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This paper describes the development of a tool that uses human rights concepts and methods to improve relevant laws, regulations and policies related to sexual and reproductive health. This tool aims to improve awareness and understanding of States' human rights obligations. It includes a method for systematically examining the status of vulnerable groups, involving non-health sectors, fostering a genuine process of civil society participation and developing recommendations to address regulatory and policy barriers to sexual and reproductive health with a clear assignment of responsibility. Strong leadership from the ministry of health, with support from the World Health Organization or other international partners, and the serious engagement of all involved in this process can strengthen the links between human rights and sexual and reproductive health, and contribute to national achievement of the highest attainable standard of health.

Compulsory service programmes have been used worldwide as a way to deploy and retain a professional health workforce within countries. Other names for these programmes include ”obligatory”, ”mandatory”, ”required” and ”requisite.” All these different programme names refer to a country’s law or policy that governs the mandatory deployment and retention of a heath worker in the underserved and/or rural areas of the country for a certain period of time. This study identified three different types of compulsory service programmes in 70 countries. These programmes are all governed by some type of regulation, ranging from a parliamentary law to a policy within the ministry of health. Depending on the country, doctors, nurses, midwives and all types of professional allied health workers are required to participate in the programme. Some of the compliance-enforcement measures include withholding full registration until obligations are completed, withholding degree and salary, or imposing large fines. This paper aims to explain these programmes more clearly, to identify countries that have or had such programmes, to develop a typology for the different kinds and to discuss the programmes in the light of important issues that are related to policy concepts and implementation. As governments consider the cost of investment in health professionals’ education, the loss of health professionals to emigration and the lack of health workers in many geographic areas, they are using compulsory service requirements as a way to deploy and retain the health workforce.

This paper proposes an explanation concerning why some global health issues such as HIV/AIDS attract significant attention from international and national leaders, while other issues that also represent a high mortality and morbidity burden, such as pneumonia and malnutrition, remain neglected. The rise, persistence and decline of a global health issue may best be explained by the way in which its policy community - the network of individuals and organizations concerned with the problem - comes to understand and portray the issue and establishes institutions that can sustain this portrayal. This explanation emphasizes the power of ideas and challenges interpretations of issue ascendance and decline that place primary emphasis on material, objective factors such as mortality and morbidity levels and the existence of cost-effective interventions. This explanation has implications for our understanding of strategic public health communication. If ideas in the form of issue portrayals are central, strategic communication is far from a secondary public health activity: it is at the heart of what global health policy communities do.

In 2003, the Mexican Congress approved a reform establishing the Sistema de Protección Social en Salud [System of Social Protection in Health], whereby public funding for health is being increased by one percent of the 2003 gross domestic product over seven years to guarantee universal health insurance. Poor families that had been excluded from traditional social security can now enrol in a new public insurance scheme known as Seguro Popular [People's Insurance], which assures legislated access to a comprehensive set of health-care entitlements. This paper describes the financial innovations behind the expansion of health-care coverage in Mexico to everyone and their effects. Evidence shows improvements in mobilization of additional public resources; availability of health infrastructure and drugs; service utilization; effective coverage; and financial protection. Future challenges are discussed, among them the need for additional public funding to extend access to costly interventions for non-communicable diseases not yet covered by the new insurance scheme, and to improve the technical quality of care and the responsiveness of the health system. Eventually, the progress achieved so far will have to be reflected in health outcomes, which will continue to be evaluated so that Mexico can meet the ultimate criterion of reform success: better health through equity, quality and fair financing.

Mental health is a low priority in most countries around the world. Minimal research and resources have been invested in mental health at the national level. As a result, WHO has developed the Assessment Instrument for Mental Health Systems (WHO-AIMS) to encourage countries to gather data and to re-evaluate their national mental health policy. This paper demonstrates the utility and limitations of WHO-AIMS by applying the model to four countries with different cultures, political histories and public health policies: Iraq, Japan, the Philippines and The former Yugoslav Republic of Macedonia. WHO-AIMS provides a useful model for analysing six domains: policy and legislative framework; mental health services; mental health in primary care; human resources; education of the public at large; and monitoring and research. This is especially important since most countries do not have experts in mental health policy or resources to design their own evaluation tools for mental health systems. Furthermore, WHO-AIMS provides a standardized database for cross-country comparisons. However, limitations of the instrument include the neglect of the politics of mental health policy development, underestimation of the role of culture in mental health care utilization, and questionable measurement validity.

PROBLEM: In 2003, the goal of the Kenyan Ministry of Health was to avail antiretroviral treatment (ART) to 50% of the estimated 250 000 eligible individuals by the end of 2005. By July 2005, 45 000 adults and more than 2000 children were on treatment. A study was conducted to determine the barriers to identification of HIV-infected children. APPROACH: Existing government policies were reviewed and the ART register of the Kenya National AIDS Control Programme was used to identify facilities providing ART. This paper reports the findings around diagnosis and staging of HIV infection in children. LOCAL SETTING: At the time of the study, 58 health facilities were providing ART to children. Only one institution had achieved universal HIV testing in the antenatal clinics. Six facilities systematically followed up HIV-exposed children. HIV antibody testing was not readily available to the children. Although four research centres were capable of carrying out diagnostic HIV polymerase chain reaction (PCR), the services were restricted to research purposes. Other constraints were inadequate physical infrastructure, inadequate systems for quality control in the laboratories and shortage of staff. LESSONS LEARNT: The policy framework to support identification of HIV-infected children had been established, albeit with narrow focus on sick children. The assessment identified the weaknesses in the structures for systematic diagnosis of HIV through laboratory or clinical-based algorithms. The researchers concluded that health staff training and implementation of a systematic standard approach to identification of HIV-infected children is urgently required.

In the 132nd session of the Executive Board of the World Health Organization (WHO), held in January of this year, the phrase “health diplomacy” was mentioned time and time again. Indeed, the Director-General used it in her opening remarks: “Health diplomacy works.”1 In two papers published in this Bulletin in 2007, we underscored the importance of global health diplomacy, particularly the need to build capacity in this domain within WHO and in WHO’s Member States, in line with changes in the global environment.2,3 During the years that have since transpired, it has become amply clear that health diplomacy is not a transient fashion. In fact, the Global Health Programme 2012, launched by The Graduate Institute in Geneva to promote research and knowledge translation and diffusion, represents a turning point in global health diplomacy training. This training takes the form of face-to-face as well as online courses for diplomats, health attaches and staff of international organizations. WHO staff at headquarters, regional offices and country offices take part in the programme, and China, Hungary, Indonesia and Turkey are now co-hosting courses with the Institute or WHO.4 Four elements have contributed to the ascent of global health diplomacy. First, foreign affairs ministries are becoming more involved in health because of its relevance for soft power, security policy, trade agreements and environmental and development policy. Countries need to address trans-border challenges that can undermine global stability, such as pandemics and climate change.5 Health touches on matters of national and economic interest; it embodies the tensions between national sovereignty and global collective action. New skills are needed to negotiate global regimes. Some countries have addressed this by seeking greater coherence “at home” between foreign policy and health policy through national global health strategies that bring together different ministries concerned with domestic and global issues so they can speak with one voice in the global arena.6 Second, the venues of health diplomacy are expanding; many new actors outside WHO have become (health) diplomats.7 “Global health diplomacy” refers to both a system of organization and to communication and negotiation processes that shape the global policy environment in the sphere of health and its determinants. Health is part of summit diplomacy in the United Nations and of club and head-of-state diplomacy involving countries such as the group of eight (G8), the group of twenty (G20) and BRICS (Brazil, the Russian Federation, India, China and South Africa). The European Union (EU) has adopted the European Council’s conclusions on the EU’s role in global health in 2010 and the Organisation of Islamic Cooperation has recently established a unit for health issues. Global issue diplomacy continues in connection with human immunodeficiency virus infection, children’s health and non-communicable diseases – and it is particularly in this area that nongovernmental organizations, foundations and companies have become health diplomats. The ministries of health now play a dual role: to promote the country’s health and to advance the health of the global community. Third, globalization, new donor–recipient relationships, new types of health alliances and the rise of cooperation between low- and middle-income countries have heightened the need for health diplomacy.8,9 More long-term negotiation processes for both binding and non-binding agreements are taking place. One example is the WHO Pandemic Influenza Preparedness Framework. Approved by the World Health Assembly in 2010, it is a milestone in global health governance.10 The 2011 United Nations (UN) High-Level Meeting on Non-Communicable Diseases adopted the Political Declaration on the Prevention and Control of Non-communicable Diseases. The Protocol to Eliminate Illicit Trade in Tobacco Products was adopted by the parties to the WHO Framework Convention on Tobacco Control in 2012. New challenges are in the wings: negotiating ways to implement the recommendations of the Consultative Expert Working Group on Research and Development; finalizing decisions on the WHO reform process; embedding health within a UN Framework Convention on Climate Change and, of course, establishing health goals in the post-2015 development agenda. Fourth, we need competent health diplomats more than ever. Fly-in, fly-out negotiations for health no longer suffice.11 The many health negotiations taking place in different venues involve interactions at many levels of governance and a new interface between domestic and foreign policy. Representatives of countries and other interested actors are continuously engaged in negotiations in hubs such as Geneva, New York, Brussels and Addis Ababa, and health attaches play an important role, but not many countries can dedicate substantial resources to these negotiation processes. At the recent session of WHO’s Executive Board, Member States underlined the importance of good preparation at the national and, increasingly, at the regional level. Global health diplomacy, if well conducted, results in improved global health, greater equity, better relations and trust between states and a strengthened commitment on the part of stakeholders to work together to improve health nationally and globally. We hope that there will be increasing willingness to support countries seeking to strengthen their capacity not only in the governance of health systems, but also in global health diplomacy.

