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Corruption can have a devastating impact on the availability, quality and accessibility of human rights-related goods and services. Moreover, it undermines the functioning and legitimacy of institutions and processes, the rule of law and ultimately the State itself.

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The announcement of a controversial aid deal between the UK and Saudi Arabia has been branded a "national disgrace".

Amid further outcry over Britain's relationship with the Gulf state, government ministers have signed a £100m aid agreement with Riyadh to coincide with Crown Prince Mohammed bin Salman's visit to London this week.

The government described the deal as a "new long-term partnership" to improve livelihoods and boost economic development in some of the world's poorest countries.

But the accord has been greeted with fury by opposition MPs and the aid sector, with grave concerns expressed about Saudi Arabia's role in the Yemen conflict.

Kate Osamor, the shadow international development secretary, said the agreement "made a mockery" of Britain's reputation as a global leader in delivering humanitarian aid.

"Theresa May implied she would lobby Mohammed bin Salman to stop bombing civilians and end the use of starvation as a weapon of war," said Osamor.

"Over 22 million Yemeni lives depend on permanent, full access for aid, food and fuel in Yemen. Instead, she has won no concessions and simply handed on a plate to Saudi Arabia a new humanitarian partnership and an endorsement from DfID [the Department for International Development], the world's best aid agency.

"It will whitewash Saudi Arabia's reputation and role in the war, and it is a national disgrace."

Osamor said that in signing an agreement with Saudi Arabia, Britain had aligned itself with the country primarily responsible for one of the world's biggest humanitarian crises. A total of 8.4 million people in Yemen are in imminent danger of famine.

The partnership, which will pool the development expertise of both countries, is the first of its kind between Britain and the Saudi Fund for Development.

The aim, said DfID, would be to create vital infrastructure in drought and conflict-stricken countries.

Penny Mordaunt, the international development secretary, said: "The Saudi Fund has a long record of investing in successful development projects around the world.

"We are sharing the best of British expertise, and our collective efforts will help create jobs and livelihoods to support the poorest people to stand on their own two feet. This in turn will help to boost global prosperity, which is in all of our interests."

Mordaunt had previously said Saudi Arabia had no excuse for blocking aid to Yemen, warning that the use of starvation as a weapon was in breach of humanitarian law, but a DfID statement announcing the deal said the UK was "encouraged by the easing of restrictions into Yemen".

Critics have questioned claims of progress, however, arguing that the Saudi-led coalition is only permitting goods through ports on a month-by-month basis, dramatically limiting the efforts of NGOs, traders and shipping agents to get supplies into Yemen.

Osamor said: "In the same breath as announcing this new deal, the government acknowledges there can be 'no excuse' for stopping humanitarian supplies, and has claimed this week there is no blockade."

She added: "Fuel deliveries are estimated to be at just 19% of what is needed and, in January, seven cities shut down their water systems for lack of fuel.

"Before signing off on any new humanitarian partnership, Theresa May and Penny Mordaunt should have insisted on full, permanent access so millions of Yemeni lives can be saved. It is unforgivable that they did not."

Osamor said the burden was now on the government to show the new partnership had substance and was more than "just big business".

Allan Hogarth, head of policy and government affairs at Amnesty International UK, also voiced concern over the deal.

He said: "British overseas aid is important in many ways, but at a time when the UK is arming a Saudi-led military coalition that's laying waste to homes, hospitals and schools in Yemen, this raises troubling questions.

"It is not good enough for the UK to provide humanitarian aid on the one hand and supply the weapons that fuel a humanitarian crisis on the other."

Bin Salman's three-day charm offensive has included talks with Theresa May and the Archbishop of Canterbury, and an audience with the Queen.

Kevin Watkins, chief executive of Save the Children, blasted the government over the welcome lavished on the prince, who is taking steps to modernise the ultra-conservative Arab state.

Speaking in London at the launch of a report on crimes against children in warzones, Watkins said: "It has become acceptable to operate humanitarian blockades which, if not explicitly designed to starve children and harm children, will have that inevitable consequence.

"The fact that we have the head of state of a government that has been operating such a blockade - Saudi Arabia - recently invited to Buckingham Palace and Downing Street while the military ... is orchestrating what will potentially become the worst famine in the last 50 years, I think speaks volumes."

Noting a "growing sense of impunity surrounding crimes against children", Watkins added: "The fact that you can rape, murder, kidnap, bomb schools, bomb clinics with no consequence, speaks I think to the heart of the deeper challenge."

Yemen, which borders southern Saudi Arabia, has been embroiled in a bloody civil war since 2014, when rebels took over the capital, Sana'a.

Saudi Arabia is the main player in a coalition supporting the Yemeni government against the Houthis in a war that has caused a humanitarian catastrophe.

Downing Street defended Bin Salman's visit, saying trade deals worth £65bn had been agreed.
Topics

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department for international development (dfid)

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'A national disgrace': fury over £100m aid deal between UK and Saudi Arabia

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The announcement of a controversial aid deal between the UK and Saudi Arabia has been branded a "national disgrace". Amid further outcry over Britain's relationship with the Gulf state, government ministers have signed a £100m aid agreement with Riyadh to coincide with Crown Prince Mohammed bin Salman's visit to London this week.

