THE WORLD HEALTH REPORT 2005: MAKE EVERY MOTHER AND CHILD COUNT

The Word Health Organization, Switzerland, Geneva

Available at: http://www.who.int/whr/2005/en/index.html

This year's World Health Report comes at a time when only a decade is left to achieve the Millennium Development Goals (MDGs), which set internationally agreed development aspirations for the world's population to be met by 2015. These goals have underlined the importance of improving health, and particularly the health of mothers and children, as an integral part of poverty reeducation.

The health of mothers and children is a priority that emerged long before the 1990s - it builds on a century of programmes, activities and experience. What is new in the last decade, however, is the global focus of the MDGs and their insistence on tracking progress in every part of the world. Moreover, the nature of the priority status of maternal and child health (MCH)) has changed over time. Whereas mothers and children were previously thought of as targets for well-intentioned programmes, they now increasingly claim the right to access quality care as an entitlement guaranteed by the state. In doing so, they have transformed maternal and child health from a technical concern into a moral and political imperative.

This report identifies exclusion as a key feature of inequity as well as a key constraint to progress. In many countries, universal access to the care all women and children are entitled to is still far from realizatiion. Taking stock of the erratic progress to date, the report sets out the strategies required for the accelerated improvements that are known to be possible. It is necessary to refocus the technical strategies developed within maternal and child health programmes, and also to put more emphasis on the importance of the often overlooked health problems of newborns. In this regard, the report advocates the repositioning of MCH as MNCH (maternal, newborn and child health).

The proper technical strategies to improve MNCH can be put in place effectively only if they are implemented, across programmes and service providers, throughout pregnancy and childbirth through to childhood. It makes no sense to provide care for a child and ignore the mother, or to worry about a mother giving birth and fail to pay attention to the health of the baby. To provide families universal access to such a continuum of care requires programmes to work together, but is ultimately dependent on extending and strengthening health systems. At the same time, placing MNCH at the core of the drive for universal access provides a platform for building sustainable health systems where existing structures are weak or fragile. Even where the MDGs will not be fully achieved by 2015, moving towards universal access has the potential to transform the lives of millions for decades to come.

THE COMMISSION FOR AFRICA REPORT: ACTION FOR A STRONG AND PROSPEROUS AFRICA

March 11, 2005

Available at www.commissiionforafrica.org.

African poverty and stagnation is the greatest tragedy of our time. Poverty on such a scale demands a forceful response. And Africa - at country, regional, and continental levels - is creating much stronger foundations for tackling its problems. Recent years have seen improvements in economic growth and in governance. But Africa needs more of both if it is to make serious inroads into poverty. To do that requires a partnership between Africa and the developed world which takes full account of Africa's diversity and particular circumstances.

For its part, Africa must accelerate reform. And the developed world must increase and improve its aid, and stop doing those things which hinder Africa's progress. The developed world has a moral duty - as well as a powerful motive of self-interest - to assist Africa. We believe that now is the time when greater external support can have a major impact and this is a vital moment for the world to get behind Africa's efforts.

The actions proposed by the Commission constitute a coherent package for Africa. The problems they address are interlocking. They are vicious circles which reinforce one another. They must be tackled together. To do that Africa requires a comprehensive 'big push' on many fronts at once. Partners must work together to implement this package with commitment, perseverance and speed, each focusing on how they can make the most effective contribution.

Getting Systems Right: Governance and Capacity-Building: Africa's history over the last fifty years has been blighted by two areas of weakness. These have been capacity - the ability to design and deliver policies; and accountability - how well a state answers to its people. Improvements in both are first and foremost the responsibility of African countries and people. But action by rich nations is essential too.

Building capacity takes time and commitment. Weak capacity is a matter of poor systems and incentives, poor information, technical inability, untrained staff and lack of money. We recommend that donors make a major investment to improve Africa's capacity, starting with its system of higher education, particularly in science and technology. They must help to build systems and staff in national and local governments, but also in pan-African and regional organisations, particularly the African Union and its NEPAD programme. Donors must change their behaviour and support the national priorities of African governments rather than allowing their own procedures and special enthusiasms to undermine the building of a country's own capacity.

Improving accountability is the job of African leaders. They can do that by broadening the participation of ordinary people in government processes, in part by strengthening institutions like parliaments, local authorities, trade unions, the justice system and the media. Donors can help with this. They can also help build accountable budgetary processes so that the people of Africa can see how money is raised and where it is going. That kind of transparency can help combat corruption, which African governments must root out. Developed nations can help in this too. Money and state assets stolen from the people of Africa by corrupt leaders must be repatriated. Foreign banks must be obliged by law to inform on suspicious accounts. Those who give bribes should be dealt with too; and foreign companies involved in oil, minerals and other extractive industries must make their payments much more open to public scrutiny. Firms who bribe should be refused export credits.

The Need for Peace and security: The most extreme breakdown of governance is war. Africa has experienced more violent conflict than any other continent in the last four decades. In recent years things have improved in many countries, but in other places violence conflict is still the biggest single obstacle to development. Investing in development is investing in peace.

The most effective way to tackle conflict - to save both lives and money - is to build the capacity of African states and societies to prevent and manage conflict. That means using aid better to tackle the causes of conflict. It means improving the management of government incomes from natural resources and international agreements on how to control the 'conflict resources' which fuel or fund hostilities. It means controlling the trade in small arms.

