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Holding to account | E4 on professional integrity of handouts, gifts and grants from industry is farreaching (see also part B, chapter 2 on handouts from drug companies). But what of the other key actors? This section presents a first attempt to develop a scorecard of the past and present performance of some of them. The scores are not based on a structured appraisal but have been compiled through a consensus process, involving a number of people from academia, IBFAN and WABA centrally involved in the promotion of breastfeeding and protection of public health. They are presented here as an example of one possible approach to monitoring of performance of key global health institutions. More rigorous assessment of performance is of course needed: this is just a starting point. Indicator 1: Overall promotion of breastfeeding and support for the code Under political pressure, WHO has not played a strong leadership role in ensuring compliance with the code. It came under significant pressure from the US administration to water down its promotion of the code. Much of its effort to promote the code has been weak, and leadership on the issue in Geneva has been poor – thus losing extrabudgetary support from two bilateral donors during the 1980s and early 1990s. UNICEF has played a more significant role in promoting breastfeeding. It started talking about the importance of breastfeeding in the early 1980s, did a lot of work on the code in the 1980s and began to fund programmes by around 1990, despite threats from the US government to withdraw funding if it took too strong a line against the unethical marketing practices of the baby food companies. Without its intervention, the support of the Swedish and Dutch aid agencies and the lobbying of international NGOs, the code could have suffered an early demise. UNICEF also deserves much of the credit for the Baby-Friendly Hospital Initiative, widely successful in increasing exclusive breastfeeding in the early weeks of life. However, along with other UN agencies’ work on breastfeeding, this work greatly declined after 1997 as a result of the diversion of staff time and funding to the new UN policy on HIV and infant feeding. UNICEF’s pro-breastfeeding talk has recently returned to early 1980s levels, but the funding is not yet back to the levels seen in the 1990s. After years of depending on extrabudgetary funds for a post for legal work on the code, UNICEF has recently incorporated the post into its core budget, signalling a commitment to continue its support for implementation of the code. However, WHO’s recent performance is considered less positive. Staff in the nutrition department with responsibility for the code are considered to have done too little to promote it and have at times even undermined it in public meetings. 316
USAID has also funded work on breastfeeding, mainly through NGOs like WELSTART and LINKAGES. The Canadian International Development Agency has also begun to take an interest. The work of all these agencies should likewise be monitored. Promotion of breastfeeding scorecard UNICEF: B + (requires more funding to reach an A grade) WHO: C + Swedish and Dutch aid agencies: A Other Scandinavian bilaterals: B+ USAID and CIDA: B - Support of the code scorecard UNICEF: A+ Swedish and Dutch aid agencies: A WHO: C Indicator 2: Promoting HIV-free survival in infants born to HIV-positive mothers In 1997, UNICEF joined WHO and UNAIDS in changing UN agency recommendations on the feeding of infants born to HIV-positive mothers in low-income settings, in response to political pressure. This was done with little consultation or involvement of child health and breastfeeding experts. Part of the motivation for the change was that breastfeeding reduced the overall impact of short-course AZT (an antiretroviral drug) in reducing vertical HIV transmission. However, the initial enthusiasm to reduce mother-to-child transmission did not consider carefully enough the trade-off between HIV transmission and the impact of breastmilk substitution on infant survival. In addition, UNICEF programmes and other programmes began to subsidize and provide free infant formula to HIV-positive mothers. In 1998 UN- AIDS, UNICEF and WHO announced they were giving free formula to 30,000 babies born to low-income mothers at 11 pilot sites. Concerns that this would lead to unsafe feeding or mixed feeding (which might result in a higher rate of HIV transmission from breastmilk) were not addressed. It was commonly explained that informed choice on how to feed was a human right, and that the provision of free formula helped women to fulfil their right. Amazingly, these pilot sites were only evaluated in relation to logistical issues, and not in relation to child health outcomes. Given the failure to evaluate child health outcomes and the difficulty of keeping an infant alive without breastmilk in low-income settings, it is impossible to know whether this new policy has led to any increase in HIV-free survival of infants born to HIV- Big business 317
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About this book Today’s global he
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Global Health Watch 2005-2006 An al
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Contents Boxes, figures and tables
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C2.1 The facts about disability 180
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Illustrations 1 Medicine cannot dea
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Acknowledgements The following indi
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London School of Hygiene and Tropic
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Victoria, Canada; Centre for Health
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Foreword New reports on different a
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Introduction Origins The Global Hea
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Child malnutrition, death and disab
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Human rights and responsibilities A
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impacting on health. The Watch hope
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part a | Health and globalization T
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Health and globalization | A1 and h
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Health and globalization | A1 in 20
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Health and globalization | A1 is gl
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Health and globalization | A1 peopl
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Health and globalization | A1 numbe
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Health and globalization | A1 and p
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Health and globalization | A1 econo
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Health and globalization | A1 Box A
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Health and globalization | A1 half
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Health and globalization | A1 appro
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table a1 Key health concerns with W
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Health and globalization | A1 Healt
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Health and globalization | A1 merci
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Health and globalization | A1 thems
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Health and globalization | A1 Even
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Health and globalization | A1 • A
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Health and globalization | A1 non-v
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Health and globalization | A1 27-28
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Health and globalization | A1 Jenki
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Health and globalization | A1 Satte
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Health and globalization | A1 WHO (
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and regulatory authorities mandated
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Health care systems | B1 4) selecti
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Health care systems | B1 • And si
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Health care systems | B1 • declin
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Health care systems | B1 user charg
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Health care systems | B1 focus on t
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Health care systems | B1 for health
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Health care systems | B1 their cont
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Health care systems | B1 health car
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Health care systems | B1 ing servic
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Health care systems | B1 Box B1.7 G
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Health care systems | B1 many of th
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Health care systems | B1 the lack o
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Macro-economic factors Impoverished
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Health care systems | B1 HALE 2000
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Health care systems | B1 But improv