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Re-education camps in China and Human Rights violations

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Re-education camps in China and Human Rights violations

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Women in China's "re-education" camps for Uighurs have been systematically raped, sexually abused, and tortured, according to detailed new accounts obtained by the BBC.

You may find some of the details in this story distressing.

The men always wore masks, Tursunay Ziawudun said, even though there was no pandemic then.

They wore suits, she said, not police uniforms.

Sometime after midnight, they came to the cells to select the women they wanted and took them down the corridor to a "black room", where there were no surveillance cameras.

Several nights, Ziawudun said, they took her.

"Perhaps this is the most unforgettable scar on me forever," she said.

"I don't even want these words to spill from my mouth."

Tursunay Ziawudun spent nine months inside China's vast and secretive system of internment camps in the Xinjiang region. According to independent estimates, more than a million men and women have been detained in the sprawling network of camps, which China says exist for the "re-education" of the Uighurs and other minorities.

Human rights groups say the Chinese government has gradually stripped away the religious and other freedoms of the Uighurs, culminating in an oppressive system of mass surveillance, detention, indoctrination, and even forced sterilisation.

The policy flows from China's President, Xi Jinping, who visited Xinjiang in 2014 in the wake of a terror attack by Uighur separatists. Shortly after, according to documents leaked to the New York Times, he directed local officials to respond with "absolutely no mercy". The US government said last month that China's actions since amounted to a genocide. China says reports of mass detention and forced sterilisation are "lies and absurd allegations".

First-hand accounts from inside the internment camps are rare, but several former detainees and a guard have told the BBC they experienced or saw evidence of an organised system of mass rape, sexual abuse and torture.

Tursunay Ziawudun, who fled Xinjiang after her release and is now in the US, said women were removed from the cells "every night" and raped by one or more masked Chinese men. She said she was tortured and later gang-raped on three occasions, each time by two or three men.

Ziawudun has spoken to the media before, but only from Kazakhstan, where she "lived in constant fear of being sent back to China", she said. She said she believed that if she revealed the extent of the sexual abuse she had experienced and seen, and was returned to Xinjiang, she would be punished more harshly than before. And she was ashamed, she said.

It is impossible to verify Ziawudun's account completely because of the severe restrictions China places on reporters in the country, but travel documents and immigration records she provided to the BBC corroborate the timeline of her story. Her descriptions of the camp in Xinyuan county - known in Uighur as Kunes county - match satellite imagery analysed by the BBC, and her descriptions of daily life inside the camp, as well as the nature and methods of the abuse, correspond with other accounts from former detainees.

Internal documents from the Kunes county justice system from 2017 and 2018, provided to the BBC by Adrian Zenz, a leading expert on China's policies in Xinjiang, detail planning and spending for "transformation through education" of "key groups" - a common euphemism in China for the indoctrination of the Uighurs. In one Kunes document, the "education" process is described as "washing brains, cleansing hearts, strengthening righteousness and eliminating evil".

The BBC also interviewed a Kazakh woman from Xinjiang who was detained for 18 months in the camp system, who said she was forced to strip Uighur women naked and handcuff them, before leaving them alone with Chinese men. Afterwards, she cleaned the rooms, she said.

"My job was to remove their clothes above the waist and handcuff them so they cannot move," said Gulzira Auelkhan, crossing her wrists behind her head to demonstrate. "Then I would leave the women in the room and a man would enter - some Chinese man from outside or policeman. I sat silently next to the door, and when the man left the room I took the woman for a shower."

The Chinese men "would pay money to have their pick of the prettiest young inmates", she said.

Some former detainees of the camps have described being forced to assist guards or face punishment. Auelkhan said she was powerless to resist or intervene.

Asked if there was a system of organised rape, she said: "Yes, rape."

"They forced me to go into that room," she said. "They forced me to take off those women's clothes and to restrain their hands and leave the room."

Some of the women who were taken away from the cells at night were never returned, Ziawudun said. Those who were brought back were threatened against telling others in the cell what had happened to them.

"You can't tell anyone what happened, you can only lie down quietly," she said. "It is designed to destroy everyone's spirit."

Mr Zenz told the BBC that the testimony gathered for this story was "some of the most horrendous evidence I have seen since the atrocity began".

"This confirms the very worst of what we have heard before," he said. "It provides authoritative and detailed evidence of sexual abuse and torture at a level clearly greater than what we had assumed."

The Uighurs are a mostly Muslim Turkic minority group that number about 11 million in Xinjiang in north-western China. The region borders Kazakhstan and is also home to ethnic Kazakhs. Ziawudun, who is 42, is Uighur. Her husband is a Kazakh.

The couple returned to Xinjiang in late 2016 after a five-year stay in Kazakhstan, and were interrogated on arrival and had their passports confiscated, Ziawudun said. A few months later, she was told by police to attend a meeting alongside other Uighurs and Kazakhs and the group was rounded up and detained.

