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measures are especially critical given the large scope and increased complexity of health services required. The universal health coverage (UHC) target of the health SDG stipulates that everyone can obtain essential health services at high quality without suffering financial hardship, yet quality has not been widely tracked. 11 There is no benefit to UHC if people are un willing to use services due to the poor quality of the services for which they are financially covered. Even if people are accessing services, poor quality will undermine health outcomes, reducing the value of UHC. Finally, high-quality health services attract the public support that contributes to governments providing sustained financing.

In recent decades, the influence of Brazil, the Russian Federation, India, China and South Africa (BRICS) within the international arena has increased enormously.1 These countries represent around 25% of the world’s gross national income, more than 40% of the world’s population and about 30% of the world’s land area.2 Although much attention has been paid to their economic performance, less widely noted is the fact that these countries are uniquely positioned to exert a decisive influence on health at the global level. Within BRICS countries, hundreds of millions of people have been lifted out of poverty. This has resulted in marked improvements in health outcomes and in substantial progress towards achieving the Millennium Development Goals.3,4 BRICS countries are also gravitating towards universal health coverage, although not at an even pace. They are leaders in the manufacture of low-cost medicines and vaccines.5 Their experiences in reducing poverty and strengthening health systems, together with their booming economies and large populations, explain why they exert such an enormous influence on health worldwide. Besides, in only a few years they have amassed a wealth of experience and knowledge from which other low- and middle-income countries can draw valuable examples. Despite their many assets, however, BRICS countries face important health problems. India has the highest number of maternal and infant deaths of any country in the world. South Africa has the greatest number of people with human immunodeficiency virus infection. Alcohol abuse is a major public health concern in the Russian Federation. In addition, BRICS countries’ strong economic growth has created a new set of problems that need to be addressed. Over the last decade, inequities in health and in the socioeconomic sphere have become accentuated in most of these countries.6 Although life expectancy has improved substantially in Brazil, China and India, BRICS countries as a whole still account for about 40% of the global burden of disease.7 They also face a “double” disease burden resulting from the coupling of infectious diseases with the emergence of new health problems triggered by environmental factors and to an increase in road traffic injuries and noncommunicable diseases. Tackling the social determinants of health continues to be a priority for BRICS countries. Globally, BRICS countries are becoming increasingly important partners in international development cooperation.8 They are helping to reshape the landscape of aid effectiveness. According to the final declaration of the Fourth High Level Forum on Aid Effectiveness, held in 2011 in Busan, the Republic of Korea, the nature, modalities and responsibilities that apply to South–South cooperation differ from those that apply to North–South cooperation.9 Although the development cooperation coming from BRICS countries has increased substantially in recent years, estimates vary because of differences in the approaches and methods used to report development cooperation for countries not represented in the Development Assistance Committee.10,11 Through “South–South” health cooperation, BRICS countries are able to reach populations beyond their own borders. These countries can engage in cooperation of this type either individually through bilateral agreements or collectively. Inter-BRICS cooperation is gaining momentum, as highlighted in the recent meeting of ministers of health held on 10–11 January 2013 in New Delhi.12 Moreover, the establishment of the BRICS development bank, agreed upon by BRICS leaders on 27 March 2013 in Durban, South Africa, will also contribute to the advancement of health in BRICS countries and beyond. The Bulletin plans to publish a theme issue on BRICS and global health to enhance people’s understanding of the dynamics of health and development in BRICS countries and of how these countries contribute to global health, both by improving health outcomes in their own territories and by engaging in mutual cooperation. This issue will cover these countries’ key health policy achievements and their most important health challenges, as well as their rising influence on international health cooperation. We welcome papers for all sections of the Bulletin and encourage authors to consider contributions on any of the following topics as they pertain to BRICS countries: universal health coverage; universal access to medicines or vaccines; emerging and existing public health challenges, notably health inequities and the double burden of disease; South–South cooperation and inter-BRICS cooperation. The deadline for submissions is October 2013. Manuscripts should be prepared in accordance with the Bulletin’s Guidelines for contributors and authors should mention this call for papers in a covering letter. All submissions will go through the Bulletin’s peer review process. Please submit to: http://submit.bwho.org.

In most regions, over the past 50 years, socioeconomic development has been accompanied by large falls in fertility and equally dramatic increases in life expectancy.1 This phenomenon has led to rapidly ageing populations around the world. The fastest change is occurring in low- and-middle-income countries. Even in sub-Saharan Africa, which has the world’s youngest population structure, the number of people older than 60 years is expected to increase by over threefold, from 46 million in 2015 to 147 million in 2050.2 Increasing life expectancy presents many opportunities to individuals as well as the communities they live in. Older people contribute to society in many ways, for example, through participation in the workforce, the taxes they pay, the direct economic support they can give to younger family members, or through the sharing of their experience.3 Even in high-income countries that have comprehensive social protection platforms, the economic value of these contributions outweigh the direct costs of pensions, health care and other services that governments provide.3 However, the extent of these opportunities and contributions will depend heavily on the health of these older populations. In rich countries, it is often assumed that older people live these later years of life in good health. Unfortunately, while there is some evidence that cognitive declines may be occurring at later ages than seen in the past, there is very little evidence that older people today are enjoying better physical capacity than their parents did at the same age.4,5 In low- and middle- income countries, older people experience even higher rates of ill-health and impaired function.6 Yet this does not have to be the case. Most poor health in older age is the consequence of chronic diseases, many of which can be prevented, or, if detected early, can be effectively controlled. Even in cases where older people experience declines in capacity, supportive environments can ensure that they continue to live their lives with meaning and dignity. Increased longevity is one of the great achievements of the 20th century. Ensuring the added years can be enjoyed in good health will be one of the biggest public health challenges of the first half of the 21st century. Addressing this challenge will require changing perceptions and assumptions about health in older age. Changes are also needed in the way that health systems are designed and the ways in which care is delivered and measured. Several global initiatives are shaping discussions on how these challenges might be addressed. The first ever World report on ageing and health1 was released in 2015 and the Global Strategy and Implementation Plan on Ageing and Health will be considered at the 2016 World Health Assembly. The report presented a conceptual framework for healthy ageing built around the functional ability of older people, rather than the absence of disease. It highlighted knowledge gaps as a major barrier to global action. It also emphasized that any action to address healthy ageing requires sound evidence stemming from careful evaluation of cost-effective interventions. Evidence on how to ensure healthy ageing, particularly in people living in low- and middle-income countries, is scarce. This is partly because the transition to an ageing population in these countries has been relatively recent and more rapid than in high income countries. The limited research that has been conducted on the effectiveness of relevant interventions has been done mostly in high-income countries. The Bulletin of the World Health Organization will publish a theme issue on actions and approaches to support the development of resilient health and long-term care systems for ageing populations. This theme issue will include original research, examine available knowledge and share evidence on best practices around healthy ageing. It will include papers that will highlight the interconnectedness of health and social issues in maintaining healthy ageing and how the combination of appropriate health and social strategies can promote functional ability and lead to a happier and healthier older population. We welcome papers for all sections of the Bulletin, around the following themes: (i) use of technologies and innovations to improve functional ability and promote healthy ageing; (ii) effectiveness of public health and clinical interventions to prevent and reverse declines in physical and mental capacities; (iii) community-based public health interventions to support caregivers of older people; (iv) determinants of different trajectories of function; (v) long-term care systems in low- and middle- income countries; (vi) elements of effective integrated care service delivery models; (vii) management of geriatric conditions, such as frailty, sarcopenia, urinary incontinence, and dementia. The deadline for submission is 1 November 2016. Manuscripts should be submitted in accordance with the Bulletin’s Guidelines for contributors (http://submit.bwho.org), and the cover letter should mention this call for papers.

The end of the millennium development goals (MDGs) in 2015 marked a turning point in addressing some of the world’s most pressing and complex development challenges outlined in 2000 by the global development community. The goals, which were designed to mobilize global attention around eight priority development issues, were unprecedented in both scale and pace. Their implementation has led to significant achievements including a decline in mortality from tuberculosis and human immunodeficiency virus (HIV) infections, a decline in child and maternal mortality and improved access to safe drinking water and sanitation. These achievements show that many of the goals have been met.1 However, the MDGs and their focus on aggregate-level measures of progress masked the inequalities in health outcomes that existed between and within countries, regions and subgroups in a given population.2,3 Learning from the MDG experience, the new 2030 agenda for sustainable development has been firmly anchored in the principles of universality.4 Its goals are applicable to all regardless of their country’s level of development. The goals are non-discriminatory to ensure that no one is left behind.5 The sustainable development agenda places social justice, equity, efficacy and a people-centred approach at its core. It calls for targeted attention to the needs and rights of the most vulnerable and excluded,4 to ensure a life of dignity for all.3 While the ambitious sustainable development goals (SDGs) are welcomed, the challenge of translating them into action is significant.5 Effective implementation requires defining the vulnerable – those who are left behind – and giving priority to those furthest behind. Vulnerability or exclusion in its broad definition can vary significantly and may change over time.6 Individual factors such as sex, age, race, gender, ethnicity, displacement, disability and health status can lead to increased vulnerability of individuals and communities. These vulnerability factors often overlap and can contribute to poor health outcomes.6 MDG progress reports show that some population groups systematically had worse health outcome measures.3 The aim of targeted action focused on leaving no one behind is to recognize that vulnerable groups exist in all communities and vulnerability occurs within various social and economic contexts. Implementation of the SDGs requires metrics to measure inclusion and exclusion of specific population groups.6 There are methods in selected disciplines to measure social inclusion and exclusion, health inequality, discrimination, the cost of exclusion to societies, cost–effectiveness of addressing marginalization and promoting a universal and equitable development agenda. There are also effective interventions to tackle the causes of vulnerability in different groups and settings. The Bulletin of the World Health Organization will publish a theme issue on addressing the health of vulnerable populations. For the purpose of this theme issue, the term vulnerability encompasses the effects of marginalization, exclusion and discrimination that contribute to poor health outcomes. It will focus on vulnerable groups, the drivers behind their marginalization or exclusion from wider development progress and emerging strategies to accelerate progress tailored to their needs. It will include original research articles on two challenges that are expected to be facing those implementing the 2030 agenda for sustainable development: how to identify those who are being left behind and how to measure and monitor progress in addressing inequality. Articles will provide experience from country-level implementation of effective interventions targeting vulnerable groups. We welcome papers for all sections of the Bulletin, around four themes: (i) who, where and why vulnerable populations exist; (ii) constructs of social exclusion and the measurement of social inclusion and exclusion; (iii) interventions that reach vulnerable populations in the context of the SDGs at the micro- and macro-policy levels; (iv) factors contributing to and exacerbating vulnerabilities. The deadline for submissions is 31 May 2016. Manuscripts should be submitted in accordance with the Bulletin’s Guidelines for contributors (http://submit.bwho.org), and the cover letter should mention this call for papers. All submissions will be peer reviewed.

WHO’s South-East Asia Region, comprising 11 member countries, is home to 26% of the world’s population and 30% of the world’s poor.1,2 Of the 14 million deaths that occur annually in this region, 40% are due to communicable diseases compared with the global proportion of 28%.3 A high density of population, poverty, poor sanitation and tropical climate create an environment conducive to the emergence and propagation of communicable diseases.4 As a result, the region is at high risk for new and emerging infectious disease events and has become a hotspot for many zoonoses, drug-resistant pathogens and vector-borne diseases. The region is the epicentre of avian influenza, which has the potential for causing an influenza pandemic. Multidrug-resistant malaria, including artemisinin resistance at the border of Cambodia and Thailand, threatens to jeopardize the provision of effective antimalarial treatment worldwide.5 Chikungunya virus has re-emerged after 30 years, the spread of dengue is expanding geographically, and the impact of climate change on these vector-borne diseases is a matter of increasing concern. As many as 1.3 billion people in the region live in high-risk areas for malaria and dengue fever. The region alone bears 35% of the global burden of tuberculosis, 60% of lymphatic filariasis and 80% of leprosy cases.6 Fortunately, there is a high level of political commitment towards combating both old diseases as well as new and re-emerging ones. Successful examples include eradication of guinea-worm disease, elimination of yaws from India, excellent progress in tuberculosis control and in combating HIV. The opportunities for eliminating diseases such as visceral leishmaniasis are unique to this region. Though polio remains a lingering problem, enormous efforts are being made towards its eradication. Basic systems and human resources are in place and can be used to their full potential. Good work that is already underway needs to be documented and shared more widely. The WHO South-East Asia Region has been undergoing rapid economic development over the past few decades. While this has worked in favour of combating communicable diseases in terms of greater financial resources and priority given to health, it has had profound impact on communicable diseases in the context of globalization. The ease of international travel, population movement, urbanization, unplanned and unregulated developmental activities are all facilitating the spread of diseases, both within and across borders, thus threatening international health security. Furthermore, the economic growth has not been equitable and poor health is both a cause and consequence of non-inclusive growth.7 Innovative strategies are being implemented in the region to address these issues. The social insurance scheme in Thailand,8 national rural health mission in India,9 partnerships between the government and nongovernmental organizations in Bangladesh are just a few example of initiatives that governments are taking to address the concerns of the poor and to ensure equity and social justice in the health area. Core capacity is being built for early detection and rapid response to these new pathogens in the context of the International Health Regulations (IHR 2005). Developing robust health delivery mechanisms is a key area for policy and research. WHO’s South-East Asia Region has a vibrant private health sector, including advanced pharmaceutical and biotechnology research, development and manufacturing capacity, which can be engaged towards further strengthening health services. Existing infrastructure can be used as a foundation to allow appropriate components of communicable disease control to be managed by primary health care. A theme issue of the Bulletin will provide a forum for sharing the region’s successes, and its future opportunities in disease control and research. The issue aims to foster greater international collaboration and partnership. Since the region has such a high communicable disease burden and risk, greater investment and collaboration will benefit not only the communities it serves but the entire world. The deadline for submissions to this issue is 1 June 2009. Manuscripts should be submitted to: http://submit.bwho.org and should respect the Guidelines for Contributors, available at: http://www.who.int/bulletin/volumes/84/current_guidelines/en/index.html. They should be accompanied by a cover letter mentioning this call for papers. All submissions will go through the Bulletin’s peer review process. ■

Many – some would argue all – successful public health initiatives would not be possible without strategic communications. Paradoxically, the discipline remains misunderstood, underfunded and underutilized. Communication is too often neglected and only incorporated into public health programmes as an afterthought. That is why for the first time the Bulletin is devoting a theme issue to the dynamic field of public health communication. The theme issue, scheduled for August 2009, is seeking diverse contributions, including research on work related to developing countries that increases knowledge on the subject and catalyses more such research in the future. It also invites studies of new and effective ways of evaluating the impact of public health communications – one of its most illusive but compelling aspects. Expanding the existing evidence base, the theme issue will seek to underscore a conviction among professional communicators that communication is a public health intervention in its own right and not merely a supporting role. The theme issue will explore five key areas of public health communication. The first is the challenging question of how to reach the “unreached”. These may be the communities that cannot be reached physically, due to geographical isolation, insecurity or other obstacles. They may lack access to common communication outlets, such as radio, newspapers or the internet, or they may speak a different language. The second area is the financial and human cost of poor communication, examining public health failures and seeking lessons from successful “anti-public health” campaigns, such as those run by the tobacco industry. Communication in extreme situations – major health crises, humanitarian disasters or epidemics – will be the third major area of the Bulletin theme issue. The fourth will be the contrasting roles of new and traditional technology in reaching public health communication goals, such as mobile-phone text messages and radio broadcasting. Finally, the Bulletin theme issue will highlight monitoring and evaluation of the impact of public health communication. This area is often neglected or done on an ad hoc basis, but it is critical particularly when investment needs to be justified. Evaluation also allows us to learn from past mistakes or successes. Communication is at the heart of public health. Practitioners understand intuitively the role that the exchange of information plays in achieving results in public health – when doctors interpret a patient’s symptoms, when public health authorities give timely advice to a community at risk or when researchers exchange data as they grapple with the complexities of a disease. Too often we lack the evidence that would allow public health communicators to maximize the efficacy of such interchanges. We lack cost–benefit data that could be used to make a case for investing in strategic communication in some of the world’s most vulnerable communities. This theme issue seeks to increase this evidence base and raise awareness among public health managers about the importance of communication in public health. It seeks to break new ground by throwing light on a core but neglected specialization of public health. In extreme situations, communication assumes a critical role in protecting people’s health around the world. In outbreaks and epidemics, successful communication of risk and the mitigating actions that can be taken is often the most crucial element of effective outbreak management.1 During humanitarian crises, effective communication highlights urgent life-saving interventions and plays a critical role in mobilizing resources for health response. But public health crises are littered with communication failures – often we do not have information management and dissemination systems that can withstand the stress of an emergency. Like public health itself, communication must be seen in the context of a rapidly evolving landscape. Globalization has led to an increased appetite for information of all kinds. People seek health information through outlets not even conceived 10 years ago. For example, the mobile phone market is growing globally, with Africa experiencing more than 350% growth between 2002 and 2005.2 These changes provide an opportunity to reach many for the first time. Furthermore, newer satellite and web technologies allow the public to influence public health messaging through electronic means. Upheavals in the world economy and political climate affect the composition of target audiences and the content of messages. The successes in public health communication are well-documented. From disseminating basic public health messages (such as the benefits of hand washing in preventing diarrhoea) to raising awareness and advocacy to stop people from smoking and encouraging them to lead a healthy lifestyle, communication is not a supporting actor but takes a leading role: it is the primary public health intervention that cuts across all others. Even in countries with a weak infrastructure and limited resources, strategic communication is not only possible but essential. Without it, other interventions may waste precious time and money, and reap little or no result. Manuscripts on any of the above topics should be submitted to: http://submit.bwho.org by 1 November 2008. ■

Background When researchers embark on a clinical trial, they make a commitment to conduct the trial and to report the findings in accordance with basic ethical principles. This includes preserving the accuracy of the results and making both positive and negative results publicly available. (1) However, a significant proportion of health-care research remains unpublished and, even when it is published, some researchers do not make all of their results available. (2) Selective reporting, regardless of the reason for it, leads to an incomplete and potentially biased view of a trial and its results. (3) The consequences of publication bias and selective reporting have gained the attention of health-care consumers, the media and politicians. All have recognized the impact that undisclosed results can have on the ability of patients, practitioners and policy-makers to make well-informed decisions about healthcare. Concern over the underreporting of adverse events, in particular, has increased the demand for more transparent processes for registering clinical trials and reporting their findings. In recent years, trial registration has become increasingly widely accepted and implemented. There are now well-established mechanisms to register trials, assign unique identifiers and make this information publicly available. WHO's International Clinical Trials Registry Platform Search Portal helps bring the data from these registers together, making it much easier to search for the existence of a trial (available at: http://www.who.int/trialsearch). The value of registration goes far beyond the administrative benefits of having a complete collection of all trials. Trial registers may facilitate recruitment into clinical trials by raising awareness of their existence among potential participants and health-care practitioners. They may also lead to more ethical and successful research by avoiding the unintentional duplication of research already under way elsewhere. From the perspective of this paper, however, the greatest benefit of trial registration is enhanced transparency; that is, making it clear which trials are being conducted so that people can anticipate their results. The next step to informed decision-making is to make the findings of clinical trials available, since it is knowledge of the findings, rather than of the existence of a trial, that is likely to have the greatest impact on people trying to choose between alternative interventions. The arrival and growth of electronic publishing and the Internet as dissemination tools without page or length restrictions has greatly expanded the ability of people to make findings available and accessible in full. The recognition of the need for reliable evidence to improve health care and to facilitate the synthesis of the results of research into systematic reviews has fuelled the demand for access to the findings of all research, as have the needs of the numerous other stakeholders in clinical research. A proposed position The position proposed by the members of the WHO Registry Platform Working Group on the Reporting of Findings of Clinical Trials is that "the findings of all clinical trials must be made publicly available". This paper discusses the principles underlying this position. Our goal is to contribute to the ongoing debate and to foster the collaboration that is necessary to ensure that the findings of clinical trials do not remain hidden from the people who need access to them. What is a finding? The language used to discuss the reporting of clinical trials usually focuses on "results"--often taken to mean the numerical results of an analysis for a specific outcome. For example, a summary estimate such as a relative risk. However, the reader or user of research also needs background information that will allow them to correctly interpret the results for specific outcomes. The type and amount of information required will depend on the nature of the audience and how it will use the information received but will have four key elements: 1. …

Tuberculosis (TB) has been a major killer disease for several thousand years. Despite intensive efforts to combat the disease over the past twenty years TB remains one of the leading causes of morbidity and mortality in many settings particularly in the worlds poorest countries. TB is primarily a disease of poverty but is a significant public health problem also in wealthier countries where pockets of poverty and marginalized population groups exist. It is estimated that around 1.7 million people die each year from TB; and in 2004 figures indicate that approximately 8.9 million people developed the disease. (excerpt)