Unless the concept is clearly understood, "universal coverage" (or universal health coverage, UHC) can be used to justify practically any health financing reform or scheme. This paper unpacks the definition of health financing for universal coverage as used in the World Health Organization's World health report 2010 to show how UHC embodies specific health system goals and intermediate objectives and, broadly, how health financing reforms can influence these. All countries seek to improve equity in the use of health services, service quality and financial protection for their populations. Hence, the pursuit of UHC is relevant to every country. Health financing policy is an integral part of efforts to move towards UHC, but for health financing policy to be aligned with the pursuit of UHC, health system reforms need to be aimed explicitly at improving coverage and the intermediate objectives linked to it, namely, efficiency, equity in health resource distribution and transparency and accountability. The unit of analysis for goals and objectives must be the population and health system as a whole. What matters is not how a particular financing scheme affects its individual members, but rather, how it influences progress towards UHC at the population level. Concern only with specific schemes is incompatible with a universal coverage approach and may even undermine UHC, particularly in terms of equity. Conversely, if a scheme is fully oriented towards system-level goals and objectives, it can further progress towards UHC. Policy and policy analysis need to shift from the scheme to the system level.Si le concept est correctement défini, la «couverture universelle» (ou la couverture maladie universelle, CMU) peut être utilisée pour justifier pratiquement toute réforme ou tout régime du financement des soins de santé. Ce document présente la définition du financement des soins de santé pour une couverture universelle, telle qu'elle apparaît dans le Rapport sur la santé dans le monde 2010 de l'Organisation mondiale de la Santé, afin de montrer comment la CMU incarne les objectifs spécifiques et intermédiaires du système de santé et, plus généralement, comment les réformes du financement du système de santé peuvent influencer ces objectifs.Tous les pays cherchent à améliorer l'équité dans l'utilisation des services de santé, dans la qualité des services et dans la protection financière des populations. Par conséquent, la survie de la CMU reste pertinente pour tous les pays. La politique de financement des soins de santé fait partie intégrante des efforts réalisés pour faire de la CMU une réalité, mais pour que cette politique de financement permette la survie de la CMU, les réformes du système de santé doivent viser explicitement l'amélioration de la couverture santé et les objectifs intermédiaires qui y sont liés, à savoir, l'efficacité, l'équité dans la répartition des ressources de la santé, ainsi que la transparence et la responsabilisation.L'unité d'analyse de ces objectifs doit prendre en compte la population et le système de santé dans son ensemble. Ce qui importe, ce n'est pas comment un système de financement particulier affecte chacun de ses membres, mais plutôt comment il influe sur les progrès et conduit vers une CMU à l'échelle des populations. Les préoccupations autour des programmes spécifiques sont incompatibles avec une approche de couverture universelle et peuvent même nuire à la CMU, notamment en termes d'équité. Et inversement, si un régime est pleinement orienté sur des objectifs systémiques, il peut étendre les progrès réalisés à la CMU. Les analyses des politiques et les politiques elles-mêmes doivent changer d'échelle pour passer du simple régime au système.A menos que se entienda el concepto con claridad, “cobertura universal” (o cobertura sanitaria universal) se puede utilizar para justificar casi cualquier reforma o plan de financiación sanitaria. El presente documento amplía la definición de financiación de la salud para una cobertura universal, tal y como se utiliza en el Informe sobre la salud en el mundo 2010 de la Organización Mundial de la Salud, a fin de mostrar cómo la cobertura sanitaria universal abarca los objetivos concretos e intermedios relacionados con los sistemas sanitarios y, en sentido amplio, cómo pueden influir en los mismos las reformas de financiación sanitaria.Todos los países pretenden mejorar la igualdad en la utilización de los servicios sanitarios, la calidad de estos y la protección financiera de su población. Por ello, la búsqueda de una cobertura sanitaria universal es importante para cada país. La política de financiación de la salud es un elemento esencial en los esfuerzos para avanzar hacia la cobertura sanitaria universal. Sin embargo, para que las estrategias de financiación de la salud estén en línea con la procura de la cobertura sanitaria universal, las reformas del sistema sanitario deben aspirar de forma explícita a mejorar la cobertura y los objetivos intermedios relacionados con esta, a saber, la eficacia, la igualdad en la distribución de los recursos, así como la transparencia y la responsabilidad.La unidad sobre la cual se deben analizar las metas y objetivos debe ser la población y el sistema sanitario en conjunto. Lo importante no es cómo un modelo particular de financiación afecta a cada uno de sus miembros, sino cómo influye en el progreso hacia la cobertura sanitaria universal a nivel de la población. Si únicamente concierne a proyectos concretos, será incompatible con un enfoque universal e incluso podría minar la cobertura sanitaria universal, particularmente en lo que respecta a la igualdad. Por el contrario, si un plan se enfoca por completo hacia los objetivos y las metas a nivel del sistema, se puede continuar avanzando hacia la cobertura sanitaria universal. Las estrategias y los análisis de estrategias tienen que cambiar desde el nivel del plan al nivel del sistema.يمكن استخدام "التغطية الشاملة" (أو التغطية الصحية الشاملة، UHC) لتبرير أي إصلاح أو مخطط في مجال التمويل الصحي بشكل عملي، ما لم يتم فهم المفهوم بوضوح. وتشرح هذه الورقة تعريف التمويل الصحي من أجل التغطية الشاملة وفق استخدامه في التقرير الخاص بالصحة في العالم لعام 2010 الصادر عن منظمة الصحة العالمية، لإيضاح مدى اشتمال التغطية الصحية الشاملة على مرامي معينة وأغراض متوسطة للنظام الصحي، والكيفية التي يمكن أن تؤثر بها إصلاحات التمويل الصحي عليها، على نحو واسع. تسعى جميع البلدان لتحسين الإنصاف في استخدام الخدمات الصحية وجودة الخدمات والحماية المالية لسكانها. ولذا، توجد صلة لهدف التغطية الصحية الشاملة بكل بلد. وتعد سياسة التمويل الصحي جزءاً لا يتجزأ من الجهود الرامية للتوجه صوب التغطية الصحية الشاملة، ولكن لكي تتماشى سياسة التمويل الصحي مع هدف التغطية الصحية الشاملة، يجب أن تستهدف إصلاحات النظم الصحية بوضوح تحسين التغطية والأغراض المتوسطة المرتبطة بها، وتحديدًا، الكفاءة والإنصاف في توزيع الموارد الصحية والشفافية والمساءلة. يجب أن تكون وحدة التحليل للمرامي والأغراض هي السكان والنظام الصحي ككل. وما يستحق الاهتمام ليس الكيفية التي يؤثر بها مخطط تمويلي معين على أعضائه الفرديين، وإنما هو الكيفية التي يؤثر بها على التقدم صوب التغطية الصحية الشاملة على الصعيد السكاني. ولا يتوافق القلق بشأن مخططات معينة فقط مع أسلوب التغطية الشاملة بل قد يقوض التغطية الصحية الشاملة، ولاسيما الإنصاف. وفي مقابل ذلك، إذا تم توجيه أحد المخططات بشكل كامل صوب المرامي والأغراض على مستوى النظام، فإنه يستطيع إحراز مزيد من التقدم صوب التغطية الصحية الشاملة. ويتعين أن تتحول السياسات وتحليل السياسات من المخطط إلى مستوى النظام.除非概念非常清楚,“全面医保”(或全民健康保险,UHC)实际上可以用来证明任何医疗融资改革或计划。本文分析世界卫生组织的《2010年世界卫生报告》中使用的全面医保的卫生筹资定义,以说明UHC如何体现特定卫生系统目标和中间目标,并更广泛地说明卫生筹资改革如何影响这些目标。所有国家都追求提高其公民在使用卫生服务、服务质量和金融保护方面的公平性。因此,UHC目标对每个国家都很重要。卫生筹资政策是实现UHC的工作组成部分,但卫生筹资政策要与UHC目标看齐,卫生系统改革需要明确改善医保范围以及与其关联的中间目标,即在卫生资源分配、透明度和问责制方面的效率和公平。目的和目标的分析单位必须是整体人口与健康系统。重要的不是特定的筹资计划如何影响其个别成员,而是它如何影响群体水平上的UHC进展。只局限于具体方案的做法与合全民医保方法格格不入,甚至可能破坏UHC,在公平方面尤其如此。反之,如果计划完全面向系统层面的目标和目的,它可以进一步迈向UHC。政策和政策分析需要从计划转移到系统层面。В отсутствие четкого понимания соответствующей концепции понятие «единая система» (или «единая система здравоохранения», ЕСЗ) может использоваться при обосновании практически любой реформы или схемы финансирования. В данной статье раскрыто понятие финансирования здравоохранения применительно к единой системе здравоохранения, которое используется в публикации «Доклад о состоянии здравоохранения в мире в 2010 году» Всемирной Организации Здравоохранения, чтобы продемонстрировать, как ЕСЗ реализует конкретные задачи системы здравоохранения и достигает ее промежуточных целей, а также показать в общих чертах, как на это могут повлиять реформы финансирования системы здравоохранения.Все государства стремятся к обеспечению равенства доступа населения к медицинским услугам, качеству обслуживания и финансовой защите. Поэтому стремление к созданию ЕСЗ свойственно каждому из них. Политика финансирования здравоохранения является составной частью усилий по продвижению к ЕСЗ, однако, чтобы она соответствовала стремлению к ЕСЗ, реформы системы здравоохранения должны быть четко направлены на улучшение охвата и достижение связанных с ним промежуточных целей, а именно, на эффективность, справедливое распределение ресурсов здравоохранения, обеспечение прозрачности и ответственности.Предметом анализа для определения целей и задач должны быть население и система здравоохранения в целом. Это подразумевает изучение не того, как конкретная схема финансирования воздействует на ее отдельных участников, а скорее того, как она влияет на продвижение к ЕСЗ на уровне населения. Интерес только к конкретным схемам несовместим с подходом, который подразумевается единой системой здравоохранения, и даже может подрывать принципы ЕСЗ, особенно в плане обеспечения справедливости. И наоборот, если схема полностью ориентирована на достижение целей и задач на уровне всей системы, она способна обеспечить дальнейшее продвижение к ЕСЗ. Политика и ее анализ должны перейти с уровня схемы на уровень системы.

