A decade of neglect has weakened UNICEF and threatened the future of child survival

As a high-level forum assessing the progress on global health in relation to the millennium development goals concludes its meeting in Abuja, Nigeria, today, the rhetoric of success repeated by those charged with ending the needless deaths of millions of the world's children masks their own deep-seated failure to grapple with critical institutional weaknesses in their own ranks.

The LANCET has published online an analysis of UNICEF, its decade-long failure to create and implement a strategy for child survival (the fourth Millennium Development Goal) and a call to action as the UN secretary-general, Kofi Annan, begins the process to appoint a new leader in 2005.

UNICEF's new leader will be appointed by Kofi Annan next year. The process of selecting a new executive director for UNICEF is flawed. Lancet Editor Richard Horton comments: "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".

In June 2003 THE LANCET published a series of articles which highlighted the shocking reality of global child health. The series sought to explain one very simple question: where and why are 10 million children dying every year? The answer-most deaths occur in 6 countries; two-thirds are preventable-elicited a widespread response, although not from UNICEF. Indeed, under UNICEF's present executive director, Carol Bellamy, the agency has lost its way over the most important part of its mission-to ensure the fundamental right of the child to survive.

Dr Horton continues: "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." The previous three executive directors-notably Bellamy's predecessor, James Grant-placed child survival at the centre of UNICEF's work, making the agency the most respected part of the UN.

"What are the skills and experiences that Kofi Annan should be looking for in the next executive director of UNICEF?...There are several general 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 4 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 appointment process of the next incumbent is also shrouded in secrecy and is being influenced by political lobbying. Sources close to Kofi Annan indicate that the new executive director will most likely be an American-irrespective of their skills and experience. The selection process needs to be opened up. Candidates' names should be on the public record. And they should be questioned before a specially convened intergovernmental committee of the UN.

Dr Horton concludes: "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. Be their voice".