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

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

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

An unintended consequence of the current focus on the control of HIV/AIDS, tuberculosis and malaria has been a relative neglect of other infectious diseases, such as pneumonia and diarrhoea, which still kill many children in the developing world.1 Why has the control of pneumonia in young children been so neglected? Reasons that have been suggested include the nature of the target group (children in deprived communities), the multiple etiologies of pneumonia, lack of agreement among experts on the most appropriate intervention strategies and incorporation of case management of pneumonia into the Integrated Management of Childhood Illnesses (IMCI) strategy, which has reduced the disease’s visibility. Over the past few years, several attempts have been made to raise the profile of childhood pneumonia as a public health priority2 but much more needs to be done. A recent step forward has been the establishment of the Global Action Plan for the Prevention and Control of Pneumonia (GAPP), which to date has held two formal meetings (March 2007 and February 2008), several informal discussions, and developed a draft action plan. This issue of the Bulletin contains a series of papers commissioned by GAPP, together with some other relevant papers. The GAPP initiative is helping to advance the case for control of childhood pneumonia as a public health emergency; however, an enhanced, high-level, sustained advocacy campaign is needed if pneumonia in children is to receive the attention that it deserves from those who guide and fund international health. A successful advocacy programme requires a clear definition of the problem, identification of effective interventions to deal with it, a plan for implementing these interventions, and an assessment of their likely costs and economic benefits. Until recently, there was insufficient information to mount such a campaign for childhood pneumonia, but a great deal of progress in this direction has recently been made, as evidenced in the papers in this issue of the Bulletin. As reported by Rudan et al.,3 there are now reasonably accurate estimates of the annual number of episodes of pneumonia among children less than 5 years old (ca. 150 million) and of the annual number of pneumonia deaths (ca. 2 million), and two groups of effective interventions have been identified – vaccination and case management. Excellent progress has been made recently in increasing coverage with measles vaccination,4 and Madhi et al.5 report that there is now solid evidence to support widespread introduction of Haemophilus influenzae type b and pneumococcal conjugate vaccines in developing countries. These vaccines are safe; and DeStefano et al.6 report that the only possibly significant side-effect associated with pneumococcal conjugate vaccines has been an increase in the incidence of reactive airway disease shortly after vaccination. Other potentially effective ways of preventing pneumonia in young children include the promotion of exclusive breastfeeding during the first few months of life, zinc supplementation (Roth et al.)7 and a reduction in indoor air pollution (Dherani et al.).8 However, more research is needed on how the latter two interventions could be implemented most effectively before national scale-up can be recommended. None of these preventive measures is likely to completely prevent childhood pneumonia so there is still a need for an effective case-management strategy. Treatment with antibiotics in the community reduces mortality and morbidity from pneumonia9 but, as reported by Marsh et al.10 this approach has not been implemented widely because of concerns over the use of antibiotics by relatively untrained staff. To ensure that every child with severe pneumonia has rapid access to treatment with an effective antibiotic, treatment in the community by workers with limited training is necessary in many developing country situations (Kallander et al.)11 and is essential in ensuring equity in access to treatment (Mulholland et al.).12 Community management programmes can be scaled up effectively, as reported for Nepal by Dawson et al.13 Community health workers are likely to be most effective in rural areas with scattered populations. In many urban areas in the developing world, treatment for pneumonia is frequently provided outside the formal health sector by practitioners with various levels of training. More could be done to improve the quality of the care that they provide, for example by training and franchising shop keepers. Care of children with pneumonia in health facilities also needs to be improved (Graham et al.)14 and requires the availability of oxygen (Enarson et al.).15 A strong and competitive case will be needed to persuade the major international donors to invest in the control of pneumonia in children at country and global levels. Drawing this up is now an urgent priority and will require a substantial amount of work by a dedicated team of qualified experts who will need appropriate financial support. The papers presented in this issue of the Bulletin provide a good basis for starting this process. ■

The ethical obligations of those who work for health are as old as the health professions themselves; indeed, the commitment to place the interests of clients above all else is one of the hallmarks of professionalism. Ethical prescriptions are found in many cultures, such as the oath and associated writings of Hippocrates in ancient Greece and the writings of the medieval Jewish philosopher Maimonides. Though originating with the professions, ethical duties are of concern to society in general, and their violation – as by the doctors who conducted experiments in the Nazi prison camps – can constitute human rights as well as ethical violations. In response to the tremendous expansion of the powers of medicine and biomedical science in the 20th century, the new field of bioethics emerged in the 1960s, first in North America and western Europe and eventually around the world. With contributions not only from moral philosophers but also from physicians, nurses and other health professionals, social and natural scientists and lawyers, bioethics has become a field of major concern. Health professionals, health authorities and the public debate the issues raised by organ and tissue transplantation, unequal access to life-saving medicines, new reproductive technologies and vast increases in the numbers and types of clinical trials. While