"The road to hell is paved with good intentions", and few people can deny that the Millennium Development Goals reached by consensus of 189 countries in September 2000, is nothing if not a clear set of good intentions. While I doubt the MDG road will ultimately lead us to a hell of any kind, there are times when I wonder if it will lead us anywhere at all.

I was inspired the first time I read the MDGs: 8 definitive areas had been singled out for attention, with specific measurable targets to achieve within a finite time period. It seemed like the first real decisive action taken on such a scale to address the needs of the majority of populations whose voices are often unheard or underrepresented in the global arena. I still get that tingle of "what if" when I think of how different the world would be if we were able to achieve those goals: halving the proportion of people who suffer from hunger; reducing maternal mortality by 75% and child mortality by 66%; improving access to safe drinking water and sanitation and ensuring affordable, safe access to essential drugs. We could finally give those who have nothing the opportunity to experience a level of health that adds value to their lives.

So the question remains, having decided on our course of action, how far have we come in realizing it? With a third of the time elapsed, 2005 is a year for crucial evaluation and reflection on what progress, if any, has been made in those countries most affected by the issues under scrutiny. Firstly it is important to evaluate the merits of the MDGs themselves and decide if they really address the issues facing the developing world. One criticism leveled at the MDGs is that it does not address the issue of reproductive health. Those of us living in sub-Saharan Africa realize that AIDS is not a disease of poverty or lack of education: it affects all people from all walks of life. The factors that determine its current epidemiological profile owe a great deal to the plethora of social and cultural norms that make up our society, and until we address the disease in that context we will continue to fight a losing battle against the problem instead of preventing it in the first place. HIV is not a problem in isolation, but forms part of the experience of many women in this part of the world, where their needs are not heard or valued, and they have to first be empowered to determine their own health before significant progress can be made. Giving attention to the social determinants of health is essential to dealing with any disease, communicable or not, in a comprehensive and definitive manner.

Another criticism is that the MDGs do not address the issue of non-communicable diseases, which constitute a significant proportion of the global burden of disease. With reference to the developing world, the problem is often eclipsed by the overwhelming scope of the burden of infectious diseases. Again, in order to address what may be considered diseases of lifestyle, one needs to look at social determinants of health, as well as the nature and scale of interventions needed. Lifestyle modification with regard to specific recognizable risk factors can prevent many of these diseases, but requires sufficient infrastructure to allow for patient education and assistance with lifestyle modification. It is difficult to modify your diet when you are happy to simply have food at times, or to quit smoking when the immediate effects are obvious and the nebulous threat of lung cancer seems purely theoretical. In South Africa, people are dying from infectious causes (often by opportunistic pathogens in immunocompromised patients) long before they manifest symptoms of the majority of non-communicable diseases. Until we have the resources to adequately address both, we are forced to prioritize one above the other.

A final criticism of the MDGs is that they provide no guidance on how to reach the targets. Each country is left to its own devices to effect change at local level, with supervision and guidance from WHO, but this means that any change is ultimately dependent on the political commitment and will of the government in power. I sat in the 58th World Health Assembly listening to people from every WHO department and every country represented at the assembly ask the same question: why, when we know what needs to be done, are the countries who need intervention the most lagging furthest behind in reaching the targets? No one seemed willing to point out that if governments were indeed doing what they promised, and actively seeking to implement new strategies, instead of waiting for someone to hand them the solution on a beautiful blank cheque from the World Bank, we would have greater promise of fulfilling our goals. I heard every African Minister of Health who spoke at the Assembly request developed countries to pour more money into the developing world, citing financial constraints as the reason for failure to progress. I listened with a great deal of cynicism to that request. The MDGs do not take account of the vital role of health care systems in achieving a greater state of health. We have to design interventions with delivery in mind, and there will be little benefit to the public if money pours into a country to be used to procure drugs and implement interventions that an infrastructure cannot sustain beyond the immediate present. The South African Minister of Health declared that what was lacking in my country was sufficient research needed to strengthen the health care system, and that we needed to find incentives to attract bright young graduates to this field. A lack of human and financial resources will eventually cripple local implementation of global strategies.

The limitations of the MDGs can be summarized into target constraints that are selective and quantitative. Selectivity precludes focus on:

• Reproductive health
• Health systems
• Human resources
• Conflict and violence
• Food security
• Non-communicable diseases Disability

Quantitatively, the MDGs fail to capture inequity or answer the questions about why data collection and resources should prioritize targets rather than the goals themselves. Current statistics are based on figures from the previous decade, favouring recent poor achievers and populous nations and easily hiding disparities in averages. Most importantly, it does not address sustainability. In my view, where the MDGs really fail is in the lack of emphasis on empowerment. Developing countries look to developed countries for deliverance from their internal problems, and a recurrent theme is one of greater sharing of global resources. How can we look at sustainability without prioritizing empowerment?

Sri Lanka is the country recovering fastest from the devastation of the tsunami. They resisted pressure for privatization of their health care system for the longest period of any Asian country, insisting on free inpatient care because they recognized that catastrophic illness cripples everyone regardless of background. They took responsibility for their own health care delivery and empowered themselves as individuals capable of determining and thereby sustaining their own health care systems, even in the face of natural disaster on such a scale.

We will not be able to achieve the MDGs by 2015 without significant progress in sub-Saharan Africa, but it is leadership that will make the difference between lives lost and lives saved. We must not focus solely on increasing available resources and health services, but also aim to make its value and purpose understood. An ancient Chinese proverb says "A justified cause wins much support; an unjustified one wins very little". Without doubt, we are fighting for a justified cause, but it will require a great deal more support and strength of will from those in power before we can hope to achieve our goals.

Serini Murugasen (South African) - President National Executive Board South African Medical Students Association