Friday, September 12, 2008

Renaissance of Primary Health Care? Fact or Fiction?

A renaissance in primary health care

30 years ago, in the midst of the Cold War, health experts and policy makers from 134 WHO member states convened in the former USSR to attend a conference on international primary health care. On Sept 12, 1978, the Alma-Ata Declaration was signed, with the ambitious target of achieving “Health for All by 2000”.

In 1978, 2000 million people were estimated to have no access to adequate health care. There were vast inequalities between rich and poor countries, and between rich and poor populations within countries. The Alma-Ata Declaration revolutionised the world's interpretation of health.

Its message was that inadequate and unequal health care was unacceptable: economically, socially, and politically. Unfortunately, the goal of “health for all”, while a rallying call to action, was not met.

Theories for this failure abound: the vision for primary health care was politically unacceptable to some nations and so was marginalised; emerging health threats took precedence (no one imagined the global disease burden that HIV/AIDS would bring); and health priorities shifted (to the Millennium Development Goals [MDGs]).

30 years on, what is the relevance of the Alma-Ata Declaration in 2008? In short, primary health care is now offering global health a lifeline. Progress towards the MDGs has stalled. Weak health systems have restricted the success of efforts to improve maternal, newborn, and child health, and to reduce the disease burden from malaria and tuberculosis.

New epidemics of chronic disease threaten to reverse what small gains have been achieved. To get back on track, and to meet the MDGs by 2015, countries need to strengthen their health systems through the implementation of effective primary health care.

Now is the right moment to proclaim the urgent need for a renaissance in primary health care.

The continuing relevance of this 30-year-old Declaration is remarkable. Many of the challenges faced in 1978 remain, such as infectious diseases (eg, the ongoing threat of H5N1 avian influenza and HIV/AIDS), political instability and conflict (most recently seen in Iraq and Zimbabwe), and worsening poverty (the World Bank last month estimated that 1·4 billion people now live in poverty).

In recognition of this timely reawakening of interest in primary health care, this week's Lancet revisits, updates, and relaunches the key messages from Alma-Ata.

A series of eight papers begins with an analysis of modern primary health care, and issues such as implementing cost-effective interventions in low-resource settings and tackling the growing burden of chronic diseases. We publish an analysis of individual country progress since 1978, with possible lessons for those who have shown the least advance.

Involvement of communities in planning and implementation of health care (one of the main tenets of the Alma-Ata Declaration) is explored in the context of maternal, newborn, and child health, as are the roles of national policies and effective service integration, all foundations of a successful primary health care service. The final paper in the series looks to the future and provides a series of action points to revitalise primary health care,both nationally and globally.

WHO's vision for health—complete physical, mental, and social wellbeing—is the key to achieving Alma-Ata's prime goal of “health for all”. This week's research articles also focus on these three principles.

Stephen Tollman and colleagues discuss the challenges in managing chronic diseases in primary health care and the importance of providing adequate services to ensure physical wellbeing.

Atif Rahman and co-workers tackle mental health in Bangladesh, with a psychological intervention that can be delivered within communities to treat mothers with perinatal depression. And the importance of social development is shown by Luis Huicho and authors who present data from four countries highlighting the importance of health workers with shorter durations of training in providing vital care to people in low-resource settings.

Importantly, WHO, under Margaret Chan's effective leadership and together with her regional directors, has reaffirmed its commitment to primary health care. This revisioning of the principles of Alma-Ata is welcome and illustrates a new unity of purpose across global health institutions.

Political progress is also encouraging. Following the G8 meeting earlier this year, Japan has announced its own commitment to lead international initiatives to strengthen health systems.

Such renewed global interest in primary health care is promising. The need remains great and there are no shortcuts to success. But with refined international relationships, new and emerging technologies, and 30 years of experience, “health for all” need not be a dream buried in the past.

The right to the highest attainable standard of health can be a reality within our grasp.
The Lancet

Thursday, September 11, 2008

Tied like a knot a 14 year old song

"Tied Like A Knot" By: Abigail Belai

We were swingin' in the playground
that day after school
when you said the words
that helped me get through the hard times
you held on so tight
I was sitting on your bed
when I got the news
we didn't even move
all you heard were soft cries
we held on so tight

I remember
that week of March 21st
when I went through the worst
you said we were tied like a knot
baby tied like a knot
we held on so strong
I remember
that last night of summer
we said we would never
break apart, cuz were tied like a knot
we'd never break apart
cuz were tied like a knot

We were stayin' up on a late night
talking on the phone
you fekt so alone
like a part of you was out in the cold
we should have known
that we'd be in different places
at different times
but being seperated dosen't mean we gotta cry
we held on so tight

I remember
that week of March 21st
when I went through the worst
you said we were tied like a knot
baby tied like a knot
we held on so strong
I remember
that last night of summer
we said we would never
break apart, cuz were tied like a knot
we'd never break apart
cuz were tied like a knot

After all these years
you kept your word
we never broke apart
how 'bout we add a double knot
cuz love never breakes apart

I remember
that week of March 21st
when I went through the worst
you said we were tied like a knot
baby tied like a knot
we held on so strong
I remember
that last night of summer
we said we would never
break apart, cuz were tied like a knot
we never broke apart
cuz were still tied like a knot

Tuesday, September 09, 2008

The Infinite Human Memory Discovered?

Humans Have Astonishing Memories, Study Finds Clara Moskowitz
LiveScience Staff Writer
Tue Sep 9, 12:02 AM ET

If human memory were truly digital, it would have just received an upgrade from something like the capacity of a floppy disk to that of a flash drive. A new study found the brain can remember a lot more than previously believed.

In a recent experiment, people who viewed pictures of thousands of objects over five hours were able to remember astonishing details afterward about most of the objects.

Though previous studies have never measured such astounding feats of memory, it may be simply because no one really tried.

"People had never tested whether people could remember this much detail about this many objects," said researcher Timothy Brady, a cognitive neuroscientist at MIT. "Nobody actually pushed it this far."

When they did push the human brain to its limits, the scientists found that under the right circumstances, it can store minute visual details far beyond what had been imagined.

Those circumstances include looking at images of objects that are familiar, such as remote controls, dollar bills and loaves of bread, as opposed to abstract artworks.

Another factor that seemed to help was motivation to do well: The participant who scored highest won a small prize of money (the researchers refused to say exactly how much).

"You have to try," said MIT co-author Talia Konkle. "You have to want to do it."

The study, funded by the National Science Foundation, National Institutes of Health, a National Defense Science and Engineering Graduate Fellowship, and a National Research Service Award, was detailed in the Sept. 8 issue of the journal Proceedings of the National Academy of Sciences.

In the experiment, 14 people ranging from age 18 to 40 viewed nearly 3,000 images, one at a time, for three seconds each. Afterwards, they were shown pairs of images and asked to select the exact image they had seen earlier.

The test pairs fell into three categories: two completely different objects, an object and a different example of the same type of object (such as two different remote controls), and an object along with a slightly altered version of the same object (such as a cup full and another cup half-full).

Stunningly, participants on average chose the correct image 92 percent, 88 percent and 87 percent of the time, in each of the three pairing categories respectively. Though 14 subjects may not sound like a huge sample, the fact that they each recalled the objects with very similar rates of success suggests the results are not a fluke.

"To give just one example, this means that after having seen thousands of objects, subjects didn't just remember which cabinet they had seen, but also that the cabinet door was slightly open," Brady said.