abundant analysis and official guidelines have been produced on most of the ethical issues in health care and research, until recently the field of public health received relatively little attention among ethicists. Similarly, while ethical questions have always been an implicit part of public health practice, the idea of incorporating a formal process of ethical deliberation into public health policy-making remains relatively new. As the ethics of public health receives greater attention, new paradigms and methods of ethical analysis will have to be developed. In particular, whereas medical ethics has traditionally aimed to protect individual interests in the context of the physician–patient relationship, public health ethics focuses on the design and implementation of measures to monitor and improve the health of broader populations. In addition, public health ethics must look beyond health care per se to consider the structural conditions, and social and economic determinants that promote or inhibit the development of healthy societies. Incorporating ethical analysis into public health raises many challenging questions. For example, what does ethical analysis add to public health beyond legal or public policy analysis? Is the law itself subject to a process of ongoing ethical scrutiny? When ethicists appeal to “values”, who gets to decide which values are worthy of protection or how these values should be prioritized in cases of conflict? How should ethical analysis address the tension between universal principles and culturally specific values, and find common ground among individuals from diverse cultural backgrounds? Such questions have practical implications for how public health policies are designed, implemented and evaluated. For example, when public health authorities make decisions about allocating limited resources, they will implicitly or explicitly determine which principles and values underlie those decisions. Such decisions also vary according to the processes by which they are made and to what extent the public, nongovernmental and international organizations, and national or regional governments participate in these processes. A Bulletin theme issue, to be published in August 2008, will provide a forum for examining these and related issues. The goal of this theme issue is to explore how ethical considerations have been and should be incorporated into decision-making about public health issues. The Bulletin encourages the submission of papers covering practical examples that illustrate how ethical questions have been addressed at the domestic and international levels. For example, how have governments or professional associations used ethical analysis to evaluate health-care workers’ obligations during influenza pandemics? What does ethics have to say about the use of financial incentives to increase the supply of organs for transplantation? In general, we seek to publish specific examples of structures and processes that have been used for ethical deliberation, combined with a candid examination of these options’ advantages and drawbacks. Contributions from authors from developing countries are particularly welcome. It is hoped that the papers in this issue will help national policy-makers reflect on the need to consider ethics in formulating and implementing health policies, while also providing best practices that can be adapted to specific national contexts. The issue will provide a forum for units at WHO headquarters and regional offices that have engaged in ethical analysis of their programmes to share their work. Finally, the empirical basis of the papers will provide much-needed data about global efforts to address ethical issues and the impact these efforts are having on the health of populations. The deadline for submissions is 11 January 2008. All submissions will go through the Bulletin’s peer review process. ■

The World Health Organization has recommended that Member States consider taxing energy-dense beverages and foods and/or subsidizing nutrient-rich foods to improve diets and prevent noncommunicable diseases. Numerous countries have either implemented taxes on energy-dense beverages and foods or are considering the implementation of such taxes. However, several major challenges to the implementation of fiscal policies to improve diets and prevent noncommunicable diseases remain. Some of these challenges relate to the cross-sectoral nature of the relevant interventions. For example, as health and economic policy-makers have different administrative concerns, performance indicators and priorities, they often consider different forms of evidence in their decision-making. In this paper, we describe the evidence base for diet-related interventions based on fiscal policies and consider the key questions that need to be asked by both health and economic policy-makers. From the health sector's perspective, there is most evidence for the impact of taxes and subsidies on diets, with less evidence on their impacts on body weight or health. We highlight the importance of scope, the role of industry, the use of revenue and regressive taxes in informing policy decisions.L'Organisation mondiale de la Santé a recommandé aux États membres d'envisager de taxer les boissons et aliments à haute teneur énergétique et/ou de subventionner les denrées riches en nutriments, en vue d'améliorer les régimes alimentaires et de prévenir les maladies non transmissibles. Aujourd'hui, nombreux sont les pays à avoir instauré des taxes sur les boissons et aliments à haute teneur énergétique ou à envisager de le faire. Néanmoins, d'importants défis subsistent pour la mise en application de ce type de politiques fiscales. Certains sont liés à la nature intersectorielle des interventions appropriées. Par exemple, comme les responsables des politiques économiques et les responsables des politiques de santé ont des préoccupations administratives, des priorités et des indicateurs de performances différents, ils s'appuient souvent sur différentes formes de données dans leur prise de décisions. Dans le présent document, nous décrivons les données probantes susceptibles d'orienter les interventions sur l'alimentation fondées sur des politiques fiscales et nous évoquons les principales problématiques auxquelles doivent répondre à la fois les responsables des politiques économiques et les responsables des politiques de santé. D'un point de vue de santé publique, les preuves de l'impact des taxes et subventions sur les habitudes alimentaires sont plus nombreuses que les preuves de leur impact sur le poids ou la santé. Nous abordons également