African regional organizations and the UN can help prevent and resolve conflict when tensions cannot be managed at the national level, through, for example, effective early warning, mediation and peacekeeping. Donors can support this by providing flexible funding to the African Union and the continent's regional organizations; and supporting the creation of a UN Peace building Commission. The coordination and financing of post-conflict peace building and development must be improved to prevent states emerging from violent conflict from sliding back into it.

Leaving No-One Out: Investing in People: Poverty is more than just a lack of material things. Poor people are excluded from decision-making and from the basic services the state ought to provide. Schools and clinics must be available to the poorest people in Africa. This is an urgent matter of basic human rights and social justice. But it is also sound economics: a healthy and skilled workforce is a more productive one, fulfilling their potential with dignity. Investing for economic growth means rebuilding African health and education systems, many of which are now on the point of collapse. This requires major funding, but it is not only a question of resources. It is also about delivery and results. These are powerfully strengthened when local communities are involved in decisions that affect them.

Properly funding the international community's commitment to Education for All will provide all girls and boys in sub-Saharan Africa with access to basic education to equip them with skills for contemporary Africa. Secondary, higher and vocational education, adult learning, and teacher training should also be supported within a balanced overall education system. Donors need to pay what is needed to deliver their promises - including the cost of removing primary school fees.

The elimination of preventable diseases in Africa depends above all on rebuilding systems to deliver public health services in order to tackle diseases such as TB and malaria effectively. This will involve major investment in staff, training, the development of new medicines, better sexual and reproductive health services and the removal of fees paid by patients, until countries can afford it. Funding for water supply and sanitation should be immediately increased, reversing years of decline.

Top priority must be given to scaling up the services needed to deal with the catastrophe of HIV and AIDS which is killing more people in African than anywhere else in the world. But this must be done through existing systems, rather than parallel new ones. Governments should also be supported to protect orphans and vulnerable children and other groups who would otherwise be left out of the growth story. Almost half of the extra aid we are recommending should be spent on health, education and HIV and AIDS.

Going for Growth and Poverty Reduction: Africa is poor, ultimately because its economy has not grown. The public and private sectors need to work together to create a climate which unleashes the entrepreneurship of the peoples of Africa, generates employment and encourages individuals and firms, domestic and foreign, to invest. Changes in governance are needed to make the investment climate stronger. The developed world must support the African Union's NEPAD programme to build public-private partnerships in order to create a stronger climate for growth, investment and jobs.

Growth will also require a massive investment in infrastructure to break down the internal barriers that hold Africa back. Donors should fund a doubling of spending on infrastructure - from rural roads and small-scale irrigation to regional highways, railways, larger power projects and Information & Communications Technology (ICT). That investment must include both rural development and slum upgrading without which the poor people in Africa will not be able to participate in growth. And policies for growth must actively include - and take care not to exclude - the poorest groups. There should be particular emphasis on agriculture and on helping small enterprises, with a particular focus on women and young people. For growth to be sustainable, safeguarding the environment and addressing the risks of climate change should be integral to donor and government programmes. This programme for growth takes over a third of the total additional resources we propose.

More Trade and Fairer Trade: Africa faces two major constraints on trade. It does not produce enough goods, of the right quality or price, to enable it to break into world markets. And it faces indefensible trade barriers which, directly or indirectly, tax its goods as they enter the markets of developed countries.

To improve its capacity to trade Africa needs to make changes internally. It must improve its transport infrastructure to make goods cheaper to move. It must reduce and simplify the tariff systems between one African country and another. It must reform excessive bureaucracy, cumbersome customs procedures, and corruption by public servants, wherever these exist. It must make it easier to set up businesses. It must improve economic integration within the continent's regional economic communities. Donors can help fund these changes.

But the rich nations must also dismantle the barrier they have erected against African goods, particularly in agriculture. These barriers hurt citizens in both rich and poor countries. They must abolish trade-distorting subsidies to their agriculture and agribusiness which give them an unfair advantage over poor African farmers. They must lower tariffs and other non-tariff barriers to African products, including stopping the bureaucratic application of rules of origin which excludes African goods from preferences to which they are entitled. And they must show this ambition by completing the current Doha Round of world trade talks in a way which does not demand reciprocal concessions from poor African nations. Careful attention must be given to ensure that the poorest people are helped to take advantage of the new opportunities and to cope with the impacts of a more open system of world trade. Africa must be provided with the funds that can help it adjust to the new opportunities of a changed world-trading regime.

Where Will the Money Come from: To support the changes that have begun in Africa, we call for an additional US$25 billion per year in aid, to be implemented by 2010. Donor countries should commit immediately to provide their fair share of this. Subject to a review of progress then, there would be a second stage, with a further US$25 billion a year to be implemented by 2015. Ensuring the money is well spent will depend on two factors. First, good governance in Africa must continue to advance. But, second, donors must significantly improve the quality of aid and how it is delivered; that means more grants, more predictable and untied aid, and donor processes that are less burdensome on the already stretched administrations of African countries. It must also be better harmonized with the aid of other donors and better in line with the priorities, procedures and systems of African governments. Above all, it must be given in ways that make governments answerable primarily to their own people.