Even the researchers didn't expect quite such high recall rates.

"We had the intuition that it might be possible, but we were surprised by the magnitude of the effect," said study leader Aude Oliva, also of MIT. "These numbers, higher than 85 and 90 percent, impressed us and also impressed a lot of people who heard about the work."

So now that we know the brain's memory is so fantastic, are we all out of excuses for forgetting friends' birthdays?

Luckily not, Brady said.

"To some extent it's about attention, actively encoding specific details into memory," he told LiveScience. "If we tried really hard we actually could remember when someone's birthday was: if you say to yourself, 'The birthday is on this day and that relates to these other things that I remember.'"

Basically, he said, we can remember most things we put our minds to, if we invest enough attention and effort into trying to store them in the first place.

Video: Attention Training Video: A Turn-off Switch for Alzheimer's Top 10 Mysteries of the Mind Original Story: Humans Have Astonishing Memories, Study Finds chronicles the daily advances and innovations made in science and technology.

We take on the misconceptions that often pop up around scientific discoveries and deliver short, provocative explanations with a certain wit and style. Check out our science videos, Trivia & Quizzes and Top 10s.

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Friday, September 05, 2008

Francis Falceto's Ethiopique Compilation

September 05, 2008
Ethiopia: Swinging Addis Comes Back

Mahmoud Ahmed, back in the day.
Photo: by John Oseid

Get your streamers ready. Enqutatash, the Ethiopian New Year, arrives September 11; it will be the year 2001 in the Orthodox calendar. Now's your chance to get hooked--like me--on one of the coolest, most beguiling, and most unlikely musical revivals in years.

At a French embassy soirée in Addis Ababa some years ago, I was told that Ethiopian jazz was all the rage in the waning years of Haile Selassie's long reign, and that the swell society used to gather in posh hotels and party away to the music. "Swinging Addis," they called it. Then came the Mengistu regime in the mid-seventies and the fun door was slammed shut for 18 years.

The Golden Era stars, now septuagenarians, have made an improbable comeback, and their R&B- and soul-inflected jazz is a huge hit both on disc and in concert. A number of them recently gave a smashing Lincoln Center performance.

Here's an enthusiastic review of the packed spectacle I caught in late August at Lincoln Center's Damrosch Park bandshell. Ethiopians of all ages were there, and so was the porkpie-hatted, goateed Brooklyn hipster crowd. Among the audience members, I stumbled upon Saturday Night Live's ridiculously talented Fred Armisen, who said he was mesmerized by the show.

Elegant singer Mahmoud Ahmed, dressed in a white tunic with a red sash, had the crowd on its feet with his shimmying and clapping. Alemayehu Eshete, a singer known for his James Brown-like persona, joined him on stage. They were backed by the Massachusetts-based jazz group Either/Orchestra, which some years ago latched on to the Ethio pentatonic sound and now plays regularly with these guys. Saxophonist Getatchew Mekurya fronted a hard driving set with Dutch punk band The Ex. Here's a fun amateur video.

The Horn of Africa musical explosion can be traced to one man's labor of love. A decade ago, Frenchman Francis Falceto began compiling Golden Era music. By now, his Paris-based label Buda Musique has released well over 20 volumes in the Ethiopique series. Not only have European and American hipsters caught on, but also director Jim Jarmusch employed the dean of Ethio-jazz, arranger and vibraphone player Mulatu Astatke, for the sound track of his film Broken Flowers.

For Ethiopian New Years, I will be partying at New York City's popular downtown nightclub SOB's on Friday, September 12, where the young singer Zeritu Kebede is coming directly from Ethiopia. Here's a clip of her in action. America's larger cities now all have vibrant Habesha (as Ethiopians call themselves) communities. Keep your eyes open for shows and get ready for an awesome new experience.

Further reading:
* Britain's Independent newspaper profiles Francis Falceto's Ethiopique compilations and previews a UK performance.
* In an NPR interview, Falceto discusses the history of his Ethiopique series.
* Falceto's Abyssinie Swing is a coffee table book of black and white photographs.

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Tuesday, September 02, 2008

Business Process ReEngineering a Value adding tool or a dehumanizing gadget

Business process reengineering

Business process reengineering (BPR) is a management approach aiming at improvements by means of elevating efficiency and effectiveness of the processes that exist within and across organizations.

The key to BPR is for organizations to look at their business processes from a "clean slate" perspective and determine how they can best construct these processes to improve how they conduct business.

Business process reengineering is also known as BPR, Business Process Redesign, Business Transformation, or Business Process Change Management.

Contents [hide]
1 History
2 Definition of BPR
3 The role of information technology
4 Methodology
5 Successes
6 Critique
7 Development after 1995
8 See also
9 External links
10 Notes


In 1990, Michael Hammer, a former professor of computer science at the Massachusetts Institute of Technology (MIT), published an article in the Harvard Business Review, in which he claimed that the major challenge for managers is to obliterate non-value adding work, rather than using technology for automating it (Hammer 1990).

This statement implicitly accused managers of having focused on the wrong issues, namely that technology in general, and more specifically information technology, has been used primarily for automating existing work rather than using it as an enabler for making non-value adding work obsolete.

Hammer's claim was simple: Most of the work being done does not add any value for customers, and this work should be removed, not accelerated through automation. Instead, companies should reconsider their processes in order to maximize customer value, while minimizing the consumption of resources required for delivering their product or service.

A similar idea was advocated by Thomas H. Davenport and J. Short (1990), at that time a member of the Ernst & Young research center, in a paper published in the Sloan Management Review the same year as Hammer published his paper.

This idea, to unbiasedly review a company’s business processes, was rapidly adopted by a huge number of firms, which were striving for renewed competitiveness, which they had lost due to the market entrance of foreign competitors, their inability to satisfy customer needs, and their insufficient cost structure.

Even well established management thinkers, such as Peter Drucker and Tom Peters, were accepting and advocating BPR as a new tool for (re-)achieving success in a dynamic world. During the following years, a fast growing number of publications, books as well as journal articles, was dedicated to BPR, and many consulting firms embarked on this trend and developed BPR methods.

However, the critics were fast to claim that BPR was a way to dehumanize the work place, increase managerial control, and to justify downsizing, i.e. major reductions of the work force (Greenbaum 1995, Industry Week 1994), and a rebirth of Taylorism under a different label.

Despite this critique, reengineering was adopted at an accelerating pace and by 1993, as many as 65% of the Fortune 500 companies claimed to either have initiated reengineering efforts, or to have plans to do so. This trend was fueled by the fast adoption of BPR by the consulting industry, but also by the study Made in America, conducted by MIT, that showed how companies in many US industries had lagged behind their foreign counterparts in terms of competitiveness, time-to-market and productivity.

Definition of BPR

This article or section contains too many quotations for an encyclopedic entry.
Please improve the article or discuss proposed changes on the talk page.
You can edit the article to add more encyclopedic text or link the article to a page of quotations, possibly one of the same name, on Wikiquote. See Wikipedia's guide to writing better articles for further suggestions. (April 2008)

Different definitions can be found. This section contains the definition provided in notable publications in the field.

Hammer and Champy (1993) define BPR as

"... the fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in critical contemporary measures of performance, such as cost, quality, service, and speed."

Thomas H. Davenport (1993), another well-known BPR theorist, uses the term process innovation, which he says

”encompasses the envisioning of new work strategies, the actual process design activity, and the implementation of the change in all its complex technological, human, and organizational dimensions”.