l'importance du périmètre d'action, le rôle de l'industrie, l'utilisation des recettes fiscales et la régressivité des taxes, dans l'optique d'éclairer les décisions politiques.La Organización Mundial de la Salud ha recomendado a los Estados Miembros considerar la posibilidad de aplicar un impuesto a las bebidas y los alimentos de alto contenido energético y/o subvencionar los alimentos ricos en nutrientes para mejorar las dietas y prevenir enfermedades no contagiosas. Numerosos países ya aplican impuestos a bebidas y alimentos de alto contenido energético o consideran la implementación de dichos impuestos. Sin embargo, persisten varios desafíos importantes para la implementación de políticas fiscales para mejorar las dietas y prevenir las enfermedades no contagiosas. Algunos de estos desafíos están relacionados con la naturaleza intersectorial de las intervenciones correspondientes. Por ejemplo, puesto que los encargados de la formulación de políticas de salud y economía tienen diferentes preocupaciones administrativas, indicadores de rendimiento y prioridades, a menudo tienen en cuenta diferentes formas de pruebas en su toma de decisiones. En este documento, se describe la base de pruebas para intervenciones relacionadas con la dieta basadas en políticas fiscales y se consideran las preguntas clave que deben formular tanto los responsables de la política económica como de la de salud. Desde la perspectiva del sector de la salud, existen muchas pruebas del impacto de los impuestos y subsidios en las dietas, con menos pruebas de sus impactos sobre el peso o la salud corporal. Se destaca la importancia del alcance, el papel de la industria, el uso de los ingresos y los impuestos regresivos para informar sobre las decisiones políticas.أوصت منظمة الصحة العالمية الدول الأعضاء بدراسة فرض ضرائب على المشروبات والأطعمة كثيرة السعرات الحرارية و/أو دعم الأطعمة الغنية بالمغذيات وذلك من أجل تحسين الأنظمة الغذائية ومقاومة الأمراض غير المعدية. وقد قامت العديد من البلدان بفرض الضرائب بالفعل على المشروبات والأطعمة كثيرة السعرات الحرارية أو تدرس فرض ضرائب من هذا النوع، إلا أن العديد من التحديات الرئيسية تواجه تنفيذ السياسات المالية لتحسين الأنظمة الغذائية والوقاية من الأمراض غير المعدية. وتتعلق بعض هذه التحديات بطبيعة التدخلات ذات الصلة والمشتملة على عدة قطاعات. على سبيل المثال، فإن تباين الاهتمامات الإدارية ومؤشرات الأداء والأولويات لدى مقرري السياسات الاقتصادية والصحية غالبًا ما يدفعهم إلى اعتماد أشكال مختلفة للأسس الدلالية التي يستندون إليها في عملية اتخاذ القرار. ونصف في هذا التقرير الأساس الدلالي للتدخلات ذات الصلة بالأنظمة الغذائية والمعتمدة على السياسات المالية، ونبحث الأسئلة الرئيسية الوارد طرحها من جانب من كلٍ من مقرري السياسات الاقتصادية والصحية. ومن منظور القطاع الصحي تشير معظم الدلائل إلى حدوث تأثير ناتج عن فرض الضرائب والدعم على الأنظمة الغذائية، في حين توجد دلائل أقل تشير إلى تأثيرها على وزن الجسم أو الصحة. ونحن نقوم بتسليط الضوء على أهمية النطاق ودور الصناعة والاستفادة من الإيرادات والضرائب التنازلية في اتخاذ القرارات المستنيرة المتعلقة بالسياسات.世界卫生组织建议会员国考虑对高能量饮料和食品征税和/或给予富含营养物质的食品补贴，以改善饮食和预防非传染性疾病。许多国家要么已经对高能量饮料和食品征税，要么正在考虑实施此项税赋。但是，实施改善饮食和预防非传染性疾病的财政政策仍然面临若干重大挑战。其中一些挑战与相关干预的跨部门性质有关。例如，由于卫生和经济决策者的行政关注、绩效指标和优先事项有所不同，决策者在制定决策时往往会考虑不同形式的依据。在本文中，我们描述了基于财政政策的饮食相关干预的依据基础，并考虑了卫生和经济决策者都需要提出的关键问题。从卫生部门的角度来看，很多依据可以证明税收和补贴对饮食的影响，但很少有依据可以证明其对体重或健康的影响。我们强调了范围、行业角色、营业税和累退税的使用在传达政治决策中的重要性。.Всемирная организация здравоохранения рекомендовала государствам-членам рассмотреть вопрос об обложении налогом высококалорийных напитков и продуктов питания и (или) субсидировании богатых питательными веществами продуктов питания для улучшения рациона и профилактики неинфекционных заболеваний. Многие страны либо применяют налоги на высококалорийные напитки и продукты питания, либо рассматривают возможность применения таких налогов. Тем не менее остается несколько серьезных проблем, связанных с осуществлением налогово-бюджетной политики, направленной на улучшение рациона и профилактику неинфекционных заболеваний. Некоторые из этих проблем связаны с межсекторальным характером соответствующих интервенций. Например, поскольку лица, определяющие политику в области здравоохранения и экономики, имеют разные по характеру административные проблемы, показатели эффективности и приоритеты, они часто учитывают различные формы доказательных данных в процессе принятия решений. В этой статье мы описываем доказательную базу для связанных с рационом интервенций на основе налогово-бюджетной политики и рассматриваем ключевые вопросы, которыми должны задаваться лица, определяющие политику в области здравоохранения и экономики. С точки зрения сектора здравоохранения имеется больше данных о влиянии налогов и субсидий на рацион при меньшем объеме данных об их воздействии на вес тела или здоровье. Мы подчеркиваем важность сферы применения, роли промышленности, использования доходов и регрессивных налогов для принятия политических решений.

Law lies at the centre of successful national strategies for prevention and control of noncommunicable diseases. By law we mean international agreements, national and subnational legislation, regulations and other executive instruments, and decisions of courts and tribunals. However, the vital role of law in global health development is often poorly understood, and eclipsed by other disciplines such as medicine, public health and economics. This paper identifies key areas of intersection between law and noncommunicable diseases, beginning with the role of law as a tool for implementing policies for prevention and control of leading risk factors. We identify actions that the World Health Organization and its partners could take to mobilize the legal workforce, strengthen legal capacity and support effective use of law at the national level. Legal and regulatory actions must move to the centre of national noncommunicable disease action plans. This requires high-level leadership from global and national leaders, enacting evidence-based legislation and building legal capacities.Le droit est au cœur des stratégies nationales efficaces de lutte contre les maladies non transmissibles. Par droit, nous entendons les accords internationaux, les législations nationales et infranationales, les réglementations et autres instruments exécutifs, et les décisions des cours et des tribunaux. Cependant, le rôle vital du droit dans le développement de la santé à l'échelle mondiale est souvent mal compris, et éclipsé par d'autres disciplines telles que la médecine, la santé publique et l'économie. Cet article définit des domaines d'intersection clés entre le droit et les maladies non transmissibles, en commençant par le rôle du droit en tant qu'outil pour mettre