Her first stint in detention was comparatively easy, she said, with decent food and access to her phone. After a month she developed stomach ulcers and was released. Her husband's passport was returned and he went back to Kazakhstan to work, but authorities kept Ziawudun's, trapping her in Xinjiang. Reports suggest China has purposefully kept behind and interned relatives to discourage those who leave from speaking out. On 9 March 2018, with her husband still in Kazakhstan, Ziawudun was instructed to report to a local police station, she said. She was told she needed "more education".

According to her account, Ziawudun was transported back to the same facility as her previous detention, in Kunes county, but the site had been significantly developed, she said. Buses were lined up outside offloading new detainees "non-stop".

The women had their jewellery confiscated. Ziawudun's earrings were yanked out, she said, causing her ears to bleed, and she was herded into a room with a group of women. Among them was an elderly woman who Ziawudun would later befriend.

The camp guards pulled off the woman's headscarf, Ziawudun said, and shouted at her for wearing a long dress - one of a list of religious expressions that became arrestable offences for Uighurs that year.

"They stripped everything off the elderly lady, leaving her with just her underwear. She was so embarrassed that she tried to cover herself with her arms," Ziawudun said.

"I cried so much watching the way they treated her. Her tears fell like rain."

The women were told to hand over their shoes and any clothes with elastic or buttons, Ziawudun said, then taken to cellblocks - "similar to a small Chinese neighbourhood where there are rows of buildings".

Nothing much happened for the first month or two. They were forced to watch propaganda programmes in their cells and had their hair forcibly cut short.

Then police began interrogating Ziawudun about her absent husband, she said, knocking her on the floor when she resisted and kicking her in the abdomen.

"Police boots are very hard and heavy, so at first I thought he was beating me with something," she said. "Then I realised that he was trampling on my belly. I almost passed out - I felt a hot flush go through me."

A camp doctor told her she might have a blood clot. When her cellmates drew attention to the fact that she was bleeding, the guards "replied saying it is normal for women to bleed", she said.

According to Ziawudun, each cell was home to 14 women, with bunk beds, bars on the windows, a basin and a hole-in-the-floor-style toilet. When she first saw women being taken out of the cell at night, she didn't understand why, she said. She thought they were being moved elsewhere.

Then sometime in May 2018 - "I don't remember the exact date, because you don't remember the dates inside there" - Ziawudun and a cellmate, a woman in her twenties, were taken out at night and presented to a Chinese man in a mask, she said. Her cellmate was taken into a separate room.

"As soon as she went inside she started screaming," Ziawudun said. "I don't know how to explain to you, I thought they were torturing her. I never thought about them raping."

The woman who had brought them from the cells told the men about Ziawudun's recent bleeding.

"After the woman spoke about my condition, the Chinese man swore at her. The man with the mask said 'Take her to the dark room'.

"The woman took me to the room next to where the other girl had been taken in. They had an electric stick, I didn't know what it was, and it was pushed inside my genital tract, torturing me with an electric shock."

Ziawudun's torture that first night in the dark room eventually came to an end, she said, when the woman intervened again citing her medical condition, and she was returned to the cell.

About an hour later, her cellmate was brought back.

"The girl became completely different after that, she wouldn't speak to anyone, she sat quietly staring as if in a trance," Ziawudun said. "There were many people in those cells who lost their minds."

Alongside cells, another central feature of the camps is classrooms. Teachers have been drafted in to "re-educate" the detainees - a process activists say is designed to strip the Uighurs and other minorities of their culture, language and religion, and indoctrinate them into mainstream Chinese culture.

Qelbinur Sedik, an Uzbek woman from Xinjiang, was among the Chinese language teachers brought into the camps and coerced into giving lessons to the detainees. Sedik has since fled China and spoken publicly about her experience.

The women's camp was "tightly controlled", Sedik told the BBC. But she heard stories, she said - signs and rumours of rape. One day, Sedik cautiously approached a Chinese camp policewoman she knew.

"I asked her, 'I have been hearing some terrible stories about rape, do you know about it?' She said we should talk in the courtyard during lunch.

"So I went to the courtyard, where there were not many cameras. She said, 'Yes, the rape has become a culture. It is gang rape and the Chinese police not only rape them but also electrocute them. They are subject to horrific torture.'"

That night Sedik didn't sleep at all, she said. "I was thinking about my daughter who was studying abroad and I cried all night."

In separate testimony to the Uyghur Human Rights Project, Sedik said she heard about an electrified stick being inserted into women to torture them - echoing the experience Ziawudun described.

There were "four kinds of electric shock", Sedik said - "the chair, the glove, the helmet, and anal rape with a stick".

"The screams echoed throughout the building," she said. "I could hear them during lunch and sometimes when I was in class."

Another teacher forced to work in the camps, Sayragul Sauytbay, told the BBC that "rape was common" and the guards "picked the girls and young women they wanted and took them away".

She described witnessing a harrowing public gang rape of a woman of just 20 or 21, who was brought before about 100 other detainees to make a forced confession.

"After that, in front of everyone, the police took turns to rape her," Sauytbay said.

"While carrying out this test, they watched people closely and picked out anyone who resisted, clenched their fists, closed their eyes, or looked away, and took them for punishment."

The young woman cried out for help, Sauytbay said.

"It was absolutely horrendous," she said. "I felt I had died. I was dead."