An adequate, performing health workforce is vital for improving health service coverage and health outcomes.1 Yet the availability, distribution, capacity and performance of human resources for health (HRH) varies widely and many countries have fewer health workers than needed for high coverage of essential health services, according to the World health report 2006.2 Signs of progress are emerging, though; several countries are successfully addressing their problems in the area of HRH, resulting in improvements in health outcomes.3 These gains are, however, vulnerable: shortages of and inequitable access to health workers still thwart many countries’ attempts to achieve the Millennium Development Goals (MDGs) and their efforts to scale up their response against noncommunicable diseases and attain universal health coverage. Universal Health Care (UHC) was defined by the World Health organization in 2005.4 Since then it has gained increased recognition as a framework for embracing various global health priorities. New evidence, policy options and advocacy5 in support of the progressive achievement of UHC have been the focus of the World health report: health systems financing6 and of numerous global health events.7,8 In 2011 the World Health Assembly adopted a resolution on UHC,9 and in 2012 a United Nations General Assembly resolution bolstered political momentum in support of UHC and underscored the need for an “adequate, skilled, well-trained and motivated workforce”.10 In this context ensuring that appropriate HRH strategies and priorities are embedded in the UHC and post-MDG agenda becomes crucial. As health systems progressively broaden their scope to cover noncommunicable diseases and other priorities, health workers will face new demands for more comprehensive and equitable service delivery. The challenge lies in addressing past and present gaps while simultaneously anticipating future actions to strengthen the health workforce as an integral part of health systems. The HRH needs demand renewed attention, strategic intelligence and action. Gaps in health worker distribution, competency, quality, motivation and performance need to be addressed in addition to sheer numbers. Fundamental changes in the way in which health workers are trained, managed, regulated and supported and in the role of the public sector in shaping labour market forces will be necessary. Against this background, the Bulletin will publish a theme issue on HRH and universal health coverage to provide an opportunity to identify the changes in HRH investment, production, deployment and retention required to achieve UHC. Its publication will coincide with the Third Global Forum on Human Resources for Health, to be held in Recife, Brazil, on 10–13 November 2013. The Third Global Forum is convened by the Global Health Workforce Alliance (GHWA) – a multisectoral partnership established in 2006 to spearhead the response to HRH challenges – in conjunction with WHO, the Pan American Health Organization and the Government of Brazil. The First Global Forum (Uganda, 2008) resulted in the development of a global HRH roadmap;11 at the Second Global Forum (Thailand, 2011), countries and stakeholders reconvened to review progress and renew their commitments towards increased investment, sustained leadership and the adoption of effective HRH policies. The Third Global Forum will provide an opportunity to update the HRH agenda, to make it more relevant to the current global health policy discourse, including the focus on achieving the health MDGs, the objective of UHC and the emerging debate on the post-2015 agenda. Additionally, countries and HRH stakeholders will be invited to explicitly commit to HRH actions as the basis for an inclusive accountability framework. The Third Global Forum’s programme will position health workforce development as a critical requirement for effective UHC and will be designed around one overarching theme – “human resources for health: foundation for universal health coverage and the post-2015 development agenda” – as well as five sub-themes and their corresponding tracks: (i) leadership, partnerships and accountability for HRH development; (ii) impact-driven HRH investments towards UHC; (iii) a supportive HRH legal and regulatory landscape for UHC; (iv) empowerment of health workers by overcoming policy, social and cultural barriers; (v) the harnessing of HRH innovation and research through new management models and technologies.12 To provide a solid evidence base and background to the Third Global Forum’s proceedings, the theme issue will feature commissioned as well as independently submitted articles that will set the scene for and generate innovative thinking on HRH for UHC. GHWA and WHO welcome contributions on the Forum’s general theme, five sub-themes and tracks, especially those emphasizing aspects of HRH directly related to achieving UHC. Submission of relevant country experiences is particularly encouraged. The deadline for submissions is 10 March 2013. Manuscripts should respect the Bulletin’s Guidelines for contributors (available at: http://submit.bwho.org) and mention this call for papers in the cover letter. All submissions will be reviewed by peers.

As Pisani & AbouZahr have identified, there are many obstacles to the publishing of data: social (incentives for researchers to make the effort to publish), financial (having adequate financing to cover short-term publishing and long-term curation costs), and technical (standards and systems).1 This paper looks at some of the technical challenges of publishing data professionally and describes the discoverability and citability benefits that follow. Let’s take it as read that publishing research data is a “good thing,” that researchers are as willing to publish data as they are research papers and funding is in place to make them available online in the long run. Job done? Well, no, not by a long chalk. Just as loading a journal article onto a web site somewhere isn’t the same as publishing it properly, so the same is true for data. To be as discoverable and as citable as research articles, data sets need to be published using an infrastructure that is compatible with research articles. It is not enough that data sets hang like dongles off a research article; they need to be discoverable and citable in their own right – just like a journal article. This means the metadata must be compatible with existing bibliographic management and citation systems like Ref Works® and CrossRef®. Users will expect search engines, abstracting and indexing services and library catalogues to reference data sets, so, for example, librarians will need MARC (MAchine-Readable Cataloging) records. Is this overkill? Well, the Organisation for Economic Co-operation and Development (OECD) doesn’t think so. OECD publishes more than 390 data sets as stand-alone objects, as well as thousands of data sets as supplemental data to its books and journal articles. Sub-sets of the data sets are also posted on the web as stand-alone objects too. So it is no surprise that, in the absence of good discovery metadata and systems, the number one complaint from users is the challenge of finding a relevant data set. They know the data is there, but they can’t find it – even with Google’s help. To solve this problem, OECD’s Publishing Division has spent the past three years grappling with the challenge of how to publish these many thousands of data objects so that users can not only find the data they need, but can then cite and manage the data sets using the same tools that they already use to manage journal articles or book chapters. The first result was a white paper,2 first released in March 2009, which described this challenge and proposed a set of metadata schema for databases in their own right, sub-sets of databases and supplemental data. More significantly, was the launch of OECD iLibrary, OECD’s new publishing platform, in July 2009. OECD iLibrary3 hosts all OECD books, working papers, journals and data sets in a seamless manner. OECD iLibrary puts the white paper’s proposed bibliographic schema for data objects into practice. Search for “health data” and the search results include data sets, book chapters – even individual tables found inside books. OECD’s data sets can now be discovered more easily and they can be cited as simply and as easily as a research article using the downloadable citation provided. Later in 2010, librarians will be supplied with MARC records and the bibliographic records for OECD data sets will be shared with discovery platforms like RePEc (Research Papers in Economics)4 – the world’s largest collection of economics grey literature – enabling visitors to find data objects alongside working papers and journal articles. Imagine being able to discover and cite data sets as easily and as simply as journal articles. Imagine no more.

The 2030 agenda for sustainable development calls on the international community to prioritize the needs and rights of vulnerable populations, so that no one is left behind. (1) The sustainable development goals (SDGs) are supremely ambitious, broad-based in their scope and strongly focused on the root causes of human misery, including the multiple interacting forces that make populations vulnerable to ill-health and premature death. Vulnerability is often associated with poverty, but it is also shaped by political processes and policies, legislation that excludes population groups or criminalizes certain behaviours, and social attitudes that marginalize, stigmatize and discriminate. Vulnerable populations addressed in this issue include remote rural populations and the urban poor, children affected by drought and conflict, people living with the human immunodeficiency virus (HIV) and at risk of tuberculosis, persons with physical disabilities, undocumented migrant workers and gender minorities. The SDG target for universal health coverage requires that the health needs of these and other vulnerable groups be met. As universal health coverage entails social protection against financial hardship caused by health-care costs, it also contributes to the overarching SDG objective of poverty alleviation. Papers in this issue cover a range of practical strategies for reaching vulnerable populations and addressing the multiple social, economic and environmental determinants of health. Research in Ethiopia shows how examining the effects of drought and conflict on the prevalence of wasting in children can guide the design of population-wide interventions. (2) Gavi, the Vaccine Alliance, has developed a tool for monitoring equitable vaccine coverage, using equity benchmarks that reflect the ambitions of the sustainable development agenda. (3) In Thailand, a programme for modifying the homes of people with disabilities proved technically and financially feasible, with support from government subsidies. (4) In Nepal, using peers to contact people living with HIV for tuberculosis screening resulted in a high participation rate and the identification of a considerable number of HIV-positive tuberculosis patients, illustrating one way to break through the barriers of discrimination. (5) Models for extending service coverage stress the importance of education, training and community engagement. Enhanced recruitment, training, supervision, and compensation of community health workers rapidly improved coverage with maternal and child health services in rural areas of Liberia. (6) Brazil has used a package of incentives to recruit physicians to work in remote and deprived areas and to improve the primary health-care infrastructure, leading to better working conditions and better quality of care. (7) Political commitment can be decisive. A paper on the fate of underserved and marginalized populations during donor transition shows how limited political commitment can lead to the persecution of vulnerable groups, pointing to the need to engage key populations in planning, implementing, and monitoring the transition. …

To perform a systematic review of the literature on the prevalence of cognitive impairment and dementia in sub-Saharan Africa.Five electronic databases were searched for relevant abstracts and to identify papers eligible for full-text review. A study was included if two authors agreed that it had a cohort, case-control or cross-sectional design and reported population-level data; was limited to black African adults older than 50 years or described as "elderly" or "old"; reported data for individuals residing in sub-Saharan Africa; and reported at least one measure of cognitive impairment or clinical outcomes relevant to cognitive decline. References of papers included in our study were searched to identify additional candidate publications. Disagreements about inclusion were adjudicated during discussions involving all authors. Data were extracted independently by two authors, using a form developed by the authors and tested on a sample of papers.A total of 2320 unique papers was found; the full text of 87 was reviewed. Nineteen papers featuring 11 cross-sectional studies were included; all were published during 1995-2011. Studies occurred in Benin, Botswana, the Central African Republic, the Congo and Nigeria and enrolled approximately 10,500 participants. The prevalence of dementia ranged from 0%, in Nigeria, to 10.1% (95% confidence interval, CI: 8.6-11.8), also in Nigeria. The prevalence of cognitive impairment ranged from 6.3%, in Nigeria, to 25% (95% CI: 21.2-29.0), in the Central African Republic.Prevalences of dementia and cognitive impairment in sub-Saharan Africa varied widely, with few published studies revealed by the literature search.Réaliser une étude systématique de la littérature consacrée à la prévalence de la déficience cognitive et de la folie en Afrique subsaharienne.Cinq bases de données ont été fouillées afin de trouver des résumés pertinents et d'identifier les journaux éligibles pour une étude en texte intégral. Une étude était inclue si deux auteurs reconnaissaient qu'elle était de type cohorte, cas-témoins ou transversale et relevait des données de l’l'échelle de la population; qu'elle était limitée aux adultes africains noirs âgés de plus de 50 ans ou décrits comme «âgés» ou «vieux»; qu'elle relevait des données concernant des individus résidant en Afrique subsaharienne; et qu'elle relevait au moins une mesure de déficience cognitive ou de résultats cliniques liés au déclin cognitif. Les références de journaux inclus dans notre étude ont été fouillées pour identifier des publications supplémentaires potentielles. Les désaccords quant à une inclusion étaient réglés au cours de discussions impliquant tous les auteurs. Des données étaient extraites indépendamment par deux auteurs, au moyen d'un formulaire développé par les auteurs et testées sur un échantillon de journaux.Au total, 2320 journaux uniques ont été trouvés; le texte intégral de 87 d'entre eux a été analysé. Dix-neuf journaux présentant 11 études transversales ont été inclus; tous avaient été publiés entre 1995 et 2011. Les études avaient eu lieu au Bénin, au Botswana, en République centrafricaine, au Congo et au Nigéria et impliquaient environ 10 500 participants. La prévalence de la démence allait de 0% au Nigéria à 10,1% (intervalle de confiance 95%, IC: 8,6-11,8) également au Nigéria. La prévalence de la déficience cognitive allait de 6,3% au Nigéria à 25% (IC 95%: 21,2-29,0) en République centrafricaine.Les prévalences de démence et de déficience cognitive en Afrique subsaharienne variaient sensiblement et peu d'études publiées ont été révélées par la recherche de littérature.Realizar una revisión sistemática de la literatura sobre la prevalencia del deterioro cognitivo y la demencia en el África subsahariana.Se hicieron búsquedas en cinco bases de datos electrónicas a fin de hallar resúmenes pertinentes e identificar los documentos que cumplieran con los requisitos para una revisión del texto completo. Los estudios se incluyeron cuando dos autores coincidían en que el diseño era de cohorte, de casos y controles o transversal y si presentaban los datos a nivel de población, si se limitaban a los adultos africanos negros mayores de 50 años o descritos como "personas mayores" o "ancianas", si incluían datos correspondientes a las personas que residen en el África subsahariana y si presentaban, al menos, un grado de deterioro cognitivo o resultados clínicos relevantes sobre el deterioro cognitivo. Se realizaron búsquedas de las referencias de los artículos incluidos en nuestro estudio a fin de identificar más publicaciones que cumplieran los requisitos, se arbitraron los desacuerdos sobre la inclusión en las discusiones que involucraban a todos los autores y se recogieron los datos de forma independiente por dos autores mediante un formulario desarrollado por los autores y probado en una muestra de trabajos.Se halló un total de 2320 documentos únicos y se revisó el texto completo de 87 de ellos. Se seleccionaron diecinueve documentos que incluían 11 estudios transversales, todos ellos publicados entre 1995 y 2011. Los estudios tuvieron lugar en Benin, Botswana, la República Centroafricana, el Congo y Nigeria, en los que se registraron aproximadamente 10 500 participantes. La prevalencia de la demencia varió del 0 % en Nigeria, al 10,1 % (intervalo de confianza del 95 %, IC: 8,06-11,08), también en Nigeria. La prevalencia del deterioro cognitivo varió del 6,3 % en Nigeria, al 25 % (IC del 95 %: 21,2 a 29,0) en la República Centroafricana.La prevalencia de la demencia y el deterioro cognitivo en el África subsahariana variaron mucho, y fueron pocos los estudios publicados que se revelaron mediante la búsqueda bibliográfica.إجراء استعراض منهجي للمؤلفات حول انتشار الخلل الإدراكي والخرف في أفريقيا جنوب الصحراء الكبرى.تم البحث في خمس قواعد بيانات إلكترونية عن الملخصات ذات الصلة وللتعرف على الأوراق البحثية التي تصلح لاستعراض نصوصها الكاملة. وكانت الدراسة صالحة للتضمين إذا اتفق اثنان من المؤلفين على أنها ذات تصميم متناسق، أو لحالات مرتبطة بضوابط أو ذات تصميم مقطعي، وأبلغت عن بيانات على مستوى السكان؛ واقتصرت على الأشخاص البالغين الأفارقة السود الأكبر من 50 عاماً أو الذين يوصفون بأنهم "مسنين" أو "كبار السن"؛ وأبلغت عن بيانات للأفراد المقيمين في أفريقيا جنوب الصحراء الكبرى؛ وأبلغت عن مقياس واحد على الأقل للخلل الإدراكي أو النتائج السريرية المتصلة بالتدهور الإدراكي. وتم البحث في مراجع الأوراق البحثية المتضمنة في دراستنا لتحديد المنشورات الإضافية المقترحة. وكان الفصل في الخلافات بشأن التضمين يتم من خلال مناقشات يشترك فيها كل المؤلفين. وتم استخلاص البيانات بشكل مستقل بواسطة اثنين من المؤلفين، باستخدام استمارة وضعها المؤلفون وتم اختبارها على عينة من الأوراق البحثية.تم العثور على إجمالي 2320 ورقة بحثية فريدة؛ وتم استعراض النص الكامل لسبع وثمانين دراسة منها. وتم تضمين تسع عشرة ورقة بحثية تضم 11 دراسة مقطعية؛ وقد نشرت كلها خلال الفترة من 1995 إلى 2011. وأجريت الدراسات في بنين وبتسوانا وجمهورية أفريقيا الوسطى والكونغو ونيجيريا، وأدرجت حوالي 10500 مشارك. وتراوح انتشار الخرف من 0 % في نيجيريا، إلى 10.1 % (فاصل الثقة 95 %، فاصل الثقة: 8.6–11.8)، أيضاً في نيجيريا. وتراوح انتشار الخلل الإدراكي من 6.3 %، في نيجيريا، إلى 25 % (فاصل الثقة 95 %، فاصل الثقة: 21.2–29.0) في جمهورية أفريقيا الوسطى.تباينت معدلات انتشار الخرف والخلل الإدراكي في أفريقيا جنوب الصحراء الكبرى بقدر واسع، مع وجود القليل من الدراسات المنشورة التي كشف عنها البحث في المؤلفات.进行撒哈拉以南非洲认知障碍和痴呆发病率相关文献的系统评价。检索五个电子数据库的相关摘要，并确定出符合全文评价条件的文章。将研究纳入的条件是：有两位作者同意某研究具有队列、病例对照或横断面设计并且报告了群体水平的数据；研究限于年龄在 50 岁以上或被描述为“上年纪”或“年老”的非洲成年黑人；报告居住在撒哈拉以南非洲个体的数据；报告至少一种认知障碍或认知衰退相关临床结果的量度。对于我们研究中所纳入的文章，也对其参考文献进行检索，以确定更多的其他候选发表文章。在涉及所有作者的讨论中对有关是否纳入的分歧进行评判。数据由两位作者独立提取，提取时使用了作者编制并在论文样本上进行过检测的表格。总计找到 2320 篇单独的文章；对 87 篇全文进行评价。纳入了 11 项横断面研究的 19 篇文章；所有文章都发表于 1995–2011 年间。这些研究在贝宁、博茨瓦纳、中非共和国、刚果和尼日利亚开展，招募了约 1.05 万名患者。痴呆的发病率范围在尼日利亚的 0% 到同样是尼日利亚的 10.1%（95% 置信区间，CI：8.6–11.8）之间。认知障碍的发病率范围在尼日利亚的 6.3% 到中非共和国的 25% 之间（95% CI：21.2–29.0）。痴呆和认知障碍的发病率在撒哈拉沙漠以南非洲差异巨大，通过文献检索发现的已发表研究很少。Выполнить систематический обзор публикаций, посвященных распространенности когнитивных нарушений и деменции в странах Африки к югу от Сахары.Поиск выдержек подходящей тематики и публикаций для полнотекстового обзора был выполнен в пяти базах данных. Исследование включалось в обзор в том случае, если, по мнению двух авторов, оно проводилось либо по когортной схеме, либо по перекрестной схеме, либо по схеме «случай–контроль», а его результатами были данные на уровне популяции;касалось исключительно чернокожих африканцев в возрасте старше 50 лет или описывавшихся как «пожилые» или «старые»; содержало сведения о жителях стран Африки к югу от Сахары; в нем упоминалось как минимум об одном параметре когнитивных нарушений или клинических исходах, связанных с ухудшением когнитивной функции. Дополнительный поиск публикаций-кандидатов, заслуживавших включения в обзор, проводился по ссылкам из работ, охваченных нашим исследованием. Урегулирование разногласий относительно возможности включения публикации в обзор осуществлялось посредством обсуждения с привлечением всего авторского коллектива. Извлечение данных осуществлялось двумя авторами независимо друг от друга при помощи авторской формы, апробированной на ряде тестовых публикаций.Всего было обнаружено 2 320 отдельных публикаций; 87 из них были подвергнуты полнотекстовому анализу. В обзор вошли девятнадцать публикаций, вышедших в 1995–2011 гг.; в одиннадцати из них были представлены материалы перекрестных исследований. Исследования проводились в Бенине, Ботсване, Конго, Нигерии и Центральноафриканской Республике и охватили около 10 500 человек. Распространенность деменции варьировалась от 0% в Нигерии до 10,1% (доверительный интервал (ДИ) 95%: от 8,6 до 11,8) также в Нигерии. Распространенность когнитивных нарушений варьировалась от 6,3% в Нигерии до 25% (ДИ 95%: от 21,2 до 29,0) в Центральноафриканской Республике.По данным нескольких опубликованных исследований, обнаруженных в результате поиска литературы, распространенность деменции и когнитивных нарушений в странах Африки к югу от Сахары существенно разнится.