Introduction What will it take to eliminate the gross health inequities that continue to plague the world, the unconscionable health gaps between the rich and poor? The eyes of the global health community are focused on the post-2015 sustainable development goals, with the World Health Organization [WHO] advocating for universal health coverage. Adding healthy life expectancy as an overarching goal would capture the broader determinants of health and offer a richer integration of multiple sectors. Beyond improving health, the United Nations [UN] should focus on equity, human rights, inclusive participation and accountability, (2) The stage is set for the post-2015 agenda to embrace global health with justice--improving healthy lives for everyone, with particular attention to marginalized communities. The sustainable development agenda, however, cannot achieve global health with justice without robust global governance. We urge adoption of a legally binding global health treaty--a framework convention on global health grounded in the right to health. What are the purposes and content of a framework convention and how can such a treaty help to achieve global health with justice? And what steps need to be taken to galvanize support for its adoption and implementation? This perspectives paper seeks to spark international dialogue on a framework convention on global health and to explore the pathways towards a global health treaty. Core purposes and content The Millennium Development Goals were instrumental in achieving considerable progress in global health, but they failed to close the health gap. The overriding purpose of a framework convention on global health would be to dramatically reduce the health disadvantages experienced by the marginalized and the poor, both within countries and between them, while reducing health injustices across the socioeconomic gradient. Guided by principles underlying the right to health and mutual responsibility, a framework convention would universally ensure three conditions that are essential for a healthy life: a well-functioning health system providing quality health care; a full range of public health services, such as nutritious food, clean water, and a healthy environment; and broader economic and social conditions conducive to good health, such as employment, housing, income support and gender equality. Substantial improvements in health would be achieved through a population-based strategy centred on the essential conditions for the public's health, ranging from food, water and clean air to hygienic conditions, injury prevention and liveable communities conducive to physical activity and to healthful eating habits. By embedding the conditions for good health within the environment and bringing these benefits to everyone, including the poorest and most remote communities, public health services would give everyone a fair chance for a healthy life. Universal access to all levels of health care [community services and primary, secondary and tertiary care] and to financial protection [to prevent impoverishment and catastrophic health expenditures] would afford everyone the services needed to prevent and treat injury and disease. Importantly, policies and actions across the full spectrum of government ministries are needed to ensure education, employment, housing, clean energy, transportation, gender equity and all other positive social determinants of health. A framework convention would establish a health financing framework with clear obligations, and would create an accountability regime with robust standards, monitoring and enforcement. It would advance health justice through engaging marginalized and underserved populations in making and evaluating policies and through comprehensive strategies and targeted interventions designed to overcome the barriers that prevent these populations from enjoying the conditions required for good health. …

In China, alcohol consumption is increasing faster than anywhere else in the world. A steady increase in alcohol production has also been observed in the country, together with a rise in alcohol-related harm. Despite these trends, China's policies on the sale and consumption of alcoholic beverages are weak compared with those of other countries in Asia. Weakest of all are its policies on taxation, drink driving laws, alcohol sale to minors and marketing licenses. The authors of this descriptive paper draw attention to the urgent need for public health professionals and government officials in China to prioritize population surveillance, research and interventions designed to reduce alcohol use disorders. They describe China's current alcohol policies and recent trends in alcohol-related harm and highlight the need for health officials to conduct a thorough policy review from a public health perspective, using as a model the World Health Organization's global strategy to reduce the harmful use of alcohol.En Chine, la consommation d'alcool augmente plus rapidement que partout ailleurs dans le monde. Une augmentation constante de la production d'alcool a également observée dans le pays, ainsi qu'une augmentation des méfaits de l'alcool. Malgré ces tendances, les politiques de la Chine en matière de vente et de consommation de boissons alcoolisées sont faibles comparées à celles des autres pays d'Asie. Les plus faibles de toutes sont ses politiques sur la taxation, les lois relatives à l'alcool au volant, la vente d'alcool aux mineurs et la commercialisation des licences. Les auteurs de cet article descriptif attirent l'attention sur la nécessité urgente pour les professionnels de la santé publique et les fonctionnaires gouvernementaux chinois d'accorder la priorité à la surveillance de la population, la recherche et les interventions destinées à réduire les troubles liés à la consommation d'alcool. Ils décrivent les politiques actuelles sur l'alcool en Chine et les tendances récentes des méfaits de l'alcoolisme. Ils soulignent également la nécessité pour les autorités sanitaires de procéder à un examen approfondi de la politique dans une perspective de santé publique, en prenant comme modèle la stratégie globale de l'Organisation mondiale de la Santé afin de réduire l'usage nocif de l'alcool.En China, el consumo de alcohol está aumentando con mayor rapidez que en cualquier otro lugar del mundo, y también se ha observado un crecimiento constante de la producción de alcohol en el país, junto con un aumento de los daños relacionados con esta sustancia. A pesar de estas tendencias, las políticas chinas sobre la venta y consumo de bebidas alcohólicas son débiles en comparación con las de otros países asiáticos. Las políticas más débiles son las que regulan los impuestos, las leyes de consumo y conducción, la venta de alcohol a menores de edad y las licencias para la venta de alcohol. Los autores de este artículo descriptivo llaman la atención sobre la necesidad urgente de que los funcionarios gubernamentales y los profesionales de la sanidad pública chinos den prioridad a la vigilancia de la población, a la investigación y a las intervenciones diseñadas para reducir los trastornos provocados por el consumo de alcohol. Describen las políticas actuales chinas relativas al alcohol, así como las tendencias presentes de los daños relacionados con el alcohol y destacan la necesidad de que los funcionarios de salud lleven a cabo una revisión de toda la política desde la perspectiva de la sanidad pública, usando como modelo la estrategia global de la Organización Mundial de la Salud para reducir el uso nocivo de alcohol.يزداد استهلاك الكحول في الصين على نحو أسرع عن أي مكان آخر في العالم. وقد لوحظ كذلك وجود تزايد مطّرد في إنتاج الكحول في البلد، مع ازدياد الأضرار الناجمة عن تعاطي الكحول. وعلى الرغم من هذه الاتجاهات، إلا أن سياسات الصين المعنية ببيع المشروبات الكحولية واستهلاكها ضعيفة مقارنة بسياسات البلدان الأخرى في آسيا، وأضعف هذه السياسات جميعاً، سياساتها المعنية بالضرائب وقوانين القيادة تحت تأثير الكحول وبيع الكحول للقصر وتراخيص التسويق. ويسترعي مؤلفو هذه الورقة الوصفية الاهتمام إلى الحاجة الماسة لكي يقوم العاملون في مجال الصحة العمومية والمسؤولون الحكوميون في الصين بتحديد الأولويات لترصد السكان والبحث والتدخلات المصممة للتقليل من الاضطرابات الناجمة عن تعاطي الكحول. ويصفون السياسات الراهنة المعنية بالكحول في الصين والاتجاهات الحديثة في الأضرار الناجمة عن تعاطي الكحول، ويؤكدون على حاجة المسؤولين الصحيين لإجراء مراجعة شاملة للسياسات من منظور الصحة العمومية، واستخدام الاستراتيجية العالمية للحد من تعاطي الكحول على نحو ضار الصادرة عن منظمة الصحة العالمية كنموذج.酒精饮料的消费在中国的增长速度比世界上的其他任何地方都要快。据观察,该国的酒精饮料生产量也在稳定增长,且酒相关性伤害也随之加剧。纵然有这样的趋势,较之于亚洲其他国家,中国有关酒精饮料的销售和消费政策仍然较为薄弱,尤其的是其在税收、酒后驾车法规、向未成年人销售酒类产品和营销许可证方面的政策。本篇描述性论文作者试图唤起中国公共卫生专业人员和政府官员的对这类问题的关注,迫切需要优先考虑人群监测、科学研究和干预措施,以减少酒精的无序使用。作者们描述了中国当前的酒精饮料政策和酒精所引起危害的最新趋势,强调卫生官员需要从公共卫生的角度进行彻底的政策评估,并作为世界卫生组织减少有害饮酒的全球策略的一个范例。Потребление алкоголя в Китае растет быстрее, чем где-либо еще в мире. В стране также наблюдается устойчивый рост производства алкоголя, соответственно, увеличивается и вред, связанный с его потреблением. Несмотря на эти тенденции, политика Китая по вопросам продажи и потребления алкогольных напитков является слабой, по сравнению с другими странами Азии. Самыми слабыми ее аспектами являются вопросы налогообложения, законы, связанные с вождением в нетрезвом виде, продажей алкоголя несовершеннолетним и маркетинговые лицензии. Авторы данного исследования обращают внимание на срочную необходимость того, чтобы работники общественного здравоохранения и чиновники правительства Китая начали уделять приоритетное внимание популяционному надзору, научным исследованиям и мероприятиям, направленным на сокращение нарушений, связанных с употреблением алкоголя. В документе описана текущая антиалкогольная политика Китая и последние тенденции в области связанного с алкоголем вреда. Также подчеркивается необходимость для руководителей системы здравоохранения провести тщательный пересмотр политики с точки зрения общественного здоровья, используя в качестве модели глобальную стратегию Всемирной организации здравоохранения по освобождению от вредной привычки употребления алкоголя.

PROBLEM: Outbreak analysis and mathematical modelling are crucial for planning public health responses to infectious disease outbreaks, epidemics and pandemics. This paper describes the data analysis and mathematical modelling undertaken during and following the 2009 influenza pandemic, especially to inform public health planning and decision-making. APPROACH: Soon after A(H1N1)pdm09 emerged in North America in 2009, the World Health Organization convened an informal mathematical modelling network of public health and academic experts and modelling groups. This network and other modelling groups worked with policy-makers to characterize the dynamics and impact of the pandemic and assess the effectiveness of interventions in different settings. SETTING: The 2009 A(H1N1) influenza pandemic. RELEVANT CHANGES: Modellers provided a quantitative framework for analysing surveillance data and for understanding the dynamics of the epidemic and the impact of interventions. However, what most often informed policy decisions on a day-to-day basis was arguably not sophisticated simulation modelling, but rather, real-time statistical analyses based on mechanistic transmission models relying on available epidemiologic and virologic data. LESSONS LEARNT: A key lesson was that modelling cannot substitute for data; it can only make use of available data and highlight what additional data might best inform policy. Data gaps in 2009, especially from low-resource countries, made it difficult to evaluate severity, the effects of seasonal variation on transmission and the effectiveness of non-pharmaceutical interventions. Better communication between modellers and public health practitioners is needed to manage expectations, facilitate data sharing and interpretation and reduce inconsistency in results.