In the camp in Kunes, Ziawudun's days drifted into weeks and then months. The detainees' hair was cut, they went to class, they underwent unexplained medical tests, took pills, and were forcibly injected every 15 days with a "vaccine" that brought on nausea and numbness.

Women were forcibly fitted with IUDs or sterilised, Ziawudun said, including a woman who was just about 20 years old. ("We begged them on her behalf," she said.) Forced sterilisation of Uighurs has been widespread in Xinjiang, according to a recent investigation by the Associated Press. The Chinese government told the BBC the allegations were "completely unfounded".

As well as the medical interventions, detainees in Ziawudun's camp spent hours singing patriotic Chinese songs and watching patriotic TV programmes about Chinese President Xi Jinping, she said.

"You forget to think about life outside the camp. I don't know if they brainwashed us or if it was the side effect of the injections and pills, but you can't think of anything beyond wishing you had a full stomach. The food deprivation is so severe."

Detainees had food withheld for infractions such as failing to accurately memorise passages from books about Xi Jinping, according to a former camp guard who spoke to the BBC via video link from a country outside China.

"Once we were taking the people arrested into the concentration camp, and I saw everyone being forced to memorise those books. They sit for hours trying to memorise the text, everyone had a book in their hands," he said.

Those who failed tests were forced to wear three different colours of clothing based on whether they had failed one, two, or three times, he said, and subjected to different levels of punishment accordingly, including food deprivation and beatings.

"I entered those camps. I took detainees into those camps," he said. "I saw those sick, miserable people. They definitely experienced various types of torture. I am sure about that."

It was not possible to independently verify the guard's testimony but he provided documents that appeared to corroborate a period of employment at a known camp. He agreed to speak on condition of anonymity.

The guard said he did not know anything about rape in the cell areas. Asked if the camp guards used electrocution, he said: "Yes. They do. They use those electrocuting instruments." After being tortured, detainees were forced to make confessions to a variety of perceived offences, according to the guard. "I have those confessions in my heart," he said.

President Xi looms large over the camps. His image and slogans adorn the walls; he is a focus of the programme of "re-education". Xi is the overall architect of the policy against the Uighurs, said Charles Parton, a former British diplomat in China and now senior associate fellow at the Royal United Services Institute.

"It is very centralised and it goes to the very top," Parton said. "There is absolutely no doubt whatsoever that this is Xi Jinping's policy."

It was unlikely that Xi or other top party officials would have directed or authorised rape or torture, Parton said, but they would "certainly be aware of it".

"I think they prefer at the top just to turn a blind eye. The line has gone out to implement this policy with great sternness, and that is what is happening." That left "no real constraints", he said. "I just don't see what the perpetrators of these acts would have to hold them back."

According to Ziawudun's account, the perpetrators did not hold back.

"They don't only rape but also bite all over your body, you don't know if they are human or animal," she said, pressing a tissue to her eyes to stop her tears and pausing for a long time to collect herself.

"They didn't spare any part of the body, they bit everywhere leaving horrible marks. It was disgusting to look at.

"I've experienced that three times. And it is not just one person who torments you, not just one predator. Each time they were two or three men."

Later, a woman who slept near Ziawudun in the cell, who said she was detained for giving birth to too many children, disappeared for three days and when she returned her body was covered with the same marks, Ziawudun said.

"She couldn't say it. She wrapped her arms around my neck and sobbed continuously, but she said nothing."

The Chinese government did not respond directly to questions from the BBC about allegations of rape and torture. In a statement, a spokeswoman said the camps in Xinjiang were not detention camps but "vocational education and training centres".

"The Chinese government protects the rights and interests of all ethnic minorities equally," the spokeswoman said, adding that the government "attaches great importance to protecting women's rights".

Ziawudun was released in December 2018 along with others who had spouses or relatives in Kazakhstan - an apparent policy shift she still doesn't fully understand.

The state returned her passport and she fled to Kazakhstan and then, with the support of the Uyghur Human Rights Project, to the US. She is applying to stay. She lives in a quiet suburb not far from Washington DC with a landlady from the local Uighur community. The two women cook together and take walks in the streets around the house. It's a slow, uneventful existence. Ziawudun keeps the lights low when she is in the house, because they shone brightly and constantly in the camp. A week after she arrived in the US, she had surgery to remove her womb - a consequence of being stamped on. "I have lost the chance to become a mother," she said. She wants her husband to join her in the US. For now, he is in Kazakhstan.

For a while after her release, before she could flee, Ziawudun waited in Xinjiang. She saw others who had been churned through the system and released. She saw the effect the policy was having on her people. The birth rate in Xinjiang has plummeted in the past few years, according to independent research - an effect analysts have described as "demographic genocide".

Many in the community had turned to alcohol, Ziawudun said. Several times, she saw her former cellmate collapsed on the street - the young woman who was removed from the cell with her that first night, who she heard screaming in an adjacent room. The woman had been consumed by addiction, Ziawudun said. She was "like someone who simply existed, otherwise she was dead, completely finished by the rapes".

"They say people are released, but in my opinion everyone who leaves the camps is finished."

