In 2005, Carol Bellamy,
UNICEF's executive director, steps down from a position that she has occupied
for 10 years. As the world's most senior advocate for child health, she leaves
at a critical time. All the indications are that the fourth Millennium
Development Goal--reducing by two-thirds, between 1990 and 2015, the under-five
mortality rate--will not be met in many countries.
The World Bank recently
reported that "progress against child mortality has so far been so slow that no
sub-Saharan country in Africa is on target to reach that MDG".(1) Given this
continuing failure, one would be forgiven for thinking that the appointment of
Bellamy's successor would be generating widespread professional and public
discussion. Yet there is no discussion--only private lobbying and public
silence. The entire appointment process for this vital leadership role is
shrouded in secrecy.
The selection of UNICEF's next executive director
lies in the gift of Kofi Annan, the UN's secretary-general. This mysterious
procedure leaves open the possibility of crude political deal-making in
identifying an acceptable candidate --acceptable,
many observers suspect, to
the UN's largest funder, the US government. Those close to the secretary-general
concede that the next executive director of UNICEF is likely to be an American,
irrespective of the person's skills or experience. And here is the
intractable difficulty for Kofi Annan--there are no agreed criteria by which
the global political or health community can judge a candidate to lead UNICEF.
This discredited process threatens to damage the integrity of the UN system and,
more importantly, it may well prove disastrous for the future of child health.
It is widely, if regrettably, accepted that UNICEF has lost its
way
during Carol Bellamy's long term of office. A corporate lawyer
and financier
for many years, Bellamy went on to become a New York
politician who was
thrust into a position that demanded deep
experience of children's issues,
and child health especially,
worldwide. It was a role that she was
ill-equipped for, despite
her evident enthusiasm for UNICEF's ideals. While
Bellamy has
focused on girl's education, early childhood development,
immunization, HIV/AIDS, and protecting children from violence,
abuse,
exploitation, and discrimination, she has failed to address
the essential
health needs of children. It was left to independent
child health
researchers and advocates, driven by intense
frustration at Bellamy's
unwillingness to engage with child
survival, to draw attention to UNICEF's
pervasive neglect of its
central mission. The call for a reorientation of
UNICEF's work
came with a simple question: "Where and why are 10 million
children dying every year?".(2) Based on new data from the Child
Health
Epidemiology Reference Group, Robert Black and colleagues
reported that half
the world's deaths among children under 5 years
of age occurred in just six
countries-- India (2.4 million
deaths); Nigeria (834,000); China (784,000);
Pakistan (565,000),
Democratic Republic of Congo (484,000); and Ethiopia
(472,000).
Although the highest absolute number of deaths occurred in south
Asia, the highest rates were found in sub-Saharan Africa, where
mortality in many countries is actually increasing.
These figures
were shocking to those who believed that UNICEF had
been making steady
progress in improving child survival. Worse
still, over 60% of these deaths
were and remain preventable.
Undernutrition contributes to the deaths of
over half of all
children. Cost-effective interventions are available for
all major
causes of child mortality. But coverage levels for these
interventions are appallingly low in the 42 countries that account
for
90% of child deaths. 80% of children do not receive oral
rehydration therapy
when they need it. 61% of children under 6
months of age are not exclusively
breastfed. 60% do not receive
treatment for acute respiratory infections.
45% do not receive
vitamin A supplements. A quarter of children do not
receive the
diphtheria-pertussis-tetanus vaccine. And the gap in survival
between the richest and poorest children is increasing. In sum,
for
almost a decade, child survival has failed to get the
attention it deserves.
Child health needs better leadership,
improved coordination of services, and
increased funding.
This analysis brought an immediate response--but not
from UNICEF.
Instead, it was left to WHO's newly elected director-general,
Lee
Jong-wook, to respond to the call for action.(3,4) He acknowledged
that three commitments must be made "urgently and unremittingly".
First,
that children must be "reinstated as an important focus of
organizational
agendas". Second, that children who were dying had
to be reached through
scaled-up services, based on strong primary
care led health systems.
Finally, that there had to be stronger
capacity at community level--to
monitor the needs of children and
to enable decisions of policy-makers to be
implemented
successfully.
One immediate result of this renewed
global commitment was the
creation of the Child Survival Partnership.