Low fruit and vegetable consumption is an important contributor to the global burden of disease. In the wake of the United Nations High-level Meeting on Non-Communicable Diseases (NCDs), held in September 2011, a rise in the consumption of fruits and vegetables is foreseeable and this increased demand will have to be met through improved supply. The World Health Organization, the Food and Agriculture Organization and the World Bank have highlighted the potential for developing countries to benefit nutritionally and economically from the increased production and export of fruit and vegetables.Aid for Trade, launched in 2005 as an initiative designed to link development aid and trade holistically, offers an opportunity for the health and trade sectors to work jointly to enhance health and development. The Aid for Trade work programme stresses the importance of policy coherence across sectors, yet the commonality of purpose driving the Aid for Trade initiative and NCD prevention efforts has not been explored.In this paper food supply chain analysis was used to show health policy-makers that Aid for Trade can provide a mechanism for increasing the supply of fruits and vegetables in developing countries. Aid for Trade is an existing funding channel with clear accountability and reporting mechanisms, but its priorities are determined with little or no input from the health sector. The paper seeks to enable public health policy-makers, practitioners and advocates to improve coherence between trade and public health policies by highlighting Aid for Trade's potential role in this endeavour.RésuméLa faible consommation de fruits et de légumes contribue de manière significative à la charge mondiale de morbidité. Au lendemain de la Réunion de haut niveau des Nations Unies sur les maladies non transmissibles (MNT), qui s’est tenue en septembre 2011, une hausse de la consommation de fruits et de légumes est à prévoir, et cette demande accrue devra être satisfaite par une offre accrue. L’Organisation mondiale de la Santé, l’Organisation des Nations Unies pour l’alimentation et l’agriculture et la Banque mondiale ont mis en évidence le potentiel existant, pour les pays en voie de développement, à bénéficier sur le plan nutritionnel et économique de l’augmentation de la production et de l’exportation de fruits et de légumes.L’Aide pour le commerce, lancée en 2005 en tant qu’initiative visant à lier de manière holistique l’aide au développement et le commerce, permet aux secteurs de la santé et du commerce de travailler conjointement afin d’améliorer la santé et de renforcer le développement. Le programme de travail de l’Aide pour le commerce met l’accent sur l’importance de la cohérence des politiques intersectorielles, pourtant l’objectif commun motivant l’initiative de l’Aide pour le commerce et les efforts de prévention liés aux MNT n’a pas été étudié.Dans ce document de travail, l’analyse de la chaîne de l’approvisionnement alimentaire été utilisée pour montrer aux décideurs des politiques de santé que l’Aide pour le commerce peut fournir un mécanisme d’augmentation de l’offre en fruits et légumes dans les pays en voie de développement. L’Aide pour le commerce est un canal de financement préexistant, aux responsabilités et aux mécanismes déclaratifs clairs. Toutefois ses priorités sont déterminées avec peu ou pas d’apport de la part du secteur de la santé. Ce document de travail vise à permettre aux décideurs de la santé publique, aux praticiens et aux défenseurs d’améliorer la cohérence entre commerce et politiques de santé publique, en mettant en avant le rôle potentiel de l’Aide pour le commerce dans cette entreprise.ResumenEl consumo bajo de fruta y verdura contribuye de forma importante a la carga de morbilidad en el mundo. A raíz de la reunión de alto nivel de las Naciones Unidas sobre enfermedades no transmisibles, celebrada en septiembre de 2011, se prevé un aumento en el consumo de fruta y verdura, y se deberá hacer frente a esa demanda mayor incrementando el suministro. La Organización Mundial de la Salud, la Organización de las Naciones Unidas para la Agricultura y la Alimentación y el Banco Mundial han destacado la posibilidad que tienen los países en desarrollo de beneficiarse económica y nutricionalmente de este aumento de la producción y exportación de fruta y verdura.Ayuda para el Comercio, que comenzó en el año 2005 como una iniciativa diseñada para unir por completo la ayuda al desarrollo y el comercio, ofrece a los sectores de la salud y del comercio la oportunidad de trabajar juntos para mejorar la salud y el desarrollo. El programa de trabajo de Ayuda para el Comercio enfatiza la importancia de la coherencia de las estrategias en todos los sectores, aunque la mayor parte del objetivo de la iniciativa Ayuda para el Comercio y los esfuerzos de prevención de enfermedades no transmisibles no se han examinado todavía.En este artículo se empleó un análisis de la cadena de suministro de alimentos para mostrar a los legisladores que Ayuda para el Comercio puede proporcionar un instrumento para incrementar el suministro de fruta y verdura en los países en desarrollo. Ayuda para el Comercio es un canal de financiación existente con una responsabilidad clara y mecanismos de presentación de informes, pero sus prioridades están poco o nada condicionadas por aportaciones del sector sanitario. El presente documento pretende permitir a los legisladores de la sanidad pública, médicos y abogados mejorar la coherencia entre las estrategias comerciales y de salud pública destacando el posible papel de Ayuda para el Comercio en este empeño.ملخص يمثل انخفاض استهلاك الفواكه والخضروات عاملاً مهماً في العبء العالمي للمرض. وفي أعقاب اجتماع الأمم المتحدة رفيع المستوى بشأن الأمراض غير السارية الذي عقد في أيلول/ سبتمبر 2011، أصبح من الممكن التنبؤ بارتفاع استهلاك الفواكه والخضروات، وسيتعين تلبية هذا الطلب المتزايد من خلال زيادة الإمدادات. وأكدت منظمة الصحة العالمية ومنظمة الأغذية والزراعة والبنك الدولي على إمكانية استفادة البلدان النامية من الناحية الغذائية والاقتصادية من الزيادة في إنتاج وتصدير الفواكه والخضروات. يتيح تقديم المعونة للتجارة، التي تم إطلاقها في عام 2005 كمبادرة مصممة لربط المعونة الإنمائية بالتجارة على نحوٍ شامل، فرصة لقطاعي الصحة والتجارة للعمل المشترك من أجل تعزيز الصحة والتنمية. ويؤكد برنامج عمل تقديم المعونة للتجارة على أهمية الالتزام بالسياسة عبر القطاعات، ومع ذلك لم يتم استكشاف شيوع الغرض الدافع لمبادرة تقديم المعونة للتجارة وجهود توقي الأمراض غير السارية. في هذه الورقة، تم استخدام تحليل سلسلة توريد الأغذية بهدف الإيضاح لصناع السياسة الصحية أن تقديم المعونة للتجارة يمكن أن يوفر آلية لزيادة إمدادات الفواكه والخضروات في البلدان النامية. ويمثل تقديم المعونة للتجارة قناة تمويل قائمة مع مساءلة وآليات تقارير واضحة، غير أن أولوياتها محددة بقلة الإسهامات الواردة من قطاع الصحة أو عدمها. وتسعى الورقة إلى تمكين صناع السياسة والممارسين والمناصرين في مجال الصحة العمومية من تحسين التناسق بين التجارة وسياسات الصحة العمومية من خلال التأكيد على الدور الممكن لتقديم المعونة للتجارة في هذا المسعى.摘要水果和蔬菜消费量低是全球疾病负担的重要诱因。伴随2011 年9 月召开的非传染性疾病（NCD）联合国高级别会议，水果和蔬菜的消费量有望提高，这种需求的提高将需要通过增加供应来满足。世界卫生组织、粮食及农业组织和世界银行强调了发展中国家增加水果和蔬菜的生产和出口而在营养和经济上产生的潜在利益。启动于2005 年的贸易援助计划旨在整体关联发展援助和贸易，为卫生和贸易部门提供共同努力以增进卫生和发展的机会。贸易援助工作计划强调各部门政策一致性的重要性，然而还未探讨推动贸易援助计划和NCD预防工作的目标共性。本文使用食品供应链分析向卫生决策者说明贸易援助可以为发展中国家提供增加水果和蔬菜供应的机制。贸易援助是现有具有明确责任和报告机制的资金筹措渠道，但在确定其优先级方面没有或很少有来自卫生部门的输入。本文力图通过强调贸易援助在此举措中的潜在作用，让公共卫生决策者、从业人员和支持者来强化贸易和公共卫生政策之间的一致性。РезюмеНизкое потребление фруктов и овощей является важным глобальным фактором щаболеваемости. Согласно выводам совещания Генеральной Ассамблеи ООН высокого уровня по профилактике неинфекционных заболеваний (НИЗ), состоявшегося в сентябре 2011 г. прогнозируется рост потребления фруктов и овощей, и данный растущий спрос должен быть удовлетворен за счет роста предложения. Всемирная организация здравоохранения, Продовольственная и сельскохозяйственная организация и Всемирный банк подчеркнули потенциал для развивающихся стран, как с точки зрения питания, так и экономики, от увеличения производства и экспорта фруктов и овощей.Инициатива «Помощь в интересах торговли» (Aid for Trade), запущенная в 2005 г., призвана целостно связать помощь в развитии и торговлю, обеспечивая возможность сотрудничества этих отраслей в целях укрепления здоровья и развития. Данная инициатива с самого начала подчеркивала важность согласованности политики в различных сферах, однако не была подробно описана общность целей, лежащих в основе программы «Помощь в интересах торговли», и усилий по профилактике НИЗ.В настоящей статье проводится анализ пищевой цепи с целью показать политикам в области здравоохранения, что инициатива «Помощь в интересах торговли» может обеспечить механизм увеличения поставок фруктов и овощей в развивающихся странах. Инициатива «Помощь в интересах торговли» представляет собой существующий канал финансирования с четкими механизмами ответственности и отчетности, но ее приоритеты недостаточно учитывают или почти не учитывают взаимодействие с областью здравоохранения. Целью статьи является разъяснение потенциала программы «Помощь в интересах торговли» с целью повысить согласованность усилий политиков, практиков и сторонников более тесного взаимодействия торговли и общественного здравоохранения.

This paper considers new developments to strengthen sexual and reproductive health and HIV linkages and discusses factors that continue to impede progress. It is based on a previous review undertaken for the United Kingdom Department for International Development in 2006 that examined the constraints and opportunities to scaling up these linkages. We argue that, despite growing evidence that linking sexual and reproductive health and HIV is feasible and beneficial, few countries have achieved significant scale-up of integrated service provision. A lack of common understanding of terminology and clear technical operational guidance, and separate policy, institutional and financing processes continue to represent significant constraints. We draw on experience with tuberculosis and HIV integration to highlight some lessons. The paper concludes that there is little evidence to determine whether funding for health systems is strengthening linkages and we make several recommendations to maximize opportunities represented by recent developments.

The links between rapid population growth and concerns regarding climate change have received little attention. Some commentators have argued that slowing population growth is necessary to reduce further rises in carbon emissions. Others have objected that this would give rise to dehumanizing "population control" programmes in developing countries. Yet the perspective of the developing countries that will be worst affected by climate change has been almost completely ignored by the scientific literature. This deficit is addressed by this paper, which analyses the first 40 National Adaptation Programmes of Action reports submitted by governments of least-developed countries to the Global Environment Facility for funding. Of these documents, 93% identified at least one of three ways in which demographic trends interact with the effects of climate change: (i) faster degradation of the sources of natural resources; (ii) increased demand for scarce resources; and (iii) heightened human vulnerability to extreme weather events. These findings suggest that voluntary access to family planning services should be made more available to poor communities in least-developed countries. We stress the distinction between this approach, which prioritizes the welfare of poor communities affected by climate change, and the argument that population growth should be slowed to limit increases in global carbon emissions. The paper concludes by calling for increased support for rights-based family planning services, including those integrated with HIV/AIDS services, as an important complementary measure to climate change adaptation programmes in developing countries. Une traduction en francais de ce resume figure a la fin de l'article. Al final del articulo se facilita una traduccion al espanol. .ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا

This paper examines the evidence base for the use of pre-employment/pre-placement medical examinations. The use of pre‑employment examinations is often driven more by cultural practices than evidence. There is a lack of evidence on their effectiveness in preventing health-related occupational risks. Hypertension screening is highlighted as a common pre-employment practice for which there is no standardized criteria to use to determine fitness for work. There are inherent problems in screening for psychiatric disorders and substance abuse as well as potential for racial bias and other unintended negative effects. This paper questions the economic case for this practice and also expresses concerns about paternalism related to identified risk factors. Health assessments should only be included when appropriate to the task environment and the general use of pre-employment exams and drug screening should be eliminated. Generally, a health assessment by questionnaire should suffice. Occupational health providers should advise against the application of physical or mental standards that are not relevant to fulfilment of the essential job functions. Consensus development regarding best practice, as well as consideration for acquiring outcome data related to pre-employment practice, is recommended.

Scientific progress is a significant basis for change in public-health policy and practice, but the field also invests in value-laden concepts and responds daily to sociopolitical, cultural and evaluative concerns. The concepts that drive much of public-health practice are shaped by the collective and individual mores that define social systems. This paper seeks to describe the ethics processes in play when public-health mechanisms are established in low- and middle-income countries, by focusing on two cases where ethics played a crucial role in producing positive institutional change in public-health policy. First, we introduce an overview of the relationship between ethics and public health; second, we provide a conceptual framework for the ethical analysis of health system events, noting how this approach might enhance the power of existing frameworks; and third, we demonstrate the interplay of these frameworks through the analysis of a programme to enhance road safety in Malaysia and an initiative to establish a national ethics committee in Pakistan. We conclude that, while ethics are gradually being integrated into public-health policy decisions in many developing health systems, ethical analysis is often implicit and undervalued. This paper highlights the need to analyse public-health decision-making from an ethical perspective.

In January 2006, the Stop TB Partnership launched the Global Plan to Stop TB 2006-2015, which describes the actions and resources needed to reduce tuberculosis (TB) incidence, prevalence and deaths. A fundamental aim of the Global Plan is to expand equitable access to affordable high-quality anti-tuberculous drugs and diagnostics. A principal tool developed by the Stop TB Partnership to achieve this is the Global Drug Facility (GDF). This paper demonstrates the GDFs unique, holistic and pioneering approach to drug procurement and management by analysing its key achievements. One of these has been to provide 9 million patient-treatments to 78 countries in its first 6 years of operation. The GDF recognized that the incentives provided by free or affordable anti-tuberculosis drugs are not sufficient to induce governments to improve their programmes standards and coverage, nor does the provision of free or affordable drugs guarantee that there is broad access to, and use of, drug treatment in cases where procurement systems are weak, regulatory hurdles exist or there are unreliable distribution and storage systems. Thus, the paper also illustrates how the GDF has contributed towards making sustained improvements in the capacity of countries worldwide to properly manage their anti-TB drugs. This paper also assesses some of the limitations, shortcomings and risks associated with the model. The paper concludes by examining the GDFs key plans and strategies for the future, and the challenges associated with implementation.

The targets of tuberculosis (TB) control programmes are to detect 70% of new sputum smear-positive cases of TB and to cure 85% of these. The Stop TB Partnership has set additional targets related to the Millennium Development Goals: to halve TB prevalence and mortality between 1990 and 2015. This paper assesses how confident we can be about the data on TB case detection, cure rates, prevalence and mortality. Countries were grouped into those with good, limited or poor information on the burden of TB (based on notification data, population surveys and vital registration systems). Of 211 countries with a total population of 6.4 billion and an estimated 8.9 million cases of TB, 27 countries with a total population of 2.2 billion and an estimated 1.8 million cases of TB had estimates based on good information (i.e. a good-quality surveillance system detecting > 70% of all cases, or a good-quality TB prevalence survey). Of the 22 countries with a high burden of TB and bearing 80% of the global burden, none had a good surveillance system in 1997. Vital registration systems were good in 81 countries with a total population of 2.7 billion. This paper suggests that globally and in the 22 countries with a high burden of TB there is considerable uncertainty about indicators to measure progress towards the Millennium Development Goals. Routine surveillance and vital registration systems need to be strengthened. We recommend that national TB prevalence surveys be performed in selected high-burden countries, in Africa in particular.

This paper proposes a basic approach to ensuring that knowledge from research studies is translated for use in health services management with a view towards building a "learning organization". (A learning organization is one in which the environment is structured in such a way as to facilitate learning as well as the sharing of knowledge among members or employees.) This paper highlights various dimensions that determine the complexity of knowledge translation, using the problem-solving cycle as the backbone for gaining a better understanding of how different types of knowledge interact in health services management. It is essential to use an integrated and interactive approach to ensure that knowledge from research is translated in a way that allows a learning organization to be built and that knowledge is not used merely to influence a single decision in isolation from the overall services and management of an organization.