Additionally, Davenport (ibid.) points out the major difference between BPR and other approaches to organization development (OD), especially the continuous improvement or TQM movement, when he states:

"Today firms must seek not fractional, but multiplicative levels of improvement – 10x rather than 10%."

Finally, Johansson et al. (1993) provide a description of BPR relative to other process-oriented views, such as Total Quality Management (TQM) and Just-in-time (JIT), and state:

"Business Process Reengineering, although a close relative, seeks radical rather than merely continuous improvement. It escalates the efforts of JIT and TQM to make process orientation a strategic tool and a core competence of the organization. BPR concentrates on core business processes, and uses the specific techniques within the JIT and TQM ”toolboxes” as enablers, while broadening the process vision."

In order to achieve the major improvements BPR is seeking for, the change of structural organizational variables, and other ways of managing and performing work is often considered as being insufficient.

For being able to reap the achievable benefits fully, the use of information technology (IT) is conceived as a major contributing factor. While IT traditionally has been used for supporting the existing business functions, i.e. it was used for increasing organizational efficiency, it now plays a role as enabler of new organizational forms, and patterns of collaboration within and between organizations.

BPR derives its existence from different disciplines, and four major areas can be identified as being subjected to change in BPR - organization, technology, strategy, and people - where a process view is used as common framework for considering these dimensions. The approach can be graphically depicted by a modification of "Leavitt’s diamond" (Leavitt 1965).

Business strategy is the primary driver of BPR initiatives and the other dimensions are governed by strategy's encompassing role. The organization dimension reflects the structural elements of the company, such as hierarchical levels, the composition of organizational units, and the distribution of work between them. Technology is concerned with the use of computer systems and other forms of communication technology in the business.

In BPR, information technology is generally considered as playing a role as enabler of new forms of organizing and collaborating, rather than supporting existing business functions. The people / human resources dimension deals with aspects such as education, training, motivation and reward systems. The concept of business processes - interrelated activities aiming at creating a value added output to a customer - is the basic underlying idea of BPR. These processes are characterized by a number of attributes: Process ownership, customer focus, value adding, and cross-functionality.

The role of information technology

Information technology (IT) has historically played an important role in the reengineering concept. It is considered by some as a major enabler for new forms of working and collaborating within an organization and across organizational borders.

The early BPR literature, e.g. Hammer & Champy (1993), identified several so called disruptive technologies that were supposed to challenge traditional wisdom about how work should be performed.

Shared databases, making information available at many places
Expert systems, allowing generalists to perform specialist tasks
Telecommunication networks, allowing organizations to be centralized and decentralized at the same time

Decision-support tools, allowing decision-making to be a part of everybody's job
Wireless data communication and portable computers, allowing field personnel to work office independent

Interactive videodisk, to get in immediate contact with potential buyers
Automatic identification and tracking, allowing things to tell where they are, instead of requiring to be found

High performance computing, allowing on-the-fly planning and revisioning
In the mid 1990s, especially workflow management systems were considered as a significant contributor to improved process efficiency. Also ERP (Enterprise Resource Planning) vendors, such as SAP, JD Edwards, Oracle, PeopleSoft, positioned their solutions as vehicles for business process redesign and improvement.


Although the labels and steps differ slightly, the early methodologies that were rooted in IT-centric BPR solutions share many of the same basic principles and elements. The following outline is one such model, based on the PRLC (Process Reengineering Life Cycle) approach developed by Guha (1993).

Simplified schematic outline of using a business process approach, examplified for pharmceutical R&D:
1. Structural organization with functional units
2. Introduction of New Product Development as cross-functional process
3. Re-structuring and streamlining activities, removal of non-value adding tasksEnvision new processes
Secure management support
Identify reengineering opportunities
Identify enabling technologies
Align with corporate strategy
Initiating change
Set up reengineering team
Outline performance goals
Process diagnosis
Describe existing processes
Uncover pathologies in existing processes
Process redesign
Develop alternative process scenarios
Develop new process design
Design HR architecture
Select IT platform
Develop overall blueprint and gather feedback
Develop/install IT solution
Establish process changes
Process monitoring
Performance measurement, including time, quality, cost, IT performance
Link to continuous improvement
-> Loop-back to diagnosis

Benefiting from lessons learned from the early adopters, some BPR practitioners advocated a change in emphasis to a customer-centric, as opposed to an IT-centric, methodology. One such methodology, that also incorporated a Risk and Impact Assessment to account for the impact that BPR can have on jobs and operations, was described by Lon Roberts (1994).

Roberts also stressed the use of change management tools to proactively address resistance to change—a factor linked to the demise of many reengineering initiatives that looked good on the drawing board.

Also within the management consulting industry, a significant number of methodological approaches have been developed. A set of short papers, outlining and comparing some of them can be found here, followed by some guidelines for companies considering to contract a consultancy for a BPR initiative:

Andersen Consulting (now Accenture)
Bain & Co.
Boston Consulting Group
McKinsey & Co.
Guidelines for BPR consulting clients


This article or section is written like an advertisement.

Please help rewrite this article from a neutral point of view.
For blatant advertising that would require a fundamental rewrite to become encyclopedic, use {{db-spam}} to mark for speedy deletion. (April 2008)

BPR, if implemented properly, can give huge returns. BPR has helped giants like Procter and Gamble Corporation and General Motors Corporation succeed after financial drawbacks due to competition.

It helped American Airlines somewhat get back on track from the bad debt that is currently haunting their business practice. BPR is about the proper method of implementation.

General Motors Corporation implemented a 3-year plan to consolidate their multiple desktop systems into one. It is known internally as "Consistent Office Environment" (Booker, 1994). This reengineering process involved replacing the numerous brands of desktop systems, network operating systems and application development tools into a more manageable number of vendors and technology platforms.

According to Donald G. Hedeen, director of desktops and deployment at GM and manager of the upgrade program, he says that the proces
s "lays the foundation for the implementation of a common business communication strategy across General Motors." (Booker, 1994).

Lotus Development Corporation and Hewlett-Packard Development Company, formerly Compaq Computer Corporation, received the single largest non-government sales ever from General Motors Corporation. GM also planned to use Novell NetWare as a security client, Microsoft Office and Hewlett-Packard printers.

According to Donald G. Hedeen, this saved GM 10% to 25% on support costs, 3% to 5% on hardware, 40% to 60% on software licensing fees, and increased efficiency by overcoming incompatibility issues by using just one platform across the entire company.

Michael Dell is the founder and CEO of DELL Incorporated, which has been in business since 1983 and has been the world's fastest growing major PC Company. Michael Dell's idea of a successful business is to keep the smallest inventory possible by having a direct link with the manufacturer.

When a customer places an order, the custom parts requested by the customer are automatically sent to the manufacturer for shipment. This reduces the cost for inventory tracking and massive warehouse maintenance. Dell's website is noted for bringing in nearly "$10 million each day in sales."(Smith, 1999).

Michael Dell mentions: "If you have a good strategy with sound economics, the real challenge is to get people excited about what you're doing. A lot of businesses get off track because they don't communicate an excitement about being part of a winning team that can achieve big goals.

If a company can't motivate its people and it doesn't have a clear compass, it will drift." (Smith, 1999) Dell's stocks have been ranked as the top stock for the decade of the 1990s, when it had a return of 57,282% (Knestout and Ramage, 1999).

Michael Dell is now concentrating more on customer service than selling computers since the PC market price has pretty much equalized. Michael Dell notes: "The new frontier in our industry is service, which is a much greater differentiator when price has been equalized.