en œuvre des politiques visant à prévenir et maîtriser les principaux facteurs de risque. Nous mettons en évidence des mesures que l'Organisation mondiale de la Santé et ses partenaires pourraient prendre pour mobiliser les professionnels du droit, renforcer les capacités juridiques et soutenir une utilisation efficace du droit au niveau national. Des mesures juridiques et réglementaires doivent être placées au centre des plans d'action nationaux pour la lutte contre les maladies non transmissibles. Cela nécessite un leadership de haut niveau de la part des dirigeants internationaux et nationaux, à travers l'adoption de lois fondées sur des données scientifiques et un renforcement des capacités juridiques.La ley es la clave del éxito de las estrategias nacionales para la prevención y el control de las enfermedades no contagiosas. Por ley entendemos los acuerdos internacionales, la legislación nacional y subnacional, los reglamentos y otros instrumentos ejecutivos, así como las decisiones de los tribunales y las cortes de justicia. Sin embargo, el papel vital de la ley en el desarrollo de la salud mundial a menudo no se comprende bien y se ve eclipsado por otras disciplinas como la medicina, la salud pública y la economía. Este documento identifica las áreas clave de intersección entre la ley y las enfermedades no contagiosas, empezando por el papel de la ley como herramienta para implementar políticas de prevención y control de los principales factores de riesgo. Se determinan las medidas que la Organización Mundial de la Salud y sus asociados podrían adoptar para movilizar al personal legal, fortalecer la capacidad jurídica y apoyar el uso eficaz de la legislación a nivel nacional. Las acciones legales y reglamentarias deben pasar a ser el centro de los planes de acción nacionales para las enfermedades no contagiosas. Esto requiere un liderazgo de alto nivel por parte de los líderes mundiales y nacionales, para promulgar una legislación basada en pruebas y crear capacidades jurídicas.يمثل القانون حجر الزاوية بالنسبة للاستراتيجيات الوطنية الناجحة للوقاية من الأمراض غير المعدية ومكافحتها. والمقصود بالقانون هو الاتفاقات الدولية، والتشريعات الوطنية ودون الوطنية، واللوائح وغيرها من الوسائل الإدارية وقرارات المحاكم والهيئات القضائية. ورغم ذلك، فإن الدور الحيوي للقانون في مجال التنمية الصحية العالمية غالباً ما يكون غير مفهوم بشكل جيد، ويتفوق عليه التخصصات الأخرى مثل الطب والصحة العامة وعلم الاقتصاد. يحدد هذا البحث المجالات الرئيسية للتداخل بين القانون والأمراض غير المعدية، بدءا من دور القانون كأداة لتنفيذ سياسات الوقاية والتحكم في عوامل الخطر الرئيسية. نحن نحدد الإجراءات التي يمكن أن تتخذها منظمة الصحة العالمية وشركاؤها لتعبئة القوى العاملة القانونية، وتعزيز الصلاحيات القانونية ودعم الاستخدام الفعال للقانون على المستوى الوطني. يجب أن تكون الإجراءات القانونية والتنظيمية في قلب خطط العمل الوطنية للامراض غير المعدية. ويتطلب ذلك قيادة عالية المستوى من القادة العالميين والوطنيين، وسن تشريعات قائمة على الأدلة، وبناء الصلاحيات القانونية.法律是成功制订预防和控制非传染性疾病的国家战略核心。我们所说的法律是指国际协议、国家和地方法律、法规和其它执行文书,以及法院和法庭的判决。但是,人们对法治在全球卫生发展中的重要作用知之甚少,且法学的作用往往被医学、公共卫生和经济学等其它学科所替代。本文确定了法律与非传染性疾病交叉的关键领域,以法治工具作为实施预防和控制主要风险因素政策的开端。我们明确世界卫生组织及其合作伙伴可以采取行动来动员合法劳动力,加强法律能力并支持法律在国家层面上的有效利用。法律和法规行为必须转向国家非传染性疾病行动计划的中心。这需要在国际和国家层面上实施基于实证的立法和建设法律能力的高层领导。.Закон лежит в основе успешных национальных стратегий по профилактике и борьбе с неинфекционными заболеваниями. Под законом подразумеваются международные соглашения, национальное и субнациональное законодательство, нормативные акты и другие постановления исполнительных органов, а также решения судов и трибуналов. Однако исключительно важная роль закона в области развития глобального здравоохранения часто плохо осознается и перекрывается такими дисциплинами, как медицина, общественное здравоохранение и экономика. Настоящий документ определяет основные области пересечения между законом и лечением неинфекционных заболеваний, начиная с роли закона как инструмента для реализации стратегий по профилактике и борьбе с ведущими факторами риска. Авторы определяют меры, которые могут быть предприняты Всемирной организацией здравоохранения и ее партнерами по мобилизации юридического персонала, укреплению правоспособности и поддержке эффективного использования закона на национальном уровне. Правовые и нормативные меры должны стать основой для разработки национальных планов действий по борьбе с неинфекционными заболеваниями. Для этого необходимо заручиться поддержкой мировых и национальных лидеров, обеспечить принятие научно обоснованных законов и развитие правового потенциала.

A robust health infrastructure in every country is the most effective long-term preparedness strategy for global health emergencies. This includes not only health systems and their human resources, but also countries' legal infrastructure for health: the laws and policies that empower, obligate and sometimes limit government and private action. The law is also an important tool in health promotion and protection. Public health professionals play important roles in health law - from the development of policies, through their enforcement, to the scientific evaluation of the health impact of laws. Member States are already mandated to communicate their national health laws and regulations to the World Health Organization (WHO). In this paper we propose that WHO has the authority and credibility to support capacity-building in the area of health law within Member States, and to make national laws easier to access, understand, monitor and evaluate. We believe a strong case can be made to donors for the funding of a public health law centre or unit, that has adequate staffing, is robustly networked with its regional counterparts and is integrated into the main work of WHO. The mission of the unit or centre would be to define and integrate scientific and legal expertise in public health law, both technical and programmatic, across the work of WHO, and to conduct and facilitate global health policy surveillance.Avoir une infrastructure sanitaire solide dans chaque pays est la meilleure stratégie à long terme de préparation aux urgences sanitaires mondiales. Il s'agit non seulement des systèmes de santé et de leurs ressources humaines, mais aussi de l'infrastructure juridique des pays en matière de santé: les lois et les politiques qui permettent, obligent et parfois limitent l'action du gouvernement et du secteur privé. La législation est également un outil important pour la promotion et la protection de la santé. Les professionnels de la santé publique jouent un rôle important vis-à-vis de la législation sanitaire - de l'élaboration des politiques à leur application, en