These changes are needed not just from individual donor nations but also from multilateral institutions - both African and global. The African Development Bank needs to be strengthened and the role of the Economic Commission for Africa enhanced. The IMF and World Bank need to give higher priority to Africa's development. They also need to become more accountable both to their shareholders and to their clients, and to give Africa a stronger voice in their decision-making.

Rich nations should commit to a timetable for giving 0.7 per cent of their annual income in aid. To provide the critical mass of aid which is needed now, the aid should be front-loaded through the immediate implementation of the International Finance Facility. Practical proposals should be developed for innovative financing methods such as international levies on aviation, which can help secure funding for the medium and longer term.

For poor countries in sub-Saharan Africa which need it, the objective must be 100 per cent debt cancellation as soon as possible. This must be part of a financing package for these countries - including those excluded from current debt schemes - to achieve the MDGs, as promised in Monterrey and Kananaskis.

Conclusion: Bold comprehensive action on a scale needed to meet the challenges can only be done through a new kind of partnership. In the past contractual and conditional approaches were tried, and failed. What we are suggesting is a new kind of development, based on mutual respect and solidarity, and rooted in a sound analysis of what actually works. This can speed up progress, building on recent positive developments in Africa, towards a just world of which Africa is an integral part.

COMMISSION FOR AFRICA: THE DECLARATIONS ON MARCH 11, 2005

Available at: www.commissionforafrica.org

The Commission for Africa finds the conditions of the lives of the majority of African to be intolerable and an affront to the dignity of all mankind. We insist upon an alteration of these conditions through a change of policy in favour of the weak.

Having analyzed and costed how this may be achieved, we call for our conclusions to be implemented forthwith in the cause of right and justice and in the name of our shared humanity.

On the edge of this new century, in an age of unprecedented wealth and economic progress by continents, it is unacceptable that Africa drifts further from the rest of the world, unseen in its misery and ignored in its pain.

The Commission, its members acting in their capacity as individuals, has assimilated the analysis of years and all extant reports into our findings. These clearly show how things may have been otherwise.

However we exist in contemporary realities. The world is vastly different to that of 20 years ago when we forcefully acknowledged the pity of the Great African Famine of 1984-85. The world, then locked into its Cold War political stasis, remained rigid in its competitive ideologies. The breaking of this deadlock, and the increase in global trade that followed, allied to new technologies and cultural shifts, have created a more fluid, less predictive yet more interdependent world.

This world influx has brought great opportunities along with confusion, change and anxiety. But such change poses great possibilities for us all and especially for Africa, that great giant finally beginning to stir itself from its enforced slumber. We need, then to seek to understand these newer forces in play about us, attempt to define them and in so doing set the framework for policies that favour the poor.

The great nations of the world, in alliance with their African neighbours, must now move together, in our common interest. How they may proceed will be determined by each nation's needs and desires. But all must immediately begin the journey that leads us to the ultimate common destination of a more equitable world. Our task was the first step. It is done.

ACTION ON THE SOCIAL DETERMINANTS OF HEALTH: LEARNING FROM PREVIOUS EXPERIENCES

The World Health Organization, Secretariat of the Commission on Social Determinants of Health.

http://www.who.int/social.determinants/en/

Today an unprecedented opportunity exists to improve health in some of the world's poorest and most vulnerable communities by tackling the root causes of disease and health inequalities. The most powerful of these causes are the social conditions in which people live and work, referred to as the social determinants of health (SDH). The Millennium Development Goals (MDGs) shape the current global development agenda. The MDGs recognize the interdependence of health and social conditions and present an opportunity to promote health policies that tackle the social roots of unfair and avoidable human suffering.

The Commission on Social determinants of Health (CSDH) is poised for leadership in this process. To reach its objectives, however, the CSDH must learn from the history of previous attempts to spur action on SDH. This paper pursues three questions: (1) Why didn't previous efforts to promote health policies on social determinants succeed? (2) Why do we think the CSDH can do better? (3) What can the Commission learn from previous experiences - negative and positive -that can increase its chances for success?

Strongly affirmed in the 1948 WHO Constitution, the social dimensions of health were eclipsed during the subsequent public health era dominated by technology-based vertical programmes. The social determinants of health and the need for intersectoral action to address them re-emerged strongly in the Health for All movement under the leadership of Halfdan Mahler. Intersectoral action on SDH was central to the model of comprehensive primary health care proposed to drive the Health for All agenda following the 1978 Alma-Ata conference. During this period, some low-income countries made important strides in improving population health statistics through approaches involving action on key social determinants. Rapidly, however, a scaled-back version of primary health care, "selective primary health care", gained influence. Selective primary health care focused on a small number of cost-effective interventions and downplayed the social dimension. The most important example of selective primary health care was the GOBI strategy (growth monitoring, oral rehydration, breastfeeding and immunization) promoted by UNICEF in its "child survival revolution". The contrast in approaches between comprehensive and selective PHC raises strategic questions for the CSDH.

Like other aspects of comprehensive primary health care, action on determinants was weakened by the neoliberal economic and political consensus dominant in the 1980s and beyond, with its focus on privatization, deregulation, shrinking states and freeing markets. Under the prolonged ascendancy of variants of neoliberalism, state-led action to improve health by addressing underlying social inequities appeared unfeasible in many contexts. The 1990s saw an increasing influence of the World Bank in global health policy, with mixed messages from WHO. During this period, however, important scientific advances emerged in the understanding of SDH, and in the late 1990s several countries, particularly in Europe, began to design and implement innovative health policies to improve health and reduce health inequalities through action on SDH. These policies targeted different entry points. The more ambitious aimed to alter patterns of inequality in society through far-reaching redistributive mechanisms. Less radical, palliative programmes sought to protect disadvantaged populations against specific forms of exposure and vulnerability linked to their lower socioeconomic status.