And that, she said, was the plan. The surveillance, the internment, the indoctrination, the dehumanisation, the sterilisation, the torture, the rape.

"Their goal is to destroy everyone," she said. "And everybody knows it."

Photographs by Hannah Long-Higgins

Readers in the UK affected by sexual abuse or violence can find support information via the BBC website here.

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Just this month, millions of Colombians head to the polls to elect their next president. This is a remarkable period for Colombia, especially because this is the first national election since the government of President Juan Manual Santos and the Revolutionary Armed Forces of Colombia (FARC) Rodrigo Londoño agreed to the peace accord in November 2016. Since then, political optimism for Colombia's future has gained traction, while Colombians try to learn from several decades of armed conflict and hostility between the state and the FARC rebels.

Yet, the Colombian state has yet to fully uphold justice for the thousands of civilian lives killed in the context of armed clashes against the FARC rebels. Abusive military officers still enjoy impunity for the killings of thousands of unarmed civilians.

As shown in my recently published research in a leading academic journal, besides domestic factors within Colombia, American foreign aid and policy discourses under the Bush administration facilitated the numerous human rights abuses that occurred in the context of Colombia's post-9/11 war on drugs - or the government's fight against narco-terrorism.

More than anything else, the sudden increase in violent state repression requires a compelling set of justifications, arguments, and an overarching ideology in order to radically depart from the status quo. In the case of post-9/11 global war on terror, the Bush administration upheld that militaristic and coercive instruments of repression were necessary to combat non-state terrorism. US allies - including Pakistan, Thailand, Saudi Arabia, to name a few -supported the idea that combating non-state terrorism requires apolitical strategy based on the overarching logic of violent state repression and military security. To quell violent political dissidence, states have to embolden military and police forces, consequently undermining terrorists through the grand showmanship of even more threatening instruments of state violence.

In post-9/11 Colombia, the government of President Alvaro Uribe warmly received the sudden increase of US military aid that was deemed necessary back then to finally quell FARC rebels. At that time, the FARC constituted around 17,000 armed rebels, and the US government formally classified the Colombian armed group as a terrorist organization. US and Colombian officials promoted the idea that groups involved in illegal drug production and trafficking perpetrated a wide array of terrorist activities. Such a causal idea gave birth to the term 'narco-terrorism', a very appealing and powerful term that the Colombian government used in order to justify the US-funded war on drugs. Essentially, the goal was to embolden the Colombian national security state that conscripts the military in domestic crimes such as counter-terrorism and combating illegal drugs.

To justify violent state repression amid increasing human rights abuses, the Uribe-led government inaugurated his 'Democratic Security' strategy, which makes the state's human rights obligations conditional upon establishing state security through militaristic means. That strategy required bolstering the coercive capabilities of Colombian armed forces and police agencies, even if the consequence of such a policy constituted many collateral and intended human rights abuses.

Implicated in the widely known 'false positives' scandal, Colombian soldiers in more than 180 army units allegedly implemented around 5,700 extrajudicial killings of unarmed civilians between 2000 and 2010. In fact, Colombia's armed forces killed far more unarmed civilians than armed rebels during the term of President Alvaro Uribe in the years 2002 to 2010. Even worse, commanding military officers incriminated in the killings have succeeded in securing high-ranking posts in the armed forces and have clearly evaded any form of judicial persecution. Cash incentives fueled this killing spree of Colombian state agents, who were promised 1,500 USD for producing evidence of the death of an armed rebel. Specifically, Colombian state forces targeted and forcibly relocated many poor and other vulnerable Colombians into FARC-dominated territories. In doing so, soldiers killed these civilians, who were made to appear as FARC rebels. US military aid fueled the Colombian state apparatus that made the killing spree possible.

While the current occupant in the Oval Office has been quite committed to deep cuts in foreign aid, US foreign aid to Colombia for 2018 is likely to remain stable compared to recent years and is pegged at around 391 million USD, thereby making it one of the biggest recipients worldwide. Although such an amount of aid represents US support for the peace accord in 2016, with around 143 million USD allocated for human rights promotion, the successor of President Santos has to use such aid and domestic resources to bring the perpetrators of abuses into justice. The effective and efficient prosecution of human rights violators within the Colombian state is a clear step towards peace. Indeed, the integrity of the peace deal and Colombia's political future depend on how the country deals with its violent past through the mechanisms of transitional justice and criminal accountability.

Aid is neither good nor bad for human rights. Rather, the ideas, political strategies, and normative justifications shape foreign aid's political consequences in recipient countries. If politicians and state officials deem that human rights are subservient to state security, then foreign aid and domestic resources are likely to generate human rights abuses. The goal is to defeat those shared and emerging ideas that any human individual's right to life is subservient to the powerful actor's claim for upholding public security.

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A documentary to help you understand Colombia's troubled history and why 2016 was a significant year in the country's progress.
It also helps provide a context for why the USA gives Colombia military aid.

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To what extent has the USA been successful in Afghanistan?

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To what extent has the USA been successful in Afghanistan?

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An additional example you may wish to add to your notes to showcase the progress that Afghanistan made following US intervention. Think about the different types of data used to portray this improvement and contrast it with what you learnt in the last section about women's rights in Afghanistan.