passant par l'évaluation scientifique de l'impact des lois sur la santé. Les États membres sont déjà chargés de faire part de leurs lois et règlements nationaux en matière de santé à l'Organisation mondiale de la Santé (OMS). Le présent article suggère que l'OMS, qui dispose de l'autorité et de la crédibilité pour le faire, participe au renforcement des capacités dans le domaine de la législation sanitaire des États membres et facilite l'accès, la compréhension, le contrôle et l'évaluation des lois nationales. Des arguments convaincants peuvent être présentés aux bailleurs de fonds pour le financement d'un centre ou d'une unité de législation de la santé publique qui disposerait du personnel nécessaire, entretiendrait de solides relations avec ses homologues régionaux et serait intégré aux principaux travaux de l'OMS. La mission de cette unité ou de ce centre consisterait à définir et intégrer l'expertise scientifique et juridique dans la législation de la santé publique, sur le plan technique et programmatique, dans le cadre des travaux de l'OMS, et à réaliser et faciliter la surveillance des politiques sanitaires mondiales.Una infraestructura sanitaria firme en todos los países es la estrategia de preparación más eficaz a largo plazo para tratar las emergencias sanitarias en todo el mundo. Esto no solo incluye los sistemas sanitarios y sus recursos humanos, sino también la infraestructura legal para la salud de cada país: las leyes y políticas que facultan, obligan y, en ocasiones, limitan la acción privada y del gobierno. La legislación también es una herramienta importante para el fomento y la protección de la salud. Los profesionales de la salud pública tienen funciones fundamentales en la legislación sanitaria: desde el desarrollo de políticas a través de su puesta en vigor, hasta la evaluación científica del impacto sanitario de las leyes. Ya se ha encomendado a los Estados Miembros que comuniquen sus leyes y normativas de salud nacionales a la Organización Mundial de la Salud (OMS). Este artículo propone que la OMS tenga la autoridad y credibilidad para dar apoyo a la creación de capacidad de las leyes sanitarias de los Estados Miembros, y para facilitar el acceso, la comprensión, la supervisión y la evaluación de las leyes nacionales. Creemos que hay argumentos firmes a favor de las contribuciones para la financiación de un centro o unidad de derecho de salud pública que cuente con el personal adecuado, tenga un sistema de redes sólido con sus contrapartes regionales y esté integrado con el trabajo principal de la OMS. La misión de la unidad o centro sería definir e integrar la experiencia científica y legal en la ley de salud pública, tanto en el aspecto técnico como programático, a través del trabajo de la OMS, así como dirigir y facilitar el control de las políticas sanitarias globales.إن إنشاء بنية تحتية قوية للصحة في كل بلد يمثل استراتيجية التأهب الأكثر فعالية على المدى الطويل لحالات الطوارئ الصحية العالمية. وهذا الأمر لا يشمل فقط أنظمة الصحة والموارد البشرية الخاصة بها، وإنما يمتد أيضًا ليشمل البنية التحتية القانونية للصحة في البلدان، بما يشمل: القوانين والسياسات التي تعمل على تمكين وفرض الإجراءات الحكومية والخاصة وأحيانًا الحد من تأثيرها. ويمثل القانون أيضًا أداةً مهمة في مجال حماية الصحة وتشجيع الحفاظ عليها. ويؤدي المتخصصون في مجال الصحة العامة أدوارًا هامة في قانون الصحة – بداية ًمن وضع السياسات، حتى إنفاذها، ونهايةً بإجراء التقييم العلمي عن التأثير الصحي للقوانين. تم إلزام الدول الأعضاء بالفعل بإعلام منظمة الصحة العالمية بقوانينها الصحية الوطنية ولوائحها التنظيمية. نقترح في هذه الدراسة منح منظمة الصحة العالمية الصلاحية والمصداقية لدعم بناء القدرات في مجال القوانين الصحية داخل نطاق الدول الأعضاء، وتسهيل الاطلاع على القوانين الوطنية وفهمها ومتابعتها وتقييمها بشكلٍ أكبر. ونحن نعتقد أنه يمكن تقديم عرض مُقنِع للجهات المانحة لتمويل مركز أو وحدة قانون الصحة العامة، التي يتواجد فيها عدد كافٍ من الموظفين، والتي يتم توصيلها بشبكة قوية بنظيراتها الإقليمية، مع دمجها في نطاق العمل الرئيسي لمنظمة الصحة العالمية. وعلى أن تتمثل مهمة الوحدة أو المركز في تحديد ودمج الخبرات العلمية والقانونية في قانون الصحة العامة، لكل من الخبرات التقنية والبرمجية، وذلك عبر نطاق الأعمال التي تؤديها منظمة الصحة العالمية، والعمل على إجراء أعمال مراقبة السياسة الصحية العالمية وتسهيلها.在每个国家建立稳健的卫生基础设施是应对全球性卫生突发事件最有效的长期准备战略。 这不仅包括卫生系统及其人力资源,而且还包括各国有关卫生的法律基础设施: 赋予权力、义务并且有时限制政府和民间活动的法律和政策。 法律也是促进卫生和卫生防护的重要工具。 从政策的制定、执行,到科学评估法律对卫生的影响——公共卫生专业人员在卫生法律中发挥重要的作用。 成员国必须将其国家卫生法律和法规传达给世界卫生组织。 在本文中,我们建议世界卫生组织凭借其权威性和公信力在成员国中支持卫生法律领域的能力建设,并且使国家法律更加便于查阅、了解、监控和评估。 我们认为应强力主张捐助方为公共卫生法律中心或部门提供经费,使这些中心或部门配备足够的工作人员,与区域内的同行稳健地联网并且融入世界卫生组织的主要工作中。 这些部门或中心的任务将是在世界卫生组织的整个工作范围内确定与整合公共卫生法律中的科学与法律专业知识(包括技术和程序知识),并且开展和促进全球卫生政策监督。.Поддержание сильной инфраструктуры системы здравоохранения в каждой стране является наиболее эффективной долгосрочной стратегией обеспечения готовности к чрезвычайным ситуациям в области мирового здравоохранения. В данном случае под инфраструктурой понимаются не только системы здравоохранения и их людские ресурсы, но и правовая инфраструктура стран в области здравоохранения, а именно законы и положения, которые расширяют возможности, налагают обязательства и иногда вводят ограничения для деятельности правительств и частных лиц. Законодательство также является важным инструментом укрепления и охраны здоровья. Профессиональные работники сферы общественного здравоохранения играют важные роли в сфере здравоохранительного права, от разработки стратегий, их реализации до научной оценки воздействия законов на здоровье. Государства-участники уже приняли на себя обязательство сообщать Всемирной организации здравоохранения (ВОЗ) о своих национальных законах и правилах, относящихся к области здравоохранения. В данной статье высказывается предположение, что ВОЗ обладает достаточным авторитетом и репутацией для поддержки наращивания потенциала в сфере здравоохранительного права государств-участников и для облегчения доступа к внутренним законам, их понимания, отслеживания и оценки. Авторы уверены, что существуют веские доводы, которые можно привести донорам, в пользу финансирования ориентированного на сферу общественного здравоохранения юридического центра или группы, которые располагали бы кадровым составом соответствующего уровня подготовки, прочными связями со своими региональными партнерами и были бы вовлечены в основную деятельность ВОЗ. Миссия этой группы или центра заключалась бы в определении научных и юридических знаний (как технических, так и программных), их внедрении в законодательство, относящееся к общественному здравоохранению, во всех областях деятельности ВОЗ, а также в осуществлении надзора за политикой в сфере мирового здравоохранения и содействии ему.