Noncommunicable diseases pose an increasingly high burden of disease that threatens economic and social development, yet cost-effective health interventions exist. World leaders recognized the compelling case for action with the declaration at the United Nations high-level meeting on noncommunicable diseases in September 2011. (1,2) Since that meeting, the World Health Organization (WHO) has been developing a Global Monitoring Framework and the United Nations Secretary-General is preparing to report to the 67th session of the General Assembly in September 2012 on ways to tackle noncommunicable diseases across different sectors. This paper aims to inform these debates by reviewing the declarations that resulted from WHO regional meetings held in preparation for last September's high-level meeting (Table 1). We identified four "ethical tensions" that must be resolved. These tensions are not exhaustive or mutually exclusive but provide a framework for debate. Human rights approaches Effective action on noncommunicable diseases involves addressing multiple human rights, such as the right to information to make informed choices about diet and activity (e.g. food labels that people can understand), the right to bodily integrity (e.g. freedom from exposure to second-hand smoke); and the right to health (including access to essential medicines). These human rights may conflict with corporate rights, such as the right of pharmaceutical companies to exploit patents or express freedom of speech (through marketing). Human rights language featured much more prominently in United Nations declarations on the human immunodeficiency virus (HIV) than those on noncommunicable disease. The European Region was the only one to argue that "Member states need to ... respond effectively and equitably to the health-care needs of people with NCDs [noncommunicable diseases] as part of the fundamental human rights of every human being"? There has been no reference to essential medicines in any of the regional declarations, despite evidence of the benefits of cheap generic drugs, such as the polypill. Social determinants Political leaders face difficult decisions about where to invest resources along the causal chain of disease. They must care for those already ill but also tackle the underlying causes of the diseases. Five of the seven regional documents mention the importance of action on social determinants. For example, the Brazzaville declaration noted how " ... risk factors and the systems put in place to deal with the conditions in which people live are shaped by political, social, behavioural, environmental and economic determinants" (4) Others did not use the term "social determinants" but they were considered implicitly (2) Funding Governments must balance the needs of their own citizens with their obligations to provide aid to other countries. There is a glaring global inequality in the burden of noncommunicable diseases and in the domestic resources available to address them. This raises the basic question of the obligations of rich countries to help poor countries to deal with these diseases. It is difficult to draw on self-interest arguments, such as threats to national security, as has been posed for tackling HIV/AIDS. And, while many health interventions are considered for the global public good, this argument may not be sufficient. There is currently little appetite in rich countries for committing more aid funding. Donors face the dilemma of whether to re-allocate existing funds targeting infectious diseases to noncommunicable diseases. Although these diseases may benefit from a shift from disease-specific programmes to one focused on health systems strengthening, it is difficult to see where resource-poor countries will find funding specifically for action on noncommunicable diseases. All of the regional declarations (except the one made in Nadi which did not address resource issues) (6) argued that noncommunicable diseases should be included in international development goals, although they differed in how this might be supported financially. …

In 2005, the Member States of WHO adopted a resolution encouraging countries to develop health financing systems capable of achieving and/or maintaining universal coverage of health services - where all people have access to needed health services without the risk of severe financial consequences. In doing this, a major challenge for many countries will be to move away from out-of-pocket payments, which are often used as an important source of fund collection. Prepayment methods will need to be developed or expanded but, in addition to questions of revenue collection, specific attention will also have to be paid to pooling funds to spread risks and to enable their efficient and equitable use. Developing prepayment mechanisms may take time, depending on countries' economic, social and political contexts. Specific rules for health financing policy will need to be developed and implementing organizations will need to be tailored to the level that countries can support and sustain. In this paper we propose a comprehensive framework focusing on health financing rules and organizations that can be used to support countries in developing their health financing systems in the search for universal coverage.

Health technology assessment (HTA) is the multidisciplinary study of the implications of the development, diffusion and use of health technologies. It supports health-policy decisions by providing a joint knowledge base for decision-makers. To increase its policy relevance, HTA tries to extend beyond effectiveness and costs to also considering the social, organizational and ethical implications of technologies. However, a commonly accepted method for analysing the ethical aspects of health technologies is lacking. This paper describes a model for ethical analysis of health technology that is easy and flexible to use in different organizational settings and cultures. The model is part of the EUnetHTA project, which focuses on the transferability of HTAs between countries. The EUnetHTA ethics model is based on the insight that the whole HTA process is value laden. It is not sufficient to only analyse the ethical consequences of a technology, but also the ethical issues of the whole HTA process must be considered. Selection of assessment topics, methods and outcomes is essentially a value-laden decision. Health technologies may challenge moral or cultural values and beliefs, and their implementation may also have significant impact on people other than the patient. These are essential considerations for health policy. The ethics model is structured around key ethical questions rather than philosophical theories, to be applicable to different cultures and usable by non-philosophers. Integrating ethical considerations into HTA can improve the relevance of technology assessments for health care and health policy in both developed and developing countries.

Based on articles found on the PubMed and Popline databases on the provision of first-trimester abortion by mid-level providers, this article describes policies on type of abortion provider, comparative studies of different types of abortion provider, provider perspectives, and programmatic experience in Bangladesh, Cambodia, France, Mozambique, South Africa, Sweden, the United States of America and Viet Nam. It shows that it is safe and beneficial for suitably trained mid-level health-care providers, including nurses, midwives and other non-physician clinicians, to provide first-trimester vacuum aspiration and medical abortions. Moreover, it finds that projects in Kenya, Myanmar and Uganda have successfully trained nurse-midwives to provide post-abortion care for incomplete abortion with manual vacuum aspiration, and that studies in Ethiopia and India have recommended that providers such as auxiliary nurse-midwives should be trained in abortion service delivery to ensure that they provide safe abortions for low-income women. The paper recommends the authorization of all qualified mid-level health-care providers to carry out first-trimester abortions, and it also recommends the integration of training in providing first-trimester abortion care into basic education and clinical training for all mid-level providers and medical students interested in obstetrics and gynaecology. Finally, it calls for documentation of the role of mid-level providers in managing second-trimester medical abortions to further inform policy and practice.

Health has gained recognition as a foreign policy concern in recent years. Political leaders increasingly address global health problems within their international relations agendas. The confluence of health and foreign policy has opened these issues to analysis that helps clarify the tenets and determinants of this linkage, offering a new framework for international health policy. Yet as health remains profoundly bound to altruistic values, caution is required before generalizing about the positive outcomes of merging international health and foreign policy principles. In particular, the possible side-effects of this framework deserve further consideration. This paper examines the interaction of health and foreign policy in humanitarian action, where public health and foreign policy are often in direct conflict. Using a case-based approach, this analysis shows that health and foreign policy need not be at odds in this context, although there are situations where altruistic and interest-based values compete. The hierarchy of foreign policy functions must be challenged to avoid misuse of national authority where health interventions do not coincide with national security and domestic interests.

Agriculture and health are linked in many ways. First, agriculture is essential for good health: it produces the world's food, fibre and materials for shelter; in many countries it is also an important source of livelihood among the poor. At the same time, agriculture can be linked with poor health, including malnutrition, malaria, foodborne illnesses, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), livestock-related diseases, chronic diseases and occupational ill-health. Health also affects agriculture: people's health status influences the demand for agricultural outputs, and in agricultural communities, poor health reduces work performance, reducing income and productivity and perpetuating a downward spiral into ill-health. This paper presents an overview of the bidirectional links between agriculture and health with a focus on the developing world. It develops a conceptual framework that brings together the various links between agriculture and health into a single broad framework. The framework comprises the core components of the agricultural supply chain (producers, systems and outputs), key health concerns and the mechanisms of common interaction between the agricultural and health components: income, labour, environment and access -- all key social determinants of health. These links between agriculture and health present an opportunity for the two sectors to work together to find solutions to each other's problems. Yet the health and agricultural sectors remain poorly coordinated. Leadership from global health and agricultural institutions is needed to build policies and good governance to facilitate integration, while capacity building is needed at all levels to help translate the conceptual links into comprehensive action on the ground. Health and agricultural researchers likewise need to work more closely together to achieve common goals.

New drugs and vaccines are needed for tackling diseases of poverty in low- and middle-income countries. The lack of effective demand or market for these products translates into insufficient investment being made in research and development to meet the need for them. Many have advocated cost-reducing (push) and market-enhancing (pull) incentives to tackle this problem. Advance price or purchase commitments (APPCs) funded by international agencies and governments offer one way forward. This paper looks at design issues for APPCs for drugs and vaccines for diseases of poverty drawing on experience and lessons from three case studies: the introduction of the meningitis C vaccine in the United Kingdom; the Orphan Drug Act (ODA) in the United States of America (US); and the newly legislated US Project BioShield for bioterrorist interventions. Our key conclusion is that that APPCs have the potential to be a powerful tool and should be tried. The correct structure and design may only be determined through the process of taking action to set one up.

Health impact assessment (HIA) is a multidisciplinary aid to decision-making that assesses the impact of policy on public health and on health inequalities. Its purpose is to assist decision-makers to maximize health gains and to reduce inequalities. The 1999 Gothenburg Consensus Paper (GCP) provides researchers with a rationale for establishing community participation as a core value of HIA. According to the GCP, participation in HIA empowers people within the decision-making process and redresses the democratic deficit between government and society. Participation in HIA generates a sense that health and decision-making is community-owned, and the personal experiences of citizens become integral to the formulation of policy. However, the participatory and empowering dimensions of HIA may prove difficult to operationalize. In this review of the participation strategies adopted in key applications of HIA in the United Kingdom, we found that HIA's aim of influencing decision-making creates tension between its participatory and knowledge-gathering dimensions. Accordingly, researchers have decreased the participatory dimension of HIA by reducing the importance attached to the community's experience of empowerment, ownership and democracy, while enlarging its knowledge-gathering dimension by giving pre-eminence to "expert" and "research-generated" evidence. Recent applications of HIA offer a serviceable rationale for participation as a means of information gathering and it is no longer tenable to uphold HIA as a means of empowering communities and advancing the aims of participatory democracy.