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A U.S.-sponsored mortality survey released last year announced huge improvements in health across Afghanistan. But the gains are so great that experts are still arguing about whether it's correct.

During three decades of war, Afghanistan remained a black hole of health information. The few mortality studies looked at a small slice of the population and then extrapolated.

We were all surprised. That's what led to additional review and much more analysis.

The numbers were horrific. Life expectancy in 2004 was measured at just 42 years; 25 percent of children did not survive until the age of 5. For every 100,000 deliveries, a staggering 1,600 women died in childbirth, the second-worst rate in the world.

Enter last year's $5 million Afghanistan Mortality Survey, which was funded by the U.S. Agency for International Development with a contribution from the U.N. Children's Fund. Officials say the new survey provides the most accurate snapshot ever of health in Afghanistan - and it delivered shockingly good news.

Afghan surveyors in all 34 provinces brought back data suggesting that life expectancy at birth is now 62 years. Child mortality under age 5 dropped to 10 percent. Of 100,000 live births, the maternal mortality number was down to 327.

"We were all surprised," says Susan Brock, health adviser with USAID in Kabul. "That's what led to additional review and much more analysis."

Brock says it was such an improvement compared with previous surveys that USAID delayed the release to crunch the numbers again. Last November, after months of re-examining results and meetings of technical experts in Dubai and in Washington, the agency confirmed the findings and released the survey with great fanfare.

But believing the new numbers are accurate probably means accepting that the old numbers were way off, which makes it impossible to say exactly how much health has really improved. It's unlikely that both the old life expectancy of 42 years and the new estimate of 62 years are correct.
'Huge Question Marks'
Some experts who worked on the survey still think it shows too much of a leap forward to be credible. Dr. Kenneth Hill, a Harvard University demographer and technical adviser on the survey, says there are too many anomalies.

"If the results had come out closer to expectations, they would have been hugely valuable, I think," Hill says. "But because there are still huge question marks hanging over the estimates, I'm not sure there is an enormous value in the data."

The survey divided Afghanistan into three regions: north, center and south. In many findings, the southern zone is excluded, because security made it impossible to conduct polling. Cultural taboos about discussing female family members meant that the birthrate of female children was underreported, and that's also likely true of infant mortality.

The survey clearly and honestly explains these facts, and USAID says that statisticians accounted for many such factors. But Hill says he suspects the raw data is off.

"Conditions for data collection are desperately difficult," he says. "Knocking on someone's door and asking them details about their children and their household is not something most people would want to do."

Three of the six experts on the survey's technical advisory group told NPR they still have doubts, even after the extra analysis. That includes Julia Hussein, of Aberdeen University.

"You've got to match what you know in terms of evidence with what you see with your eyes," says Hussein, who has worked on maternal mortality in Afghanistan since the 1990s.

"My instinctive reaction to figures reported in the survey - I just find them unbelievable, knowing what sort of care is available in Afghanistan," she says.

You've got to match what you know in terms of evidence with what you see with your eyes. My instinctive reaction to figures reported in the survey, I just find them unbelievable, knowing what sort of care is available in Afghanistan.

But defenders of the study say people can't believe the numbers because they've become accustomed to thinking of Afghanistan as hopeless.

Dr. Mohammad Rasooly, with the Afghan Ministry of Public Health, was the lead technician from the Afghan side of the survey. He says health care in his country is improving dramatically, and in many different ways.

"If we consider only the example of midwives, 10 years back we had only 400 midwives at the national level. So, today we have more than 3,000. This is very important for maternal care," Rasooly says.

Now, new paved roads mean that a journey to one of the thousands of newly built clinics takes hours instead of days in rural areas, says Rasooly. Widespread mobile phones have helped save the lives of people who in the past had no way to call for help. And there is little doubt that women have much more access to health care.

Maternal mortality is notoriously hard to measure, and the new figure of 327 maternal deaths per 100,000 births has a margin of error that could make it much higher. It could be nearer 500, says Rasooly, but it's certainly not 1,600, which is progress.
Need For Aid Still Acute
It's not about knowing the exact number, says Ken Yamashita, USAID mission director in Afghanistan.

"We're quite confident of the numbers. In the end, it's a survey, so any survey has an error margin," he says.

Yamashita says the new mortality survey is the best ever done in Afghanistan.

"What it represents is a more representative survey on the one hand, and two, a very real improvement in health," he says.

The only way to know will be to conduct more surveys a few years down the road, at the same comprehensive standard, says Yamashita. He adds that even the new, more encouraging numbers show that Afghanistan is still desperately in need of international aid to help improve the health of its people.

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Gains In Afghan Health: Too Good To Be True?

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A U.S.-sponsored mortality survey released last year announced huge improvements in health across Afghanistan. But the gains are so great that experts are still arguing about whether it's correct. During three decades of war, Afghanistan remained a black hole of health information. The few mortality studies looked at a small slice of the population and then extrapolated.

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To what extent has the USA been successful in Afghanistan?

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To what extent has the USA been successful in Afghanistan?