The 2000s have seen a pendulum swing in global health politics. Health stands higher than ever on the international development agenda, and stakeholders increasingly acknowledge the inadequacy of health strategies that fail to address the social roots of illness and well being. Momentous for action on the social dimensions of health is building. The Millennium Development Goals were adopted by 189 countries at the United Nations Millennium Summit in 2000. They set ambitious targets in poverty and hunger reduction; education; women's empowerment; child health; maternal health; control of epidemic diseases; environmental protection; and the development of a fair global trading system, to be reached by 2015. The MDGs have created a favourable climate for multisectoral action and underscored connections between health and social factors. An increasing number of countries are implementing SDH policies, but there is an urgent need to expand this momentum to developing countries where the effects of SDH are most damaging for human welfare. This is the context in which the CSDH will begin its work.

Based on the historical survey, four key issue areas are highlighted, in which the members of the CSDH must take strategic decisions early in their process.

(1) The first concerns the scope of change the Commission will seek to promote and appropriate policy entry points. Here the CSDH will face its own version of the choice between comprehensive and selective primary health care that confronted public health leaders in the 1980s. The CSDH will need evaluation criteria for identifying appropriate policy entry points for different countries/jurisdictions. (2) Potential resistance to CSDH messages can be anticipated from several constituencies, which the Commission should seek to engage proactively. The Commission will want to identify a set of potential "quick wins" for itself and for national political leaders taking up an SDH agenda. Commissioners will want to develop a strategy for dialogue with the international financial institutions, in particular the World Bank. (3) The CSDH will also benefit from exceptional political opportunities. It will effectively position itself within the global and national processes connected to the MDGs. Alliances with both the business community and civil society are possible, but competing interests will need to be managed. The opportunity and limits of economic arguments for SDH policies remain to be clarified, and such arguments raise deeper ethical questions. (4) In addition to robust evidence, the Commission needs a compelling, collectively owned "story line" about the social determinants of health, in which the evidence can be embedded and communicated. What story does the CSDH want to tell about social conditions and human well-being?

With answer to these questions in place, the Commission will lead a global effort to protect vulnerable families and secure the health of future generations by tackling disease and suffering at their roots.

REPORT OF THE UN SECRETARY GENERAL AT THE FIFTY-NINTH SESSION

Five years into the new millennium, we have it in our power to pass on to our children a brighter inheritance than that bequeathed to any previous generation. We can have global poverty and halt the spread of major known diseases in the next 10 years. We can reduce the prevalence of violent conflict and terrorism. We can increase respect for human dignity in every land. And we can forge a set of updated international institutions to help humanity achieve these noble goals. If we act boldly- and if we act together - we can make people everywhere more secure, more prosperous and better able to enjoy their fundamental human rights.

All the conditions are in place for us to do so. In an era of global interdependence, the glue of common interest, if properly perceived, should bind all States together in this cause, as should the impulses of our common humanity. In an era of global abundance, our world has the resources to reduce dramatically the massive divides that persist between rich and poor, if only those resources can be unleashed in the service of all peoples. After a period of difficulty in international affairs, in the face of both new threats and old ones in new guises, there is a yearning in many quarters for a new consensus on which to base collective action. And a desire exists to make the most far-reaching reforms in the history of the United Nations so as to equip and resource it to help advance this twenty-first century agenda.

The year 2005 presents an opportunity to move decisively in this direction. In September, world leaders will come together in New York to review progress made since the United Nations Millennium Declaration, adopted by all Member states in 2000. In preparation for that summit, Member States have asked me to report comprehensively on the implementation of the Millennium Declaration. I respectfully submit that report today. I annex to it a proposed agenda to be taken up, and acted upon, at the summit.

In preparing the present report, I have drawn on my eight years' experience as Secretary-General, on my own conscience and convictions, and on my understanding of the Charter of the United Nations whose principles and purposes it is my duty to promote. I have also drawn inspiration from two wide-ranging reviews of our global challenges - one from the 16member High-level Panel on threats, Challenges and Change, whom I asked to make proposals to strengthen our collective security system (see A/59/565); the other from the 250 experts who undertook the Millennium Project, which required them to produce a plan of action to achieve the Millennium Development Goals by 2015.

In the present report, I have resisted the temptation to include all areas in which progress is important or desirable. I have limited myself to items on which I believe action is both vital and achievable in the coming months. These are reforms that are within reach reforms that are actionable if we can garner the necessary political will. With very few exceptions, this is an agenda of highest priorities for September. Many other issues will need to be advanced in other forums and on other occasions. And, of course, none of the proposals advanced here obviate the need for urgent action this year to make progress in resolving protracted conflicts that threaten regional and global stability

The Challenges of a changing world: In the Millennium Declaration, world leaders were confident that humanity could, in the years ahead, make measurable progress towards peace, security, disarmament, human rights, democracy and good governance. They called for a global partnership for development to achieve agreed goals by 2015. They vowed to protect the vulnerable and meet the special needs of Africa. And they agreed that the United Nations needed to become more, not less, actively engaged in shaping our common future.