In our industry, there's been a pretty huge gap between what customers want in service and what they can get, so they've come to expect mediocre service. We may be the best in this area, but we can still improve quite a bit—in the quality of the product, the availability of parts, service and delivery time." (Smith, 1999) Michael Dell understands the concept of BPR and really recognizes where and when to reengineer his business.

Ford reengineered their business and manufacturing process from just manufacturing cars to manufacturing quality cars, where the number one goal is quality. This helped Ford save millions on recalls and warranty repairs.

Ford has accomplished this goal by incorporating barcodes on all their parts and scanners to scan for any missing parts in a completed car coming off of the assembly line. This helped them guarantee a safe and quality car. They have also implemented Voice-over-IP (VoIP) to reduce the cost of having meetings between the branches.

A multi-billion dollar corporation like Procter and Gamble Corporation, which carries 300 brands and growing really has a strong grasp in re-engineering. Procter and Gamble Corporation's chief technology officer, G. Gil Cloyd, explains how a company which carries multiple brands has to contend with the "classic innovator's dilemma — most innovations fail, but companies that don't innovate die.

His solution, innovating innovation..." (Teresko, 2004). Cloyd has helped a company like Procter and Gamble grow to $5.1 billion by the fiscal year of 2004. According to Cloyd's scorecard, he was able to raise the volume by 17%, the organic volume by 10%, sales are at $51.4 billion up by 19%, with organic sales up 8%, earnings are at $6.5 billion up 25% and share earnings up 25%. Procter and Gamble also has a free cash flow of $7.3 billion or 113% of earnings, dividends up 13% annually with a total shareholder return of 24%. Cloyd states: "The challenge we face is the competitive need for a very rapid pace of innovation.

In the consumer products world, we estimate that the required pace of innovation has double in the last three years. Digital technology is very important in helping us to learn faster." (Teresko, 2004) G. Gil Cloyd also predicts, in the near future, "as much as 90% of P&G's R&D will be done in a virtual world with the remainder being physical validation of results and options." (Teresko, 2004).


The most frequent and harsh critique against BPR concerns the strict focus on efficiency and technology and the disregard of people in the organization that is subjected to a reengineering initiative. Very often, the label BPR was used for major workforce reductions. Thomas Davenport, an early BPR proponent, stated that

"When I wrote about "business process redesign" in 1990, I explicitly said that using it for cost reduction alone was not a sensible goal. And consultants Michael Hammer and James Champy, the two names most closely associated with reengineering, have insisted all along that layoffs shouldn't be the point. But the fact is, once out of the bottle, the reengineering genie quickly turned ugly." (Davenport, 1995)

Michael Hammer similarly admitted that

"I wasn't smart enough about that. I was reflecting my engineering background and was insufficient appreciative of the human dimension. I've learned that's critical." (White, 1996)

Other criticism brought forward against the BPR concept include

lack of management support for the initiative and thus poor acceptance in the organization.

exaggerated expectations regarding the potential benefits from a BPR initiative and consequently failure to achieve the expected results.

underestimation of the resistance to change within the organization.
implementation of generic so-called best-practice processes that do not fit specific company needs.

overtrust in technology solutions.
performing BPR as a one-off project with limited strategy alignment and long-term perspective.

poor project management.

Development after 1995

With the publication of critiques in 1995 and 1996 by some of the early BPR proponents, coupled with abuses and misuses of the concept by others, the reengineering fervor in the U.S. began to wane. Since then, considering business processes as a starting point for business analysis and redesign has become a widely accepted approach and is a standard part of the change methodology portfolio, but is typically performed in a less radical way as originally proposed.

More recently, the concept of Business Process Management (BPM) has gained major attention in the corporate world and can be considered as a successor to the BPR wave of the 1990s, as it is evenly driven by a striving for process efficiency supported by information technology. Equivalently to the critique brought forward against BPR, BPM is now accused of focusing on technology and disregarding the people aspects of change.

See also
Business Process Management
process improvement
Service-Oriented Modeling Framework (SOMF)
Business Process Modeling Notation (BPMN)

External links
BPR Articles
Hammering Hammer (A Critical Analysis of Michael Hammer's Process Enterprise approach.)
BPR : Decision engineering in a strained industrial and business environment

Davenport, Thomas & Short, J. (1990), The New Industrial Engineering: Information Technology and Business Process Redesign, in: Sloan Management Review, Summer 1990, pp 11-27
Davenport, Thomas (1993), Process Innovation: Reengineering work through information technology, Harvard Business School Press, Boston
Davenport, Thomas (1995), Reengineering - The Fad That Forgot People, Fast Company, November 1995.
Drucker, Peter (1972), Work and Tools, in: W. Kranzberg and W.H. Davenport (eds), Technology and Culture, New York
Greenbaum, Joan (1995), Windows on the workplace, Cornerstone
Guha, S.; Kettinger, W.J. & Teng, T.C., Business Process Reengineering: Building a Comprehensive Methodology, Information Systems Management, Summer 1993
Hammer, Michael (1990), Reengineering Work: Don’t automate, obliterate, Harvard Business Review, Jul/Aug 1990, pp 104-112
Hammer, Michael and Champy, James (1993), Reengineering the Corporation: A Manifesto for Business Revolution, Harper Business Chapter 1 excerpt
Industry Week (1994), De-engineering the corporation, Industry Week article, 4/18/94
Johansson, Henry J. (1993), Business Process Reengineering: BreakPoint Strategies for Market Dominance, John Wiley & Sons
Leavitt, H.J. (1965), Applied Organizational Change in Industry: Structural, Technological and Humanistic Approaches, in: James March (ed.), Handbook of Organizations, Rand McNally, Chicago
Loyd, Tom (1994), Giants with Feet of Clay, Financial Times, Dec 5 1994, p 8
Malhotra, Yogesh (1998), Business Process Redesign: An Overview, IEEE Engineering Management Review, vol. 26, no. 3, Fall 1998.
Roberts, Lon (1994), Process Reengineering: The Key To Achieving Breakthrough Success, Quality Press, Milwaukee.
Taylor (1911), Frederick, The principles of scientific management, Harper & Row, New York
Thompson, James D. (1969), Organizations in Action, MacGraw-Hill, New York
White, JB (1996), Wall Street Journal. New York, N.Y.: Nov 26, 1996. pg. A.1
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Reengineering Success Factors

More than half of early reengineering projects failed to be completed or did not achieve bottom-line business results, and for this reason business process reengineering "success factors" have become an important area of study. The success factors below are derived from benchmarking studies with more than 150 companies over a 24 month period.

Success factors are a collection of lessons learned from reengineering projects. Reengineering team members and consultants that have struggled to make their projects successful often say,

"If I had it to do over again, I would…" ,

and from these lessons common themes have emerged. In this module we examine these themes or success factors that lead to successful outcomes for reengineering projects. These include:

Top Management Sponsorship (strong and consistent involvement)

Strategic Alignment (with company strategic direction)

Compelling Business Case for Change (with measurable objectives)

Proven Methodology (that includes a vision process)

Effective Change Management (address cultural transformation)

Line Ownership (pair ownership with accountability)

Reengineering Team Composition (in both breadth and knowledge)

Top Management Sponsorship

Major business process change typically affects processes, technology, job roles and culture in the workplace. Significant changes to even one of these areas requires resources, money, and leadership. Changing them simultaneously is an extraordinary task. If top management does not provide strong and consistent support, most likely one of these three elements (money, resources, or leadership) will not be present over the life of the project, severely crippling your chances for success.