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An additional example you may wish to add to your notes to showcase the progress that Afghanistan made following US intervention. Think about the different types of data used to portray this improvement and contrast it with what you learnt in the last section about women's rights in Afghanistan.

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Why shut down such a successful program? The short answer is that SIGAR's is a peculiar concept of caution.

Strikingly, the auditors' report calling for the funding freeze for the health program doesn't claim any evidence of serious fraud or waste. Instead, it raises hypothetical concerns about the Afghan government's ability to manage aid money well, including evidence that some salaries were paid in cash, as well as the absence of double entry bookkeeping.

While the U.S. military can produce receipts for bombs and bullets bought in America, the Afghan government struggles to do the same for vaccines dispensed in remote rural clinics. Thus, from a government auditor's perspective, it is riskier to give Afghan citizens health care than to shoot their insurgents.

Sopko had already appealed to Congress to reconsider future aid to the Afghan government. Over the summer, the SIGAR public affairs office launched an accompanying media blitz, complete with a New York Times editorial expressing grave concern over "lapses in accountability," and a Twitter account tweeting mundane ways in which U.S. agencies are failing: " State Dept. never finalized draft 2010 U.S. anti-corruption strategy for #Afghanistan," or " USAID could not provide documentation showing methodology used to calculate $236M program cost estimate." This outreach culminated with a publicity stunt demanding that State Department, Pentagon, and USAID officials engage in public self-criticism by nominating a top 10 list of their own worst aid projects.

Unsurprisingly, Sopko's anti-government spending campaign caught the attention of Tea Party members in Congress, who took up his talking points that giving money to Afghanistan was simply too risky. Notably, the concept of risk used here is completely unrelated to the 20% risk of death before age five faced by Afghan children as of 2004; a risk which has declined by half with the help of American aid.

***

Since 2001, USAID has been called on to assist U.S. military efforts in Iraq, Afghanistan and beyond, as the softer side of a counter-insurgency strategy. And aid has shared the blame for the failure of that strategy. "President Obama's strategy depended upon the civilian experts at USAID making smart decisions to help the Afghans," writes the Washington Post's Rajiv Chandrasekaran in his book on the Obama administration's surge in Afghanistan. "But the agency kept making mistakes ... The result was a gross failure to capitalize on security improvements, paid for by the lives and limbs of American troops."

Aid will never be a substitute for a military strategy. Aid is not a counter-terrorism policy. But the lesson of USAID in Afghanistan is not that help is futile; on the contrary. When America gives aid for the sake of saving lives rather than winning hearts and minds, it can be incredibly effective, even in the inauspicious conditions of rural Afghanistan.

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Here's the Best Thing the U.S. Has Done in Afghanistan

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Why shut down such a successful program? The short answer is that SIGAR's is a peculiar concept of caution. Strikingly, the auditors' report calling for the funding freeze for the health program doesn't claim any evidence of serious fraud or waste.

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A 26 minute documentary looking at the UK's arms deals with Saudi Arabia and the impact this is having on the war in Yemen

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Channel 4's award-winning investigative current affairs programme

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An insight into the Tutsi President who has reduced levels of poverty in Rwanda, but what of the human rights for the people in Rwanda?

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Rwanda's eternal president, Paul Kagame | The Economist

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Australia's human rights record has serious shortcomings.

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Australia's human rights record has serious shortcomings.

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An article looking at the shortcomings of Australia's human rights record when it was elected on to the UN Human Rights Council

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Australia's human rights record attacked in global report for 'serious shortcomings'

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Human Rights Watch criticises Indigenous incarceration rate, counter-terrorism laws and detention centre abuse

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As women's roles expand in Bolivian politics so do attacks.

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As women's roles expand in Bolivian politics so do attacks.

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How violence against women politicians has increased since they have played an increasing role in the politics of Bolivia

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ACHOCALLA, Bolivia (AP) - Few countries in the world have advanced so quickly toward gender parity in politics as has Bolivia, where women now hold almost half the seats in congress and laws mandate gender equality at lower levels too.

But some male Bolivian politicians have resisted the change, and women's rights activists report a sharp increase in violence against female politicians as their numbers rise.

Mary de la Cruz, a city councilwoman in a town on the outskirts of La Paz, said the town's mayor accosted her as she walked with colleagues through a plaza in Achocalla and punched her in the face, knocking her to the ground. She said he was apparently angry she had complained of irregularities in public works contracts.

De la Cruz filed a complaint, but so far authorities have taken no action against Mayor Damaso Ninaja, who has denied punching the councilwoman, saying she merely fell.

"It hasn't been easy for me to get where I am," said de la Cruz, who complained the mayor also had been spreading false rumors about her sex life. "And the man thinks that we are inferior creatures, that a punch isn't anything, that's its normal."

Bolivia began addressing gender imbalance in politics in 1997 with a law that at least 30 percent of candidates for many races be women. The Andean nation subsequently refined the laws to guarantee parity.

A decade ago, women held only 4 percent of posts in municipal assemblies. By 2015, they held 50 percent - a group that included De la Cruz, 38.

But women's rising profile "has also led to problems related to discrimination, manipulation and violence," a report by UN Women said.