Five years later, a point-by-point report on the implementation of the Millennium Declaration would, I feel, miss the larger point, namely, that new circumstances demand that we revitalize consensus on key challenges and priorities and convert that consensus into collective action.

Much has happened since the adoption of the Millennium Declaration to compel such an approach. Small networks of non-State actors - terrorists - have, since the horrendous attacks of 11 September 2001, made even the most powerful States feel vulnerable. At the same time, many States have begun to feel that the sheer imbalance of power in the world is a source of instability. Divisions between major powers on key issues have revealed a lack of consensus about goals and methods. Meanwhile, over 40 countries have been scarred by violent conflict. Today, the number of internally displaced people stands at roughly 25 million, nearly one third of whom are beyond the reach of United Nations assistance, in addition to the global refugee population of 11 to 12 million, and some of them have been the victims of war crimes and crimes against humanity.

Many countries have been torn apart and hollowed out by violence of a different sort. HIV/AIDS, the plague of the modern world, has killed over 20 million men, women and children and the number of people infected has surged to over 40 million. The promise of the Millennium Development Goals still remains distant for many. More than one billion people still live below the extreme poverty line of one dollar per day, and 20,000 die from poverty each day. Overall global wealth has grown but is less and less evenly distributed within counties, within regions and in the world as a whole. While there has been real progress towards some of the Goals in some countries, too few Governments - from both the developed and developing world - have taken sufficient action to reach the targets by 2015. And while important work has been done on issues as diverse as migration and climate change, the scale of such long-term challenges is far greater than our collective action to-date to meet them.

Events in recent years have also led to declining public confidence in the United Nations itself, even if for opposite reasons. For instance, both sides of the debate on the Iraq war feel let down by the Organization

-for failing, as one side saw it, to enforce its own resolutions, or as the other side saw it, for not being able to prevent a premature or unnecessary war. Yet most people who criticize the United Nations do so precisely because they think the Organization is vitally important to our world. Declining confidence in the institution is matched by a growing belief in the importance of effective multilateralism.

I do suggest that there has been no good news in the last five years. On the contrary, there is plenty we can point to which demonstrates that collective action can produce real results, from the impressive unity of the world after 11 September 2001 to the resolution of a number of civil conflicts, and from the appreciable increase of resources for development to the steady progress achieved in building peace and democracy in some war-torn lands. We should never despair. Our problems are not beyond our power to meet them. But we cannot be content with incomplete successes and we cannot make do with incremental responses to the shortcomings that have been revealed. Instead, we must come together to bring about far-reaching change.

Larger freedom: Development, security and human rights: Our guiding light must be the needs and hopes of peoples everywhere. In my Millennium Report, "We the peoples" (A/54/2000), I drew on the opening words of the Charter of the United Nations to point out that the United Nations, while it is an organization of sovereign States, exists for and must ultimately serve those needs. To do so, we must aim, as I said when first elected eight years ago, "to perfect the triangle of development, freedom and peace".

The framers of the Charter saw this very clearly. In setting out to save succeeding generations from the scourge of war, they understood that this enterprise could not succeed if it was narrowly based. They therefore decided to create an organization to ensure respect for fundamental human rights, establish conditions under which justice and the rule of law could be maintained, and "promote social progress and better standards of life in larger freedom".

I have named the present report "In larger freedom" to stress the enduring relevance of the Charter of the United Nations and to emphasize that its purposes must be advanced in the lives of individual men and women. The notion of larger freedom also encapsulates the idea that development, security and human rights go hand in hand.

Even if he can vote to choose his rulers, a young man with AIDS who cannot read or write and lives on the brink of starvation is not truly free. Equally, even if she earns enough to live, a woman who lives in the shadow of daily violence and has no say in how her country is run is not truly free. Larger freedom implies that men and women everywhere have the right to be governed by their own consent, under law, in a society where all individuals can, without discrimination or retribution, speak, worship and associate freely. They must also be free from want - so that the death sentences of extreme poverty and infectious disease are lifted from their lives - and free from fear - so that their lives and livelihoods are not ripped apart by violence and war. Indeed, all people have the right to security and to development.

Not only are development, security and human rights all imperative; they also reinforce each other. This relationship has only been strengthened in our era of rapid technological advances, increasing economic interdependence, globalization and dramatic geopolitical change. While poverty and denial of human rights may not be said to "cause" civil war, terrorism or organized crime, they all greatly increase the risk of instability and violence. Similarly, war and atrocities are far from the only reasons that countries are trapped in poverty, but they undoubtedly set back development. Against, catastrophic terrorism on one side of the globe, for example an attack against a major financial centre in a rich country, could affect the development prospects of millions on the other by causing a major economic downturn and plunging millions into poverty. And countries which are well governed and respect the human rights of their citizens are better placed to avoid the horrors of conflict and to overcome obstacles to development.

Accordingly, we will not enjoy development without security, we will not enjoy security without development, and we will not enjoy either without respect for human rights. Unless all these causes are advanced, none will succeed. In this new millennium, the work of the United Nations must move our world closer to the day when all people have the freedom to choose the kind of lives they would like to live, the access to the resources that would make those choices meaningful and the security to ensure that they can be enjoyed in peace.