Informed by a wide
network of child health researchers and advocates, this
partnership was created through the collaborative efforts of WHO,
World
Bank, Gates Foundation, US Agency for International
Development, Canadian
International Development Agency--and
UNICEF. Despite meagre resources, it
is providing a forum for
coordinated action across agencies, consistent
approaches between
partners, and concrete efforts at country level to reduce
child
mortality. For example, in November, 2004, a national conference
for child survival and development took place in New Delhi to
accelerate
improvements in Indian child health. This gathering
simply would not have
taken place without the Child Survival
Partnership. Its work is only just
beginning but it is already
mobilizing strong support. The partnership will
have four task
forces--on country support, monitoring and evaluation,
advocacy,
and research. India, Ethiopia, and Cambodia have joined, while
Pakistan and Bangladesh have made pledges. Funding remains a
concern. A
2005 budget of $2.3 million is needed, but only a
fraction of that amount
has so far been promised.
Yet now is an important moment for those
concerned about child
survival. Meeting in Abuja, Nigeria, this week, a
high-level forum
on the health MDGs brought together politicians,
policy-makers,
and global health experts. The forum is co-sponsored by WHO
and
the World Bank to promote actions to achieve international health
goals--notably, greater national government and donor funding,
better
coordination between donors, and a new focus on the massive
shortage of
health workers to deliver these goals.(5) But the
statements issued by those
charged with ending the needless deaths
of millions of the world's children
mask their own failures to
grapple with catastrophic institutional
weaknesses in their own
ranks.
In early 2005, the Millennium
Project, an advisory group reporting
to the UN secretary-general and which
is composed of 10 task
forces, will publish its conclusions on progress
towards the MDGs.
This project, which is directed by the economist Jeffrey
Sachs,
will also make recommendations as to how the goals can best be
achieved. Task force 4 is devoted to child and maternal health. In
September, 2005, world leaders will convene in New York to review
these
issues once again, 5 years after the original Millennium
Declaration. Next
year is the last chance politicians will have
to make the decisions needed
to translate words into deeds.
There ought to be growing optimism about
what is achievable.
Research has delivered reliable answers to questions
about how
best to reduce the burden of child mortality. The multi-country
evaluation of a program of integrated management of childhood
illness
(IMCI)--a program that has been adopted by over 100
countries--found that
this strategy, when properly implemented,
not only works but also is good
value for money.(6,7) The issue
now is how to scale up IMCI in
high-mortality areas to ensure
high coverage. The importance of parallel
health-sector reform at
regional(8) and community (9) levels is being
recognized with
evidence that should enhance political commitment to child
survival. Cost-effective treatments are regularly being reported,
for
example, the recent finding that co-trimoxazole is effective
as prophylaxis
against opportunistic infections in children living
with HIV.(10) Results
such as these are directly influencing
guidance offered by UN agencies.(11)
Finally, an appreciation of
the value of health systems research to improve
service delivery
has progressed from academic proclivity to ministerial
priority.(12)
Given this escalating evidence base for child health,
but all on
a paradoxical background of failure to meet the MDG on child
survival, UNICEF clearly has a pivotal role to lead the world's
efforts
to make children a global priority. Under Bellamy's
leadership, UNICEF is
presently in a poor position to do so. Her
distinctive focus has been to
advocate for the rights of children.
This rights-based approach to the
future of children fits well
with the zeitgeist of international development
policy. But a
preoccupation with rights ignores the fact that children will
have
no opportunity for development at all unless they survive. The
language of rights means little to a child stillborn, an infant
dying in
pain from pneumonia, or a child desiccated by famine. The
most fundamental
right of all is the right to survive. Child
survival must sit at the core of
UNICEF's advocacy and country
work. Currently, and shamefully, it does not.
UNICEF was created in December, 1946. The UN International
Children's Emergency Fund was needed because of the threats posed
to
children in Europe from disease and famine after World War II.
With each of
the three executive directors before Bellamy, health
became an increasingly
important part of UNICEF's work. In 1982
came UNICEF's greatest contribution
to date to the welfare of
children worldwide: the child survival revolution,
which was based
on four simple interventions--growth monitoring, oral
rehydration
therapy, breastfeeding, and immunization. The great strength of
UNICEF, then and now, lies in its decentralization. Almost 90% of
the
agency's highly regarded staff work within 157 countries. The
organization's
concern to find "practical ways to realize the
rights of children and women"
is monitored by a 36-member
executive board made up of government
representatives elected by
the UN Economic and Social Council. But during
Bellamy's time at
UNICEF, this board has failed badly to make sure that the
agency
capitalizes on the legacies left by past executive directors,
especially that of James Grant.