This paper examines the policy context of the rise in the international mobility and migration of nurses. It describes the profile of the migration of nurses and the policy context governing the international recruitment of nurses to five countries: Australia, Ireland, Norway, the United Kingdom, and the United States. We also examine the policy challenges for workforce planning and the design of health systems infrastructure. Data are derived from registries of professional nurses, censuses, interviews with key informants, case studies in source and destination countries, focus groups, and empirical modelling to examine the patterns and implications of the movement of nurses across borders. The flow of nurses to these destination countries has risen, in some cases quite substantially. Recruitment from lower-middle income countries and low-income countries, as defined by The World Bank, dominate trends in nurse migration to the United Kingdom, Ireland, and the United States, while Norway and Australia, primarily register nurses from other high-income countries. Inadequate data systems in many countries prevent effective monitoring of these workforce flows. Policy options to manage nurse migration include: improving working conditions in both source and destination countries, instituting multilateral agreements to manage the flow more effectively, and developing compensation arrangements between source and destination countries. Recommendations for enhancements to workforce data systems are provided.

Antenatal syphilis control is an integral component of reproductive health policies in most countries. In many of these countries, however, the existence of a health policy does not automatically translate into an effective health programme. We argue that neglecting to take into account the perspectives of all stakeholders when planning programmes may be the reason that functional and sustained interventions for antenatal syphilis are lacking. Stakeholders may include health policy decision-makers, programme managers, service delivery personnel (on whom implementation depends), as well as the pregnant women, families, and communities who will most benefit from the intervention. We describe how to undertake a multilevel assessment in order to identify stakeholders, identify interlinked perspectives, and analyse these perspectives within the socioeconomic, cultural and political environment within which an intervention is designed to be delivered. Using this multidisciplinary approach, we propose that the barriers to, and opportunities for, turning health policy into effective practice will be identified, and the result will be the formulation of a broad programme response to ensure implementation of the policy. Undertaking a multilevel assessment is but the first step in identifying barriers to successful programmes. Currently there is a lack of strong political support for this intervention at national and international levels. Devising strategies to address these potential barriers requires a broad range of skills and approaches some of which are outlined in this paper.

Preventing congenital syphilis is not technically difficult, however operational difficulties limit the effectiveness of programmes in many settings. This paper reports on programmes in Bolivia, Kenya, and South Africa. All three countries have established antenatal syphilis control programmes. Early antenatal syphilis screening and management of positive cases were difficult to implement since most women presented for their first antenatal clinic visit after 6 months of pregnancy. Most women had rapid plasma reagin (RPR) testing; results were available on the same day in some clinics but took up to 4 weeks in others. No clinic had a system for tracking RPR-reactive women who did not return for their results. There were no guidelines for providers in Kenya and Bolivia. In all countries, supplies, drugs, notification cards, and other consumables were often unavailable. Health-care providers were unmotivated in Kenya and reported an excessive client load. In South Africa and Kenya some clients reported at their exit interview that they had never heard of syphilis nor had they been informed why blood was collected. Several prevention strategies could be implemented at the clinic level. These include encouraging women to attend for antenatal care before the fourth month of pregnancy, providing point-of-care testing so that results are available immediately and women who test positive can be treated, implementing presumptive treatment of sexual partners of women who test positive, adding a second test later in pregnancy so that incident cases can be managed, and improving the quality of syphilis care during pregnancy, delivery, and the neonatal period.

Genomics, the comprehensive examination of an organism's entire set of genes and their interactions, will have a major impact on the way disease is diagnosed, prevented and treated in the new millennium. Despite the tremendous potential it holds for improving global health, genomics challenges policy-makers to ensure that its benefits are harnessed equitably across populations and nations. The classification of genomics as a global public good and the inequity encountered in the development and application of genomics knowledge are outlined in this paper, We examine the effect of the current patent system on the distribution of costs and benefits relating to genomics knowledge between countries of different economic strength. The global public goods concept provides a normative economic rationale for the modification of certain aspects of the current patent system and for the creation of complementary mechanisms to respond to the health needs of low-income and middle-income countries.

This paper describes (i). how a national health information System was designed, tested and implemented in Papua New Guinea, (ii). how the system was integrated with other management information systems, and (iii). how information has been used to support decision-making. It concludes that central coordination of systems design is essential to make sure that information systems are aligned with government priorities and can deliver the information required by managers. While there is often scope for improving the performance of existing information systems, too much emphasis can be placed on revising data collection procedures and creating the perfect information system. Data analysis, even from imperfect systems, can stimulate greater interest in information, which can improve the quality and completeness of reporting and encourage a more methodical approach to planning and monitoring services. Our experience suggests that senior decision-makers and political leaders can play an important role in creating a culture of information use. By demanding health information, using it to formulate policy, and disseminating it through the channels open to them, they can exert greater influence in negotiations with donors and other government departments, encourage a more rational approach to decision-making that will improve the operation of health services, and stimulate greater use of information at lower levels of the health system. The ability of information systems to deliver these benefits is critical to their sustainability.

It is not clear how policy-making in the field of reproductive health relates to changes associated with programmes for the reform of the health sector in developing countries. There has been little communication between these two areas, yet policy on reproductive health has to be implemented in the context of structural change. This paper examines factors that limit dialogue between the two areas and proposes the following framework for encouraging it: the identification of policy groups and the development of bases for collaborative links between them; the introduction of a common understanding around relevant policy contexts; reaching agreement on compatible aims relating to reproductive health and health sector change; developing causal links between policy content in reproductive health and health sector change as a basis for evidence-based policy-making; and strengthening policy-making structures, systems, skills, and values.