The imperative of collective action: In a world of inter connected threats and challenges; it is in each country's self-interest that all of them are addressed effectively. Hence, the cause of larger freedom can only be advanced by broad, deep and sustained global cooperation among States. Such cooperation is possible if every country's policies take into account not only the needs of its own citizens but also the needs of others. This kind of cooperation not only advances everyone's interests but also recognizes our common humanity.

The proposals contained in the present report are designed to strengthen States and enable them to serve their peoples better by working together on the basis of shred principles and priorities - which is, after all, the very reason the United Nations exists. Sovereign States are the basic and indispensable building blocks of the international system. It is their job to guarantee the rights of their citizens, to protect them from crime, violence and aggression, and to provide the framework of freedom under law in which individuals can prosper and society develop. If States are fragile, the peoples of the world will not enjoy the security, development and justice that are their right. Therefore, one of the great challenges of the new millennium is to ensure that all States are strong enough to meet the many challenges they face.

States, however, cannot do the job alone. We need an active civil society and a dynamic private sector. Both occupy an increasingly large and important share of the space formerly reserved for States alone, and it is plain that the goals outlined here will not be achieved without their full engagement.

We also need agile and effective regional and global intergovernmental institutions to mobilize and coordinate collective action.; As the world's only universal body with a mandate to address security, development and human rights issues, the United Nations bears a special burden. As globalization shrinks distances around the globe and these issues become increasingly interconnected, the comparative advantages of the United Nations become ever more evident. So too, however, do some of its real weaknesses. From overhauling basic management practices and building a more transparent, efficient and effective Untied Nations system to revamping our major intergovernmental institutions shows that they reflect today's world and advance the priorities set forth in the present report, we must reshape the Organization in ways not previously imagined and with a boldness and speed not previously shown.

In our efforts to strengthen the contributions of States, civil society, the private sector and international institutions to advancing a vision of larger freedom, we must ensure that all involved assume their responsibilities to turn good words into good deeds. We therefore need new mechanisms to ensure accountability - the accountability of States to their citizens, of States to each other, of international institutions to their members and of the present generation to future generations. Where there is accountability we will progress; where there is none we will under perform. The business of the summit to be held in September 2005 must be to ensure that, from now on, promises made are promises kept.

Time to decide: At this defining moment in history, we must be ambitious. Our action must be as urgent as the need, and on the same scale. We must face immediate threats immediately. We must take advantage of an unprecedented consensus on how to promote global economic and social development, and we must forge a new consensus on how to confront new threats. Only by acting decisively now can we both confront the pressing security challenges and win a decisive victory in the global battle against poverty by 2015.

In today's world, no State, however powerful, can protect itself on its own. Likewise, no country, weak or strong, can realize prosperity in a vacuum. We can and must act together. We owe it to each other to do so, and we owe each other an account of how we do so. If we live up to those mutual commitments, we can make the new millennium worthy of its name.

PUBLIC HEALTH IN THE NEW ERA: IMPROVING HEALTH THROUGH COLLECTIVE ACTION

Robert Beaglehole, Ruth Bonita, Richard Horton, Orvill Adams, Martin McKee

The Lancet Vol.363, No.9426 June 19, 2004@ www.thelancet.com

The world is entering a new era in which, paradoxically, improvements in some health indicators and major reversals in other indicators are occurring simultaneously. Rapid changes in an already complex global health situation are taking place in a context in which the global public-health workforce is unprepared to confront these challenges. This lack of preparation is partly because the challenges are large and complex the public-health workforce and infrastructure have been neglected, and training programmes are inadequate. These problems are exacerbated by the concentration of funding on biomedical research and the failure to confront and work with vested interests, which promote and sustain unhealthy behaviour patterns.

If public-health practitioners are to address national and global health challenges effectively, the way they work and make their work relevant to these challenges will require a major reorientation. A clear vision of what public health is, and what it can offer, is required. To be achievable, the vision must then be communicated not only to its practitioners, but also to the wider policy community, whose actions are necessary to improve the health of the public. Here, we propose a reformulation of public health appropriate for the global and national health challenges in this new era.

Approaches to the practice of public health are contingent on time and place. They are distinguished mainly by the amount of authority vested in the state and their main disciplinary base. In terms of state involvement and responsibility, there are two extreme approaches: the state medicine model and the market model. The practice of public health in the USA is an example of the market approach. The aim of this model is to limit government responsibility for public health and to encourage individual responsibility for health improvement, on the assumption that the market will respond to individuals demand for goods that promote health. The state medicine model, by contrast, envisages a strong role for the state, encroaching in many areas that some might consider private life. A particular version was transposed to the Soviet Union, where public health became a central part of state policy, summarized by Lenin's comment that "if communism does not destroy the louse, the louse will destroy communism". Another version was seen in China for several decades after the evolution of 1949.

The disciplinary base of public health can be narrow mainly the medical sciences - or broad and inclusive, bringing together a wide range of disciplines including the political sciences. The medical model has traditionally been identified with the UK, where public health was, until recently, regarded as a specialist branch of clinical medicine. The broad multidisciplinary approach to public health, sometimes referred to as the social justice model, has a long tradition in several European countries, beginning with Virchow in Prussia at the end of the 19th century, with a brief reappearance in some universities in England in the middle of the last century. This approach to public health has been especially strong in Latin America since the middle of the last century, and has echoes in both the Alma-Ata model of primary health care and the new public health of the 1980s. The practice of social medicine has focused on the social and environmental determinants of health and disease and the effects of social and economic policies on health status; this approach has rarely been able to bridge the divide between rhetoric and policy.

