PHA-Exchange> UNICEF leadership 2005-2015: a call for strategic change Article on :

[Ghassan Shahrour]

Dear Colleagues of PHA,

First Eid Adha Mubarek.

It pleases me to share with you this article on: 
UNICEF leadership 2005-2015: a call for strategic change, AU: R Horton 
SO: The Lancet 11 Dec 2004, 364(9451): 2071-74. 
    http://image.thelancet.com/extras/04cmt425web.pdf 



Pls, note thae date of the article;

Hope you find it interesting.

Best Regards

Ghassan Shahrour, 
Yarmouk
P O Box 14189 Damascus - Syria
Email 1:  afodafro at scs-net.org
Email 2:  syria at icbl.org


--------------------------

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. 

References are available upon request at info at healthnet.org 
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