To systematically review published studies of interventions to reduce people's intake of dietary trans-fatty acids (TFAs).We searched online databases (CINAHL, the CRD Wider Public Health database, Cochrane Database of Systematic Reviews, Ovid®, MEDLINE®, Science Citation Index and Scopus) for studies evaluating TFA interventions between 1986 and 2017. Absolute decrease in TFA consumption (g/day) was the main outcome measure. We excluded studies reporting only on the TFA content in food products without a link to intake. We included trials, observational studies, meta-analyses and modelling studies. We conducted a narrative synthesis to interpret the data, grouping studies on a continuum ranging from interventions targeting individuals to population-wide, structural changes.After screening 1084 candidate papers, we included 23 papers: 12 empirical and 11 modelling studies. Multiple interventions in Denmark achieved a reduction in TFA consumption from 4.5 g/day in 1976 to 1.5 g/day in 1995 and then virtual elimination after legislation banning TFAs in manufactured food in 2004. Elsewhere, regulations mandating reformulation of food reduced TFA content by about 2.4 g/day. Worksite interventions achieved reductions averaging 1.2 g/day. Food labelling and individual dietary counselling both showed reductions of around 0.8 g/day.Multicomponent interventions including legislation to eliminate TFAs from food products were the most effective strategy. Reformulation of food products and other multicomponent interventions also achieved useful reductions in TFA intake. By contrast, interventions targeted at individuals consistently achieved smaller reductions. Future prevention strategies should consider this effectiveness hierarchy to achieve the largest reductions in TFA consumption.Effectuer une revue systématique des études publiées portant sur des interventions qui visent à réduire la consommation par les individus d'acides gras trans alimentaires.Nous avons recherché dans des bases de données en ligne (CINAHL, The CRD Wider Public Health database, The Cochrane Database of Systematic Reviews, Ovid®, MEDLINE®, Science Citation Index et Scopus) des études évaluant les interventions relatives aux acides gras trans entre 1986 et 2017. Le principal critère d'évaluation était la baisse absolue de la consommation d'acides gras trans (g/jour). Nous avons exclu les études mentionnant uniquement la teneur en acides gras trans dans les produits alimentaires sans établir de lien avec leur consommation. Nous avons inclus des essais, des études observationnelles, des méta-analyses et des études de modélisation. Nous avons réalisé une synthèse descriptive afin d'interpréter les données en regroupant les études selon un continuum allant des interventions ciblant des individus à des changements structurels au niveau de la population.Après avoir examiné 1084 études, nous en avons sélectionné 23: 12 études empiriques et 11 études de modélisation. Au Danemark, de multiples interventions ont permis de faire passer la consommation d'acides gras trans de 4,5 g/jour en 1976 à 1,5 g/jour en 1995, jusqu'à une élimination virtuelle suite à l'adoption d'une loi en 2004 interdisant les acides gras trans dans les produits alimentaires industriels. Dans d'autres pays, des réglementations imposant une reformulation des aliments ont réduit la teneur en acides gras trans d'environ 2,4 g/jour. Des interventions sur les lieux de travail ont induit des baisses de 1,2 g/jour en moyenne. L'étiquetage des produits alimentaires et la fourniture de conseils diététiques individualisés ont quant à eux entraîné des diminutions d'environ 0,8 g/jour.La stratégie la plus efficace consistait en des interventions à plusieurs composantes incluant une loi destinée à éliminer les acides gras trans des produits alimentaires. La reformulation des produits alimentaires et d'autres interventions à plusieurs composantes ont également permis de réduire efficacement la consommation d'acides gras trans. En revanche, les baisses induites par les interventions ciblant des individus étaient systématiquement moins importantes. Cette hiérarchie de l'efficacité doit être prise en compte dans les futures stratégies de prévention afin de réduire au maximum la consommation d'acides gras trans.Revisar de forma sistemática los estudios publicados sobre intervenciones para reducir la ingesta de ácidos grasos trans (TFA, por sus siglas en inglés) en la dieta.En bases de datos en línea (CINAHL, la base de datos de salud pública más amplia del CRD, la base de datos Cochrane sobre revisiones sistemáticas, Ovid®, MEDLINE®, Science Citation Index y Scopus), se buscaron estudios que evaluasen las intervenciones de TFA entre 1986 y 2017. El descenso absoluto del consumo de TFA (g/día) fue la principal medida como resultado. Se excluyeron los estudios que informan solo sobre el contenido de TFA en los productos alimenticios sin relacionarlos con la ingesta. Se incluyeron ensayos, estudios observacionales, metanálisis y estudios de modelación. Se llevó a cabo una síntesis narrativa para interpretar los datos, agrupando los estudios en un continuo que va desde las intervenciones dirigidas a personas hasta los cambios estructurales en toda la población.Después de examinar 1084 documentos candidatos, se incluyeron 23 artículos: 12 estudios empíricos y 11 de modelación. Las múltiples intervenciones en Dinamarca lograron una reducción en el consumo de TFA de 4,5 g/día en 1976 a 1,5 g/día en 1995 y posteriormente la eliminación virtual tras la legislación de 2004 que prohibió los TFA en los alimentos manufacturados. En otros lugares, las regulaciones que obligan a la reformulación de los alimentos redujeron el contenido de TFA en unos 2,4 g/día. Las intervenciones en el lugar de trabajo consiguieron reducciones con un promedio de 1,2 g/día. El etiquetado de los alimentos y el asesoramiento alimenticio individual mostraron reducciones de alrededor de 0,8 g/día.Las intervenciones de componentes múltiples, incluida la legislación para eliminar los TFA de los productos alimenticios, fueron la estrategia más efectiva. La reformulación de los productos alimenticios y otras intervenciones de componentes múltiples también lograron reducciones útiles en la ingesta de TFA. Por el contrario, las intervenciones dirigidas a personas lograron sistemáticamente reducciones más pequeñas. Las futuras estrategias de prevención deberían tener en cuenta esta jerarquía de efectividad para conseguir la mayor reducción posible en el consumo de TFA.إجراء مراجعة منهجية للدراسات التي سبق نشرها بشأن التدخلات الرامية إلى خفض الكمية التي يستهلكها الأفراد من الأحماض الدهنية المتحولة (TFA) في النظام الغذائي.بحثنا في قواعد البيانات المتاحة عبر الإنترنت (CINAHL، وقاعدة بيانات CRD Wider Public Health، وقاعدة بيانات Cochrane للمراجعات المنهجية، و‎Ovid®، وMEDLINE®‎، وScience Citation Index، وScopus) عن الدراسات التي تقيّم التدخلات المتعلقة بالأحماض الدهنية المتحولة في الفترة بين عامي 1986 و2017. وكان المقياس الرئيسي للنتائج يتمثل في الانخفاض الكبير في معدل استهلاك الأحماض الدهنية المتحولة (غم/يوم). واستبعدنا الدراسات التي تسجل فقط احتواء المنتجات الغذائية على الأحماض الدهنية المتحولة دون ربط ذلك بالكمية المستهلكة. وتضمن البحث بعض التجارب، ودراسات رصدية، وتحليلات تلوية، ودراسات تعتمد على النمذجة. كما اتبعنا أسلوبًا تجميعيًا سرديًا لتفسير البيانات، مع تصنيف الدراسات في مجموعات ضمن سلسلة تبدأ من التدخلات التي تستهدف الأفراد وصولاً إلى التغييرات الهيكلية التي تتم على مستوى السكان جميعًا.بعد فرز 1084 دراسة من بين الدراسات البحثية المرشحة، فقد أدرجنا 23 دراسة بحثية، بواقع 12 دراسة تجريبية و11 دراسة تعتمد على النمذجة. وقد نجحت تدخلات متعددة في الدانمرك في خفض معدل استهلاك الأحماض الدهنية المتحولة من 4.5 غم/يوم في عام 1976 ليصل إلى 1.5 غم/يوم في عام 1995، ونجحت أيضًا بعد ذلك في تحقيق ما يُعد شبه منع لاستهلاك تلك الأحماض، وذلك عقب إصدار تشريع في عام 2004 يحظر احتواء المأكولات المُصنعة على الأحماض الدهنية المتحولة. وفيما يتعلق بالبلدان الأخرى، فقد نجحت اللوائح التنظيمية التي ألزمت بوضع أسلوب جديد لإعداد المأكولات في خفض معدل استهلاك الأحماض الدهنية المتحولة بالمأكولات بمقدار 2.4 غم/يوم تقريبًا. ونجحت التدخلات المتعلقة بمواقع العمل في خفض معدل الاستهلاك بمتوسط يبلغ 1.2 غم/يوم. وظهرت حالات انخفاض في معدل الاستهلاك بمقدار 0.8 غم/يوم تقريبًا نتيجة الملصقات الموجودة على المأكولات والاستشارات بشأن النظام الغذائي للأفراد.إن التدخلات متعددة العناصر والتي اشتملت على التشريع الذي حظر احتواء المنتجات الغذائية على الأحماض الدهنية المتحولة كانت أكثر الاستراتيجيات فعالية. ونجح أيضًا الأسلوب الجديد لإعداد المأكولات وكذلك التدخلات الأخرى متعددة العناصر في تحقيق حالات انخفاض في استهلاك الأحماض الدهنية المتحولة. وعلى النقيض من ذلك، دائمًا ما كانت التدخلات التي استهدفت الأفراد تحقق معدلات انخفاض أقل في الاستهلاك. ويجب مراعاة هذا التدرج في مستوى الفعالية عند وضع الاستراتيجيات الوقائية المستقبلية، وذلك لتحقيق أقصى معدلات لخفض استهلاك الأحماض الدهنية المتحولة.旨在系统评价已发表的关于降低人类摄取膳食反式脂肪酸 (TFA) 干预措施的研究。.我们调查了在线数据库（CINAHL、CRD Wider Public Health 数据库、Cochrane Database of Systematic Reviews、Ovid®、MEDLINE®、Science Citation Index 和 Scopus）中评估 1986 至 2017 年间膳食反式脂肪酸 (TFA) 干预措施的研究。反式脂肪酸 (TFA) 消耗量（克/天）的明显降低是主要的结果测量指标。我们排除了仅报告反式脂肪酸 (TFA) 在食品中的含量而与摄取量无关的研究。纳入了试验、观察性研究、元分析和建模研究。我们进行了叙述性汇总以解读数据，并且开展了范围从针对个人的干预到群体范围内的结构变化的连续性小组研究。.在筛选了 1084 篇候选文章之后，我们收录了 23 篇论文：12 份经验性研究和 11 份建模研究。在丹麦的多项干预措施达到了将反式脂肪酸 (TFA) 消耗量从 1976 年的 4.5 克/天降低到 1995 年的 1.5 克/天的效果，2004 年禁止加工食品中含有反式脂肪酸 (TFA) 的禁令颁布后，现已基本消除。在其他地方，强制重新制定食物配方的法规要求使得反式脂肪酸 (TFA) 含量降低约 2.4 克/天。工作场所干预措施达到平均降低 1.2 克/天的效果。食物标签和个人饮食辅导分别降低约 0.8 克/天。.包含立法要求的多元干预措施是最有效的消除食品中反式脂肪酸 (TFA) 的策略。重新制定食品配方以及其他多元干预措施也达到了有效降低反式脂肪酸 (TFA) 摄取量的效果。相比之下，针对个人的干预措施所达到的降低效果普遍偏低。未来的预防策略应当考虑这种效果层次，以达到最有效降低反式脂肪酸 (TFA) 消耗量的目的。.Проведение систематического обзора опубликованных исследований мероприятий, направленных на сокращение потребления с пищей транс-изомеров жирных кислот (ТИЖК).Был проделан поиск по базам данных в Интернете (CINAHL, база данных CRD Wider Public Health, Cochrane Database of Systematic Reviews (Кокрановская база данных систематических обзоров), Ovid®, MEDLINE®, Science Citation Index (Индекс научного цитирования) и Scopus) на предмет исследований, оценивающих мероприятия по сокращению потребления ТИЖК за период с 1986 по 2017 год. Абсолютное снижение потребления ТИЖК (г/сут) было основным критерием результата. Исследования, сообщающие только о содержании ТИЖК в продуктах питания без указания количества потребления, были исключены. В обзор также включались испытания, обсервационные исследования, метаанализы и исследования с применением моделирования. Исследователи провели нарративный синтез, чтобы интерпретировать данные, группируя исследования по континууму, начиная с мероприятий, направленных на отдельных лиц, и заканчивая структурными изменениями, затрагивающими все слои населения.После отбора из 1084 статей-кандидатов в обзор были включены 23 статьи: 12 эмпирических и 11 модельных исследований. Многочисленные мероприятия в Дании привели к сокращению потребления ТИЖК с 4,5 г/сут в 1976 году до 1,5 г/сут в 1995 году, а затем к фактическому устранению ТИЖК из рациона в 2004 году после принятия законодательства, запрещающего присутствие ТИЖК в готовых продуктах питания. В других местах правила, предусматривающие изменение состава продуктов питания, способствуют снижению потребления TИЖК примерно на 2,4 г/сут. Мероприятия на рабочих местах привели к сокращению потребления ТИЖК в среднем на 1,2 г/сут. Маркировка продуктов питания и индивидуальное консультирование диетологов привели к снижению потребления примерно на 0,8 г/сут.Наиболее эффективная стратегия — многокомпонентные мероприятия, в том числе введение в силу законов, запрещающих присутствие ТИЖК в продуктах питания. Изменение рецептуры продуктов питания и другие многокомпонентные мероприятия также привели к заметному сокращению потребления ТИЖК. Напротив, мероприятия, последовательно направленные на отдельных лиц, приводили к меньшему сокращению потребления. Стратегии будущей профилактики должны учитывать эту иерархию эффективности для достижения максимального сокращения потребления ТИЖК.

The United Nations sustainable development goal (SDG) 3 seeks "to ensure healthy lives and promote well-being for all and at all ages". (1) To build healthcare systems that were able to progress towards the millennium development goals, many countries had to extend delivery systems to increase coverage. They also greatly improved measurement of people's contacts with the health system. However, with the reduction in disease burden due to specific infectious diseases and childhood illnesses, people tend to live longer, have multiple noncommunicable diseases and require more complex services. The focus on measuring access is not sufficient to capture whether people receive effective care; hence this month's papers on measurement of quality of care in low- and middle-income countries. In papers published online and in this issue, Akachi et al. explain why the quality of health-care services in low-and middle-income countries has been largely overlooked as an important contributor to health outcomes. (2) Sharma et al. observe the management of childbirth at public and private hospitals in Uttar Pradesh, India and conclude that care provided to women and their newborns is of poor quality. (3) Brenner et al. study the effects of a results-based financing scheme in Malawi and find improved equipment and supplies at health facilities but minimal effects on clinical performance. (4) In Ethiopia, Canavan et al. measure the quality of intrapartum care in hospitals using data from medical chart reviews and direct observations. (5) Knowlton et al. do a multinational survey of 120 hospitals and find that many lack the basic infrastructure needed to provide essential surgical care on a consistent basis. (6) Lazzerini et al. find that in Kyrgyzstan--a setting with high rates of hospitalization, over-diagnosis and over-treatment--brief training and supportive supervision by paediatricians improve quality of paediatric care in hospitals. (7) Examining variation in quality is one way to diagnose drivers of good or poor performance. Kruk et al. find that the quality of antenatal and paediatric care in seven African countries varies greatly and that this variation may result from the different approaches governments take in training providers and funding and organizing their health systems. (8) Other articles in this issue present innovations in measures and instruments to assess quality of health-care services. Bedoya et al. document compliance with infection prevention and control measures during outpatient visits in Kenya. (9) Wang et al. show how medical malpractice litigation records can be used as a source of data to assess patients' experience and their health outcomes in China. (10) Madaj et al. assess the validity of the World Health Organization's indicators for quality of care around the time of birth. (11) Despite the wide range of research presented in this issue, several aspects of health-care quality are not addressed. …

January 2016 marked the beginning of a new era for health and development. It was the start of Transforming our world: the 2030 agenda for sustainable development and its accompanying sustainable development goals (SDGs).1 All governments have committed to this ambitious sustainable agenda and its goals. The Global strategy for women’s, children’s and adolescents’ health (2016–2030)2 and its operational framework are aligned with the SDGs and provide an evidence-based roadmap for ending preventable deaths of women, children and adolescents by 2030. The global strategy can guide collective action so that every woman, child and adolescent – even those living in the most challenging settings – can achieve their full potential and rights to health and well-being. Governments are aligning their work with the SDGs and the global strategy’s three objectives – survive, thrive and transform – in ways that meet their countries’ priorities and unique contexts. The survival, health and well-being of women, children and adolescents are essential to achieving the SDGs. Analysis of lessons from the millennium development goal (MDG) implementation process – what has worked and what hasn’t – is needed to effectively implement the agenda set by the SDGs and the global strategy. Achieving the global strategy and the SDGs will require the use of the best available knowledge for action, as well as investment in new research and innovation. This month’s Bulletin theme issue seeks to broaden the evidence on effective country implementation and lessons learnt from the MDGs. Kuruvilla et al.3 summarize the current global strategy, show how the objectives of the strategy are aligned with the SDGs and how selected countries are already making progress. Several papers in this issue deal with progress on the survival objective of the global strategy; Negandhi et al.4 present a surveillance-based maternal and infant death review system in India; Murguia-Peniche et al.5 and McKinnon et al.6 address under-researched topics, such as the factors associated with stillbirths in Mexico and the high prevalence of suicidal behaviours among adolescents in low- and middle-income countries, respectively. The strategy’s thrive objective addresses the overall health and well-being of mothers, children and adolescents. Chai et al.7 determine how exposure to violence hinders child development and can affect health across the life-course and subsequent generations. Askew et al.8 describe the importance of ensuring sexual and reproductive health and rights in humanitarian settings. The transform objective of the strategy focuses on expanding enabling environments and aims to transform societies so that women, children and adolescents everywhere can realize their rights to the highest attainable standards of health and well-being. Several papers address the global strategy’s transform objective. Newberry et al.9 present a formal emergency response infrastructure developed in India for gender-based violence. This special issue also includes papers on approaches that have helped countries achieve improved health outcomes for women, children and adolescents. Marston et al.10 discuss the importance of community engagement in achieving results. Ahmed et al.11 describe policies and programmes that contributed to reductions in child and maternal mortality. Frost et al.12 explain how multistakeholder dialogues are used to clarify what works and does not work in policy-making and implementation. To drive the global strategy forward, governments, civil society, the private sector and other partners have mobilized under the banner of Every Woman Every Child and a group of political champions has been formed. A global financing facility has been established as a country-led partnership that combines domestic, external, and innovative financing for health and development. An independent accountability panel has been appointed by the United Nations Secretary-General to report on results, resources and rights for women’s children’s and adolescents’ health. This month, the World Health Assembly will consider a resolution on implementing the global strategy, giving delegations an opportunity to discuss its content and shape their own commitments. In addition, this theme issue illustrates the importance of continued investments in research and learning to support country implementation. The generation and sharing of knowledge for action is essential to achieve the global strategy’s objectives, to secure a healthy and transformative future for women, children and adolescents, their families and communities in the SDG era.

Data are the basis for public health action, and rapid data sharing is critical during an unfolding health emergency.1,2 The information disseminated through peer-reviewed journals and accompanying online data sets is vital for decision-makers.1 The deficiencies with existing data-sharing mechanisms, which were highlighted during the 2013–16 Ebola epidemic in west Africa, have brought the question of data access to the forefront of the global health agenda.2 In September 2015, agreement was reached on the need for open sharing of data and results, especially in public health emergencies.3 Subsequently, following published expressions of support by its members, the International Committee of Medical Journal Editors (ICMJE) have explicitly confirmed that pre-publication dissemination of information critical to public health will not prejudice journal publication in the context of a public health emergency declared by WHO.4 While efforts so far have focused on results from clinical trials, and on making full accompanying data sets available at the time of publication, there are further opportunities to expand access to information from observational studies, operational research, routine surveillance and the monitoring of disease control programmes. To improve timely access to data in the context of a public health emergency, the Bulletin of the World Health Organization will implement a new data sharing and reporting protocol. The protocol is established specifically to address the data gap that exists in responding to the current Zika virus epidemic, and will apply in the first instance only to articles submitted in the context of this outbreak. On submission to the Bulletin, all research manuscripts relevant to the Zika epidemic will be assigned a digital object identifier and posted online in the “Zika Open” collection within 24 hours while undergoing peer review. The data in these papers will thus be attributed to the authors while being freely available for reader scrutiny and unrestricted use, distribution and reproduction in any medium, provided that the original work is properly cited as indicated by the Creative Commons Attribution 3.0 Intergovernmental Organizations license (CC BY IGO 3.0)5. Should a paper be accepted by the Bulletin following peer review, this open access review period will be reported in the final publication. In the event that a paper does not survive peer review, and given the rapidly evolving knowledge basis on this disease, authors will be free to seek publication elsewhere. If the authors of any paper posted with the Bulletin in this context are unable to obtain acceptance with a suitable journal, WHO undertakes to publish these papers in its institutional repository as citable working papers, independently of the Bulletin. This early access to research manuscripts at WHO builds on examples of other rapid information access platforms such as PROMED and F1000Research.6,7 Given the number and complexity of unanswered questions on the mechanisms and consequences of Zika infection and associated disease, our goal is to encourage all researchers to share their data as quickly and widely as possible. With this protocol for immediate online posting, we are providing another means to achieve immediate global access to relevant data. Researchers can thus share their data while meeting their need to retain authorship, achieve precedence, and to put their research on public record. We are pleased to announce that the first paper to which this protocol applies is now available online.8

OBJECTIVE: To summarize the experience, performance and scientific output of long-running telemedicine networks delivering humanitarian services. METHODS: Nine long-running networks - those operating for five years or more- were identified and seven provided detailed information about their activities, including performance and scientific output. Information was extracted from peer-reviewed papers describing the networks' study design, effectiveness, quality, economics, provision of access to care and sustainability. The strength of the evidence was scored as none, poor, average or good. FINDINGS: The seven networks had been operating for a median of 11 years (range: 5-15). All networks provided clinical tele-consultations for humanitarian purposes using store-and-forward methods and five were also involved in some form of education. The smallest network had 15 experts and the largest had more than 500. The clinical caseload was 50 to 500 cases a year. A total of 59 papers had been published by the networks, and 44 were listed in Medline. Based on study design, the strength of the evidence was generally poor by conventional standards (e.g. 29 papers described non-controlled clinical series). Over half of the papers provided evidence of sustainability and improved access to care. Uncertain funding was a common risk factor. CONCLUSION: Improved collaboration between networks could help attenuate the lack of resources reported by some networks and improve sustainability. Although the evidence base is weak, the networks appear to offer sustainable and clinically useful services. These findings may interest decision-makers in developing countries considering starting, supporting or joining similar telemedicine networks.

OBJECTIVE: To synthesize findings from recent studies of strategies to deliver insecticide-treated nets (ITNs) at scale in malaria-endemic areas. METHODS: Databases were searched for studies published between January 2000 and December 2010 in which: subjects resided in areas with endemicity for Plasmodium falciparum and Plasmodium vivax malaria; ITN delivery at scale was evaluated; ITN ownership among households, receipt by pregnant women and/or use among children aged < 5 years was evaluated; and the study design was an individual or cluster-randomized controlled design, nonrandomized, quasi-experimental, before-and-after, interrupted time series or cross-sectional without temporal or geographical controls. Papers describing qualitative studies, case studies, process evaluations and cost-effectiveness studies linked to an eligible paper were also included. Study quality was assessed using the Cochrane risk of bias checklist and GRADE criteria. Important influences on scaling up were identified and assessed across delivery strategies. FINDINGS: A total of 32 papers describing 20 African studies were reviewed. Many delivery strategies involved health sectors and retail outlets (partial subsidy), antenatal care clinics (full subsidy) and campaigns (full subsidy). Strategies achieving high ownership among households and use among children < 5 delivered ITNs free through campaigns. Costs were largely comparable across strategies; ITNs were the main cost. Cost-effectiveness estimates were most sensitive to the assumed net lifespan and leakage. Common barriers to delivery included cost, stock-outs and poor logistics. Common facilitators were staff training and supervision, cooperation across departments or ministries and stakeholder involvement. CONCLUSION: There is a broad taxonomy of strategies for delivering ITNs at scale.

Markets for life-saving vaccines do not often generate the most desired outcomes from a public health perspective in terms of product quantity, quality, affordability, programmatic suitability and/or sustainability for use in the lowest income countries. The perceived risks and uncertainties about sustainably funded demand from developing countries often leads to underinvestment in development and manufacturing of appropriate products. The pilot initiative Advance Market Commitment (AMC) for pneumococcal vaccines, launched in 2009, aims to remove some of these market risks by providing a legally binding forward commitment to purchase vaccines according to predetermined terms. To date, 14 countries have already introduced pneumococcal vaccines through the AMC with a further 39 countries expected to introduce before the end of 2013. This paper describes early lessons learnt on the selection of a target disease and the core design choices for the pilot AMC. It highlights the challenges faced with tailoring the AMC design to the specific supply situation of pneumococcal vaccines. It points to the difficulty – and the AMC’s apparent early success – in establishing a long-term, credible commitment in a constantly changing unpredictable environment. It highlights one of the inherent challenges of the AMC: its dependence on continuous donor funding to ensure long-term purchases of products. The paper examines alternative design choices and aims to provide a starting point to inform discussions and encourage debate about the potential application of the AMC concept to other fields.

This paper considers how operational research and management science can improve the design of health systems and the delivery of health care, particularly in low-resource settings. It identifies some gaps in the way operational research is typically used in global health and proposes steps to bridge them. It then outlines some analytical tools of operational research and management science and illustrates how their use can inform some typical design and delivery challenges in global health. The paper concludes by considering factors that will increase and improve the contribution of operational research and management science to global health.