PROVISIONS FOR HEALTH AND HEALTH CARE IN THE CONSTITUTIONS OF THE COUNTRIES OF THE WORLD

Eleanor D Kinney, Hall Render Professor of Law & Co-Director, The Centre for Law and Health, Indiana University School of Law, Indianapolis.

Brian Alexander Clark, Marion County Indiana.

Cornell International Law Journal Volume 37 Issue2, 2004

Available at: http://organizations.lawschool.cornell.edu/ilj/issuepdfs/37 Issue 2.pdf

At a time of renewed interest in the international human right to health, it is useful to identify and examine the provisions of the constitutions of the world regarding health and health care. These provisions indicate a national commitment towards the assurance of access to high quality and affordable health care for all peoples. In addition, such constitutional provisions may be important factors in the international campaign to promote the recognition and implementation of the international human right to health domestically throughout the world.

This Article reports findings of an empirical analysis of the provisions of the constitutions of the world that address health and health care. The Article also examines other indices of national commitment to health and health care, such as ratification of ICESCR and relevant regional human rights treaties, and national performance in allocating budgetary resources towards health and health care. The Article concludes that the national commitment to health and health care is not highly related to whether or not a nation's constitution specifically addresses health or health care. Nevertheless, the finding that 67.5% of the constitutions of all nations have provisions regarding health and health care is important for efforts to promote recognition and implementation of the international human right to health.

THE END OF POVERTY: ECONOMIC POSSIBILITIES FOR OUR TIME

Jeffrey D Sachs, Columbia University, USA, March 2005

"Extreme poverty can be ended, not in the time of our grandchildren, but our time." Thus forecasts Jeffrey D Sachs, whose twenty-five years of experience observing the world from many vantage points has helped him shed light on the most vital issues facing our planet: the causes of poverty, the role of rich-country policies, and the very real possibilities for a poverty-free future. Deemed "the most important economist in the world" by The New York Times Magazine and "the world's best-known economist" by Time magazine, Sachs brings his considerable expertise to bear in the landmark. The End of Poverty: Economic Possibilities for Our Time, his highly anticipated blueprint for world-wide economic success - a goal, he argues, we can reach in a mere twenty years.

Marrying vivid eyewitness storytelling with concrete analysis, Sachs provides a conceptual map of the world economy and the different categories into which countries fall, explaining why wealth and poverty have diverged and evolved as they have and why the poorest nations have been so markedly unable to escape the cruel vortex of poverty. The End of Poverty does not deliver its world views from on high: Sachs plunges into the messy realities of economies, leading his readers through his work in Bolivia, Poland, Russia, India, China, and Africa, and concludes with an integrated set of solutions to the tangled economic, political, environmental, and social issues that most frequently hold societies back.

HUMAN RESOURCES FOR HEALTH: OVERCOMING THE CRISIS

Lincoln Chen, Timothy Evans, Sudhir Anand, Jo Ivey Boufford, Hilary Brown, Mushtaque Chowdhury, Maracos Cueto, Lola Dare, Gilles Dussault, Gijs Elzinga, Elizabeth fee, Demissie Habte, Piya Hanvoravangchai, Marian Jacobs, Christoph Kurowski, Sarah Michael, Ariel Pab los-Mendez, Nelson Sewankambo, Giorgio Salimano, Barbara Stilwell, Alex de Waal, Suwit Wibulpalprasert.

www.thelancet.com Vol..364 November 27, 2004

In this analysis of the global workforce, the Joint Learning Initiative - a consortium of more than 100 health leaders - proposes that mobilization and strengthening of human resources for health, neglected yet critical, is central to combating health crises in some of the world's poorest countries and for building sustainable health systems in all countries. Nearly all countries are challenged by worker shortage, skill mix imbalance, maldistribution, negative work environment, and weak knowledge base. Especially in the poorest countries, the workforce is under assault by HIV/AIDS, out-migration, and inadequate investment. Effective country strategies should be backed by international reinforcement. Ultimately, the crisis in human resources is a shared problem requiring shared responsibility for cooperative action. Alliance for action are recommended to strengthen the performance of all existing actors while expanding space and energy for fresh actors.

THE EFFECTS OF SPECIALIST SUPPLY ON POPULATIONS' HEALTH: ASSESSING THE EVIDENCE

By Barbara Starfield, Leiyu Shi, Atul Grover, and James Macinko

Health Affairs, the Journal of Health Sphere, March 1-5, 2005

The evidence suggests that populations do not necessarily benefit from an overabundance of specialists in a geographic area.

Analyses at the country level show lower mortality rates where there are more primary care physicians, but this is not the case for specialist supply. These findings confirm those of previous studies at the state and other levels. Increasing the supply of specialists will not improve the United States' position in population health relative to other industrialized countries, and it is likely to lead to greater disparities in health status and outcomes. Adverse effects from inappropriate or unnecessary specialist use may be responsible for the absence of relationship between specialist supply and mortality.