The CARICOM Summit on Chronic Non-Communicable Diseases - the first government summit ever devoted to noncommunicable diseases (NCDs) - was convened by the Caribbean Community (CARICOM) in Trinidad and Tobago in September 2007. Leaders in attendance issued the declaration of Port of Spain, a call for the prevention and control of four major NCDs and their risk factors. An accountability instrument for monitoring compliance with summit commitments was developed for CARICOM by the University of the West Indies in 2008 and revised in 2010. The instrument - a one-page colour-coded grid with 26 progress indicators - is updated annually by focal points in Caribbean health ministries, verified by each country's chief medical officer and presented to the annual Caucus of Caribbean Community Ministers of Health. In this study, the G8 Research Group's methods for assessing compliance were applied to the 2009 reporting grid to assess each country's performance. Given the success of the CARICOM Summit, a United Nations high-level meeting of the General Assembly on the prevention and control of NCDs was held in September 2011. In May 2013 the World Health Assembly adopted nine global targets and 25 indicators to measure progress in NCD control. This study shows that the CARICOM monitoring grid can be used to document progress on such indicators quickly and comprehensibly. An annual reporting mechanism is essential to encourage steady progress and highlight areas needing correction. This paper underscores the importance of accountability mechanisms for encouraging and monitoring compliance with the collective political commitments acquired at the highest level.Le Sommet de la CARICOM sur les maladies chroniques non transmissibles – le premier sommet gouvernemental entièrement consacré aux maladies non transmissibles (MNT) – a été organisé par la Communauté des Caraïbes (CARICOM) à Trinité-et-Tobago en septembre 2007. Les dirigeants présents ont publié la déclaration de Port-of-Spain, un appel pour la prévention et la lutte contre les quatre principales MNT et leurs facteurs de risque.Un instrument de responsabilisation pour le contrôle du respect des engagements du sommet a été développé pour la CARICOM par l'Université des Antilles en 2008 et modifié en 2010. L'instrument – une grille de codes couleur tenant sur une page et comportant 26 indicateurs de progression – est mis à jour chaque année par points focaux dans les ministères de la Santé des Caraïbes, vérifié par le chef du service médical de chaque pays et présenté au Conseil annuel des ministres de la Santé de la Communauté des Caraïbes. Dans cette étude, les méthodes du Groupe de recherche G8 pour évaluer la conformité ont été appliquées à la grille de rapport de 2009 pour évaluer la performance de chaque pays.Compte tenu du succès du Sommet de la CARICOM, une réunion de haut niveau des Nations unies de l'Assemblée générale sur la prévention et la lutte contre les MNT a eu lieu en septembre 2011. En mai 2013, l'Assemblée mondiale de la santé a adopté 9 objectifs mondiaux et 25 indicateurs afin de mesurer les progrès dans le domaine de la lutte contre les MNT. Cette étude montre que la grille de contrôle de la CARICOM peut être utilisée pour rendre compte des progrès sur ces indicateurs de manière rapide et compréhensible. Un mécanisme de rapport annuel est essentiel pour encourager les progrès constants et mettre en relief les zones nécessitant des corrections. Cet article souligne l'importance des mécanismes de responsabilisation pour encourager et contrôler le respect des engagements politiques collectifs acquis au plus haut niveau.En septiembre de 2007 la Comunidad del Caribe (CARICOM) convocó en Trinidad y Tobago la Cumbre de CARICOM sobre enfermedades crónicas no transmisibles, la primera cumbre gubernamental dedicada a las enfermedades no transmisibles (ENT). Los líderes que asistieron publicaron la Declaración de Puerto España, un llamamiento a la prevención y el control de cuatro ENT principales y sus factores de riesgo.En 2008, la Universidad de las Indias Occidentales desarrolló un instrumento de rendición de cuentas para supervisar el cumplimiento de los compromisos de las cumbres para CARICOM, el cual se revisó en 2010. Los centros de coordinación de los ministerios de salud del Caribe actualizan cada año dicho instrumento, una red con código de color de una página con 26 indicadores de progreso, mientras que el director médico de cada país lo verifica y se presenta al Grupo anual de Ministros de Salud de la Comunidad del Caribe. En este estudio, se aplicaron los métodos del Grupo de Investigación del G-8 para la evaluación del cumplimiento a la red de información de 2009, a fin de evaluar la actuación de cada país.A raíz del éxito de la Cumbre de CARICOM, en septiembre de 2011 se celebró una reunión de alto nivel de la Asamblea General de las Naciones Unidas sobre la prevención y control de las ENT. En mayo de 2013 la Asamblea Mundial de la Salud adoptó nueve objetivos globales y 25 indicadores para medir el progreso en el control de las enfermedades no transmisibles. Este estudio muestra que la red de vigilancia de CARICOM puede utilizarse para documentar el progreso de forma rápida y clara en base a estos indicadores. Es esencial disponer de un mecanismo de presentación de informes anual para impulsar un progreso constante y resaltar las áreas que deben corregirse. Este documento destaca la importancia de los mecanismos de rendición de cuentas para promover y controlar el cumplimiento de los compromisos políticos colectivos adquiridos al máximo nivel.عقدت الجماعة الكاريبية (CARICOM) في ترينيداد وتوباغو في أيلول/ سبتمبر 2007 قمة الجماعة الكاريبية بشأن الأمراض غير السارية المزمنة - أول قمة حكومية على الإطلاق يتم تخصيصها للأمراض غير السارية (NCD). وأصدر القادة الحضور إعلان بورت أوف سبين، وهو دعوة لتوقي ومكافحة أربعة أمراض من الأمراض غير السارية الرئيسية وعوامل اختطارها. قامت جامعة ويست إنديز في عام 2008 بوضع صك مساءلة لرصد الامتثال لالتزامات القمة من أجل الجماعة الكاريبية وتم مراجعته في عام 2010. ويتم تحديث الصك سنوياً- وهو عبارة عن جدول من صفحة واحدة بترميز لوني يحتوي على 26 مؤشراً للتقدم - عن طريق مراكز الاتصال في وزارات الصحة في منطقة الكاريبي والتحقق منه من جانب كبير المسؤولين الطبيين في كل بلد وتقديمه إلى التجمع السنوي لوزراء صحة الجماعة الكاريبية. وفي هذه الدراسة، تم تطبيق وسائل فريق البحث التابع لمجموعة البلدان الثمانية من أجل تقييم الامتثال بجدول التبليغ لعام 2009 لتقييم أداء كل بلد. نظراً لنجاح قمة الجماعة الكاريبية، تم عقد اجتماع رفيع المستوى للجمعية العامة للأمم المتحدة بشأن توقي الأمراض غير السارية ومكافحتها في أيلول/ سبتمبر 2011. وفي أيار/ مايو 2013، اعتمدت جمعية الصحة العالمية تسعة أهداف عالمية و25 مؤشراً لقياس التقدم في مكافحة الأمراض غير السارية. ويتبين من هذه الدراسة إمكانية استخدام جدول الرصد الخاص بالجماعة الكاريبية لتوثيق التقدم المحرز في هذه المؤشرات على نحو سريع ومفهوم. كما يعتبر وجود آلية تبليغ سنوية ضرورياً لتشجيع التقدم الثابت وإبراز الجوانب التي تحتاج إلى تصحيح. وتبرز هذه الورقة أهمية آليات المساءلة لتشجيع الامتثال للالتزامات السياسية الجماعية المكتسبة على أرفع مستوى ورصدها.加勒比海共同体组织(CARICOM)于2007年9月在特立尼达和多巴哥召开了慢性非传染性疾病CARICOM峰会——这是有史以来第一次致力于非传染性疾病(NCD)的政府首脑峰会。与会领导人发表了西班牙港宣言,号召预防和控制四大NCD及其风险因素。2008年,西印度群岛大学为CARICOM开发了监控峰会承诺遵从性的问责工具,并于2010年进行修订。此工具是一页纸的颜色编码网格,包含26个进展指标,每年根据加勒比地区各卫生部的焦点问题进行更新,由每个国家的首席医疗长官确认,并呈送加勒比共同体卫生部长年度会议。在本研究中,将评估遵从性的G8研究组方法应用于2009报告网格来评估每个国家的绩效。鉴于CARICOM峰会的成功,2011年9月召开了预防和控制非传染性疾病的联大高级会议。2013年5月,世界卫生大会通过了9个全球目标和25个指标来衡量NCD控制进展。本研究表明,CARICOM监控网格可用于快速明了地记录这些指标。对于鼓励稳步推进以及突出需要修正的领域来说,年度报告机制至关重要。本文强调问责机制对鼓励和监督最高层所共同达成政治承诺遵从性的重要性。Саммит Карибского сообщества (КАРИКОМ) по хроническим неинфекционным заболеваниям – первый правительственный саммит, посвященный неинфекционным заболеваниям (НИЗ) – был созван правительствами стран Карибского сообщества в Тринидаде и Тобаго в сентябре 2007 года. Лидеры стран-участниц подписали в городе Порт-оф-Спейн декларацию, призывающую к профилактике и борьбе с четырьмя основными НИЗ и их факторами рискаДля саммита КАРИКОМ Университетом Вест-Индии в 2008 году был разработан и в 2010 году пересмотрен инструмент отчетности для наблюдения за выполнением обязательств саммита. Данный инструмент отчетности – одностраничная цветовая таблица с 26 индикаторами исполнения обязательств – ежегодно обновляется координаторами в министерствах здравоохранения стран Карибского сообщества, заверяется главным врачом каждой страны и представляется на ежегодном съезде министров здравоохранения стран-участниц. В данной работе отчетные таблицы 2009 года для каждой из стран обрабатывались с помощью методов исследования аналитической группы G8 Research Group (основана Университетом Торонто) с целью оценки ситуации в каждой стране.Учитывая успех саммита КАРИКОМ, в сентябре 2011 года состоялось заседание Генеральной Ассамблеи Организации Объединенных Наций по профилактике и борьбе с НИЗ. В мае 2013 года Всемирная ассамблея здравоохранения приняла 9 глобальных целей и 25 индикаторов для оценки прогресса в области борьбы с НИЗ. Данная работа показала, что контрольная таблица стран КАРИКОМ представляет собой быстрый и понятный способ документирования достигнутых успехов по данным показателям и может быть рекомендована к применению. Механизм ежегодной отчетности необходим для поощрения устойчивого прогресса и определения областей, нуждающихся в коррекции. В статье подчеркнута важность механизмов подотчетности для поощрения и контроля за соблюдением коллективных политических обязательств, принятых на самом высоком уровне.

There is a growing consensus that achieving universal health coverage is an appropriate, feasible and important goal for all nations. Under a rallying cry of “All for universal coverage”, Garrett et al. explain in a Lancet paper that attaining universal coverage will be vital if we are to reach health, poverty eradication and human rights goals.1 Since the World Health Assembly resolution WHA58.33 of 2005,2 the World Health Organization (WHO) has been leading international efforts to achieve universal coverage. This was defined as “securing access for all to appropriate promotive, preventive, curative and rehabilitative services at an affordable cost”. In particular, WHO has been keen to focus attention on perhaps the most important factor in determining levels of coverage: health financing. When setting health financing policy, policy-makers have often treated equity as a lesser priority. As a result, many countries have inequitable coverage rates and wide differences in health outcomes across income groups.3 If we are to achieve the United Nations Millennium Development Goals (MDGs) for health by 2015 we must scale up coverage rates quickly and equitably. The best way to do this is to target the least-covered and most-needy groups first. In particular, as the MDGs specifically target child and maternal mortality, we should focus on women and children first. In recent months, the international community has been giving a much greater priority to improving the health of women and children. This effort has been encapsulated in the Consensus for Maternal, Newborn and Child Health (MNCH)4 which is built on five pillars: (i) political leadership and community engagement; (ii) effective health systems; (iii) removing barriers to access; (iv) skilled and motivated health workers; and (v) accountability. This consensus has been agreed by virtually all of the major health agencies and contains one policy recommendation that, if implemented properly, could accelerate effective health-care coverage for billions of women and children. Under the pillar of “removing barriers”, it is recommended that countries should consider providing free health services for women and children at the point of use. This statement marks a compromise made among leading agencies following decades of debate over whether countries should charge user fees for health services. The evolution of this consensus can be traced through a series of consultations hosted by Save the Children,5 the United Nations Children’s Fund (UNICEF) and the European Commission. These events included representatives from multilateral and bilateral agencies, academic institutions and civil society organizations. In each case, the final policy recommendation was the same: that when phasing-out user fees, women and children should benefit first. This common position was fed into and adopted by the MNCH consensus discussions. Already there has been high-level commitment to this position. On 23 September 2009, at a special meeting at the United Nations General Assembly, the British Prime Minister, the Director-General of WHO and the President of The World Bank all publicly supported the concept of free services at the point of delivery. In addition, the heads of state of five low-income countries (Ghana, Liberia, Malawi, Nepal and Sierra Leone) announced that they would extend the benefits of free public services in their countries. In her speech, WHO’s Director-General explained the significance of the MNCH consensus and highlighted user fees as the biggest barrier to universal coverage. In addition, a taskforce set up by the Japanese Government in 2008 recommended that developing countries should remove user fees, starting first with services relevant to MDGs 4, 5 and 6.6 This policy recommendation is gaining traction because it appears to address several key political, economic and health-related issues. Specifically, it is an appropriate compromise for the following reasons: There is overwhelming research evidence that out-of-pocket payments (user fees) are an inefficient and inequitable health financing mechanism.7 Whereas many governments seem reluctant to remove user fees for their entire population, most appear keen to exempt high-need groups. Whereas attempts to exempt people from fees on economic criteria have tended to fail, women and children are easily identifiable groups. There are historical precedents for prioritizing women and children for health-care coverage in the developed and developing world and some services (e.g. immunizations and antenatal consultations) are generally provided free of charge. These reforms have been implemented without opposition from men who tend to have more control over family income and therefore better access to private alternatives. There is therefore no reason to believe that this policy will have an adverse impact on men’s health. This targeting makes sense for countries attempting to achieve MDGs 4 (reducing child mortality) and 5 (maternal mortality). As women and children tend to have less access to financial resources, removing fees for these groups will have a greater impact on their use of services. While providing free care for women and children, countries could continue to charge fees for lesser priority groups. Ensuring that a free option is available does not mean that all providers must not charge fees. Indeed, it could be more efficient to channel people who have a greater ability to pay into the private sector. This would make the benefit incidence of public health financing more equitable. Providing services free at the point of delivery is compatible with all other financing mechanisms that rely on pre-payment methods, for example tax financing, social health insurance, community and private insurance. Countries could decide themselves which health services will be provided free of charge, depending on their priorities and the resources they have at their disposal. These should include proven cost-effective interventions such as those outlined in the MNCH consensus. Several low-income countries have already launched free health services targeted at women and children and more are set to follow. Since fees were removed in 2006, Burundi has witnessed a trebling in outpatient consultations by children and deliveries in health units have increased 146%. Sierra Leone launched free health-care services for pregnant and lactating women and children in April 2010. Launching free health services has proved to be a very popular social policy in several countries and has therefore been an attractive intervention for political leaders. For all these reasons, it makes sense for countries with poor health-care coverage to provide a package of essential health services free at the point of delivery for women and children. This policy is particularly relevant to most of the 98 low-income and lower-middle income countries that still charge user fees. However for such a policy to be successful, it is imperative that other financing mechanisms replace fee income and that additional funds are found to increase the availability and quality of services. Political leaders must realize that free health services do not exist – somebody has to pay and, if they don’t secure additional resources for health, populations will consider their pronouncements as political gimmicks. Providing free public health services for large population groups in developing countries need not be prohibitively expensive. Many low-income countries (such as Nepal, Uganda and Zambia) have introduced free public services with public health expenditure of around 2% of gross domestic product. As lower-middle income countries such as Sri Lanka have shown, universal coverage can be achieved with public funding levels of US$ 23 per capita if public financing is used efficiently. In many developing countries there is a lot of scope to improve the efficiency of existing public funds.8 As well as finding additional domestic public funds, aid flows to health systems must increase. It is therefore very important that this policy of prioritizing free health care for women and children is rooted in the overall MNCH consensus. As well as addressing the removal of financial barriers, this stresses the importance of strengthening health systems. It will only be through dealing with demand-side and supply-side constraints simultaneously that women and children will be able to truly benefit from effective health-care coverage. With the United Nations MDG summit approaching, 2010 is going to be an extremely important year if the world is going to step up progress towards the goals set for 2015. As the health-related MDGs are so far off track, it is essential that the international community provides coherent policy advice and additional resources to help countries achieve universal coverage. In this respect, it would be useful if global leaders could agree on a timetable for achieving universal coverage compatible with the timeline of the MDGs. The world health report 2010 will demonstrate how health financing reforms can have a major impact in reaching universal coverage. But the MNCH consensus has already given us a practical policy recommendation for a first step towards this goal. If we can raise additional funds, allocate and manage them well and remove financial barriers, we really should be able to guarantee effective coverage for the world’s women and children. Providing services free at the point of delivery for women and children makes sense from a technical, ethical and political perspective. Furthermore by phasing-in universal coverage this way, we would just be following the common practice of saving lives in other emergency settings where “women and children first” is seen as an appropriate response to limited life-saving resources.