We have some comments and queries related to the paper “Access to health care and mortality of children under 5 years of age in the Gambia: a case control study” published in the Bulletin of the World Health Organization.1 We appreciate the earnest attempts of the authors in measuring the effects of non-traditional variables in addition to traditional variables. However, the instrument to measure the social support variables shows vast overlapping, with such options as “someone who understood your problem”, “showed kindness and caring” and “someone to relax”. These are shown as individual variables and are heavy in both informer and observer bias. It would have been more appropriate to combine them into a complex variable. Further, “had someone to prepare meals if you were unable to” overlaps with “some showed kindness and caring”. Whereas standard textbooks in epidemiology suggest a maximum ratio of 1:4 between cases and controls,2 the authors have not justified choosing 1:5 for their controls. Choosing controls from the same village would have strengthened the result in terms of general availability and accessibility to transport, thus minimizing the bias. Further matching for socioeconomic status (though a tough proposition) could have strengthened the results. Since 10 controls were randomly chosen for each case before deciding the first random 5 for controls, matching for socioeconomic status could have been a distinct possibility. Similarly the village of residence could also have been matched. Describing the method of deciding the centre of a village would have been useful as well. The study period stretches over 28 months (31 December 2003 to 30 April 2006). The extra cases and controls included for the last 4 months of data collection would modify additional recruitment in that season, the variation of which might have influenced the results. Under causes of deaths, “fever of unknown origin” accounts for 23.3%. We feel that such a high percentage does not realistically reflect the situation. The “non-specific cause” of 24.8% makes the picture even more vague as the close identification of these causes could have given further clues on the variables measured. In total, almost half the cases are in these two categories, which is a huge deficit of information. Table 1 in the paper says 52.9% of deaths were at home and 89.3% visited health centre or hospital. The proportion of deaths within or outside the variable of “visiting the health centre or hospital” needs further discussion. Finally, though the authors are right that further studies are required, some specific recommendations (in conclusion) from the present study should have been made, for example, organizing community creches to look after children when the primary caregiver is away. It is curious that a major conclusion is drawn from a reference3 rather than from the present study. ■

Injuries and violence are a significant and growing cause of child death and disability, as well as having other health consequences including mental health, behavioural and reproductive health problems. Every year injuries and violence kill approximately 875 000 children (aged less than 18 years of age) and injure or disable tens of millions more. Injury-related causes account for 3 of the top 15 killers of children aged 0–4 years and for 6 of the top 15 killers of children aged 5–14 years. Child maltreatment has been associated with significantly increased risk of alcoholism, drug abuse, depression, suicide attempt, smoking and sexually transmitted disease. The burden from child injury is most felt in low- and middle-income countries, where 95% of all child-injury deaths occur, and where recorded rates of child maltreatment are substantially higher than in high-income countries. This huge public health problem is all that much more tragic because it is avoidable. Through combinations of prevention and care, most high-income countries have considerably reduced rates of child-injury death and child maltreatment. Consequently, there are huge inequities globally, with annual child-injury mortality of 8.6/100 000 in high-income countries compared with 41.8/100 000 in low- and middle-income countries.1 In other words, rates of child-injury death are more than four times higher in low- and middle-income countries. A large burden of death and morbidity could be avoided by bringing violence and injury rates in low- and middle-income countries down to levels similar to those in high-income countries. Such public health benefits could be achieved by use of proven prevention methods, such as implementing and enforcing safety legislation and standards; promoting home and transport safety; modifying products or the environment; and improving care and rehabilitation of injured children. Programmes to promote safe, sustainable and nurturing relationships between children and their parents or caregivers can substantially reduce child maltreatment, and youth violence prevention programmes can significantly reduce violence-related death and injury in adolescents. These strategies, most of which are affordable and sustainable in all countries, need to be better applied globally. Child injury and violence need to be better incorporated into broader child survival strategies. Child injury and violence have been only minimally addressed thus far by the global health community and by most governments. Likewise, these topics have been inadequately addressed in the scientific literature. An upcoming theme issue of the Bulletin (May 2009) on child injury and violence will seek to address these shortcomings, to promote greater attention to these significant public health problems, to promote greater uptake of known effective prevention and treatment interventions globally, and to stimulate more research on low-cost and sustainable ways to confront these problems especially in low- and middle-income countries where most children live. The Bulletin theme issue will examine the spectrum of child injury and violence prevention and control including epidemiology, prevention, care and rehabilitation. It will contain papers in the categories of Perspectives, Policy and practice, Research, and Lessons from the field. Several papers will be commissioned. In addition, submissions from interested authors are highly encouraged. We welcome papers for all sections of the Bulletin that focus on any of the following topics: surveillance and data collection; evaluation of methods to prevent unintentional injury and violence; health systems strengthening or financing for child injury and violence prevention interventions; or methods for strengthening emergency care and/or rehabilitation of injured and maltreated children. We would especially encourage papers that go beyond the health perspective to address the cross-sectoral nature of the problem. For example, papers on transport safety could encompass the multi-sectoral nature of road traffic injury, including human behaviour, roadway infrastructure and vehicle design, and broader issues of urban design. Papers on violence could include coverage of the multi-dimensional determinants of violence, including parenting, childhood exposures and subsequent health and social consequences, and societal-level factors such as socio-economic disparities. Likewise, papers examining responses to violence could discuss actions involving the educational, welfare and criminal justice sectors, as well as the health sector. Papers discussing how child injury and violence issues can be better addressed in the broader child survival and global health agendas are encouraged. These could include discussions of the relationship of child injury and violence and Millennium Development Goals such as Goal 4 (reducing child mortality). Papers from authors in developing countries are especially encouraged. It is hoped that the papers in this issue will contribute important information that will assist public health practitioners, clinicians, researchers and policy-makers to better confront the eminently preventable problem of child injury and violence. The deadline for submissions is 1 September 2008. Manuscripts should be submitted to: http://submit.bwho.org respecting the Guidelines for Contributors and accompanied by a cover letter mentioning this call for papers. All submissions will go through the Bulletin’s peer review process. ■

The United Kingdom of Great Britain and Northern Ireland has extensive experience in allocating health service funds to regions and localities using funding formulae. This paper focuses on England. Special attention is given to recent policy concerns to reduce avoidable health inequalities by broadening the remit of the resource allocation formulae. The paper also examines the issues that arise when seeking to allocate funds to very small organizational units, such as general practices. The English example is relevant to less-developed health systems, especially for those governments seeking to decentralize, to improve accountability and to promote equity.

Introduction It is to be hoped that past mistakes are not going to overshadow the effectiveness of global health partnerships (GHPs), as they provide valuable lessons that should be taken into account. The Bulletin publishes a fascinating series of public health classics, consisting of a commentary doing a reality check on what has happened since publication of major public health landmarks. In 2005, Anne Mills commented on a landmark paper on mass campaigns and general health services of 1965. (1) One could get a bit depressed reading her article, because the bottom line is that not much has changed in the past 40 years, which have confronted believers in vertical and horizontal approaches. The terminology has changed, though. Some 20 years ago the topic shifted from vertical versus horizontal programmes to the dispute over the advantages of comprehensive versus selective primary health care. In the 1990s, this discussion cooled down and a combination of the two approaches was translated into health sector reform efforts, with widespread consensus to integrate health actions at district level. This development has been supported by changes in aid modalities such as the sector-wide approach (SWAp) funding mechanism, This evolution has come under threat, however, with the appearance of global health initiatives at the beginning of this millennium, (2) which have brought back this "old" controversy opposing today's approaches: those that have a more systemic focus or those with a more selective, often disease, orientation. With more than 70 GHPs in existence today, the former selective/ vertical party is seemingly gaining the upper hand again. The difference from before, however, is that aid effectiveness is now receiving more attention. It is noteworthy that in 2005, for the first time, a large group of donor and recipient countries, international organizations and also civil society organizations agreed in the Paris Declaration on Aid Effectiveness to set targets for aid effectiveness and to define a set of indicators to measure progress towards these targets (3) The main argument of this paper is that we should avoid the conflicts of the past. We must strive to achieve a balance between the selective approach of many GHPs and the strengthening of health systems, as they are interdependent. Effectiveness of global health partnerships Although the evidence is still scarce, there are some indications that individual GHPs have had a positive impact in some settings. (4) In many countries, they have helped--albeit in specific areas--to strengthen planning expertise. The focus of major GHPs on performancebased funding has "forced" countries to improve administrative transparency and strengthen their monitoring capacities. It is also worthy of mention that, through their efforts, awareness of specific health problems has been raised at national and international levels. Last but not least, GHPs have clearly brought to light important health problems, and some headway has been made in fighting AIDS, poliomyelitis and other communicable, otherwise neglected, diseases. Major challenges and questions remain, however. Even though there are good arguments for almost all GHPs, their large number raises the question whether the priorities thus determined for a given country really do respond to the national problem areas. The magnitude of the resources can put a considerable strain on the capacities of countries to absorb the influx of financial resources, particularly with the major bottleneck in many countries caused by the lack of local professional expertise in both quantity and quality. There is also the potential risk of an impact on the economic stability of a country. Another important concern about GHPs is sustainability. In poor countries, health systems are seriously under-funded; even if improvements can be achieved with targeted external support, they cannot easily be sustained after the period for which donor agencies are usually ready to commit funding. …

The past decade has seen a significant increase in the amount of funds available for international health activities. This is due largely to the generosity of private foundations, particularly the Bill & Melinda Gates Foundation, and some bilateral donors. Although this increase in support has already made a significant impact on the health of peoples in developing countries, the allocation of funds for disease-specific activities has become unbalanced, with some areas receiving generous support and others almost none. The most dramatic example of this is shown by the resources made available to fight AIDS, tuberculosis and malaria – the so-called “big three” – and those devoted to the two main killers of children, pneumonia and diarrhoeal disease. Pneumonia, the world’s most important cause of child death,1 has attracted remarkably little attention over the past decade. There has been very little research on the disease, apart from trials of pneumococcal and Haemophilus influenzae type b (Hib) vaccines, which included evaluations of the impact on these vaccines on pneumonia,2–5 and some studies on the case management of pneumonia.6–9 Country-level efforts to prevent pneumonia mortality have been limited to case management, particularly the Integrated Management of Childhood Illness (IMCI) strategy, which incorporates standardized case management of suspected pneumonia cases.10 A recent analysis of donor spending on maternal and child health in developing countries showed that barely 1% was allocated to IMCI.11 In contrast, new pneumococcal conjugate vaccines, whose life-saving potential is probably similar to that of IMCI, have attracted a great deal of attention, with large sums of money being allocated to support early use of these vaccines by the GAVI Alliance and through innovative funding mechanisms such as the Advanced Market Commitment (AMC) and the International Finance Facility for Immunization (IFFIm). In 2006, there was a substantial increase in international awareness about pneumonia, helped by the publication of a report by the United Nations Children’s Fund (UNICEF) and WHO.12 There are promising signs that this awareness will lead to increased funding for both control programmes and research activities. When new funds become available in a particular field, it is not uncommon to see special interest groups competing for them, claiming that their strategy or product is superior to others and should therefore receive most of the new resources. However, there are encouraging signs that this will not happen with childhood pneumonia. In March 2007, WHO and UNICEF convened a meeting in Geneva to establish a Global Action Plan for Pneumonia (GAPP). The meeting was attended by experts in the four areas that offer the best prospects for pneumonia control – case management (IMCI), vaccination (Hib and pneumococcal), environmental health (reduced indoor air pollution) and nutrition. The group unanimously concluded that attention to all of these areas will be needed to control the global problem of childhood pneumonia, and urged that the global response to pneumonia mortality be balanced and equitable. As an initial step, group members will prepare a series of review papers summarizing the evidence that specific interventions will lead to reductions in pneumonia incidence and/or pneumonia mortality. These papers will be accompanied by analyses of the comparative or additive impact of these interventions in different settings and an analysis of their potential to reduce inequity in child health and mortality. In Spring 2008, the Bulletin will publish shortened versions of some of these papers in a theme issue on childhood pneumonia prevention and control. To complement these commissioned papers, the Bulletin welcomes submissions of papers on childhood pneumonia for this theme issue. We are particularly interested in Research, Lessons from the field or Perspectives dealing with epidemiology of pneumonia, improved methods for the diagnosis of pneumonia, etiology of pneumonia, the impact on pneumonia mortality of case management, vaccines, and environmental and nutritional interventions. Manuscripts should be submitted to http://submit.bwho.org by 1 October 2007, respecting the Guidelines for Contributors and accompanied by a cover letter mentioning this call for papers. ■

A simplified grading system for trachoma was published by the World Health Organization (WHO) in 1987. Intended for use by non-specialist personnel working at community level, the system includes five signs, each of which can be present or absent in any eye: (i) trachomatous trichiasis; (ii) corneal opacity; (iii) trachomatous inflammation-follicular; (iv) trachomatous inflammation-intense; and (v) trachomatous scarring. Though neither perfectly sensitive nor perfectly specific for trachoma, these signs have been essential tools for identifying populations that need interventions to eliminate trachoma as a public health problem. In 2018, at WHO's 4th global scientific meeting on trachoma, the definition of one of the signs, trachomatous trichiasis, was amended to exclude trichiasis that affects only the lower eyelid. This paper presents the amended system, updates its presentation, offers notes on its use and identifies areas of ongoing debate.En 1987, l'Organisation mondiale de la Santé a publié un système de codage simplifié du trachome. Destiné au personnel non qualifié travaillant au sein des communautés, il comporte cinq signes, chacun pouvant être présent ou absent dans l'un ou l'autre œil: (i) le trichiasis trachomateux; (ii) l'opacité cornéenne; (iii) l'inflammation trachomateuse — folliculaire; (iv) l'inflammation trachomateuse — intense; et enfin, (v) la cicatrice trachomateuse. Bien qu'ils ne soient ni parfaitement précis, ni totalement spécifiques au trachome, ces signes constituent des outils essentiels pour identifier les populations qui nécessitent une intervention afin d'éliminer le trachome en tant que problème de santé publique. En 2018, lors de la quatrième réunion scientifique mondiale sur le trachome, la définition de l'un des signes, le trichiasis trachomateux, a été modifiée pour exclure du système de codage le trichiasis qui n'affecte que la paupière inférieure. Ce document expose le nouveau système, actualise sa présentation, formule des remarques sur son utilisation et identifie les domaines qui font encore l'objet de débats.En 1987, la Organización Mundial de la Salud (OMS) publicó un sistema de clasificación simplificado para el tracoma. Este sistema fue diseñado para que lo utilice el personal no especializado que trabaja a nivel comunitario e incluye cinco signos, cada uno de los cuales puede estar presente o ausente en los ojos: i) la triquiasis tracomatosa; ii) la opacidad corneal; iii) la inflamación tracomatosa-folicular; iv) la inflamación tracomatosa-intensa; y v) la cicatrización tracomatosa. Si bien no son perfectamente sensibles ni muy específicos del tracoma, estos signos han sido herramientas esenciales para identificar a las poblaciones que requieren intervenciones para eliminar el tracoma como problema de salud pública. En 2018, se modificó la definición de uno de los signos, la triquiasis tracomatosa, en la 4.ª Reunión Científica Mundial sobre el Tracoma de la OMS, para descartar la triquiasis que solo afecta al párpado inferior. En el presente documento se describe el sistema modificado, se actualiza su presentación, se ofrecen observaciones sobre su aplicación y se identifican los ámbitos de debate en curso.تم نشر نظام تصنيف مبسط للتراكوما من جانب منظمة الصحة العالمية (WHO) في عام 1987. وهو مخصص للاستخدام بواسطة الأشخاص غير المتخصصين الذين يعملون على مستوى المجتمع، ويشمل النظام خمس علامات يمكن أن يكون كل منها موجودًا أو غير موجود في أي عين: (1) داء الشعرة التراكومي؛ و(2) عتامة القرنية؛ و(3) الالتهاب الجريبي التراكومي؛ و(4) الالتهاب التراكومي الشديد؛ و(5) التندب التراكومي. وبالرغم من أن هذه العلامات لم تكن حساسة للغاية أو محددة للإصابة بالتراكوما، إلا أنها كانت مؤشرات أساسية لتحديد السكان الذين يحتاجون إلى تدخلات طبية للقضاء على التراكوما كمشكلة صحية عامة. في عام 2018، في الاجتماع العلمي العالمي الرابع لمنظمة الصحة العالمية حول التراكوما، تم تعديل تعريف إحدى العلامات، وهو داء الشعرة التراكومي، وذلك لاستبعاد داء الشعرة الذي يصيب الجفن السفلي فقط. تعرض هذه الورقة النظام المعدل، وتقوم بتحديث عرضه التقديمي، وتقدم ملاحظات حول استخدامه، وتحدد مجالات النقاش الدائر.1987 年,世界卫生组织 (WHO) 公布了沙眼简化分级系统。该系统旨在供社区非专业工作人员使用，具备五种体征，其中每个体征都可出现于任一眼睛中，也可能不出现：(I) 沙眼性倒睫；(ii) 角膜混浊； (iii) 沙眼性炎症-滤泡； (iv) 沙眼性剧烈-炎症；以及 (v) 沙眼性疤痕。尽管对沙眼而言，这些体征即非特别敏感，也非专属于沙眼，但其已是确定哪些民众需通过干预消除沙眼这个公共卫生问题的关键。2018 年世卫组织第四届全球沙眼科学会议对沙眼性倒睫的定义进行了修正，排除了仅影响下眼睑的倒睫。本文介绍了修正后的系统，并更新了其介绍，给出了使用说明，并确定了正在讨论中的领域。.В 1987 году Всемирная организация здравоохранения (ВОЗ) опубликовала упрощенную систему оценки трахомы. Предназначенная для использования неспециализированным персоналом, работающим на местном уровне, система включает пять признаков, каждый из которых может присутствовать или отсутствовать в любом глазу: (i) трахоматозный трихиаз; (ii) помутнение роговицы; (iii) трахоматозное воспаление фолликулярное; (iv) трахоматозное воспаление интенсивное; (v) трахоматозное рубцевание. Хотя эти признаки не являются ни абсолютно чувствительными, ни абсолютно специфичными для трахомы, они были важными инструментами для выявления групп населения, которым необходимы вмешательства для устранения трахомы как проблемы общественного здравоохранения. В 2018 году на 4-й Всемирной научной конференции ВОЗ по вопросам трахомы определение одного из признаков, трахоматозного трихиаза, было изменено, чтобы исключить трихиаз, поражающий только нижнее веко. В данном документе приведена измененная система, обновлено ее представление, даны примечания по ее использованию и определены сферы текущих дискуссий.