It may be true that consultants and reengineering managers give this topic a lot of attention. Mostly because current models of re-designing business processes use staff functions and consultants as change agents, and often the targeted organizations are not inviting the change. Without top management sponsorship, implementation efforts can be strongly resisted and ineffective.

Top management support for large companies with corporate staff organizations has another dimension. If the top management in the "line" organization and "staff" organization do not partner and become equal stakeholders in the change, AND you only have staff management support, you most likely are ill-prepared for a successful reengineering project (line management in this context are the top managers of the operation ultimately accountable for business performance -- P&L, customer service, etc.). Projects that result in major change in an organization rarely succeed without top management support in the line organization.

Strategic Alignment

You should be able to tie your reengineering project goals back to key business objectives and the overall strategic direction for the organization. This linkage should show the thread from the top down, so each person can easily connect the overall business direction with your reengineering effort. You should be able to demonstrate this alignment from the perspective of financial performance, customer service, associate (employee) value, and the vision for the organization.

Reengineering projects not in alignment with the company's strategic direction can be counterproductive. It is not unthinkable that an organization may make significant investments in an area that is not a core competency for the company, and later this capability be outsourced. Such reengineering initiatives are wasteful and steal resources from other strategic projects.

Moreover, without strategic alignment your key stakeholders and sponsors may find themselves unable to provide the level of support you need in terms of money and resources, especially if there are other projects more critical to the future of the business, and more aligned with the strategic direction.

Business Case for Change

In one page or less you must be able to communicate the business case for change. Less is preferred. If it requires more than this, you either don't understand the problem or you don't understand your customers.

You may find your first attempt at the business case is 100 pages of text, with an associated presentation of another 50 view graphs (overhead slides). After giving the business case 20 times you find out that you can articulate the need for change in 2 minutes and 3 or 4 paragraphs. Stick with the shorter version.

Why is this important? First, your project is not the center of the universe. People have other important things to do, too. Second, you must make this case over and over again throughout the project and during implementation - the simpler and shorter it is, the more understandable and compelling your case will be.

Cover the few critical points. Talk to the current state, and what impact this condition has on customers, associates and business results. State the drivers that are causing this condition to occur. State what your going to do about it (vision and plan), and make specific commitments. Keep focusing on the customer. Connect this plan to specific, measurable objectives related to customers, associates, business results, and strategic direction. Show how much time and money you need and when you expect to get it back. Don't sell past the close. No matter how long you talk, you will get resistance from some, and support from others, so you might as well keep it short.

The business case for change will remain the center piece that defines your project, and should be a living document that the reengineering team uses to demonstrate success. Financial pay back and real customer impact from major change initiatives are difficult to measure and more difficult to obtain; without a rigorous business case both are unlikely.

Proven Methodology

The previous module presented several BPR methodologies, and it is important to note that your methodology does matter. Seat-of-the-pants reengineering is just too risky given the size of the investment and impact these projects have on processes and people.

Not only should your team members understand reengineering, they should know how to go about it. In short, you need an approach that will meet the needs of your project and one that the team understands and supports.

Change Management

One of the most overlooked obstacles to successful project implementation is resistance from those whom implementers believe will benefit the most. Most projects underestimate the cultural impact of major process and structural change, and as a result do not achieve the full potential of their change effort.

Change is not an event, despite our many attempts to call folks together and have a meeting to make change happen. Change management is the discipline of managing change as a process, with due consideration that we are people, not programmable machines. It is about leadership with open, honest and frequent communication.

It must be OK to show resistance, to surface issues, and to be afraid of change. Organizations do not change. People change, one at a time. The better you manage the change, the less pain you will have during the transition, and your impact on work productivity will be minimized.

Line Ownership

Many re-design teams are the SWAT type -- senior management responding to crisis in line operations with external consultants or their own staff. It's a rescue operation. Unfortunately the ability of external consultants to implement significant change in an organization is small. The chances are only slightly better for staff groups. Ultimately the solution and results come back to those accountable for day-to-day execution.

That does not mean that consultants or staff are not valuable. What it does mean, though, is that the terms of engagement and accountability must be clear. The ownership must ultimately rest with the line operation, whether it be manufacturing, customer service, logistics, sales, etc.

This is where it gets messy. Often those closest to the problem can't even see it. They seem hardly in a position to implement radical change. They are, in a matter of speaking, the reason you're in this fix to begin with. They lack objectivity, external focus, technical re-design knowledge, and money.

On the other hand, they know today's processes, they know the gaps and issues, they have front-line, in-your-face experience. They are real. The customers work with them, not your consultants and staff personnel.

Hence your dilemma. The line operation probably cannot heal itself when it comes to major business re-design. Staff and consultants have no lasting accountability for the solution, and never succeed at forcing solutions on line organizations.

You need both. You need the line organization to have the awareness that they need help, to contribute their knowledge, and to own the solution and implementation. At the same time you need the expertise and objectivity from outside of the organization.

Building this partnership is the responsibility of the line organization, stakeholders and re-design team. No group is off the hook.

Reengineering Team Composition

The reengineering team composition should be a mixed bag. For example,

some members who don't know the process at all,
some members that know the process inside-out,
include customers if you can,
some members representing impacted organizations,
one or two technology gurus,
each person your best and brightest, passionate and committed, and
some members from outside of your company.
Moreover, keep the team under 10 players. If you are finding this difficult, give back some of the "representative" members. Not every organization should or needs to be represented on the initial core team. If you fail to keep the team a manageable size, you will find the entire process much more difficult to execute effectively.

Seven reengineering success factors have been introduced in this module. Subsequent modules in this series written by industry experts will take several of these success factors into greater depth.

Source: Prosci's 1998-1999 Reengineering Best Practices study (248 companies)


The BPR Online Learning Center offers several sources to help with reengineering and business process design projects:

free tutorials (provided in this series)
bookstore where you can purchase reengineering toolkits, templates, checklists and reference material
research results from studies with more than 400 companies involved in major change projects
article indexes of online material from other sources
yellow pages of vendors, consultants, and other resources for project teams

Welcome to the BPR Tutorial Series

Return to INDEX


Purpose of this module:

Gain an understanding of what is meant by "business process".
Understand and contrast continuous process improvement and business process reengineering (BPR).

If you have ever waited in line at the grocery store, you can appreciate the need for process improvement. In this case, the "process" is called the check-out process, and the purpose of the process is to pay for and bag your groceries. The process begins with you stepping into line, and ends with you receiving your receipt and leaving the store. You are the customer (you have the money and you have come to buy food), and the store is the supplier.

The process steps are the activities that you and the store personnel do to complete the transaction. In this simple example, we have described a business process. Imagine other business processes: ordering clothes from mail order companies, requesting new telephone service from your telephone company, developing new products, administering the social security process, building a new home, etc.

Business processes are simply a set of activities that transform a set of inputs into a set of outputs (goods or services) for another person or process using people and tools. We all do them, and at one time or another play the role of customer or supplier.

You may see business processes pictured as a set of triangles as shown below. The purpose of this model is to define the supplier and process inputs, your process, and the customer and associated outputs. Also shown is the feedback loop from customers.