Interest in global health, the relationship between health and economic development, and the impact of globalization upon both of these, has risen rapidly up international and national agendas in recent years. This expansion of interest has both formal expression, such as the Millennium Development Goals, the Commission on Macroeconomics and Health, and the Framework Convention on Tobacco Control, and more informal expressions, through concerns and negotiations focusing upon pandemic influenza, the role of the food industry in nutrition-related chronic disease and the role of patent protection in access to essential medicines. These, and many other instances, serve to demonstrate that there is no such thing as national health or a national health system; in today’s world, all health is global health. This has led to a welcome concomitant increase in funding allocated to global health, both through traditional aid routes and increasingly through new initiatives, most notable perhaps being the Global Fund to Fight AIDS, Tuberculosis and Malaria. However, this increase has not been universally applauded and there have been criticisms, mostly focused upon the reinforcement of the “vertical” approach, emphasizing a disease-specific approach to securing health improvement. This has come at a time when many in the international health community were feeling that there had finally been a breakthrough in securing recognition that health improvement can only be achieved through strengthening of health systems more generally; the so called “horizontal” approach. More recently a consensus may be emerging that both approaches have strengths and weaknesses, and that synergies may be capitalized upon if both are pursued in tandem; simultaneously strengthening the health system while focusing upon those diseases that are the major burden to a country. It is this tandem, or “diagonal”, approach that Anna Gatti & Andrea Boggio emphasize in this book. In their introduction they emphasize this perspective and outline a matrix that seeks to combine both vertical and horizontal aspects to aid resource allocation. This is a novel and potentially illuminating means of categorizing interventions. The remainder of the book then comprises four sections written by a wide variety of authors internal and external to WHO. Part 1, on the global health arena, considers especially the role of WHO in global health. Part 2, on health and development looks in more detail at various perspectives on global health and development, including those of evolution, economics, law and ethics. Part 3, on global health and vulnerability, focuses on the experiences of the elderly, children and women. Part 4 considers the interrelation between specific disease and development, then shifts the focus to specific diseases of chronic illness, malaria, HIV/AIDS and tuberculosis. In the main, the book is relatively neutral in its presentation, provides a good deal of evidence – some of it new – and is authored by those with a good knowledge of their subjects. Certainly some of the perspectives by those working in or with international organizations provides interesting insights at times. The book is pervaded by the emphasis on building systems and capacities, rather than new technological discoveries, as the key to future health improvement. It is likely that readers interested in global health will find much that appeals and informs, and it is certainly a welcome addition to my bookshelf. I read the book over a period of several weeks' travelling, something many readers may do, and the edited nature of the book lends itself very well to this style of reading as each chapter stands alone. However, once I had finished the final chapter, I found myself somewhat disappointed that there was no final section or chapter to turn to that deals with the performance of the matrix approach that was introduced at the beginning of the book. The book begins with the authors “propos[ing] a matrix as a tactical tool to be used to define optimal allocation of (scarce) resources” (p.xxiii). However, it is not made clear how the various chapters link to this, or how the analyses are informed by it, and the chapters themselves do not tend to make reference to this matrix. It is therefore disappointing to get to the end and find that there is no chapter to bring the book full circle and reflect upon the material in these chapters from this matrix perspective, or to offer a summary of the research and policy agenda’s arising from them. This lack of emphasis on the matrix makes one wonder at the appropriateness of the subtitle of the book as, apart from a brief discussion in the introduction, the matrix approach does not appear and the book then becomes another collection – albeit an interesting collection – of papers with some specific views and opinions on globalization, health and development. A further feature to bear in mind is that 12 of the 16 authors are current or ex-WHO staff and this is reflected in an often uncritical reflection upon the role and activities of WHO (perhaps the best example being the discussion in chapter 2). Although there have clearly been considerable successes achieved by the Organization over the past 60 years, this uncritical reflection of its role in the current global environment is a weakness, as there is considerable debate – internal and external to WHO – about the role the Organization will play in the next 60 years; for example vis-a-vis other international organizations, such as the World Trade Organization, concerning issues of trade and health. This emphasis of the role WHO does and should play seems critical to any discussion of the links between health and development. In summary, this is a useful and accessible book that offers much benefit for those interested in global health. This is especially true of those who are active in the field in research and policy but it may also be of some value to graduate students, probably as an optional reading or reading of selective chapters. I only wish that the editors had taken that final step to conclude with something more on their proposed matrix! ■

… The fifth strategy is to separate, in space or time, the energy being released from the susceptible structure, whether living or inanimate: the evacuation of the Bikini islanders and test personnel, the use of sidewalks and the phas-ing of pedestrian and vehicular traffic, the elimination of vehicles and their pathways from community areas commonly used by children and adults, the use of lightning rods, and the placing of electric power lines out of reach. This strategy, in a sense also concerned with rate-of-release modification, has as its hallmark the elimination of intersections of energy and susceptible structure – a common and important approach.”For the full text of the paper by W Haddon Jr

Introduction Health promotion is becoming a noticeable policy in both developed and developing countries facing a burden of both communicable and noncommunicable diseases. This paper discusses the focus of health promotion policy, financing arrangements and the perspectives of social health insurance to fund health promotion. The population health status in Japan is among the highest in the world despite an increasing incidence of cancer, heart, cardiovascular diseases and diabetes. Communicable diseases such as HIV/ AIDS and new types of influenza also pose threats to public health. In Mongolia, both communicable and noncommunicable diseases are a serious public health concern. Since 1995, cardiovascular diseases, cancer and injuries have been the leading causes of mortality. Tobacco and alcohol consumption, physical inactivity and unhealthy diet are common risk factors for many chronic diseases. Japan In 2000, Japan announced the National Health Promotion Movement in the 21st century, with the shortened name of Healthy Japan 21. This policy aims to encourage all citizens to be healthy and free of disease. It focuses on healthy dietary habits, promotion of physical activities, diagnostic tests and reduction of tobacco use. Traditionally, health promotion is regarded as a useful means to prevent disease and promote health among different social groups. Municipal governments, health centres and urban communities play a major role in implementing health promotion activities. Health promoting leaders have been identified and nominated by community members and trained to conduct health promoting activities in their communities. These include advocacy of healthy lifestyle, behaviour, attitudes, dietary habits, access to health-related information and improvement of health literacy and education at community level. Studies suggest that a community participation approach suited to the socioeconomic setting has been effective in improving health-related behaviour and promoting health in Japan. (1) Mongolia Since 2000, the government of Mongolia has approved 16 public health programmes with health promotion effects such tobacco control, health education, cancer and injury prevention, nutrition, population fitness activities, child and reproductive health. However, strong evidence is not available yet about whether these programmes have been successful in controlling and reducing risky behaviours among the population. Since 2002, there has been an increase in the reporting of unsafe sex practices. There is an increasing trend in tobacco consumption, especially among young people. It is estimated that about 65% of males and 20% of females consume tobacco, which is higher than the respective averages in developing countries. The 2006 STEP survey on the prevalence of noncommunicable disease risk factors estimated that 9 of every 10 people surveyed had at least one risk factor and I in 5 people had three or more risk factors for developing a disease. (2) Currently, the public health programmes in Mongolia are implemented at population level but other country experiences show that the effects of health promotion can be increased through action at the community and individual level. There is an acute lack of funding support for the public health programmes in Mongolia. Although the central government budget is referred to as the main funding source, no specific budgeting tools and guidelines are provided. The 2005 national health accounts estimated that the level of spending on public health services was less than 5% of total health expenditure. (3) Financing promotion schemes In Japan, local governments assumed the main responsibility for financing health promotion. In practice, the availability of local revenues to implement health promotion activities varied among the country's 47 prefectures. Therefore, the financial adjustment policy was implemented in the form of financial assistance from the national to local governments. …