Multimorbidity is the presence of more than one chronic disease condition in an individual. Health-related, socioeconomic, cultural and environmental factors, as well as patient behaviour, all influence the outcomes of multimorbidity. Addressing these complex and often interacting biopsychosocial factors therefore requires a shift in treatment from a physical damage model towards person-centred integrated care with increased patient agency. Education influences behaviour and can be used to empower patients and their carers with greater agency, thus allowing greater responsibility for and control over the management of patient care. In this paper we reflect on our own learning as a community of health practitioners from different disciplines. Recognizing the increasing importance of patient agency in driving the evolution of health care, we describe the concept of a web-based personal digital health hub for integrated patient care. Informed by collaboration between patient, health and education communities, we share our early experience in the implementation of a health hub around a cohort of patients with hip fractures. We also describe a vision for future health care based on the co-creation of digital health hubs centred on patients' and carers' needs. The health hub could allow important advances and efficiencies to be achieved in workforce practice and education; patient and carer engagement in self-care; and the collection of patient-reported health data required for ongoing research and improvements in health care.La multimorbidité est la présence de plus d'une maladie chronique chez un individu. L'aboutissement de la multimorbidité est influencé par des facteurs sanitaires, socio-économiques, culturels et environnementaux. Aborder ces facteurs biopsychosociaux complexes et souvent interdépendants requiert donc un changement de traitement, qui consiste à s'éloigner d'un modèle axé sur les dommages physiques pour se rapprocher d'un modèle de soins intégré et centré sur la personne, allié à une meilleure implication du patient. L'éducation a un impact sur le comportement et peut être utilisée pour renforcer la capacité d'agir des patients et de leurs soignants, ce qui permettra de conférer plus de responsabilités et un meilleur contrôle de la gestion des soins aux patients. Dans ce document, nous réfléchissons à notre propre apprentissage en tant que communauté de professionnels de la santé issus de différentes disciplines. Nous reconnaissons l'importance croissante de l'implication du patient pour stimuler l'évolution des soins de santé, et imaginons un concept de centre de santé numérique et personnalisé via site Web pour la prise en charge intégrée des patients. Grâce à la collaboration entre patients, professionnels de la santé et structures pédagogiques, nous partageons nos premières expériences en matière de mise en œuvre d'un centre de santé regroupant des patients présentant des fractures de la hanche. Nous dévoilons également notre vision d'avenir pour les soins de santé, qui repose sur la cocréation de centres de santé numériques adaptés aussi bien aux besoins des patients qu'à ceux des soignants. Ce concept pourrait faire progresser l'enseignement et la pratique pour les professionnels du secteur, mais aussi améliorer leur efficacité; favoriser la participation des patients et soignants dans les soins auto-administrés; et enfin, permettre la collecte des données fournies par les patients, et nécessaires à la poursuite des recherches et améliorations dans le domaine des soins de santé.La multimorbilidad es la presencia de más de una enfermedad crónica en un individuo. Los factores medioambientales, culturales, socioeconómicos y los relacionados con la salud, así como el comportamiento de los pacientes, influyen en los resultados de la multimorbilidad. Por lo tanto, se requiere un cambio en el tratamiento desde el modelo de daño físico hacia una atención integrada y centrada en el individuo con una mayor participación del paciente para abordar estos factores biopsicosociales complejos y a menudo interactivos. La educación influye en el comportamiento y se puede utilizar para que los pacientes y sus cuidadores tengan más capacidad de acción, lo que permite una mayor responsabilidad y control sobre la gestión de la atención al paciente. En este documento reflexionamos sobre nuestro propio aprendizaje como comunidad de profesionales de la salud de diferentes disciplinas. Se describe el concepto de un centro de salud virtual personalizado para la atención integrada del paciente, al reconocer la creciente relevancia de la participación y la acción del paciente en el proceso de evolución de la atención médica. Gracias a la colaboración entre las comunidades de pacientes, de salud y de educación, compartimos nuestra experiencia inicial sobre el establecimiento de un centro de salud en torno a una cohorte de pacientes con fracturas de cadera. Asimismo, describimos una visión de la futura atención médica basada en la creación conjunta de centros de salud virtuales que se centran en las necesidades de los pacientes y de los cuidadores. El centro de salud permitiría alcanzar importantes avances y mejoras en la práctica y la educación de la fuerza de trabajo; en el compromiso de los pacientes y los cuidadores con el autocuidado de la salud; y en la recopilación de los datos sobre la salud que los pacientes comunican y que se requieren para la investigación y las mejoras continuas en la atención médica.تعدد الأمراض هو وجود أكثر من حالة مرضية مزمنة واحدة لدى الفرد. تؤثر العوامل الاجتماعية الاقتصادية، والعوامل الثقافية والبيئية، المرتبطة بالصحة، وكذلك سلوك المريض، على نتائج تعدد الأمراض. إن التعامل مع هذه العوامل البيولوجية النفسية الاجتماعية المعقدة، والمتداخلة غالباً، تتطلب تحولاً في العلاج من نموذج الضرر الجسدي إلى الرعاية المتكاملة التي تركز على الشخص، معتمكين أكبر للمريض للمشاركة وتحمل المسؤولية في العلاج. يؤثر التعليم على السلوك، ويمكن استخدامه لتمكين المرضى ومقدمي الرعاية لهم من خلال ومشاركة أكبر، وبالتالي السماح بمزيد من المسؤولية تجاه إدارة رعاية المرضى، والتحكم فيها. نركز في هذه الورقة على تعلمنا كمجتمع من الممارسين الصحيين من مختلف التخصصات. في ظل إدراك الأهمية المتزايدة لتمكين المريض في دفع تطور الرعاية الصحية، فإننا نصف مركز الصحة الرقمية الشخصي على شبكة الإنترنت للرعاية المتكاملة للمرضى. وبناءً على التعاون بين مجتمعات المرضى والصحة والتعليم، فإننا نشارك تجربتنا المبكرة في تنفيذ مركز صحي حول مجموعة من المرضى الذين يعانون من كسور الورك. كما نصف أيضاً رؤية للرعاية الصحية المستقبلية استنادًا إلى الإنشاء المشترك لمراكز الصحة الرقمية التي تركز على احتياجات المرضى ومقدمي الرعاية. يمكن أن يسمح المركز الصحي بتحقيق تطورات وكفاءات هامة في ممارسة القوى العاملة والتعليم؛ ومشاركة المريض ومقدم الرعاية في الرعاية الذاتية؛ وجمع البيانات الصحية التي قدمها المريض، والمطلوبة للبحث والتحسينات المستمرة في الرعاية الصحية.多重病症是指一个人患有一种以上的慢性疾病。与健康有关的因素，社会经济、文化和环境方面的因素以及患者行为都会影响多重病症患者的治疗结果。因此，若要解决这些复杂且经常相互作用的生物心理社会因素，需要将治疗从物理性损伤模式转换为以患者为中心的综合护理，并提高患者在其中所发挥的作用。教育影响行为并且可以用来为患者及其照顾者赋权，让他们发挥更大的作用，从而对患者护理的管理工作承担更大的责任和管控力度。在本文中，作为一支汇聚不同学科从业人员的团队，我们反思了我们总结的经验。我们意识到患者在推动医疗护理改革方面所发挥的作用日益重要，因此我们描述了一个基于网络的个人数字医疗中枢的概念，用于整合患者护理。通过患者、卫生和教育团体之间的合作互通，我们围绕一批髋部骨折患者分享了我们在医疗中枢实施方面的早期体验。我们还基于共建以患者和护理人员需求为中心的数字医疗中枢，表达了对未来医疗卫生事业的美好愿景。医疗中枢可以在人员实践和教育方面实现重要进展和效率提升；可以让患者和照顾者参与自我护理；可以收集患者自述的医疗数据，所收集的数据用于医疗护理事业的长期研究和提升。.Мультиморбидность это наличие у одного человека нескольких хронических заболеваний. Исход мультиморбидности зависит от факторов, связанных со здоровьем, социально-экономических, культурных и экологических факторов, а также поведения пациента. Таким образом, решение вопросов относительно этих сложных и часто взаимосвязанных биопсихосоциальных факторов, требует перехода в лечении от модели физического повреждения к комплексному медицинскому обслуживанию, ориентированному на человека и предоставляющему большую свободу действий пациенту. Обучение влияет на поведение и может использоваться для расширения возможностей пациентов и ухаживающих за ними лиц, предоставляя им больше ответственности и контроля за процессом лечения и ухода. В этой статье авторы рассматривают процесс собственного обучения как сообщества практикующих специалистов из разных дисциплин. Признавая растущую важность свободы воли пациентов как движущей силы эволюции здравоохранения, авторы описывают концепцию сетевого персонального цифрового центра здоровья для комплексного подхода к лечению пациентов. Опираясь на опыт сотрудничества между пациентами и сообществами здравоохранения и образования, авторы делятся первоначальным опытом в части создания центра здоровья для контингента пациентов с переломами шейки бедра. В статье также описана концепция здравоохранения будущего, основанная на совместном создании цифровых центров здоровья, сосредоточенных вокруг потребностей пациентов и лиц, осуществляющих уход. Центр здоровья может позволить добиться значительных успехов и эффективности в сфере практической деятельности и обучения медицинских работников, вовлечения пациентов и ухаживающих за ними лиц в процесс самопомощи, а также сбора предоставляемых самим пациентом данных о его здоровье, которые необходимы для текущих исследований и совершенствования системы здравоохранения.

Empathy, compassion and trust are fundamental values of a patient-centred, relational model of health care. In recent years, the quest for greater efficiency in health care, including economic efficiency, has often resulted in the side-lining of these values, making it difficult for health-care professionals to incorporate them in practice. Artificial intelligence is increasingly being used in health care. This technology promises greater efficiency and more free time for health-care professionals to focus on the human side of care, including fostering trust relationships and engaging with patients with empathy and compassion. This article considers the vision of efficient, empathetic and trustworthy health care put forward by the proponents of artificial intelligence. The paper suggests that artificial intelligence has the potential to fundamentally alter the way in which empathy, compassion and trust are currently regarded and practised in health care. Moving forward, it is important to re-evaluate whether and how these values could be incorporated and practised within a health-care system where artificial intelligence is increasingly used. Most importantly, society needs to re-examine what kind of health care it ought to promote.L'empathie, la compassion et la confiance sont des valeurs fondamentales d'un modèle de soins de santé centré sur les relations avec le patient. Mais ces dernières années, la quête d'efficacité dans le secteur, y compris au niveau économique, a souvent relégué ces valeurs au second plan et les professionnels de la santé ont donc eu du mal à les intégrer à leur pratique. De son côté, l'intelligence artificielle gagne en importance. Cette technologie devrait accroître l'efficacité tout en libérant du temps pour les professionnels de la santé, qui pourront ainsi se concentrer sur l'aspect humain des soins, notamment en établissant une relation de confiance et en faisant preuve d'empathie et de compassion envers les patients. Le présent article s'intéresse à l'idée d'un système de soins de santé efficace, qui repose sur l'empathie et la confiance, et à laquelle adhèrent les adeptes de l'intelligence artificielle. Il suggère que l'intelligence artificielle a le potentiel nécessaire pour transformer radicalement la manière dont l'empathie, la compassion et la confiance sont considérées et appliquées aujourd'hui dans le secteur de la santé. À l'avenir, il est essentiel de réexaminer l'importance de ces valeurs et la façon dont elles pourraient être incorporées et mises en œuvre dans un système de santé où l'intelligence artificielle devient peu à peu incontournable. Et surtout, la société a besoin de se demander quel modèle de soins de santé elle souhaite promouvoir.La empatía, la compasión y la confianza son valores fundamentales de un modelo relacional de atención sanitaria centrado en el paciente. En los últimos años, la búsqueda de una mayor eficiencia en la atención sanitaria, incluida la eficiencia económica, ha dado lugar con frecuencia a que estos valores se vean relegados a un segundo plano, lo que dificulta que los profesionales sanitarios los incorporen en la práctica. La inteligencia artificial se utiliza cada vez más en la atención sanitaria. Esta tecnología promete una mayor eficiencia y más tiempo libre para que los profesionales sanitarios se centren en el lado humano de la atención, lo que incluye el fomento de las relaciones de confianza y el trato a los pacientes con empatía y compasión. En este artículo se examina la visión de una atención sanitaria eficiente, empática y confiable que proponen los defensores de la inteligencia artificial. El artículo sugiere que la inteligencia artificial tiene el potencial de alterar fundamentalmente la forma en que la empatía, la compasión y la confianza se consideran y practican actualmente en la atención sanitaria. Para avanzar, es importante volver a evaluar si dichos valores se podrían incorporar y practicar en un sistema de atención sanitaria en el que se utiliza cada vez más la inteligencia artificial, y de qué manera. Lo más importante es que la sociedad debe reconsiderar qué tipo de atención sanitaria debe promover.التعاطف والشفقة والثقة هي القيم الأساسية لنموذج الرعاية الصحية المرتكزة على المريض. في السنوات الأخيرة، أدى السعي لتحقيق المزيد من الفعالية في الرعاية الصحية، بما في ذلك الفعالية الاقتصادية، في الغالب إلى تباعد هذه القيم، مما جعل من الصعب على أخصائيي الرعاية الصحية دمجها في الممارسة. يُستخدم الذكاء الاصطناعي بشكل متزايد في الرعاية الصحية. وتقدم هذه التكنولوجيا وعوداً بمزيد من الفعالية والوقت الحر لأخصائيي الرعاية الصحية للتركيز على الجانب الإنساني من الرعاية، بما في ذلك تعزيز علاقات الثقة والاندماج مع المرضى من خلال التعاطف والشفقة. يناقش هذا المقال رؤية تتميز بالفعالية والتعاطف لرعاية صحية جديرة بالثقة، يطرحها مؤيدي الذكاء الاصطناعي. تشير الورقة إلى أن الذكاء الاصطناعي لديه إمكانية تغيير الطريقة التي ينظر بها إلى التعاطف والشفقة والثقة، وكيفية ممارسة كل منها، بشكل جذري في مجال الرعاية الصحية. ومع المضي قدما، من الهام إعادة تقييم ما إذا كان يمكن دمج وممارسة هذه القيم، داخل نظام الرعاية الصحية، حيث يستخدم الذكاء الاصطناعي بشكل متزايد، وكيفية القيام بذلك. والأهم من ذلك، يحتاج المجتمع إلى التحقق من نوع الرعاية الصحية الذي يمكن لهذه القيم أن ترتقي به.理解、同情和信任是以患者为中心的、关系型医疗保健模式的基本价值。近年来，为了提高医疗保健的效率，包括经济效率，往往导致对这些价值观的背离，使医疗保健专业人员难以将其纳入实践。人工智能正越来越多地被应用于医疗保健。这项技术为医疗保健专业人员提供了更高的效率和更多的空闲时间，使他们能够专注于人性化的护理，包括培养信任关系，理解并同情患者。本文探讨了人工智能倡导者提出的高效、理解、可信赖的医疗保健理念。本文表明，人工智能有可能从根本上改变目前人们在医疗保健中看待和实践理解、同情和信任的方式。展望未来，重新评估这些价值观是否以及如何能够在越来越多地使用人工智能的医疗保健系统中纳入和实施是一件十分重要的事。最重要的是，社会需要重新审视什么类型的医疗保健值得推广。.Эмпатия, сочувствие и доверие — это основополагающие ценности ориентированной на пациента реляционной модели здравоохранения. В последнее время стремление повысить эффективность систем здравоохранения, в том числе их рентабельность, приводит к тому, что этим ценностям часто не уделяется должного внимания, что в свою очередь значительно осложняет их использование на практике работниками сферы здравоохранения. Применение искусственного интеллекта в сфере здравоохранения неуклонно растет. Эта технология привлекательна перспективой повышенной эффективности и тем, что она оставляет медицинским работникам больше свободного времени для непосредственной работы с пациентами, в том числе для налаживания доверительных отношений и применения эмпатии и сочувствия в профессиональном общении с пациентами. В этой статье рассматривается представление об эффективной системе здравоохранения, построенной на основе эмпатии и доверия, которое предлагается специалистами, продвигающими внедрение технологий ИИ в сфере здравоохранения. В статье выдвигается предположение о том, что искусственный интеллект потенциально способен коренным образом изменить сегодняшнее представление о применении эмпатии, сочувствия и доверия в сфере здравоохранения и внедрении соответствующих практик. В дальнейшем важно заново оценить возможность включения этих ценностей в систему здравоохранения, все чаще использующую технологию искусственного интеллекта, и их применения на практике. Что наиболее важно, общество нуждается в пересмотре того, развитие какого типа системы здравоохранения следует поощрять.

Globally, countries have agreed to pursue the progressive realization of universal health coverage (UHC) and there is now a high level of political commitment to providing universal coverage of essential health services while ensuring that individuals are financially protected against high health spending. The aim of this paper is to help policy-makers think through the progressive realization of UHC. First, the pitfalls of applying global normative expenditure targets in estimating the national revenue required for UHC are discussed. Then, several recommendations on estimating national revenue are made by moving beyond the question of how much UHC will cost and focusing instead on the national health-care reforms and policy choices needed to progress towards UHC. In particular, costing exercises are recommended as a tool for comparing different service delivery options and investment in data infrastructure is recommended for improving the information needed to identify the best policies. These recommendations are intended to assist health policy-makers and international and national agencies who are developing country plans for the progressive realization of UHC.À l'échelle mondiale, les pays sont convenus de poursuivre la réalisation progressive de la couverture sanitaire universelle, et l'on observe désormais un fort niveau d'engagement politique en faveur de la couverture universelle des services de santé essentiels en veillant à ce que les individus soient financièrement à l'abri de toute dépense de santé élevée. L'objectif de cet article est d'aider les responsables politiques à effectuer un examen minutieux en vue de la réalisation progressive de la couverture sanitaire universelle. Pour commencer, nous examinons les écueils liés à l'application d'objectifs de dépenses normatifs mondiaux au moment d'estimer le revenu national requis pour la couverture sanitaire universelle. Nous formulons ensuite plusieurs recommandations concernant l'estimation du revenu national, en dépassant la question du coût de la couverture sanitaire universelle pour nous concentrer sur les réformes nationales en matière de soins de santé et sur les choix politiques nécessaires pour faire progresser la couverture sanitaire universelle. Nous recommandons notamment de procéder à des exercices d'établissement des coûts pour comparer différentes options de prestation de services et d'investir dans des infrastructures de données pour améliorer les informations nécessaires à l'identification des meilleures politiques. Ces recommandations visent à aider les responsables des politiques de santé et les organismes internationaux et nationaux qui élaborent des plans nationaux pour la réalisation progressive de la couverture sanitaire universelle.A nivel mundial, los países han acordado procurar la realización progresiva de la cobertura sanitaria universal (universal health coverage, UHC) y ahora existe un alto nivel de compromiso político para proporcionar una cobertura universal de los servicios sanitarios esenciales, al tiempo que se garantiza la protección financiera de las personas frente a los elevados gastos sanitarios. El objetivo de este documento es ayudar a los responsables de formular políticas a pensar en la realización progresiva de la UHC. Primero, se discuten las trampas en la aplicación de las metas globales de gastos normativos al estimar los ingresos nacionales requeridos para la UHC. Luego, se hacen varias recomendaciones sobre la estimación de los ingresos nacionales al ir más allá de la cuestión de cuánto costará la UHC y enfocarse en cambio en las reformas nacionales de salud y en las opciones de políticas necesarias para progresar hacia la UHC. En particular, se recomiendan ejercicios de cálculo de costos como herramienta para comparar diferentes opciones de prestación de servicios y se recomienda invertir en infraestructura de datos para mejorar la información necesaria con el fin de identificar las mejores políticas. Estas recomendaciones tienen por objeto ayudar a los responsables de formular políticas de salud y a los organismos internacionales y nacionales que están elaborando planes nacionales para la realización progresiva de la UHC.وافقت البلدان على مستوى العالم على السعي نحو التنفيذ التدريجي للتغطية الصحية الشاملة (UHC)، وهناك الآن مستوى عالٍ من الالتزام السياسي نحو توفير تغطية شاملة للخدمات الصحية الأساسية، مع ضمان الحماية المالية للأفراد ضد ارتفاع الإنفاق على الصحة. الهدف من هذه الورقة هو مساعدة صناع السياسة على التفكير من خلال التنفيذ التدريجي للتغطية الصحية الشاملة. أولاً، تمت مناقشة مخاطر تطبيق أهداف الإنفاق المعياري العالمي في تقدير الدخل الوطني المطلوب للحصول على التغطية الصحية الشاملة. بعد ذلك، يتم تقديم العديد من التوصيات الخاصة بتقدير الدخل الوطني، وذلك عن طريق التحرك لما بعد موضوع تكلفة الرعاية الصحية الشاملة، والتركيز بدلاً من ذلك على إصلاحات الرعاية الصحية الوطنية وخيارات السياسة المطلوبة للتقدم نحو التغطية الصحية الشاملة. ويوُصى على وجه الخصوص بتدريبات التكاليف كأداة لمقارنة الخيارات المختلفة لتقديم الخدمات، كما يوصى بالاستثمار في البيانات بهدف تحسين المعلومات المطلوبة لتحديد أفضل السياسات. الهدف من هذه التوصيات هو مساعدة واضعي السياسات الصحية، والهيئات الدولية والوطنية، الذين يقومون بوضع خطط الدولة للتنفيذ التدريجي للتغطية الصحية الشاملة.在全球范围内，各国已同意逐步实现全民健康覆盖 (UHC)，目前，各国在政治上高度致力于提供基本健康服务的全民覆盖范围，同时确保个人免受高额医疗支出的经济负担。本文旨在帮助政策制定者思考如何逐步实现全民健康覆盖 (UHC)。首先，讨论采用全球规范性支出目标来估算实现全民健康覆盖 (UHC) 所需的国家税收的困难。然后，对估算国家税收提出若干建议，这些建议不仅围绕全民健康覆盖 (UHC) 的成本问题，而且把重点放在推进全民健康覆盖 (UHC) 所需的国家医疗改革和政策选择上。特别是，建议将成本计算工作作为比较不同服务交付选择的工具，并建议对数据基础架构进行投资，以改进确定最佳政策所需的信息。这些建议旨在协助健康政策制定者以及正在制定逐步实现全民健康覆盖计划的国内外机构。.Страны мира пришли к соглашению о продолжении последовательной реализации программы всеобщего охвата услугами здравоохранения (ВОУЗ). В настоящее время обеспечение всеобщего охвата основными услугами здравоохранения с одновременным созданием финансовой защиты отдельных категорий лиц от высоких расходов на медицинское обслуживание получает значительную политическую поддержку. Цель данного документа — помочь лицам, формирующим политику, продумать процесс последовательной реализации программы ВОУЗ. В нем обсуждаются возможные скрытые проблемы внедрения глобальных нормативов целевых расходов при оценке национального дохода, необходимого для обеспечения всеобщего охвата услугами здравоохранения. Документ также содержит несколько рекомендаций по оценке национального дохода посредством не только рассмотрения вопроса о том, сколько будет стоить обеспечение ВОУЗ, но и заострения внимания на национальных реформах в сфере здравоохранения и изменениях в политике, необходимых для достижения прогресса в обеспечении всеобщего охвата услугами здравоохранения. В частности, рекомендуется использовать расчет стоимости в качестве инструмента сравнения различных вариантов предоставления услуг, а также инвестиции в инфраструктуру анализа данных для повышения качества информации, необходимой для разработки наиболее эффективных политик. Такие рекомендации предназначены для оказания содействия лицам, формирующим политику в сфере здравоохранения, а также международным и национальным ведомствам, разрабатывающим планы последовательной реализации программы ВОУЗ на уровне стран.