So why business process improvement?
Improving business processes is paramount for businesses to stay competitive in today's marketplace. Over the last 10 to 15 years companies have been forced to improve their business processes because we, as customers, are demanding better and better products and services. And if we do not receive what we want from one supplier, we have many others to choose from (hence the competitive issue for businesses). Many companies began business process improvement with a continuous improvement model. This model attempts to understand and measure the current process, and make performance improvements accordingly.

The figure below illustrates the basic steps. You begin by documenting what you do today, establish some way to measure the process based on what your customers want, do the process, measure the results, and then identify improvement opportunities based on the data you collected. You then implement process improvements, and measure the performance of the new process. This loop repeats over and over again, and is called continuous process improvement. You might also hear it called business process improvement, functional process improvement, etc.

This method for improving business processes is effective to obtain gradual, incremental improvement. However, over the last 10 years several factors have accelerated the need to improve business processes. The most obvious is technology. New technologies (like the Internet) are rapidly bringing new capabilities to businesses, thereby raising the competitive bar and the need to improve business processes dramatically.

Another apparent trend is the opening of world markets and increased free trade. Such changes bring more companies into the marketplace, and competing becomes harder and harder. In today's marketplace, major changes are required to just stay even. It has become a matter of survival for most companies.

As a result, companies have sought out methods for faster business process improvement. Moreover, companies want breakthrough performance changes, not just incremental changes, and they want it now. Because the rate of change has increased for everyone, few businesses can afford a slow change process. One approach for rapid change and dramatic improvement that has emerged is Business Process Reengineering (BPR).

Business Process Reengineering (BPR)
BPR relies on a different school of thought than continuous process improvement. In the extreme, reengineering assumes the current process is irrelevant - it doesn't work, it's broke, forget it. Start over. Such a clean slate perspective enables the designers of business processes to disassociate themselves from today's process, and focus on a new process. In a manner of speaking, it is like projecting yourself into the future and asking yourself: what should the process look like? What do my customers want it to look like? What do other employees want it to look like? How do best-in-class companies do it? What might we be able to do with new technology?

Such an approach is pictured below. It begins with defining the scope and objectives of your reengineering project, then going through a learning process (with your customers, your employees, your competitors and non-competitors, and with new technology). Given this knowledge base, you can create a vision for the future and design new business processes. Given the definition of the "to be" state, you can then create a plan of action based on the gap between your current processes, technologies and structures, and where you want to go. It is then a matter of implementing your solution.

In summary, the extreme contrast between continuous process improvement and business process reengineering lies in where you start (with today's process, or with a clean slate), and with the magnitude and rate of resulting changes.

Over time many derivatives of radical, breakthrough improvement and continuous improvement have emerged that attempt to address the difficulties of implementing major change in corporations. It is difficult to find a single approach exactly matched to a particular company's needs, and the challenge is to know what method to use when, and how to pull it off successfully such that bottom-line business results are achieved. Such are the topics for this module series.

The BPR Online Learning Center offers several sources to help with reengineering and business process design projects:

free tutorials (provided in this series)
bookstore where you can purchase reengineering toolkits, templates, checklists and reference material
research results from studies with more than 400 companies involved in major change projects
article indexes of online material from other sources
yellow pages of vendors, consultants, and other resources for project teams


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The Case for learnniog from and adopting the Car industry financing? Pay for staying healthy not when we are sick!

Dear Patriotic Global Citizens:

Re: Why not learn from the Car Industry? Pay the health system to keep us healthy instead of when we are sick?

Professor Marmot of London University has shown clearly the economic and social cost of health and well being.

The challenge is creating a health financing system that is paid for keeping the population healthy from conception to the grave.

Yes, we can, as Obama reminds us, it is just a frame of mind and thinking.

Imagine if we pay the Doctors and the insurance agencies for keeping us healthy, month by month and year by year with the appropriate positive and proactive screening and prevention and early intervention activities.

Just imagine what happens to the 3As, 3Es and FoC: that is accessibility, affordability and accountability, as well as Equity, Efficiency, Effectiveness and Freedom of Choice?

Just imagine!

Here is the report that indicates the challenges and making the case for changing radically the health care financing system

The challenge:Increasing health care cost that is not cost effectivde nor equitable

The Opportunity: To focus on Prevention and Early Intervention based health care financing

Make payment for keeping the population and individuals healthy by age, sex and risk factors.

Now is the time to act.

Dr b
Inequities are killing people on a "grand scale" reports WHO's Commission
28 August 2008 | GENEVA --

A child born in a Glasgow, Scotland suburb can expect a life 28 years shorter than another living only 13 kilometres away.

A girl in Lesotho is likely to live 42 years less than another in Japan.

In Sweden, the risk of a woman dying during pregnancy and childbirth is 1 in 17 400; in Afghanistan, the odds are 1 in 8.

Biology does not explain any of this. Instead, the differences between - and within - countries result from the social environment where people are born, live, grow, work and age.

Related links

The Report and background material

Executive summary [pdf 5.34Mb]

More about the Commission

These "social determinants of health" have been the focus of a three-year investigation by an eminent group of policy makers, academics, former heads of state and former ministers of health. Together, they comprise the World Health Organization' s Commission on the Social Determinants of Health. Today, the Commission presents its findings to the WHO Director-General Dr Margaret Chan.

"(The) toxic combination of bad policies, economics, and politics is, in large measure responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible," the Commissioners write in Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. "Social injustice is killing people on a grand scale."

"Health inequity really is a matter of life and death," said Dr Chan today while welcoming the Report and congratulating the Commission. "But health systems will not naturally gravitate towards equity. Unprecedented leadership is needed that compels all actors, including those beyond the health sector, to examine their impact on health. Primary health care, which integrates health in all of government's policies, is the best framework for doing so."

Sir Michael Marmot, Commission Chair said: “Central to the Commission’s recommendations is creating the conditions for people to be empowered, to have freedom to lead flourishing lives. Nowhere is lack of empowerment more obvious than in the plight of women in many parts of the world. Health suffers as a result. Following our recommendations would dramatically improve the health and life chances of billions of people.”

Inequities within countries

Health inequities – unfair, unjust and avoidable causes of ill health – have long been measured between countries but the Commission documents "health gradients" within countries as well. For example:

Life expectancy for Indigenous Australian males is shorter by 17 years than all other Australian males.

Maternal mortality is 3–4 times higher among the poor compared to the rich in Indonesia. The difference in adult mortality between least and most deprived neighbourhoods in the UK is more than 2.5 times.

Child mortality in the slums of Nairobi is 2.5 times higher than in other parts of the city. A baby born to a Bolivian mother with no education has 10% chance of dying, while one born to a woman with at least secondary education has a 0.4% chance.

In the United States, 886 202 deaths would have been averted between 1991 and 2000 if mortality rates between white and African Americans were equalized. (This contrasts to 176 633 lives saved in the US by medical advances in the same period.)
In Uganda the death rate of children under 5 years in the richest fifth of households is 106 per 1000 live births but in the poorest fifth of households in Uganda it is even worse – 192 deaths per 1000 live births – that is nearly a fifth of all babies born alive to the poorest households destined to die before they reach their fifth birthday.

Set this against an average death rate for under fives in high income countries of 7 deaths per 1000.

The Commission found evidence that demonstrates in general the poor are worse off than those less deprived, but they also found that the less deprived are in turn worse than those with average incomes, and so on. This slope linking income and health is the social gradient, and is seen everywhere – not just in developing countries, but all countries, including the richest. The slope may be more or less steep in different countries, but the phenomenon is universal.