Environmental health risks especially affect women and children, because they are more vulnerable socially and because exposures to environmental contaminants create greater risks for children's developing bodies and cognitive functions. According to the 2016 World Health Organization (WHO) estimates, modifiable environmental risk factors cause about 1.7 million deaths in children younger than five years and 12.6 million total deaths every year. (1) Although the Global strategy for women's, children's and adolescents' health (2016-2030) (2) was launched during the United Nations Sustainable Development Summit 2015, governments rarely recognize the sustainable development agenda as a transformative factor for health. The sustainable development goals (SDGs) offer opportunities for countries to create healthier environments for women, children and adolescents. This paper explores how the SDGs can be used to reduce environmental health risks and enhance the health of women, children and adolescents. In particular, we focus on drivers for urbanization and sustainable development (e.g. transport, housing, urban design and energy provision) that can advance the global strategy, but have not traditionally been a focus of health policy-making. We frame the discussion around the three pillars of the global strategy: survive, thrive and transform, while recognizing the inevitable overlap between these objectives. Survive Since women and children are especially affected by the environment, intersectoral interventions that reduce environmental risks will improve early childhood survival as well as reducing risks of premature death throughout the life-course. For instance, household air pollution from dirty fuels and inefficient cookstove technologies was estimated to have caused around 4 million premature deaths in 2012 and was responsible for more than half of deaths due to childhood pneumonia. (3) Among women, indoor exposures to household cookstove smoke were estimated to cause 34% (452 548/1336601) of chronic obstructive pulmonary disease deaths, 21% (732 937/3 476 815) of stroke deaths, 19% (93 537/489 390) of lung cancer deaths and 14% (479478/3425 835) of ischaemic heart disease deaths in 2012. (4,5) Improving access to reliable electricity and clean water in health-care facilities can also help reduce maternal and newborn mortality, as such infrastructure is a critical determinant of quality of care. (6) A review of health-care facilities in 11 sub-Saharan African countries showed that an average of 26% of facilities had no electricity whatsoever. (7) Another review of 54 low- and middle-income countries found that 38% (25 118/66 101) of health facilities lack a clean drinking water source. (8) Ensuring that health-care facilities have access to power and water is a minimum requirement for attracting women to facilities and guaranteeing quality services for safe childbirth. Thrive Housing and energy sector interventions that promote the transition to cleaner fuels and technologies for domestic cooking, heating and lighting can not only reduce deaths but improve the health of the 3 billion people worldwide who are reliant upon inefficient and polluting cookstoves. For this reason, the monitoring framework of the Global strategy for women's, children's and adolescents' health (2016-2030) explicitly tracks an indicator for "primary reliance on clean fuels and technologies" in households as part of its thrive pillar. (9) Examples of cleaner fuels and technologies include liquefied petroleum gas, biogas, ethanol and electricity including photovoltaic solar-power for lighting. Improving access to clean fuels and technologies can also reduce the burden of childhood burns and poisonings due to the use of kerosene for cooking and lighting. While most of the estimated 3 million deaths annually from outdoor ambient air pollution are among adult populations, reducing such pollution exposures are also critical to improving children's health and development across the life-course. …

The 2013-2016 Ebola virus disease outbreak in West Africa exposed an urgent need to strengthen health surveillance and health systems in low-income countries, not only to improve the health of populations served by these health systems but also to promote global health security. (1) Chronically fragile and under-resourced health systems (2) enabled the initial outbreak in Guinea to spiral into an epidemic of over 28 616 cases and 11310 deaths (as of 5 May 2016) (3) in Guinea, Liberia and Sierra Leone, requiring an unprecedented global response that is still ongoing. Control efforts were hindered by gaps in the formal health system and by resistance from the community, fuelled by fear and poor communication. Lessons learnt from this Ebola outbreak have raised the question of how the affected countries, and other low-income countries with similarly weak health systems, can build stronger health systems and surveillance mechanisms to prevent future outbreaks from escalating. (4) Factors that were important in the growth and persistence of the Ebola virus outbreak were lack of trust in the health system at the community level, the spread of misinformation, deeply embedded cultural practices conducive to transmission (e.g. burial customs), inadequate reporting of health events and the public's lack of access to health services. (1) Community health workers are in a unique position to mitigate these factors through surveillance for danger signs and mobilization of communities when an outbreak has been identified. In this paper we make the case for investing in robust national community health worker programmes as one of the strategies for improving global health security, for preventing future catastrophic infectious disease outbreaks and for strengthening health systems. Community health workers provide health education, gather information and deliver basic curative and preventive services at the community and household levels. They were first deployed in China nearly a century ago and have been deployed by both nongovernmental organizations (NGOs) and national governments over the past half-century. (5) Although community health workers play diverse roles, they share common features: they receive limited formal training and are recruited from and work in their own communities. (6) They are therefore uniquely positioned to promote healthy household practices and appropriate health-care-seeking behaviours. Large-scale national community health worker programmes are the cornerstones of primary health-care systems in many countries that have been pacesetters in improving the health of their populations, such as Brazil, Ethiopia, Malawi, Nepal and Rwanda. (7) Yet the failure of several national community health worker programmes in the 1970s and 1980s resulted in a loss of momentum for the movement. As a result of the growing success of the current programmes, (5,7) there is renewed global interest in using community health workers to strengthen primary health-care systems towards the goals of achieving universal health coverage and ending preventable child and maternal deaths. During the most recent Ebola outbreak, community health workers played several important roles. They worked with community leaders, going house to house to provide important information about Ebola and searching for active cases and contacts, (8) and they helped local religious leaders to expand their education and outreach strategies, especially in efforts to reduce transmission during funerals and burials. Many community-based agents, including community health workers working with NGOs, were deployed for contact tracing, community sensitization, promotion of epidemiologically and culturally appropriate protective practices, and data collection. (8) Networks of community health workers played key roles in limiting the spread of Ebola virus infection within Nigeria in July 2014. (9) Community health workers who were normally engaged in polio eradication initiatives were rapidly redeployed to detect patients with Ebola virus and trace their contacts. …