Not only is it difficult to change the “publish or perish” mindset among health researchers, there are other fundamental barriers in data sharing that Pisani & AbouZahr’s paper should have addressed.1 Sharing data is not only about the technical dimension such as data management, repositories and libraries; developing countries are concerned about factors that impede data sharing, in particular, fairness. Pisani & AbouZahr provide clear analyses on barriers but their proposed solutions will not be effective unless they address the fundamental problems. From the perspective of developing countries, the goal of data sharing is beyond national interests and is for the benefit of all mankind. Without this explicit goal, data sharing more often helps scientists in developed countries get published. While these scientists may have higher analytical capacities, they have neither shared the “legwork” in collecting routine administrative data nor made intellectual contributions to designing and solving problems in conducting field work with scientists in developing countries. Developing countries need to strengthen capacities in survey design, data management and analysis and policy use. There is clearly an unlevel playing field that impedes data sharing. Scientists from developed countries often take the following approach with researchers in developing countries: “Share your data with me, you do not have analytical capacities. I will analyse and publish papers for global public good.” Instead, their approach should be: “We can analyse the data together and learn from each other for the benefit of all people.” This approach would gradually create equal partnerships, a level playing field, goodwill and trust for collaborations beyond simply sharing data.2–4 International data sharing cannot be achieved through forced marriage; as shown by the defeat of the policy proposed by the Annals of Internal Medicine of a publicly accessible database as a condition for journal publication.5 The recent sharing of avian flu virus specimens by developing countries through the World Health Organization resulted in the production of avian influenza vaccines at a price of US$ 10–20 per dose. This is unaffordable in low-income countries where total health expenditure is less than US$ 30 per person. Should an avian flu pandemic occur, there would be huge death tolls in countries without access to vaccines; while rich countries’ populations would be fully protected, literally from any moral obligations to countries that shared their specimens. Such unilateral benefit inhibits data sharing. It is important to have evidence on the benefits that populations receive directly as a result of sharing, beyond publications by secondary users. Success in international data sharing may start with efforts at country level or through multi-country research partnerships. Undeniably, multi-country studies provide huge benefit in supporting evidence-based policy. Collaborative partnerships among a number of developed and developing countries, such as for maternal and perinatal health, are foundations for building long-term trust.6 In research partnerships, there is equitable access to and use of data sets, beyond the conventional practice of passive data sharing without partnership. In Thailand, rules and procedures for data sharing were developed through a research funding agency and the National Statistical Office. Primary users were granted a reasonable-use period of two years after complete data collection prior to access by secondary users. Good practices are emerging. With the aim of capacity building and mutual benefit, the National Statistical Office grants approval to international secondary users to access nationally representative household data sets, on the condition that they develop partnerships with local scientists. Such engagement gradually builds trust and longer-term partnerships between scientists from developed and developing countries.

Angel Honorio Roffo of Argentina (1882-1947) was one of the first to publish detailed accounts of animal experiments demonstrating the production of tumours by tobacco tars. As founding director of the Instituto de Medicina Experimental para el Estudio yTratamiento del Cancer, established in 1922 in Buenos Aires, he was able to examine and treat a large population of cancer patients, from whom he had learned by the end of the 1920s that smoking was a cause of many kinds of cancer. (1) During the next decade and into the early 1940s he published a series of ambitious papers pioneering the field of experimental tobacco carcinogenesis, blending experimental, clinical and statistical reasoning with a strong sense that many of the world's most common cancers could be prevented. Using a number of different experimental methods, Roffo showed that cancers all along the "smoking highway" (lips, tongue, throat, cheek, bronchial passages, etc.) must be caused by exposure to tars released in the course of smoking; he was also one of the first to realize that smoking could cause bladder cancer. Roffo's work is interesting for a number of different reasons. For one thing, there is his defence of the use of experiments to investigate tobacco carcinogenesis--as if clinical observations had already proved the point. In 1931, writing in the Zeitschrift fur Krebsforschung (he published much of his work in German), he noted that while there were cases in which tobacco was clearly to blame for the onset of certain malignancies (from clinical observations) it was nonetheless useful to document the phenomenon more generally by animal experiments. (2) Reasoning by analogy from the production of cancer using coal tars, he argued that the carcinogens in tobacco smoke must be the complex, tarry, polycyclic aromatic hydrocarbons, rather than the (chemically simpler) inorganic constituents or the alkaloid nicotine. To test this hypothesis, Roffo separated tobacco smoke into three separate distillation products, which he rubbed onto the ears of three groups of 10 rabbits each. He found that the tarry fractions produced cancers but that when nicotine alone was applied no cancers were produced, no matter how long he waited. The same (no cancerous effect) was true from the various inorganic components he had isolated from smoke, including salts such as ammonium chloride but also carbon monoxide and carbon dioxide. (2) Roffo ran many similar tests using different methods of preparing tobacco extracts, different fractions of tobacco tars, and different species of test animals. He never seems to have doubted the role of tobacco, and by the end of his career was able to claim, based on hundreds of his own published papers, that tobacco was the major cause of lung cancer, that tar rather than nicotine was the primary culprit, and that polycyclic aromatic hydrocarbons were the principal carcinogenic agents. Among these last-mentioned compounds was 1:2 benzopyrene--the subject of the paper reproduced here (3)--which Roffo was apparently the first to identify in tobacco smoke (on the basis of spectrographic signatures). (4,5) Roffo also concluded that blonde tobacco was more dangerous than black--from having higher quantities of tars--and that the most dangerous were Turkish, Egyptian, and Kentucky tobaccos. (3,6) He also showed that cancers could be induced in experimental animals even by using nicotine-flee tobacco, meaning that it must be the tar, rather than the nicotine, that was causing cancer. Tar was not a trivial component of tobacco smoke: Roffo calculated that smokers could inhale as much as 4 kg of tobacco tar in 10 years of smoking. (4) Roffo had access to a very large pool of cancer patients at his institute in Buenos Aires and used this to explore cancer causation on a statistical basis. (7) In 1934, he described how 302 of his 500 skin cancer patients had presented with malignancies of the nose, the body part most directly exposed to the sun. …

This paper provides a comprehensive overview of hospital payment systems based on diagnosis-related groups (DRGs) in low- and middle-income countries. It also explores design and implementation issues and the related challenges countries face.A literature research for papers on DRG-based payment systems in low- and middle-income countries was conducted in English, French and Spanish through Pubmed, the Pan American Health Organization's Regional Library of Medicine and Google.Twelve low- and middle-income countries have DRG-based payment systems and another 17 are in the piloting or exploratory stage. Countries have chosen from a wide range of imported and self-developed DRG models and most have adapted such models to their specific contexts. All countries have set expenditure ceilings. In general, systems were piloted before being implemented. The need to meet certain requirements in terms of coding standardization, data availability and information technology made implementation difficult. Private sector providers have not been fully integrated, but most countries have managed to delink hospital financing from public finance budgeting.Although more evidence on the impact of DRG-based payment systems is needed, our findings suggest that (i) the greater portion of health-care financing should be public rather than private; (ii) it is advisable to pilot systems first and to establish expenditure ceilings; (iii) countries that import an existing variant of a DRG-based system should be mindful of the need for adaptation; and (iv) countries should promote the cooperation of providers for appropriate data generation and claims management.Cet article donne un aperçu complet des systèmes de paiement des hôpitaux basés sur les groupes homogènes de diagnostic (DRG) dans les pays à revenu faible et moyen. Il examine également les questions de conception et de mise en œuvre, ainsi que les défis associés auxquels les pays font face.Une recherche documentaire sur les articles portant sur les systèmes de paiement basés sur les groupes homogènes de diagnostic dans les pays à revenu faible et moyen a été menée en anglais, français et espagnol dans Pubmed, la Bibliothèque régionale de l'Organisation panaméricaine de la Santé et Google.Douze pays à revenu faible et moyen ont des systèmes de paiement basés sur les groupes homogènes de diagnostic et dix-sept autres pays sont en phase pilote ou exploratoire. Les pays ont fait un choix dans une vaste gamme de modèles de groupes homogènes de diagnostic importés ou développés par eux-mêmes, et la plupart des pays ont adapté ces modèles à leurs contextes particuliers. Tous les pays ont défini un plafond de dépenses. En général, les systèmes ont été testés en phase pilote avant d'être mis en œuvre. La nécessité de répondre à certaines exigences en termes de normalisation des codes, de disponibilité des données et de technologie des informations a rendu la mise en œuvre difficile. Les prestataires de service du secteur privé n'ont pas été pleinement intégrés mais la majorité des pays ont réussi à dissocier le financement des hôpitaux de la budgétisation des finances publiques.Bien qu'il soit nécessaire d'obtenir davantage de preuves sur l'impact des systèmes de paiement basés sur les groupes homogènes de diagnostic, nos résultats suggèrent que (i) la plus grande partie du financement des soins de santé devrait provenir du public plutôt que du privé; (ii) il est recommandé de tester d'abord les systèmes en phase pilote et d'établir des plafonds de dépenses; (iii) les pays qui importent un modèle existant d'un système basé sur les groupes homogènes de diagnostic devraient être conscients de la nécessité de les adapter à leurs spécificités; et (iv) les pays devraient promouvoir la coopération de prestataires de service pour la production appropriée des données et la gestion des réclamations.Este documento ofrece una visión global de los sistemas de pago hospitalario basados en grupos relacionados por el diagnóstico (GRD) de países de ingresos bajos y medianos. Además, se analizan los problemas de diseño y ejecución, así como los desafíos relacionados a los que se enfrentan los países.Se llevó a cabo una investigación bibliográfica en inglés, francés y español de trabajos sobre los sistemas de pago basados en GRD de países de ingresos bajos y medianos a través de Pubmed, la Biblioteca Regional de Medicina de la Organización Panamericana de la salud y Google.Doce países de ingresos bajos y medianos tienen sistemas de pago basados en GRD y otros 17 se encuentran en fase experimental o exploratoria. Los países han realizado una selección de entre un amplio abanico de modelos de GRD importados y de desarrollo propio y la mayoría han adaptado estos modelos a sus contextos locales. Todos los países han establecido límites de gasto. En general, se pusieron a prueba los sistemas antes de su aplicación. La aplicación se ve dificultada por la necesidad de cumplir con ciertos requisitos en términos de la normalización de la codificación, la disponibilidad, la información y la tecnología de la información. Los proveedores del sector privado no se han integrado plenamente, pero la mayoría de los países han logrado desvincular el financiamiento hospitalario del presupuesto de las finanzas públicas.Aunque se necesitan más pruebas sobre el impacto de los sistemas de pago basados en GRD, nuestros resultados sugieren que (i) la mayor parte del financiamiento sanitario debe ser público y no privado, (ii) se recomienda poner a prueba los sistemas previamente y establecer límites de gasto, (iii) los países que importan una variante actual de un sistema basado en GRD deberían tener en cuenta la necesidad de adaptación, y (iv) los países deben promover la cooperación de los proveedores a fin de que la generación de datos y la gestión de siniestros sean adecuadas.يقدم هذا البحث نظرة عامة شاملة على أنظمة الدفع في المستشفيات على أساس المجموعات المرتبطة بالتشخيص في البلدان منخفضة ومتوسطة الدخل. كما يستكشف المسائل الخاصة بالتصميم والتنفيذ بالإضافة إلى التحديات التي تواجهها البلدان.تم إجراء بحث في المؤلفات المنشورة الخاصة بدراسات أنظمة الدفع على أساس المجموعات المرتبطة بالتشخيص في البلدان منخفضة ومتوسطة الدخل باللغات الإنجليزية والفرنسية والإسبانية من خلال قاعدة البيانات Pubmed والمكتبة الإقليمية لمنظمة الصحة للبلدان الأمريكية وغوغل.يوجد اثنا عشر بلداً من البلدان منخفضة ومتوسطة الدخل لديها أنظمة دفع على أساس المجموعات المرتبطة بالتشخيص وسبعة عشر بلداً أخرى في مرحلة التنفيذ التجريبي أو الاستكشاف. وتم اختيار البلدان من نطاق عريض من النماذج المستوردة والمطورة ذاتياً من أنظمة الدفع على أساس المجموعات المرتبطة بالتشخيص وقام معظمها بتكييف هذه النماذج وفق بيئاتها الخاصة. وقد وضعت كل البلدان أسقفاً للنفقات. وبشكل عام، تم تجربة الأنظمة قبل تنفيذها. وقد جعلت الحاجة إلى تلبية متطلبات معينة تتعلق بالتوحيد المعياري الترميزي وتوافر البيانات وتكنولوجيا المعلومات من التنفيذ عملية صعبة. ولم يتم إدماج مزودو الخدمة من القطاع الخاص بشكل كامل، ولكن معظم البلدان تمكنت من فصل تمويل المستشفيات عن موازنات التمويل العامة.رغم الحاجة إلى مزيد من الأدلة عن تأثير أنظمة الدفع على أساس المجموعات المرتبطة بالتشخيص، فإن نتائجنا تشير إلى: (1) ينبغي أن يكون الجزء الأكبر من تمويل الرعاية الصحية عاماً وليس خاصاً؛ (2) ينصح بتجربة الأنظمة أولاً ووضع أسقف للنفقات؛ (3) ينبغي أن تنتبه البلدان التي تستورد نوعاً قائماً من أنظمة الدفع على أساس المجموعات المرتبطة بالتشخيص إلى الحاجة إلى تكييفه؛ (4) ينبغي أن تشجع البلدان على التعاون بين المزودين لأغراض الإنشاء المناسب للبيانات وإدارة المطالبات.本文对中低收入国家基于诊断相关组(DRG)的医院支付系统进行综合概述。同时探讨设计和实施问题以及各国面临的相关挑战。通过Pubmed、泛美卫生组织的区域性医学图书馆和谷歌对有关中低收入国家基于DRG支付系统的英语、法语和西班牙语论文进行文献研究。12 个中低收入国家拥有基于DRG的支付系统，其他17 个国家还处于试点或探索阶段。各个国家从多种多样引进和自主开发的DRG模型中加以选择，大多数国家针对其特定国情进行了改进。所有国家都设置了封顶线。总体而言，系统在实施之前经过了试点。因为要满足编码标准化、数据可用性和信息技术方面的特定需求，令实施面临困难。私营部门提供者尚未完全融入，但多数国家都一直在设法将医院财务与公共财政预算分离。尽管还需要更多证据证明DRG支付系统的影响，我们的研究结果表明：(i) 更大部分的医疗财务应公有而非私有；(ii) 首先对系统进行试点并设置封顶线是明智之举；(iii) 引进DRG系统现有形式的国家应记住需要因地制宜；(iv) 各国应促进提供者的合作，以实现适当的数据生成和报销管理。Данный документ содержит полный обзор систем платежей по клинико-статистическим группам (КСГ) в странах с низким и средним уровнем доходов. Кроме того, в нем исследуются вопросы структуры системы и ее внедрения, а также проблемы, с которыми сталкивались некоторые страны.Исследование литературы по системам платежей для различных клинико-статистических групп в странах с низким и средним уровнем дохода было проведено на английском, французском и испанском языках с помощью текстовой базы данных Pubmed, региональной библиотеки Панамериканской организации здравоохранения и поискового сервиса Google.В двенадцати странах с низким и средним уровнем дохода системы платежей для клинико-статистических групп внедрены, а в еще семнадцати странах находятся на стадии пилотного проекта или исследования. Страны использовали различные заимствованные и самостоятельно разработанные модели КСГ, и многие из них приспособили такие модели к своим специфическим условиям. Во всех странах был установлен верхний предел расходов. Обычно проводилось испытание системы перед ее внедрением, которое осложнялось необходимостью соответствия определенным требованиям в вопросах стандартизации кода, доступности данных и информационных технологий. Частные врачи не были полностью интегрированы, но большинству стран удалось отделить финансирование больниц от государственных финансов.Несмотря на то, что необходимо собрать больше данных для определения влияния систем платежей по КСГ, по результатам нашего исследования можно сделать выводы, что (i) большая часть финансирования здравоохранения должна быть скорее государственной чем частной; (ii) рекомендуется провести испытание системы, чтобы определить верхний предел расходов; (iii) страны, заимствующие уже существующие варианты систем КСГ, должны принимать во внимание необходимость приспособления системы; и (iv) страны должны способствовать взаимодействию поставщиков медицинских услуг в вопросах получения соответствующих данных и рассмотрение претензий.

Landmines and explosive remnants of war (ERW) continue to kill, injure and destroy lives and livelihoods. They cause an estimated 11 to 12 casualties daily and are not confined to a single part of the world. The six countries with the highest landmine and ERW casualties in 2011 – Afghanistan, Cambodia, Colombia, Myanmar, Pakistan and South Sudan – belonged to different regions.1 Twenty years after the establishment of the International Campaign to Ban Landmines and 15 years after the monumental Mine Ban Treaty, the world has yet to overcome this scourge, which harms far more innocent civilians than military personnel.1 In a paper in this issue of the Bulletin, Durham et al. note that in Global Burden of Disease (GBD) studies, the true number of landmine and ERW casualties has historically been underreported.2 Their paper was written before the release in December 2012 of the GBD 2010 report, which fails to specifically discuss accidents caused by landmines and ERW and categorizes them under “collective violence”.3 In line with the Landmine Monitor’s reporting on landmine and ERW casualties, the disability-adjusted life years (DALYs) attributable to collective violence have declined.4 However, the problem of landmines and ERW persists and it would be a grave misjudgement to consider it solved. The health community has a major role to play in matters pertaining to landmines and ERW. The most apparent is ensuring an adequate health-care response, both immediate (e.g. acute trauma care and surgery) and long-term (e.g. rehabilitation), to the physical and psychological trauma of people injured by landmines and ERW casualties. Most of these people live in poverty, which tends to get worse after the accident. Furthermore, health services equipped to treat people with landmines and ERW injuries are often found in urban areas only, yet most accidents occur in rural and remote areas. Those who survive but with permanent disabilities, often face social and environmental barriers that can preclude their full and equal participation within their communities. With many health campaigns and calls to action to promote child health and survival, it is worth noting a substantial proportion of civilian landmine and ERW accidents occur in children – 42% on average, according to the Landmine monitor 2012.1 Landmine and ERW contamination can also undermine the health of a population indirectly by destroying food security as well as access to safe water and to vaccination and health facilities in general.5 These weapons can also prevent community-based health teams from carrying out their activities. As succinctly noted by Maddocks, “infectious diseases move freely … but health teams are restricted to safe areas”.6 The tragic deaths of two polio workers recently killed by a landmine blast in Pakistan drives this message home, especially now that the international health community has focused its attention on health worker safety.7 Today we understand that to improve the health of a population, we must address the social determinants of health. Landmine and ERW contamination is among these social determinants. The social detriment it causes is incompatible with sustainable development and with the three fundamental aspects of human well-being: economic development, environmental sustainability and social inclusion.8 The indirect impact of landmines and ERW on health are not reflected in GBD studies or captured by data gathered in accordance with the International Classification of Diseases. Durham et al. call for better integration of mine action and health reporting systems to better inform resource allocation and planning. Similarly, WHO Director-General Margaret Chan, in her commentary in the special edition of The Lancet on GBD 2010, warned that national health information is not fully integrated into global data collection: “…we need to agree on common standards for documentation and sharing of data … that maximises benefits to countries”.9 Assisting the victims of landmines and ERW by providing them with health care and ensuring their thorough integration into society is an obligation under two major disarmament treaties – the 1997 Mine Ban Treaty and the 2010 Convention on Cluster Munitions – and is one of the five pillars of mine action. The other four are clearance of landmines and ERW, stockpile destruction, advocacy for a universal ban and mine risk education. Despite this, victims continue to face a dire situation in most countries contaminated by landmines and ERW.10 Moreover, direct international support for victim assistance has decreased sharply; it dropped by almost 30% from 2010 to 2011, the year when it reached its lowest level since funding for monitoring mine action was initiated.1 At a time when countries are seeking to address their health problems through integrated approaches, all sectors must focus their attention on the fight against landmines and ERW.