Wealth is not necessarily a determinant

Economic growth is raising incomes in many countries but increasing national wealth alone does not necessarily increase national health. Without equitable distribution of benefits, national growth can even exacerbate inequities.

While there has been enormous increase in global wealth, technology and living standards in recent years, the key question is how it is used for fair distribution of services and institution- building especially in low-income countries.

In 1980, the richest countries with 10% of the population had a gross national income 60 times that of the poorest countries with 10% of the world's population. After 25 years of globalization, this difference increased to 122, reports the Commission. Worse, in the last 15 years, the poorest quintile in many low-income countries have shown a declining share in national consumption.

Wealth alone does not have to determine the health of a nation's population. Some low-income countries such as Cuba, Costa Rica, China, state of Kerala in India and Sri Lanka have achieved levels of good health despite relatively low national incomes. But, the Commission points out, wealth can be wisely used.

Nordic countries, for example, have followed policies that encouraged equality of benefits and services, full employment, gender equity and low levels of social exclusion. This, said the Commission, is an outstanding example of what needs to be done everywhere.

Solutions from beyond the health sector

Much of the work to redress health inequities lies beyond the health sector. According to the Commission's report, "Water-borne diseases are not caused by a lack of antibiotics but by dirty water, and by the political, social, and economic forces that fail to make clean water available to all; heart disease is caused not by a lack of coronary care units but by lives people lead, which are shaped by the environments in which they live; obesity is not caused by moral failure on the part of individuals but by the excess availability of high-fat and high-sugar foods." Consequently, the health sector – globally and nationally – needs to focus attention on addressing the root causes of inequities in health.

“We rely too much on medical interventions as a way of increasing life expectancy” explained Sir Michael. “A more effective way of increasing life expectancy and improving health would be for every government policy and programme to be assessed for its impact on health and health equity; to make health and health equity a marker for government performance.”


Based on this compelling evidence, the Commission makes three overarching recommendations to tackle the "corrosive effects of inequality of life chances":

Improve daily living conditions, including the circumstances in which people are born, grow, live, work and age.

Tackle the inequitable distribution of power, money and resources – the structural drivers of those conditions – globally, nationally and locally.

Measure and understand the problem and assess the impact of action.

Recommendations for daily living

Improving daily living conditions begins at the start of life. The Commission recommends that countries set up an interagency mechanism to ensure effective collaboration and coherent policy between all sectors for early childhood development, and aim to provide early childhood services to all of their young citizens.

Investing in early childhood development provides one of the best ways to reduce health inequities. Evidence shows that investment in the education of women pays for itself many times over.

Billions of people live without adequate shelter and clean water. The Commission's report pays particular attention to the increasing numbers of people who live in urban slums, and the impact of urban governance on health. The Commission joins other voices in calling for a renewed effort to ensure water, sanitation and electricity for all, as well as better urban planning to address the epidemic of chronic disease.

Health systems also have an important role to play. While the Commission report shows how the health sector can not reduce health inequities on its own, providing universal coverage and ensuring a focus on equity throughout health systems are important steps.

The report also highlights how over 100 million people are impoverished due to paying for health care – a key contributor to health inequity. The Commission thus calls for health systems to be based on principles of equity, disease prevention and health promotion with universal coverage, based on primary health care.

Distribution of resources

Enacting the recommendations of the Commission to improve daily living conditions will also require tackling the inequitable distribution of resources. This requires far-reaching and systematic action.

The report foregrounds a range of recommendations aimed at ensuring fair financing, corporate social responsibility, gender equity and better governance.

These include using health equity as an indicator of government performance and overall social development, the widespread use of health equity impact assessments, ensuring that rich countries honour their commitment to provide 0.7% of their GNP as aid, strengthening legislation to prohibit discrimination by gender and improving the capacity for all groups in society to participate in policy-making with space for civil society to work unencumbered to promote and protect political and social rights. At the global level, the Commission recommends that health equity should be a core development goal and that a social determinants of health framework should be used to monitor progress.

The Commission also highlights how implementing any of the above recommendations requires measurement of the existing problem of health inequity (where in many countries adequate data does not exist) and then monitoring the impact on health equity of the proposed interventions.

To do this will require firstly investing in basic vital registration systems which have seen limited progress in the last thirty years. There is also a great need for training of policy-makers, health workers and workers in other sectors to understand the need for and how to act on the social determinants of health.

While more research is needed, enough is known for policy makers to initiate action. The feasibility of action is indicated in the change that is already occurring. Egypt has shown a remarkable drop in child mortality from 235 to 33 per 1000 in 30 years. Greece and Portugal reduced their child mortality from 50 per 1000 births to levels nearly as low as Japan, Sweden, and Iceland. Cuba achieved more than 99% coverage of its child development services in 2000. But trends showing improved health are not foreordained. In fact, without attention health can decline rapidly.

Is this feasible?

The Commission has already inspired and supported action in many parts of the world. Brazil, Canada, Chile, Iran, Kenya, Mozambique, Sri Lanka, Sweden, and the UK have become 'country partners' on the basis of their commitment to make progress on the social determinants of health equity and are already developing policies across governments to tackle them. These examples show that change is possible through political will. There is a long way to go, but the direction is set, say the Commissioners, the path clear.

WHO will now make the report available to Member States which will determine how the health agency is to respond.

Comments from the Commissioners

Fran Baum, Head of Department and Professor of Public Health at Flinders University, Foundation Director of the South Australian Community Health Research Unit and Co-Chair of the Global Coordinating Council of the People’s Health Movement: "It is wonderful to have global endorsement of the Australian Closing the Gap campaign from the CSDH established by the WHO.

The CSDH sets Closing the Gap as a goal for the whole world and produces the evidence on how health inequities are a reflection of the way we organize society and distribute power and resources. The good news from the CSDH for Australia is that it provides plenty of ideas on how to set an agenda that will tackle the underlying determinants of health and create a healthier Australia for all of us"
Monique Begin, Professor at the School of Management, University of Ottawa, Canada, twice-appointed Minister of National Health and Welfare and the first woman from Quebec elected to the House of Commons: "Canada likes to brag that for seven years in a row the United Nations voted us "the best country in the world in which to live".

Do all Canadians share equally in that great quality of life? No they don't. The truth is that our country is so wealthy that it manages to mask the reality of food banks in our cities, of unacceptable housing (1 in 5), of young Inuit adults very high suicide rates. This report is a wake up call for action towards truly living up to our reputation."

Giovanni Berlinguer, Member of the European Parliament, member of the International Bioethics Committee of UNESCO (2001–2007) and rapporteur of the project Universal Declaration on Bioethics: "A fairer world will be a healthier world. A health service and medical interventions are just one of the factors that influence population health.

The growth of inequalities and the phenomena of increased injustice in health is present in low and middle income countries as well as across Europe. It would be a crime not to take every action possible to reduce them."

Mirai Chatterjee, Coordinator of Social Security for India’s Self-Employed Women’s Association, a trade union of over 900 000 self-employed women and recently appointed to the National Advisory Council and the National Commission for the Unorganised Sector: "The report suggests avenues for action from the local to national and global levels.

It has been eagerly awaited by policy-makers, health officials, grassroot activists and their community-based organizations. Much of the research and evidence is of particular relevance to the South-East Asian region, where too many people struggle daily for justice and equity in health. The report will inspire the region to act and develop new policies and programmes."