The maldistribution of health workers between urban and rural areas is a policy concern in virtually all countries. It prevents equitable access to health services, can contribute to increased health-care costs and underutilization of health professional skills in urban areas, and is a barrier to universal health coverage. To address this long-standing concern, the World Health Organization (WHO) has issued global recommendations to improve the rural recruitment and retention of the health workforce. This paper presents experiences with local and regional adaptation and adoption of WHO recommendations. It highlights challenges and lessons learnt in implementation in two countries - the Lao People's Democratic Republic and South Africa - and provides a broader perspective in two regions - Asia and Europe. At country level, the use of the recommendations facilitated a more structured and focused policy dialogue, which resulted in the development and adoption of more relevant and evidence-based policies. At regional level, the recommendations sparked a more sustained effort for cross-country policy assessment and joint learning. There is a need for impact assessment and evaluation that focus on the links between the rural availability of health workers and universal health coverage. The effects of any health-financing reforms on incentive structures for health workers will also have to be assessed if the central role of more equitably distributed health workers in achieving universal health coverage is to be supported.La mauvaise répartition des travailleurs de la santé entre les zones urbaines et rurales demeure une préoccupation politique dans pratiquement tous les pays. Elle empêche l'accès équitable aux services de santé, elle peut contribuer à une augmentation du coût des soins de santé et de sous-utilisation des compétences des professionnels de la santé dans les zones urbaines, et elle représente un obstacle à la mise en place d’une couverture maladie universelle. Pour répondre à cette préoccupation qui existe depuis longtemps, l'Organisation mondiale de la Santé (OMS) a émis des recommandations visant à améliorer le recrutement et la rétention des travailleurs du secteur de la santé en milieu rural. Ce document présente différentes expériences locales et régionales concernant l’adaptation et l’adoption des recommandations de l'OMS. Il souligne les défis et les leçons tirées de mises en œuvre dans deux pays - en République démocratique populaire lao et en Afrique du Sud - et il offre une perspective plus vaste dans deux régions - en Asie et en Europe. Au niveau des pays, l'application des recommandations a permis un dialogue plus structuré et plus ciblé sur les règlementations, qui a abouti à l'élaboration et à l'adoption de politiques plus pertinentes basées sur les faits. Au niveau régional, les recommandations ont suscité un effort plus soutenu en ce qui concerne l'évaluation des politiques entre les pays et leur apprentissage commun. Il faut évaluer l'impact des liens qui existent entre la disponibilité des travailleurs de la santé dans les zones rurales et la couverture maladie universelle. Les effets de toutes les réformes financières sur les structures d'incitation des travailleurs de la santé devront également être évalués si le but principal est de répartir plus équitablement les travailleurs de la santé et d'atteindre une couverture maladie universelle.La distribución ineficaz del personal sanitario entre las zonas urbanas y rurales constituye una preocupación política en casi todos los países, pues impide el acceso equitativo a los servicios sanitarios, puede contribuir al aumento de los costes de atención sanitaria y la infrautilización de las capacidades profesionales sanitarias en las zonas urbanas, y obstaculiza la cobertura sanitaria universal. Para solucionar este problema de larga data, la Organización Mundial de la Salud (OMS) ha publicado una serie de recomendaciones generales para mejorar la contratación a nivel rural y la conservación del personal sanitario. Este informe presenta las experiencias en relación con la adaptación local y regional, y la adopción de las recomendaciones de la OMS. Además, subraya los desafíos y las lecciones aprendidas de la aplicación en dos países, la República Democrática Popular Lao y Sudáfrica, y proporciona una perspectiva más amplia en dos regiones, en concreto, Asia y Europa. A nivel nacional, el uso de las recomendaciones facilitó un diálogo político más organizado y específico, lo que permitió el desarrollo y la adopción de políticas más relevantes con base empírica. A nivel regional, las recomendaciones motivaron un esfuerzo más firme para evaluar las políticas entre los países y el aprendizaje conjunto. Es necesario realizar una evaluación y una valoración del impacto que se centren en la relación entre la disponibilidad de personal sanitario en zonas rurales y la cobertura sanitaria universal. Asimismo, deben evaluarse los efectos de las reformas financieras en asistencia sanitaria sobre las estructuras de incentivos para el personal sanitario con miras a promover el papel central del mismo, distribuido de forma más equitativa, en la consecución de la cobertura sanitaria universal.يعتبر سوء توزيع العاملين الصحيين بين المناطق الحضرية والريفية أحد شواغل السياسة في كل البلدان تقريباً. وهو يحول دون الوصول العادل إلى الخدمات الصحية، ويمكن أن يسهم في زيادة تكاليف الرعاية الصحية وقصور استغلال المهارات المهنية الصحية في المناطق الحضرية، كما يمثل عائقاً أمام التغطية الصحية الشاملة. ولمعالجة هذا الشاغل طويل الأمد، أصدرت منظمة الصحة العالمية (WHO) توصيات عالمية لتحسين التوظيف في المناطق الريفية والاحتفاظ بقوة العمل الصحية. ويعرض هذا البحث الخبرات الخاصة بالتكييف المحلي والإقليمي وتبني توصيات منظمة الصحة العالمية. وهو يسلط الضوء على التحديات والدروس المستفادة من التنفيذ في بلدين – جمهورية لاوس الديمقراطية الشعبية وجنوب أفريقيا – ويقدم منظوراً أوسع في إقليمين – آسيا وأوروبا. وقد ساعد استخدام التوصيات، على مستوى البلدان، على الوصول إلى حوار سياسي أكثر تنظيماً وتركيزاً، وهو ما نتج عنه وضع وتبني سياسات أكثر صلة وتستند إلى الأدلة. أما على المستوى الإقليمي، فقد أسهمت التوصيات في بدء جهود أكثر استدامة لتقييم السياسة عبر البلدان والتعلم المشترك. وهناك حاجة لتقييم وتقدير التأثير الذي يركز على الروابط بين التوفر الريفي للعاملين الصحيين والتغطية الصحية الشاملة. وسينبغي أيضاً تقييم تأثيرات أية إصلاحات للتمويل الصحي على هياكل الحوافز للعاملين الصحيين، إذا كانت هناك حاجة لدعم الدور المركزي الذي يؤديه التوزيع الأكثر عدلاً للعاملين الصحيين في تحقيق التغطية الصحية الشاملة.