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Health care systems | B1 high-incom
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Health care systems | B1 Structural
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Health care systems | B1 the high t
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Health care systems | B1 and histor
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Health care systems | B1 norms (Loe
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Health care systems | B1 Foster M,
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Health care systems | B1 Toole M et
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B2 | Medicines Introduction Essenti
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Health care systems | B2 of new med
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Health care systems | B2 chapter re
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Health care systems | B2 the fourth
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Health care systems | B2 agenda thr
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Health care systems | B2 nonetheles
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Health care systems | B2 decision o
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Health care systems | B2 for the an
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Health care systems | B2 expenditur
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Health care systems | B2 Medawar C
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Health care systems | B3 between he
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Severe shortage Low density Moderat
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Health care systems | B3 sector and
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Health care systems | B3 to the US,
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Health care systems | B3 500 400 30
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Health care systems | B3 have been
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Health care systems | B3 to underta
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B4 | Sexual and reproductive health
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Health care systems | B4 10 Policy-
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Health care systems | B4 women and
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Health care systems | B4 of funding
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Health care systems | B4 debate on
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Health care systems | B4 the sexual
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Health care systems | B4 perspectiv
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Health care systems | B5 genome res
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Health care systems | B5 drugs base
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Health care systems | B5 Complete f
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Health care systems | B5 when a tes
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Health care systems | B5 are allowi
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Health care systems | B5 of life sc
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part c | Health of vulnerable group
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Health of vulnerable groups | C1 me
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Health of vulnerable groups | C1 pr
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Health of vulnerable groups | C1 Th
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Health of vulnerable groups | C1 Ca
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Health of vulnerable groups | C1 Bo
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Health of vulnerable groups | C1 Pa
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Health of vulnerable groups | C2 DP
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Health of vulnerable groups | C2 di
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part d | The wider health context T
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D1 | Climate change Introduction En
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increasing quantities are now causi
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development, local availability foo
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14 Droughts threaten the food secur
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Protocol can meet their targets by
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15 Transport and travel are major d
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• Redesign trade rules. Governmen
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D2 | Water Access to enough clean w
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water consumption worldwide. Each p
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table d2.1 Top corporate players in
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16 Protesting against the privatiza
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Box D2.3 Regulating private water c
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The private sector overestimates th
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Box D2.7 US citizens told to boil t
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to water. Worse still, it does this
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References Barlow M, Clarke T (2002
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D3 | Food Undernutrition is by far
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Functional and Productive Capacity
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table d3.1 Corporate control of US
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keting and processing means that sm
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average Indian family of four reduc
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Bank’s US$ 93.5 million loan to C
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Avery N, Drake M, Lang T (1993). Cr
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D4 | Education Some 135 million chi
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ledge about health-care practices a
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2005, and on present trends about 4
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Box D4.3 Programmes that aim to emp
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• per capita public spending fall
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unable to recruit 9000 badly needed
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Gordon D et al. (2003). The distrib
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D5 | War War has an enormous and tr
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19 Chechnya destroyed. War has wide
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initiated a ‘war on terrorism’.
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an explosive force equivalent to ab
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the risk of their misuse and divers
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Box D5.3 An agenda for peace The Ha
Page 283 and 284: Machel G (1996). Impact of Armed Co
Page 285 and 286: part e | Holding to account: global
Page 287 and 288: E1 | World Health Organization The
Page 289 and 290: The sources consulted worldwide in
Page 291 and 292: Box E1.1 Milestones in WHO history
Page 293 and 294: aised by his attempts to revitalize
Page 295 and 296: • stronger internal focus on perf
Page 297 and 298: 21 WHO - up in the clouds? Reaction
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Page 305 and 306: to medicines, and the mobilizing ro
Page 307 and 308: Recommendations WHO’s core purpos
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Page 311 and 312: E2 | UNICEF In 2005, Carol Bellamy,
Page 313 and 314: In sum, for almost a decade, childr
Page 315 and 316: prompted a global debate on how to
Page 317 and 318: E3 | The World Bank and the Interna
Page 319 and 320: 22 World Bank: the centre of world
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Page 323 and 324: tal policies should explicitly refe
Page 325 and 326: E4 | Big business This chapter deal
Page 327 and 328: 23 The Marlboro Man was described b
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Page 331 and 332: grass roots in building government
Page 333: 24 A pack of Cerelac cereal food pu
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Page 343 and 344: Global aid trends - allocation Wher
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Page 347 and 348: table e5.1 Value (in £) of new DFI
Page 349 and 350: OECD (2005). Development Co-operati
Page 351 and 352: 25 Breaking the chains of debt: pro
Page 353 and 354: Box E6.1 Zambia: inflation or death
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Page 357 and 358: E7 | Essential health research Rese
Page 359 and 360: Developing national health research
Page 361 and 362: for African Medical Editors (Certai
Page 363 and 364: Neither the consultations leading u
Page 365 and 366: Box E7.4 Asking the social-politica
Page 367 and 368: • global architecture for health
Page 369 and 370: part f | Conclusions Global Health
Page 371 and 372: current debt relief mechanism - the
Page 373 and 374: agreement, and taking health and he
Page 375 and 376: ity of the now-developed countries
Page 377 and 378: tion and water are experiencing sim
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