Yan Guo, Professor of Public Health and Vice-President of the Peking University Health Science Centre, Vice-Chairman of the Chinese Rural Health Association and Vice-Director of the China Academy of Health Policy: “A man should not be concerned with whether he has enough possessions but whether possessions have been equally distributed”, this is a time-honored teaching in China. Constructing a harmonious society is our shared aspiration, and equity, including health equity, composes the prerequisite for a harmonious development.

Eliminating determinants that are adverse to health under the efforts from all of the society, promoting social justice, and advancing human health are our shared goals. Let’s join our hands in this grand course!”

Kiyoshi Kurokawa, Professor at the National Graduate Institute for Policy Studies, Tokyo, Member of the Science and Technology Policy Committee of the Cabinet Office, formerly President of the Science Council of Japan and the Pacific Science Association: "The WHO Commission addresses one of the major issues of our global world - health inequity.

The report’s recommendations will be perceived, utilized and implemented as a major policy agenda at national and global levels. The issue will increase in importance as the general public become more engaged via civil society movements and multi-stakeholder involvement. "

Alireza Marandi, Professor of Pediatrics at Shaheed Beheshti University, Islamic Republic of Iran, former two-term Minister of Health and Medical Education, former Deputy Minister and Advisor to the Minister and recently elected to be a member of the Iranian Parliament: "According to the Islamic ideology, social justice became a priority, when the Islamic revolution materialized in Iran.

Establishing a solid Primary Health Care network in our country, not only improved our health statistics, but it was an excellent vehicle to move towards health equity. Now through the final report of the CSDH and implementing its recommendations we need to move much faster in our own country toward health equity."

Pascoal Mocumbi, High Representative of the European and Developing Countries Clinical Trials Partnership, former Prime Minister of the Republic of Mozambique, former head of the Ministry of Foreign Affairs and the Ministry of Health: "The Commission on Social Determinants of Health report will help African leaders adapt their national development strategies to address the challenges to health. These are derived from the current systemic changes taking place in the global economy that affects heavily on the poorest segments of Africa’s population."

Amartya Sen, Lamont University Professor and Professor of Economics and Philosophy at Harvard University, awarded the Nobel Prize in Economics in 1998: "The primary object of development - for any country and for the world as a whole - is the elimination of 'unfreedoms' that reduce and impoverish the lives of people. Central to human deprivation is the failure of the capability to live long and healthy lives.

This is much more than a medical problem. It relates to handicaps that have deep social roots. Under Michael Marmot's leadership, this WHO Commission has concentrated on the badly neglected causal linkages that have to be adequately understood and remedied.

A fuller understanding is also a call for action."
David Satcher, Director of the Center of Excellence on Health Disparities and the Satcher Health Leadership Institute Initiative, formerly the United States Surgeon General and Assistant Secretary for Health and also Director of the Centers for Disease Control and Prevention: "The United States of America spends more on health care than any other country in the world, yet it ranks 41st in terms of life expectancy. New Orleans and its experience with Hurricane Katrina illustrate why we need to target social determinants of health (SDH) — including housing, education, working and learning conditions, and whether people are exposed to toxins—better than any place I can think of right now. By targeting the SDH, we can rapidly move towards closing the gap that unfairly and avoidably separates the health status of groups of different socio-economic status, social exclusion experience, and educational background."

Anna Tibaijuka, Executive Director of UN-HABITAT and founding Chairperson of the independent Tanzanian National Women’s Council: "Health delivery is not possible for people living in squalor, in dehumanizing pathetic conditions prevailing in the ever growing slum settlements of cities and towns in developing countries. Investment in basic services such as water and education will always remain constrained if not wasted unless accompanied by requisite investment in decent housing with basic sanitation."

Denny Vågerö, Professor of Medical Sociology, Director of CHESS (Centre for Health Equity Studies) in Sweden, member of the Royal Swedish Academy of Sciences and of its Standing Committee on Health: "Countries of the world are presently growing apart in health terms. This is very worrying. In many countries in the world social differences in health are also growing, and this is true in Europe. We have been one-sidedly focused on economic growth, disregarding negative consequences for health and climate. We need to think differently about development. "

Gail Wilensky, Senior Fellow at Project HOPE, an international health education foundation. Previously she directed the Medicare and Medicaid programmes in the United States and also chaired two commissions that advise the United States Congress on Medicare: "What this report makes clear is that improving health and health outcomes and reducing avoidable health differences—goals of all countries-- involves far more than just improving the health care system.

Basic living conditions, employment, early childhood education, treatment of women and poverty all impact on health outcomes and incorporating their effects on health outcomes needs to become an important part of public policymaking. This is as true for wealthy countries like the United States as it is for many of the emerging countries of the world, where large numbers of people live on less than $2 per day."
For more information or interviews, please contact:

Sharad Agarwal
Communications Officer
WHO, Geneva
Tel.: +41 22 791 1905
Mob.: +41 79 621 5286
Email: agarwals@who. int
Felicity Porritt
Head, Communications
CSDH, UCL Secretariat
Mob.: +44 773 941 9219
Email: felicity.porritt@

Maintaing the appropriate level of water in the body!

The Importance of Water in the Body
Helen Taranowski

Water is vital for health. The average adult body is around 60% water and without consuming water we would be dead within a few days. The average person loses around 2.5 litres of water per day; 1.5 litres is lost in urine, 700ml through the skin and in the breath, 200ml in perspiration and 100ml in feces. Some water losses are replaced from cellular metabolism and food but we still need to consume around 1500ml of water per day from drinks to make up the remainder. The water in our bodies carries out a number of important functions.

Water is needed for regulation of body temperature at 37o C. When body temperature starts to rise, blood vessels near the surface of the skin dilate to release some of the heat, the reverse happens when body temperature starts to drop. Also, when body temperature rises, sweat glands secrete sweat, which is 99% water. As the sweat evaporates, heat is removed from the body.

Water provides lubrication for the joints as it is a component of synovial fluid. It is also a component of tears which lubricate the eyes and of saliva to provide lubrication to food which aids chewing, swallowing and digestion of food. It also has protective roles, washing away particles that get into the eyes, providing cushioning against shock for the eyes and the spinal cord. It is also a component of amniotic fluid which provides protection for the foetus during pregnancy.

There are chemical reactions in the body which require water. A synthesis reaction involves the joining of two molecules by the removal of a water molecule and a hydrolysis reaction involves a molecule being split into two smaller molecules with the addition of water.

Water is also a very good solvent for some substances as water molecules are polar; the two sides have a different electrical charge. Sodium chloride, (table salt), for example, easily dissolves in water as the sodium ion is positively charges and attracts to the negative pole of the water molecule and chloride is negatively charged and so attracts to the positive pole of the water molecule. Substances which dissolve in water this way are known as electrolytes.

Water is also the major component of the body's transport systems. Via the blood stream nutrients, oxygen, glucose and fats are transported to the various tissues and cells. Also, the waste products of cellular metabolism are removed, such as lactic acid and carbon dioxide. Via the urine, a number of waste products are transported out of the body, for example, urea, phosphates, sulphites, minerals, ketones from fat metabolism and nitrogenous waste from protein breakdown.

Exercise, especially in hot and humid conditions, can cause large water losses through sweating. For this reason, people who exercise need to ensure they are well hydrated before exercising and consume fluids containing electrolytes, such as sodium and potassium, during and after training to replace lost fluid. This will minimise the risk of a reduction in performance or any detriment to their health.

* MLA Style Citation:
Taranowski, Helen "The Importance of Water in the Body." The Importance of Water in the Body. 19 Jun. 2008. 26 Aug 2008 .