In this issue of the Bulletin of the World Health Organization, a paper by Hitchman & Fong shows a strong association between the ratio of female and male smoking rates, and gender empowerment in many countries. The association is clearly linked to the level of economic development, which is measured by income per capita and income inequality.1 In concluding, the authors pose a stark question: will the trend towards greater gender empowerment inevitably lead to a smoking epidemic among women? The findings of the paper conform with the predictions of a model of the cigarette epidemic in developed countries that was proposed by Lopez et al. based on the historical experience of several countries.2 The model describes a pattern of rapidly rising smoking prevalence that peaks after a few decades and then declines. Smoking-related mortality peaks three to four decades after the peak in smoking prevalence. Historically, female smoking has lagged male smoking, often by a few decades. Thus the adverse health effects of smoking in a population start becoming evident around the time that the female smoking adoption rate starts rising. This is considered to moderate the rise in female smoking prevalence, which has been observed to peak at about 35–40%, in contrast to peak male smoking prevalence of 50–80%.2 Most of the literature on gender differences in smoking has focused on differences in traditional sex roles. These roles have translated historically into social norms, such as disapproval of female smoking, and gender-specific personal characteristics, such as greater rebelliousness among men, which is linked to higher smoking rates.3 However, countries can vary widely in their actual experience with the smoking epidemic. It is well known that female smoking prevalence has been low in China even though male smoking prevalence has been high for several decades. The reason for the difference is generally attributed to strong and persistent social norms against female smoking. What is perhaps less well known is that in China female smoking rates have actually declined through most of the 20th century. The smoking prevalence among Chinese women born in 1908–1912 was as high as 25% but it declined sharply in successive female cohorts. In contrast, male smoking prevalence in the 1908–1912 birth cohorts was 70% and the prevalence remained high in later male cohorts.4 Widespread female smoking adoption in China in the 1930s is at least in part linked to the mass availability of cigarettes at cheap prices and aggressive advertising using female models that depicted the modern Chinese woman taking her place in a rapidly changing world. The subsequent reversal in female smoking prevalence appears, in part, to be caused by cultural and socioeconomic forces that turned back the tide of mass marketing. For instance, Madame Chiang Kai-Shek’s New Life Movement emphasized traditional Confucian values and frowned on unhealthy behaviours such as smoking.4 This pattern is not unique to China; data from Japan and the Republic of Korea also suggest that there was a decline in smoking prevalence in successive female birth cohorts over the course of much of the 20th century.4 This is a striking departure from the model described by Lopez et al. and merits further research. The key message is that, while that model does furnish a useful benchmark for projections, a sustained rise in female smoking prevalence is not necessarily inevitable. The social norms that slowed the diffusion of smoking among women are clearly diminishing in most parts of the developing world. This is one of the unwelcome consequences of the otherwise very welcome processes of gender empowerment and economic growth which allow women to freely make choices and furnish them with the economic resources to pursue those choices. An ominous clue is found in the narrowing gender gap in the rates of smoking experimentation and adoption among teenagers around the world.5 The World Health Organization is concerned enough that it made gender and tobacco the theme of the 2010 World No Tobacco Day. For effective policy-making, we need a finer understanding of the gender differences in smoking adoption, intensity and cessation. Even in a country such as Germany with a high degree of female empowerment, gender differences in observable socioeconomic characteristics such as education, employment and income appear to explain only a small fraction of the gender difference in smoking prevalence and intensity.6 More research is merited on how women view triggers that could lead to smoking adoption, such as peer pressure and role models, how addiction develops in female smokers, and how they weigh the costs and benefits of smoking. Ironically, it may be cigarette marketers who currently have the best understanding of what induces women to experiment with and eventually adopt smoking! The marketers tailor their messages to target specific demographic and socioeconomic groups. Effective social marketing by public health advocates requires a similar sophisticated and customized response that should be grounded in the local cultural context. This is important, not only because of differing social norms, but also because tobacco is consumed in many different forms across the world. Reassuringly, there is increasing evidence that mass-media campaigns can be effective in inducing desired behavioural changes.7 The social marketing response should go hand-in-hand with other policy instruments such as taxes, curbs on advertising and restrictions on availability of tobacco products.

Bangladesh has achieved a high share of tax in the price of cigarettes (greater than the 75% benchmark), but has not achieved the expected health benefits from reduction in cigarette consumption. In this paper we explore why cigarette taxation has not succeeded in reducing cigarette smoking in Bangladesh. Using government records over 2006-2017, we link trends in tax-paid cigarette sales to cigarette excise tax structure and changes in cigarette taxes and prices. We analysed data on smoking prevalence from Bangladesh Global Adult Tobacco Surveys to study consumption of different tobacco products in 2009 and 2017. Drawing on annual reports from tobacco manufacturers and other literature, we examine demand- and supply-side factors in the cigarette market. In addition to a growing affordability of cigarettes, three factors appear to have undermined the effectiveness of tax and price increases in reducing cigarette consumption in Bangladesh. First, the multitiered excise tax structure widened the price differential between brands and incentivized downward substitution by smokers from higher-price to lower-price cigarettes. Second, income growth and shifting preferences of smokers for better quality products encouraged upward substitution from hand-rolled local cigarettes (Le Bangladesh applique un fort pourcentage de taxe sur les prix du tabac (au-delà du référent habituel de 75% du prix de détail) sans pour autant avoir atteint le bénéfice sanitaire attendu de réduction du tabagisme. Cet article se penche sur les raisons pour lesquelles la taxation du tabac n'est pas parvenue à réduire le tabagisme au Bangladesh. En utilisant les données gouvernementales couvrant la période comprise en 2006 et 2017, nous avons relié les tendances de vente des produits du tabac taxés avec la structure des droits d'accise sur le tabac et avec l'évolution des prix et des taxes sur le tabac. Nous avons analysé les données relatives à la prévalence du tabagisme à partir des enquêtes sur le tabagisme des adultes (GATS) réalisées en 2009 et 2017 au Bangladesh afin d'étudier la consommation des différents produits du tabac. À partir des rapports annuels des fabricants de tabac et d'autres ressources, nous avons examiné l'évolution du marché du tabac, côté demande et côté offre. Outre le fait que les cigarettes sont devenues plus abordables au fil du temps, trois facteurs semblent avoir sapé l'efficacité de l'augmentation des prix et des taxes dans l'objectif de réduction de la consommation de tabac au Bangladesh. Premièrement, la structure multi-niveau des droits d'accise sur le tabac a eu pour effet d'augmenter le différentiel de prix entre les marques, ce qui a poussé les consommateurs à opter pour des cigarettes moins chères. Deuxièmement, l'augmentation des revenus et le changement de préférence des consommateurs en faveur de produits de meilleure qualité ont fait que les consommateurs ont délaissé le tabac à rouler local (Bangladesh ha alcanzado una elevada cuota de impuestos en el precio de los cigarrillos (superior al 75 % de referencia), pero no ha logrado los beneficios para la salud esperados de la reducción del consumo de cigarrillos. En este artículo exploramos por qué los impuestos sobre los cigarrillos no han logrado reducir el consumo de cigarrillos en Bangladesh. Utilizando los registros del gobierno entre 2006 y 2017, vinculamos las tendencias de las ventas de cigarrillos pagados con la estructura de los impuestos al consumo de cigarrillos y los cambios en los impuestos y precios de los cigarrillos. Se analizaron los datos sobre la prevalencia del tabaquismo de la Encuesta Mundial del Tabaco en Adultos de Bangladesh para estudiar el consumo de diferentes productos de tabaco en 2009 y 2017. Basándonos en los informes anuales de los fabricantes de tabaco y otras publicaciones, examinamos los factores de la demanda y la oferta en el mercado de cigarrillos. Además de la creciente asequibilidad de los cigarrillos, tres factores parecen haber socavado la eficacia de los aumentos de impuestos y precios en la reducción del consumo de cigarrillos en Bangladesh. En primer lugar, la estructura del impuesto especial de varios niveles amplió la diferencia de precios entre las marcas e incentivó la sustitución a la baja por parte de los fumadores, que pasaron de los cigarrillos de precio más alto a los de precio más bajo. En segundo lugar, el crecimiento de los ingresos y el cambio de las preferencias de los fumadores por productos de mejor calidad fomentaron la sustitución de los cigarrillos locales enrollados a mano (حققت بنغلاديش نسبة عالية من الضرائب في أسعار السجائر (بمعيار أكبر من 75٪) ولكنها لم تحقق الفوائد الصحية المتوقعة من انخفاض استهلاك السجائر. في هذه الورقة نستكشف لماذا لم ينجح فرض الضرائب على السجائر في الحد من تدخين السجائر في بنغلاديش. باستخدام السجلات الحكومية خلال الفترة من عام 2006 إلى عام 2017، فإننا نربط اتجاهات مبيعات السجائر مدفوعة الضرائب، بهيكل الضريبة المقتطعة على السجائر والتغيرات في ضرائب وأسعار السجائر. ﻗﻤﻨﺎ ﺑﺘﺤﻠﻴﻞ ﺍﻟﺒﻴﺎﻧﺎﺕ ﺣﻮﻝ ﻣﻌﺪﻝ ﺍﻧﺘﺸﺎﺭ التدخين ﻣﻦ ﺍﻻﺳﺘﻘﺼﺎﺀﺍﺕ العالمية المتعلقة ﺑﺎﻟﺘﺒﻎ بين ﺍﻟﻜﺒﺎﺭ في بنغلاديش ﻟﺪﺭﺍﺳﺔ ﺍﺳﺘﻬﻼك ﻣﻨﺘﺠﺎﺕ ﺍﻟﺘﺒﻎ المختلفة في الفترة من عام ٢٠٠٩ إلى ٢٠١٧. بالاعتماد على التقارير السنوية من شركات تصنيع التبغ والأدبيات الأخرى، نقوم بفحص عوامل جانب الطلب والعرض في سوق السجائر. بالإضافة إلى القدرة المزايدة على تحمل تكاليف السجائر، يبدو أن ثلاثة عوامل قد قللت من فعالية الضرائب وزيادة الأسعار في الحد من استهلاك السجائر في بنغلاديش. أولاً، قام هيكل الضرائب المقتطعة متعددة الأطراف بتوسيع فارق السعر بين العلامات التجارية، كما قام بتحفيز الاستبدال التنازلي بواسطة المدخنين من السجائر الأعلى سعراً إلى الأقل سعراً. ثانيا، شجع نمو الدخل وتغيير أذواق المدخنين تجاه منتجات ذات نوعية أفضل، على استبدال السجائر المحلية الملفوفة يدوياً (bidi) إلى السجائر ذات الأسعار المنخفضة المصنوعة آلياً. ثالثًا، أدى توسع السوق في صناعة التبغ واستراتيجية التسعير التفاضلية إلى تغيير السعر النسبي للحفاظ على أسعار السجائر منخفضة السعر. قد تكون الحصة الضريبية المرتفعة وحدها غير كافية كمقياس للضرائب الفعالة على التبغ في البلدان ذات الدخل المنخفض والمتوسط، خاصة عندما يكون هيكل ضريبة التبغ معقدًا، وأسعار منتجات التبغ منخفضة نسبيًا، والقدرة على تحمل تكلفة منتجات التبغ في ازدياد.孟加拉国对卷烟价格（高于基准价格 75％）实施高税收份额，但此举并未降低卷烟消费量，实现预期的健康效益。本文中，我们探讨了孟加拉国烟草税未能成功减少吸烟的原因。根据 2006 年至 2017 年的政府记录，我们将已纳税卷烟的销售趋势与卷烟消费税结构以及卷烟税及其价格的变化联系起来。我们分析了孟加拉国全球成人烟草调查的吸烟率数据，旨在研究 2009 年和 2017 年不同烟草产品的消费情况。根据烟草制造商的年度报告和其他文献，我们研究了烟草市场的供求因素。除卷烟的可负担性增加之外，似乎还存在另外三大因素，削弱了税收和价格上涨在减少孟加拉国国卷烟消费方面的有效性。首先，多层消费税结构扩大了品牌之间的价格差异，并鼓励吸烟者从高价卷烟向下寻找廉价卷烟进行替代。其次，吸烟者的收入增长和对优质产品的偏好转变，鼓励其从手工卷制的本地卷烟 (В Бангладеш достигнута высокая планка налогообложения сигарет (более 75% базисного показателя), но ожидаемой пользы для здравоохранения от сокращения потребления сигарет добиться не удалось. В данной статье рассмотрены причины, по которым налог на сигареты не привел к сокращению курения в Бангладеш. Используя правительственные данные за период с 2006 по 2017 год, авторы связали тенденции продаж облагаемых налогом сигарет со структурой акцизного налога на сигареты и с изменениями в налогообложении и ценообразовании на сигареты. Авторы проанализировали данные о частоте курения по данным Глобального опроса о потреблении табака взрослыми в Бангладеш, чтобы оценить потребление различной табачной продукции в период с 2009 по 2017 год. На основании ежегодных отчетов производителей табачных изделий и других справочных данных авторы изучили побочные факторы спроса и потребления сигарет на рынке. В дополнение к растущей доступности сигарет следующие три фактора снизили эффективность увеличения налогов и цен в вопросе снижения потребления сигарет в Бангладеш. Во-первых, многоуровневая структура акцизного налога увеличила ценовую разницу между брендами и стимулировала переход курильщиков с более дорогой продукции на более дешевую. Во-вторых, рост доходов населения и смещение предпочтений курильщиков в сторону более качественной продукции стимулировали переход с самодельных сигарет (так называемых биди) к дешевой фабричной продукции. В-третьих, расширение рынка табачной промышленности и дифференцированное ценообразование изменили относительный масштаб цен таким образом, что дешевые сигареты остались недорогими. Сама по себе высокая планка налогообложения может оказаться недостаточной для эффективного налогообложения табачных изделий в странах с малым и средним уровнем дохода. В частности, если налог на табачные изделия имеет сложную структуру, цены на табачные изделия остаются относительно низкими, а доступность табачной продукции растет.

This month in the Bulletin, a research paper by Togoobaatar et al. reveals that more than 40% of children in Mongolia are given antibiotics without prescription for respiratory tract infections.1 Another paper published recently by Kumarasamy et al. highlights the serious threat posed by the NDM-1 (New Delhi metallo-β-lactamase-1) superbug, a microbial threat for which there is limited surveillance and no effective treatment.2 Almost ten years since the WHO global strategy for containment of antimicrobial resistance was published, the World Health Organization has announced this topic as the theme for World Health Day in 2011.3 Antimicrobial resistance is a serious problem that strikes at the core of infectious disease control and has the potential to halt, and possibly even to roll back, progress. While it is a natural response of microbes, resistance can be contained through careful and appropriate antibiotic use. Western European countries have managed to decrease the rate of antimicrobial resistance in some pathogens through a multipronged approach in comprehensive well regulated health systems.4 Integrated monitoring of antibiotic consumption and resistance, prescriber and consumer education that is coordinated and paid for by the government, and regulation of use in communities and hospitals have shown that it is possible to contain antimicrobial resistance. Unfortunately, even in well regulated systems, such as those in Europe, resistance in some pathogens continues to increase unabated and problems remain in the use of antibiotics outside the health system, especially in veterinary use. What of the developing world, where there is much less regulation, diagnostics are sparse and comprehensive health care is a distant prospect? Fragmented health services, mainly in the profit-driven private sector, make antibiotics an easy target for misuse and abuse.5 Given the paucity of surveillance, it is likely that the true extent of antimicrobial resistance is unknown and it is “shooting stars” such as the NDM-1 that draw attention to the problem. There is sufficient scientific knowledge about appropriate antibiotic use. Specific antibiotics are effective only against certain organisms, must be taken in a particular dose for a specified duration, and they are ineffective against viral infections. What then are the drivers of behaviour that go against such evidence? There is the fallacy that all infections respond to antibiotics. To many patients, it seems that they do – when a patient with a viral respiratory tract infection gets better after taking amoxicillin, this is usually due to the natural course of the illness and not to the amoxicillin (they may think that the antibiotic’s side-effect of diarrhoea is actually a symptom of the illness). Mothers feel safer giving children antibiotics rather than steam inhalations and paracetamol. Physicians prescribe antibiotics for simple viral infections in otherwise healthy patients to prevent possible secondary bacterial infections, despite good clinical trials showing no value of such prophylaxis. Pharmacists readily dispense antibiotics without prescription in the developing world as their income depends on sales rather than on a professional fee or salary. Pharmaceutical companies may promote sales of antibiotics independent of patient need. Finally, most antibiotics, by virtue of their safety and short courses, lend themselves to abuse; patients often take antibiotics of their own accord, whereas few people would take antihypertensive medications on their own. Combating these behaviours in settings with poor health-care infrastructure, limited regulation and inadequate health education is a whole new challenge. Repeated calls for better regulation of medicines must not obstruct appropriate access; antibiotic use will continue to grow in low- and middle-income countries to meet underserved needs. Such increased use must be tied to rational use. Improved drug access without significant improvements in appropriate use will have dire consequences, with continued emergence of “superbugs” and untreatable infections. Fortunately, improvements in the appropriate use of antibiotics generally reduce health costs as the majority of antibiotic use in most communities is unnecessary. Containing antimicrobial resistance is the theme of World Health Day 2011. The World Health Organization is developing a comprehensive policy package for health ministries addressing nearly all stakeholders. This should be an opportunity to launch sustainable action to contain resistance, to raise awareness and education using electronic media, and to track and contain spread of resistance with improved informatics and better clinical decision support through the development and use of bedside diagnostics. Whatever is done, it would be wise to remember the mother in Mongolia. Until the total package is able to address her concerns, indiscriminate use of antibiotics will continue. Regulation, education and health care that consider sociocultural and economic factors and utilize improving global communication must be critical components of renewed efforts to contain antimicrobial resistance.

Climate change and population, taken individually, are among the most contentious issues in public policy; bringing the two issues together is a recipe for controversy. The paper by Bryant et al. (852–857) in this issue1 points towards a more constructive approach to addressing these linked concerns. For all of its complexities, the basic challenge of climate-change policy is the apparent conflict between the drive to maximize short-term individual or national gains (increasing per capita GDP through use of cheap fossil fuel energy) and the need for long-term protection of shared benefits (reducing climate change and minimizing global damage to natural and human systems). Closely tied to this is the issue of fairness. Those populations that have contributed least to past emissions of greenhouse gases are most vulnerable to the impacts of climate change, including on population health.2,3 The governments of developing countries are therefore reluctant to commit to limits on greenhouse gas emissions to help solve a problem that has, so far, been created elsewhere. For their part, the governments of richer countries generally acknowledge their responsibility to take a lead in combating climate change, but hesitate in implementing policies that they consider may harm short-term economic growth and hamper their competitiveness against rapidly developing economies. Some aspects of this debate find analogies in discussion of population policy. Again, there is a potential tension between the immediate rights of individuals (to control their own fertility) and a longer-term, population-level concern (that rapid population growth could potentially overstretch natural and socioeconomic resources, hamper development and lay conditions for conflict). These two issues are also closely linked, but discussing them together has often generated more heat than light. Although the major driver of greenhouse gas emissions remains the consumption patterns of richer populations, human population is also a fundamental determinant of this trend. However, even stating the fairly obvious fact that an individual’s number of children makes a major contribution to their “legacy” of greenhouse gas emissions4 has sparked outraged reaction in some quarters. Population growth is also fastest in developing countries, leading to suggestions that this should be the starting point to reduce climate change. In response, developing countries point out that per capita emissions of children born in poor countries are, and are likely to remain, much lower than those in richer countries, and claim that they are being stigmatized for “profligate reproductive behaviour” as a negotiating position over greenhouse gas commitments.5 Can these issues be discussed constructively? The best approach is probably to choose the least controversial entry point – identifying where human rights, health, environmental and equity objectives converge, rather than conflict. This can be framed around the fact that, in developing countries, approximately 200 million women express an unmet need for family planning services.6 Meeting this need is supported by the following arguments. First, control over reproduction is an individual right, supported through the landmark Programme of Action of the 1994 International Conference on Population and Development. Improved access to reproductive health services is also a Millennium Development Goal. Second, it provides major public health benefits; systematic reviews across multiple countries show that increasing birth spacing from less than 18 to more than 36 months correlates with a two-thirds drop in childhood mortality.7 Third, reducing local overpopulation decreases vulnerability to near-term environmental and other stresses. Fourth, over the long-term, it relieves climate change and other pressures on the global environment.8 Other studies have already identified improved access to reproductive health services as one of several “win-win” interventions that can both improve individual well-being and reduce climate change.9–11 The paper by Bryant et al., however, is the first to provide strong support for the third point – showing that the majority of the least-developed countries cite population pressure as an important determinant of their vulnerability to climate change. The fact that the affected countries themselves identify this as a local priority avoids the conflict that comes from framing population regulation as a way of reducing global greenhouse gas emissions. When developing this case, the order of the arguments is critically important. Individual rights come first, with the population health, local and global environmental benefits as welcome and important co-benefits. In contrast, using the need to reduce climate change as a justification for curbing the fertility of individual women at best provokes controversy and, at worst, provides a mandate to suppress individual freedoms. This new paper is an important contribution in its own right. It is also a reminder that, although the case for family planning services should be self-evident, it needs to be carefully constructed and sensitively handled. ■