What are the skills and experiences
that Kofi Annan should be
looking for in the next executive director of
UNICEF? I wrote to
the authors of the 2003 Lancet child survival series,
together
with others working in international child health. I sought their
views on the personal characteristics they believe are necessary
in
someone to lead UNICEF. There are several attributes that
should inform the
UN secretary-general's decision. UNICEF needs
to be led by an energetic and
inspirational individual who is
ambitious for the future of the world's
children. S/he must have
political integrity, a willingness to speak with a
strong voice
against power, and a proven interest in the well-being and
health
of children--or at the very least, s/he should be able to show an
understanding that child health is a critical factor in advancing
human
development. It is surprising that this important UN agency
should have had
four American executive directors. It is hard to
believe that the person
best equipped to address the global plight
of children can only be an
American. Kofi Annan must cast his net
for nominations far and wide, looking
especially hard at non-US
candidates.
The process of selection also
needs to change. It must be opened
up. Nominations need to be placed on the
public record. Each
nominee should appear and be questioned before a
specially
appointed UN intergovernmental committee, with balanced
representation between high, middle, and low income countries,
including
those nations that bear the greatest burden of child
mortality. In this way,
the selection process would be more
transparent, fair, meritocratic, and
based on the needs of
children, not on clandestine forces aimed at the
secretary
general. During recent months, UNICEF has tried to change the tone
of its advocacy. In response to our series last year, the agency
commented that "child survival lies at the heart of everything" it
did.
And UNICEF has taken action to house the Child Survival
Partnership. But
experienced observers of UNICEF, those who have
long worked in the field of
international child health, take a
different view. They see these words and
actions as mostly
rhetoric. UNICEF's claims do not reflect the reality of
its work
in the field. There is no organisation-wide commitment to reduce
child mortality--indeed, no comprehensive strategy exists to do
so.
There are vague promises about early childhood care, promises
that have few
clear outcomes, survival targets, or programs for
their achievement.
There is an ever-pressing need for an effective UNICEF. Bias
against
children remains in surprising places. WHO is making
maternal and child
health the subject of its 2005 World Health
Report, as well as its World
Health Day. The centrepiece of its
public relations effort around World
Health Day next April is
"Great Expectations". Six mothers-to-be living in
different parts
of the world are being followed to term and beyond--to when
their
newborns are 6 weeks old. For "Great Expectations", childhood ends
at 6 weeks. At a recent meeting in Geneva, I asked a member of the
"Great Expectations" team why they were taking such a constricted
view
of childhood. She replied that there were no resources to
take childhood
beyond 6 weeks. The World Health Report has been
hurriedly put together. The
contribution of child health experts
has been haphazard. Drafts of the
document are being circulated
only to "friends of the report." This is
hardly the kind of
independent critical peer review that recipients of the
report,
eg, WHO's member governments and senior policy-makers, would have
hoped for. Complacency still scars the global effort to improve
child
survival. This is the first challenge faced by Elizabeth
Mason, WHO's
capable and respected new director of child and
adolescent health and
development.
Nor are donors as forthcoming for child health as they
might be.
For example, the UK's Department for International Development has
declined to support the newly created Child Survival Partnership,
arguing that its commitment to the Partnership for Safe Motherhood
and
Newborn Health is sufficient--another strange, not to say
irrational,
_expression_ of commitment to child survival given that
the latter partnership
strongly emphasises safe motherhood at the
expense of newborns.
Research into how to scale up delivery of child-care services,
the
overriding lesson from IMCI, was entirely ignored in a
statement published
last month on "health research for equity" by
the Global Forum for Health
Research. And in one WHO meeting I
attended recently, a technical expert
from the agency suggested
that investment in neonatal and child health
should start with
the mother, not the child. The "incremental additional
cost" of
spending on child health would be minimised with a mother-focused
approach, she said. The child, it seems fair to point out, should
not be
viewed as an "incremental additional cost". A child should
be valued equally
with every other human being. Instead of
perpetuating a fruitless contest
between advocates of maternal
and child health, all those working on behalf
of children and
mothers (and fathers) should agree that each deserves equal,
although often programmatically related, consideration. The child
is not
less of a human being than either of its parents.
Children remain one of
the most marginalised groups in our world
today. The predicament of children
is the predicament of our
futures--and the future of our predicaments.
UNICEF needs a
visionary leader, a person of profound ability to make the
next
ten years the Decade of Child Survival and Development. Mr Annan,
this is the most important decision of your career, its effects
will
touch the lives of millions of those who have no voice.
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