This article provides an overview of the current Chinese health care system with particular emphasis on rural-urban differences. China's post-1978 economic reforms, although they improved general living standards, created some unintended consequences, as evidenced by the disintegration of the rural cooperative medical system and the sharp reduction in the number of "barefoot doctors", both of which were essential elements in the improvement of health status in rural China. The increase in the elderly population and their lack of health insurance and pensions will also place enormous pressure on services for their care. These changes have disproportionately affected the rural health care system, leaving the urban system basically intact, and have contributed to the rural-urban disparity in health care. Based on recent data the article compares current rural-urban differences in health care policy, systems, resources, and outcomes, and proposes potential solutions to reduce them.China has made significant achievements in reducing mortality, increasing life expectancy, and providing primary health care. Hospital medical costs show an increase of 30-50% annually during 1978-90. Charges include 29-63% of actual costs of services for outpatients, in-patients, and operations. This paper portrays a view of the Chinese health care system and urban-rural differences. An overview and statistical support is given for health care resources of personnel and beds during 1949-87. Current major problems are identified as funding variability between local and provincial areas and urban-rural disparity in health outcomes and access to care. The most adversely affected are the rural elderly. The cost of medical services has increased, and many rural populations lack health insurance or pensions. A major policy change occurred in 1978 with a shift to a fee for service system rather than a barefoot doctor supported cooperative medical system. The health system now is comprised of a State Council which controls 30 provinces. County governments, which supervise township governments or the former people's communes, are lower units followed by the village unit (the former brigade). Each province has about 71 counties. Each county has about 25 townships. Each township has about 14 villages of about 1000 population. Every level of government has hospitals and other specialized health units, but the main levels are care are at the village, township, and county levels. Provincial and lower levels are responsible for their own finances. A reward-penalty system operates in urban hospitals. Health care spending, resource allocation, and distribution of facilities and professionals varies widely between rural and urban areas. Differences in health outcomes are apparent, and urban residents have a better health status. Health insurance coverage is assured for most of urban government employees, college communities, and state enterprises with over 100 employees, which means most working people in urban areas. The rural elderly are the most affected by the changes. There is a need for a new elderly support system, a universal and compulsory system of financing, and evaluation of health professional needs.

Estimates of the prevalence of visual impairment caused by uncorrected refractive errors in 2004 have been determined at regional and global levels for people aged 5 years and over from recent published and unpublished surveys. The estimates were based on the prevalence of visual acuity of less than 6/18 in the better eye with the currently available refractive correction that could be improved to equal to or better than 6/18 by refraction or pinhole. A total of 153 million people (range of uncertainty: 123 million to 184 million) are estimated to be visually impaired from uncorrected refractive errors, of whom eight million are blind. This cause of visual impairment has been overlooked in previous estimates that were based on best-corrected vision. Combined with the 161 million people visually impaired estimated in 2002 according to best-corrected vision, 314 million people are visually impaired from all causes: uncorrected refractive errors become the main cause of low vision and the second cause of blindness. Uncorrected refractive errors can hamper performance at school, reduce employability and productivity, and generally impair quality of life. Yet the correction of refractive errors with appropriate spectacles is among the most cost-effective interventions in eye health care. The results presented in this paper help to unearth a formerly hidden problem of public health dimensions and promote policy development and implementation, programmatic decision-making and corrective interventions, as well as stimulate research.

De Allegri et al.1 rightly describe low enrolment as a principal problem related to the functioning of community health insurance (CHI) in sub-Saharan Africa. Furthermore, they identify a set of important factors affecting the decision to enrol. Nonetheless, on reflection about the evidence established by this paper and related research, I would like to suggest some additional considerations. First of all, the described (and not too surprising) fact that the educational and, importantly, the socioeconomic status of a household play predominant roles in the decision of whether to enrol in health insurance is depicted by a series of articles2 as well as several systematic article reviews.3 Some of them are quoted by the authors themselves.4,5 Second, the consistency of this observation and the clear-cut cause–effect relationship between socioeconomic well being and the readiness to embark on an expenditure (be it for health insurance or anything else) allow the conclusion that wealth is a fundamental predictive factor for enrolment into health insurance. Third, if then poverty can be understood as a risk factor for not embarking into health insurance, the discussion around an insurance approach for the poor should focus very much on the following three questions: What percentage of the population targeted by the envisaged or existing insurance scheme are too poor to enrol on their own? By which kind of corrective measures can they be included? What consequences do these measures have for the financial viability of the scheme? Two recent analyses from Ghana6 and Rwanda7 suggest that the capacity of households to contribute financially is so weak that the dual objectives of mobilizing significant resources for health on one side, and of covering a large percentage of the targeted rural population on the other, are mutually exclusive. That is to say that insurance schemes requiring a contribution of little more than a few US dollars per year are beyond the reach of the majority, but they still do not allow the financing of reasonable (and thus attractive) health services! Furthermore, schemes charging about ten times such an amount are still affordable by a considerable minority of the population and maximize resource mobilization in absolute terms. This phenomenon is explained largely by the highly skewed distribution of wealth in the settings studied (as expressed equally by a high Gini coefficient). This finding seems to be one of the main reasons underlying the aforementioned low enrolment rate scrutinized by De Allegri et al. In many countries in sub-Saharan Africa, health insurance schemes might find themselves in a tragic situation: Depending on the design, people are either unable to pay for the schemes, or the schemes are unable to pay for the envisaged services. Therefore, it is suggested that future research go beyond the identification of additional predictive factors for health insurance enrolment. If health insurance is to cover broader population strata in sub-Saharan Africa and to assure satisfactory health services, schemes will require continuous and long-term subsidies to bridge the gap between household capacity to contribute financially and the real costs of health care. The development of approaches addressing this dilemma should be considered as a research priority. They might include initiatives of north–south risk pooling as between the Netherlands and Ghana.8 This necessity is underpinned by the capacity of health insurance to formalize social protection and to create a market between health service providers and their “customers”, simultaneously alleviating poverty and empowering communities. Yet, available evidence points out that to play these roles, health insurance needs subsidies. ■

The base paper by Petrakova and Sadana is a thought-provoking call for innovation and action in public health education. The approach used by the BRAC University James P Grant School of Public Health (BSPH) in Bangladesh addresses many of these issues. To be relevant to the needs of society, we envision our graduates to: be committed to the health needs of the global South; be equipped to deal with problems faced by disadvantaged sections of the society; be aware of the interplay and importance of factors such as poverty, education, women’s status, environment and power relations within and beyond family, as they affect health and health care; appreciate that health is “not merely the absence of disease, but a state of complete physical, mental and social well being”; be life-long, problem-based learners and critical interdisciplinary thinkers; be promoters and practitioners of both the science and art of public health; and be future leaders in public health practice, research and teaching. Set up in 2005, two batches of 51 participants from more than 12 countries have now graduated from BRAC through its master of public health (MPH) programme, all of whom are now back in their own countries and have taken up responsibilities in government, donor agencies, media and nongovernmental organizations (NGOs). Some have started doctoral-level studies.

Under its Constitution, the World Health Organization (WHO) works with its members towards the attainment by all peoples of the highest possible level of health. The context in which WHO and its Members pursue this goal has radically changed since 1946. The interdependence produced by globalization has broken down traditional ways of conceptualizing and organizing the medical, economic, political and technological means to improve health. Nowhere is this transformation more apparent than in the rise of health as a foreign policy concern. As the papers in this issue of the Bulletin demonstrate, the relationship between health and foreign policy is vital, complex and contested. To craft health policy today, governments, international institutions and nongovernmental organizations must find mechanisms to manage health risks that spill into and out of every country. These endeavours create the new world of global health diplomacy. Critical to global health diplomacy is the relationship between health and foreign policy. Even though much of what affects health today is transnational in nature, countries remain core actors that must reorient their health and foreign policies in ways that align their national interests with the diplomatic, epidemiological and ethical realities of a globalized world. This alignment involves governments adjusting to globalization by overcoming fragmented policy competencies in national governance systems. The trade and health relationship unfolds on the cutting edge of global health diplomacy and offers lessons for the health and foreign policy nexus. The World Heath Assembly recognized this significance in a May 2006 resolution on International Trade and Health, in which the Assembly called for foreign, trade and health ministries to move towards coherency in formulating national policies on trade and health. The Assembly tasked WHO to collaborate with other international organizations to generate and share evidence on ways to align trade and health. This trade and health linkage highlights the new prominence of health within foreign policy; however, the linkage itself is not new. These enquiries allow us to see how countries historically dealt with health in their trade and foreign policies, particularly with respect to ensuring that health measures did not unnecessarily restrict international commerce. The trade and health relationship is also at the centre of international lawmaking, particularly in the World Trade Organization. International trade law allows us to analyse how countries calibrate their national interests regarding economic growth and protection of health. The trade and health arena has also seen involvement by nongovernmental entities promoting trade and health interests; these actions provide avenues for understanding how countries adjust their foreign policy strategies when non-state actors intervene. The window into global health diplomacy provided by the trade and health relationship reveals controversy, but also increasing efforts between those in trade and health ministries towards coherent policies within and among countries. WHO’s work on trade and health policy coherence reveals increasing country-level commitment to, and sophistication about, strategies to promote trade and protect health in ways that are politically feasible, economically attractive, epidemiologically informed and ethically sound. Through these efforts, health ministries are identifying how they can best inform pre-negotiation trade positions, provide input during negotiations, analyse the health costs and benefits of proposed compromises and monitor the health impacts of trade agreements. WHO is collaborating with its members and other international organizations to advance this integrated approach to foreign policy by developing a new trade and health diagnostic tool. This tool is being designed to help health and trade ministries more systematically assess trade and health issues, to empower health ministries to give better advice to their trade counterparts and to enhance health policy input into the trade community’s pursuit of integrated frameworks, trade policy reviews and aid initiatives to bolster trade capacities in developing countries. The cutting edge of global health diplomacy raises certain cautions regarding health’s role in trade and foreign policies. Competition among countries’ national interests sometimes impedes policy coherence, which makes attainment of health goals more difficult. As the trade and health relationship makes clear, health ministries, experts and advocates can affect this competition constructively by combining their epidemiological skills and ethical principles with sharpened political and economic sensibilities about global politics. Securing health’s fullest participation in foreign policy does not ensure health for all, but it supports the principle that foreign policy achievements by any country in promoting and protecting health will be of value to all. ■