working partnership within and between government, the private sector, NGOs, and civil society.

Scaling up works (box 6). But a close reading of success reveals that scale-up cannot begin without political leadership and clear government commitment. This is an absolutely necessary (though far from sufficient) condition. Once the government has committed to reaching the Goals, four specific actions are required:

Each country has its own specific set of challenges, but some broad trends can be identified as priorities. One universal challenge is to ensure that ethnic minorities, regional pockets of poverty, and slums receive targeted investments for the Goals. Some regional priorities are highlighted below and discussed in more detail across the UN Millennium Project's series of final reports.

Sub-Saharan Africa. The standard diagnosis of Sub-Saharan Africa is that it is suffering from a governance crisis. This is too simplistic. Many parts of Africa are well governed considering the income levels and extent of poverty, yet are caught in a poverty trap. The region's development challenges are much deeper than “governance.” Many countries require a big push in public investments to overcome the region's high transport costs, generally small markets, low-productivity agriculture, adverse agroclimatic conditions, high disease burden, and slow diffusion of technology from abroad.

An MDG-based strategy for Sub-Saharan Africa needs to focus on rural development for a Twenty-first Century African Green Revolution and strategies to make Africa's fast-growing cities much more productive, especially for labor-intensive exports. Africa's public health systems require major investments to address the pandemics of HIV/AIDS, tuberculosis, and malaria; to tackle the unconscionably high levels of child and maternal mortality; and to provide sexual and reproductive health services that will enable better timing and spacing of births and a voluntary reduction to desired family sizes. Education strategies need to focus on increasing the supply of infrastructure and human resources and the demand-side incentives for girls and vulnerable students. The continent also requires major investments in infrastructure for water resources management and energy. Mobilization of science and regional integration also need to be energized. In all aspects of development, Africa's strategies need to pay special attention to the situation of girls and women, who tend to face major legal, social, and political barriers and biases.

East and Southeast Asia. East and Southeast Asia have made tremendous progress toward many of the Goals, especially in reducing income poverty, hunger and gender inequality. China's economy has been growing rapidly, but it still requires large investments in public health systems, rural infrastructure, education, and environmental management, the latter to address some of the adverse consequences of rapid industrialization. The environmental challenges include managing forests and biodiversity and reducing the pollution of air and water. Other parts of East and Southeast Asia require similar investments in infrastructure, environment, and social services, plus a focus on public management systems and increased capacity for science and technology.

South Asia. South Asia is making rapid overall advances in poverty reduction, driven especially by dynamic growth in India. Yet extensive extreme poverty remains in both rural and urban areas. Priority investments include improved basic health infrastructure and services; increased access to high-quality schools; farm infrastructure (feeder roads, storage facilities); improved water management for agriculture (irrigation, water harvesting, management of groundwater supplies); slum upgrading; and improved public sector management. Investment programs should also focus on achieving gender equality, including reproductive health and rights, and integrating marginalized populations, including low-caste and outcaste communities, and tribal populations.

CIS, Central Asia. Countries of Central Asia have suffered from the multiple effects of post-Soviet economic collapse, unfavorable landlocked geography, and insufficient -investments in transport infrastructure to link the region to world markets. After a decline in many human development indicators during the past 15 years or more, a broad suite of investments is needed in basic transport and energy infrastructure, improved water and sanitation facilities, and more effective health and educational systems. Countries need to strengthen -public sector management capacity, reduce corruption, and increase cross-border- cooperation to improve regional integration and environmental management. Moreover, many countries need to improve the policy environment for private sector development.

CIS, Europe. Many of these countries are still recovering ground lost after the collapse of the Soviet Union, but overall the region is on track to achieving the Goals. Investment strategies should focus on capacity in public management systems, resources for strained health and education systems, and environmental management and planning. Many transition countries also need to target services toward excluded and marginalized groups.

Middle East and North Africa. This region is moving in the right direction on most indicators, but overall progress needs to be accelerated to achieve the Goals. Priorities include interventions to support gender equality, a major expansion of quality health services, and programs to address desertification and water scarcity. Other priorities are to expand educational and employment opportunities for young people, improve rural livelihoods, and invest in indigenous science and technology development.

Latin America and the Caribbean. Latin America, the most developed of the developing regions, has seen limited progress toward the Goals. Inequalities are extreme, often linked to ethnic divisions, and economic growth challenges remain particularly severe in the Andean, Central American, and some Caribbean countries. Throughout the region, improving environmental management and health systems are top priorities, especially in Caribbean countries where HIV/AIDS is prominent or threatening. With a majority of the region's poor people living in urban areas, urban infrastructure and slum upgrading are major needs. Countries must also make significant investments in basic rural infrastructure, targeting marginalized areas and populations. Major public investments are needed to spur local scientific innovation and technological development.

Least Developed Countries. The Least Developed Countries require special assistance because they cannot meet their basic needs from domestic resources regardless of their own policies or quality of governance. Support for them should be consistent with the United Nations Brussels Programme of Action, which outlines key areas to help break the Least Developed Countries' poverty trap, including human resource development, investments in supply-side constraints, environmental protection, and investments for food security.