城市和农村地区卫生工作者配置不合理的问题在几乎所有国家都是一个政策考虑。这种不均衡妨碍了人们公平获取卫生服务，可能增加造成更高卫生保健成本，使城市地区卫生专业人员的技能得不到充分利用，成为实现全民医疗保障制度的拦路虎。为解决这一长期存在的问题，世界卫生组织（WHO）发出了聘用和留住更多农村卫生工作者的全球建议。本文介绍了因地制宜采纳WHO建议的经验。文中重点介绍两个国家（老挝和南非）在实施中的挑战和经验教训，并展望了亚洲和欧洲这两个区域的大形势。在国家层次上，这些建议的采纳促进了更结构化、更有针对性的政策对话，从而促成更加中肯并以证据为基础的政策的制定和实施。在区域层次上，这些建议激发了人们投入更加持久的努力进行各国间政策的评估和共同学习。文中指出针对农村卫生工作者可及性和全民医保制度之间的关系，需要进行效果的评估和评价。在实现全民医保的过程中，如果能够发挥卫生工作者更合理配置的核心作用，则还必须对卫生工作者激励结构的所有卫生筹资改革效果进行评估。Неравномерное распределение работников здравоохранения между городскими и сельскими районами представляет собой проблему для политики здравоохранения практически во всех странах. Данная проблема не позволяет обеспечить равный доступ к медицинским услугам, может способствовать увеличению расходов на здравоохранение и недостаточно эффективному использованию профессиональных навыков работников здравоохранения в городских районах, а также является препятствием для всеобщего охвата населения медико-санитарными услугами. Для решения этой давней проблемы Всемирная организация здравоохранения (ВОЗ) опубликовала глобальные рекомендации по совершенствованию найма и удержания трудовых ресурсов здравоохранения в сельских районах. В этой статье описывается опыт адаптации и внедрения рекомендаций ВОЗ на местном и региональном уровнях. В ней освещаются проблемы и извлеченные уроки при применении рекомендаций в двух странах — в Лаосской Народно-Демократической Республике и Южной Африке, а также дается более широкий обзор для двух регионов — Азии и Европы. На уровне стран использование рекомендаций способствовало более структурированному и целенаправленному диалогу по вопросам выработки политики, что привело к разработке и принятию более обоснованной политики, основанной на фактах. На региональном уровне рекомендации стимулировали более последовательные усилия по сравнительным оценкам политик в различных странах региона и их совместному осмыслению. Существует необходимость проведения оценки последствий политик и анализа, в ходе которого основное внимание должно уделяться связям между наличием работников здравоохранения в сельских районах и всеобщим охватом населения медико-санитарными услугами. Кроме того, необходимо также оценить влияние всех реформ финансирования здравоохранения на структуры стимулирования работников здравоохранения, если придерживаться точки зрения, что более справедливое распределение работников здравоохранения является ключевым фактором для обеспечения всеобщего охвата населения медико-санитарными услугами.

World Rabies Day is 28 September, 2016, (1) and is designed to raise awareness about the prevention and control of this neglected disease. Almost all human rabies are transmitted by domestic dog bites or scratches, usually via saliva. Rabies virus replicates in the wound site and gains access to nerves to reach the central nervous system. The incubation period varies from five days to several years. By the time of clinical onset, the virus is widely disseminated throughout the central nervous system and the infection is invariably fatal. Prevention of human rabies and control of canine rabies have been successful in north America, western Europe and a number of Asian and Latin American countries through vaccination of dogs, responsible dog ownership, enforcement of leash laws, and provision of life-saving bite treatment. Pre-exposure immunization is strongly recommended for people in high-risk occupations such as laboratory workers dealing with live rabies virus, vaccinators and people involved in any activity that might bring them professionally or otherwise into direct contact with bats, carnivores and other mammals in rabies-affected areas. The World Health Organization (WHO), the World Organisation for Animal Health (OIE), the Food and Agriculture Organization of the United Nations (FAO) and the Global Alliance for Rabies Control (GARC) have committed to eliminating rabies deaths in humans by 2030. (2) As Margaret Chan, WHO's Director-General, said: "Rabies belongs in the history books. (6) As for many neglected diseases, data are suboptimal. An estimated 59 000 (3,4) people die from rabies every year, despite the existence of effective vaccines. Around 90% of these deaths occur among children living in rural areas in Africa and Asia,5 almost all as a consequence of dog bites. (6) The world has many competing disease-control priorities, and rabies has fallen off the global health agenda. Rabies control requires two complementary interventions. Mass dog vaccination programmes are needed to break dog-to-human transmission and people who are exposed to rabies need prompt and effective treatment. Such treatment includes wound care, immunoglobulin and vaccination. WHO, with its partners and stakeholders, are quantifying the resources required to implement these programmes on a scale sufficient to end human rabies deaths. WHO's current rabies vaccine position paper states that four to five courses of the vaccine must be given with rabies immunoglobulin to all people who have sustained bites that perforate the skin. Immunoglobulins provide passive immunity until the vaccine has stimulated the immune system. However, rabies immunoglobulins are expensive. One vial is about 39 United States dollars, and two or more vials are usually needed. (8) Immunoglobulins have to be maintained at 2-8[degrees]C, and are difficult to procure in most countries. Because it is a biological product, rabies immunoglobulin is not covered by WHO's prequalification procedures. Currently four vaccines are pre-qualified by WHO. …

The Antibiotics Smart Use (ASU) programme was introduced in Thailand as a model to promote the rational use of medicines, starting with antibiotics. The programme’s first phase consisted of assessing interventions intended to change prescribing practices; the second phase examined the feasibility of programme scale-up. Currently the programme is in its third phase, which centres on sustainability. This paper describes the concept behind ASU, the programme’s functional modalities, the development of its conceptual framework and the implementation of its first and second phases. To change antibiotic prescription practices, multifaceted interventions at the individual and organizational levels were implemented; to maintain behaviour change and scale up the programme, interventions at the network and policy levels were used. The National Health Security Office has adopted ASU as a pay-for-performance criterion, a major achievement that has led to the programme’s expansion nationwide. Despite limited resources, programme scale-up and sustainability have been facilitated by the promotion of local ownership and mutual recognition, which have generated pride and commitment. ASU is clearly a workable entry point for efforts to rationalize the use of medicines in Thailand. Its long-term sustainability will require continued local commitment and political support, effective auditing and integration of ASU into routine systems with appropriate financial incentives.