Many international Comparisons and within-country studies confirm the relationship between the adequacy of a health system's primary care infrastructure and better health outcomes. This study examines the heretofore unexplored relationship between specialist physician supply and death rates, based on data from US counties. After presenting our analysis, we discuss the complicated issues surrounding specialist supply and population health and the policy implications of our findings.

The roles and responsibilities of primary care are well known; the same is not the case for specialty care. Surgical specialists make a unique contribution through surgical interventions, but many are involved in activities other than operations. The need for specialists to deal with conditions too uncommon for primary care physicians to maintain competence in dealing with them undoubtedly is, or at least should be, the basis for specialization. Beyond this generalization, little is known about the roles of specialists. Furthermore, the boundary between "uncommon" and "not uncommon" is not well defined and may differ from place to place. In countries where specialists work in hospitals and see patients only on referral from primary care, there is a clear delineation of roles defined by what primary care physicians do. Referrals have four functions: short-term consultation for diagnosis; short-term consultation for initiation of management; long-term referral for total career of rare conditions; and recurrent consultation for continuing management. Little is known about the relative balance of these functions, although short-term consultations are far more common than long-term consultations or referrals, for virtually all specialist types in the United States.

Greater rationalization of specialist care is occurring in several countries, particularly where waiting lists for specialist care are perceived as too long. None of these efforts involves increasing the supply of specialists. Planning for these improvements is seen as a role of central or provincial governments. The special role of information systems is particularly recognized in the Canadian province of Saskatchewan, which systematically collects data on waiting lists and devises clear and transparent patient prioritization processes. In the United Kingdom, there is evidence that many specialist visits can be avoided. If primary care physicians are provided with cameras and the subsequent means to obtain dermatology consults directly 25 percent of patients who otherwise would have been referred can be managed without a specialist appointment; at least 38 percent can be saved at least one dermatology visit by initiating management without the dermatologist seeing the patient. Furthermore, the need for specialists can be reduced by enabling less costly professionals to do professionally more sophisticated interventions in less costly settings, as long as they are appropriately trained, maintain a reasonable volume, and are subject to assessment of unnecessary or inappropriate use. Experience elsewhere also shows that countries with increasing demand for specialty services are not responding by increasing their supply. In the United Kingdom, the development of primary care physicians with specialty interests is proving successful in reducing waiting time for consults in a variety of specialist types. That is, increased availability of primary care services provides a viable and much less costly alternative to increasing the number of specialists.

In view of the strong evidence that having more specialists, or higher specialist-to-population ratios, confers no advantages in meeting population health needs and may have ill effects when specialist care is unnecessary, increasing the specialist supply is not justifiable. Of course, there may be particular specialists who are in insufficient supply to meet particular needs. Moreover, there is already considerable evidence that increasing the supply of primary care physicians would have a beneficial impact on the health of the population.

ADDING MORE SPECIALISTS IS NOT LIKELY TO IMPROVE POPULATION HEALTH: IS ANYBODY LISTENING?

By Robert L Phillips Jr., Margtey S. Dodoo, and Larry A. Green

In Health Affairs, the Policy Journal of the Health Sphere, March 1-5, 2005

Before a shortage of physicians, and particularly sub specialists, in the Untied States is declared, it is worth of reviewing the considerable evidence that calls into question whether further specialization automatically improves health. Barbara Starfield and colleagues' latest research reveals, again, that having more specialists may not be a good thing. The current workforce functions well as an economic engine, but continued emphasis on market demand will likely widen disparities in workforce distribution and population health. The resurgence of interest in shaping the future physician workforce should lead to purposeful choices about what we want them to do and the outcomes we expect.

Once again the assumption that further specialization of the US physician workforce will automatically improve health care has been challenged. The findings of Barbara Starfield and colleagues make it apparent that a commitment to evidence-based practice and policy requires reconsideration of long-standing assumptions about inherent value of care by medical specialists.

Starfield and colleagues remind us that countries with primary care-based health systems have population health outcomes that are better than US outcomes, and that consistent and considerable evidence exists that in the United States, higher ratios of primary care physicians to population are associated with better health outcomes, often at lower costs. We are grateful that they have added to this discussion evidence that US counties with high ratios of primary care to population have better health outcomes, while those with higher ratios of sub specialists population have poorer overall health outcomes.

This study helps dispel concerns that previous ecological evidence was an issue of regional variations. Its greatest weakness is that it remains ecological, and, even though it extends previous findings to the county level, this is such a fairly large geographic frame. Its greatest strength is its consistency with the previous body of work showing similar effects. This type of analysis should be welcomed by anyone wanting to improve the health of Americans. Since workforce prognosticators re asking whether anyone is listening, we believe that Starfield and her colleagues of the pause for the recent rush to declare a coming physician shortage, particularly of specialists. We should instead be asking what we expect of our physician workforce, and to what end?

There is an effort afoot to convince policymakers and the public that there is or soon will be a shortage of physicians and particularly sub specialists in the United States. These models predict a shortfall of some 200,000 physicians over the next fifteen years, mostly in subspecialties. The assumptions underpinning these models have been questioned by many researchers.

Starfield and colleagues' findings suggest that their outcome may, in fact, be harmful. It is entirely possible that the positions are correct, but efforts to satiate market demand may jeopardize the health of the population. This conference suggests that a choice should be made - do we respond to market demands and use our health care system to stoke our economic engine, or do we aim for better population health?