Landlocked developing countries. Landlocked countries have a unique need for transport infrastructure, regional market integration, and harmonized trade procedures. Many relevant issues are outlined in the 2003 Almaty Programme of Action. Major improvements in rail, road, energy, and communication infrastructure are needed to reduce transport costs.

Small island developing states. Concentrated in the Caribbean and Oceania, these states face challenges posed by size and geography that limit possibilities for economic diversification and leave them highly vulnerable to environmental risks. The 1995 Barbados Programme of Action for small island developing states should receive global financial and political support. In addition to the needed MDG-focused investments, small island developing states are vulnerable to rising sea levels and coral bleaching from climate change. They will require targeted investments to adapt to the effects of global warming.

Countries vulnerable to natural hazards. Countries highly vulnerable to natural hazards (such as severe weather events, droughts, earthquakes, volcanoes, flooding, and pests) require special investments in social safety nets, disaster-mitigating infrastructure, early warning systems, precrisis emergency and contingency planning, and postcrisis emergency support. These investments need to be in place well before disasters strike, both to anticipate and mitigate disasters and to react to them in the immediate aftermath, when lives are most at stake.

Nationwide scale-ups of intervention programs generally require several key factors, ranging from political commitment to sequenced work plans and to long-term predictable funding. There are innumerable instances where developing countries harnessed these elements to deliver interventions that have dramatically improved the lives of the poor at a national scale.

• Viet Nam's success in fighting malaria. In 1991 Viet Nam suffered from an intense malaria epidemic that infected more than a million people. In response, the government made malaria one of its national priorities and dedicated significant funding to its control. It distributed insecticide-treated bed-nets for free, provided preventive malaria treatment for pregnant women, and developed and distributed new -artemisinin-based malaria drugs. It also created 400 mobile teams to supervise health workers in malaria-endemic areas and mobilized volunteer health workers at the community level. As a result of these and other efforts, malaria mortality declined by 97 percent, morbidity by 60 percent, and the incidence of epidemics by 92 percent.
• Tanzania's plan to achieve universal basic education by 2006. In 2001 Tanzania increased the education budget by 130 percent and eliminated school fees. The number of children in primary school is up 50 percent. Net enrollments have risen from 59 percent to nearly 90 percent. There are as many girls enrolled as boys. More than 30,000 new classrooms have been built. About 18,000 new teachers have been recruited. And more than 9,000 science-teaching kits have been supplied to schools.

These examples highlight the key success factors of a nationwide scale-up:

• High-level political vision and commitment—Viet Nam's political focus and leadership on combating malaria.
• A significant increase in funding—Tanzania's 130 percent increase in the education budget.
• The abolition of user fees—Tanzania's elimination of school fees.
• A focus on upgrading human resource and infrastructure capacity—Tanzania's recruitment of new teachers and construction of new classrooms.
• Coordination among the government, community organizations, international agencies, and the private sector.
• Setting concrete objectives and plans of work. Scaling up requires specific deliverables, work plans, and timelines. In sequencing investments the focus should initially be on implementing the list of Quick Win -investments and on building long-term capacity to deliver basic services to the entire population.
• Building national and local capacity in public management, human resources, and infrastructure. Expanding each country's capacity to deliver services at scale will require up-front investments in strengthening public sector management (such as training, information technology, and higher salaries for civil service workers), building and renovating infrastructure (roads, clinics, schools), and critically, training and retaining adequate numbers of workers (community health workers, teachers) to deliver services on the ground. Decentralized training efforts based on open distance learning, radio, and computer-assisted education are key to a massive build-up of human resource capacity at the local level.
• Adopting replicable and locally appropriate delivery mechanisms. Scalability is significantly aided by choosing highly replicable service -protocols where possible. Thus TB treatment protocols (DOTS) are typically -standardized, as are malaria -control -measures, family planning programs, and fertilizer combinations. Standardization also enables comparison of performance across regions, enhancing quality control.
• Monitoring to measure progress and allow for mid-course corrections. Improving the flow of information within the government is critical for fighting corruption and increasing program effectiveness. Investments in statistical services are required to provide the data needed for results-based planning, management, and assessment of the equity of program impacts. Communities and civil society organizations are -ideally -positioned to report on the impact of investments and the flow of funds, and should actively participate in monitoring.

Two other conditions necessary for scale-up are involvement and ownership of communities and long-term predictable donor funding and -technical assistance. Communities should be both architects as well as recipients of the scaling-up process, by participating in the design of programs and services. The participation of women in community planning activities is essential for success. Community members can also play an important role in implementation of these programs, either as paid workers or volunteers. Long-term and predictable funding and technical assistance from donors is crucial to provide countries with the means to proceed. Financing needs to be both increased and predictable over the period 2005–15, covering both capital and recurrent costs, including civil service salaries. Technical assistance will also be required to reinforce local management and service delivery skills.