Prosecutors say they have received 36 complaints of harassment and political violence against women so far this year. But electoral officials say they've received 60 such complaints - six times the number last year. And the Councilwomen's Association of Bolivia says it has registered 90 complaints.

Some women say they wound up dropping their complaints when a male-dominated legal system showed little interest. On the other hand, some courts have shown remarkable zeal in prosecuting women.

Monica Paye, was arrested and suspended from her position as councilwoman in the La Paz-area municipality of Callapa in May when officials accused her of losing two city-owned laptop computers, even though she offered to replace them. Paye, 34, who has remained under house arrest, had feuded with the mayor over public works contrasts in the town.

Awareness of violence against female politicians in Bolivia was raised by the 2012 killing of Ancoirames town councilwoman Juana Quispe, whose body was found with signs of violence on the banks of a river in La Paz.

Quispe's family accused then-Mayor Felix Huanca and three councilmen, whom they accused of persecuting Quispe for nearly two years because of her allegations of corruption. Relatives said Quispe had been threatened in efforts to force her from her job and at one time was beaten and dragged through a town square.

Quispe's death led to passage of a law against harassment and violence against women in public office, a law that has been held up as a model for other nations, said Carolina Taborga, UN Women representative in Bolivia. Perpetrators can be punished with up to five years in prison.

But Quispe's killing remains unsolved even as attacks on female politicians have increased.

"The law is very nice, but it's not working," said De la Cruz, who is also the mother of three children and a potato and lettuce farmer. "We're still suffering harassment and violence."

Paye said the pressure is especially strong against women in the countryside. She said pressures include false allegations of infidelity and withholding of salaries, as well as physical violence.

In some elections, candidates are required to have a running mate or alternate of the opposite sex. If a woman wins, sometimes her male alternate will seek to oust her to take power.

Sometimes women come under attack even from a male politician's family or friends.

Escoma town Councilwoman Marcela Mamani Huanca had accused the mayor of corruption shortly before he died in a car crash. His family blamed her for the death.

"Right after the mayor's wake, his sister and brother dragged me by the hair in the town square in front of my children," said Huanca, a 35-year-old butcher.

Gender-based political violence is seen throughout Latin America, particularly in Mexico, where 19 female candidates were killed and 118 were attacked ahead of the July elections. Brazilians were shocked at this year's murder of Rio de Janeiro councilwoman Marielle Franco, who was known for outspokenness against police violence. And in Peru, electoral authorities estimate that four of every 10 female candidates are victims of political harassment and if elected, two out every five women suffer political violence.

"Men think that women take on political positions to take away their jobs," said UN Women's Taborga. "This only expresses the male-chauvinistic and patriarchal mentality that persists in the organizations that that these men represent."

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As women's roles expand in Bolivian politics, so do attacks

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ACHOCALLA, Bolivia (AP) - Few countries in the world have advanced so quickly toward gender parity in politics as has Bolivia, where women now hold almost half the seats in congress and laws mandate gender equality at lower levels too.

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Why Afghanistan is still the worst place in the world to be a woman.

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Why Afghanistan is still the worst place in the world to be a woman.

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Time magazine article, with some really useful facts that can be added to your own knowledge about gender inequality in Afghanistan.

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Why Afghanistan Is Still the Worst Place in the World to Be a Woman

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"No one can save us but ourselves." Meet the women fighting for justice in the brutal war against Afghanistan's women.

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What is the United Nations Development Programme doing to help women in Afghanistan?

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What is the United Nations Development Programme doing to help women in Afghanistan?

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Information about the EGEMA programme that has seen 22 students complete Masters studies in gender equality and women's rights.

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Gulsom, 24, originally from Ghor province. Before joining this women's cooperative, she used to weave carpets to earn money but this is more profitable. Her husband's income is not enough, so the money Gulsom earns is vital to support their children. UNDP provided this women's cooperative in Mazar-e-Sharif with equipment, training and help to access new markets. Now the women are using their savings to buy land and build a new production facility that will hugely increase output. Photo: © UNDP / S. Omer Sadaat

Background
This Project is a collaborative effort between the Afghan Government and UNDP Afghanistan. Its main purpose is to strengthen the Ministry of Women Affairs so that it can implement, monitor and report on national and international commitments that affect women. This project will build upon the best practices and lessons learned from the previous UNDP gender projects (GEP I &II), which implemented effective initiatives and helped MOWA become a most effective and sustainable government entity.

EGEMA project is in line with National Action Plan for Women of Afghanistan (NAPWA) and operates under the following three pillars: 1) Institutional capacity strengthening of MoWA, which aims to turn the ministry into an efficient body to coordinate and oversee national and international commitments impacting women; II) Women's livelihoods strengthening, to enable improved access to sustainable incomes and livelihoods strategies for women; and III) Gender transformative approaches, to support behavioral and socio-cultural changes at the grassroots levels.

Response
Enhancing Gender Equality and Mainstreaming in Afghanistan (EGEMA) project provides technical assistance to the Ministry of Women Affairs (MoWA) to build its capacity and advance gender mainstreaming in government policy and planning process, coordinate and monitor implementation of National Action plan of Women, and take stronger role in women economic empowerment, behavioral socio-cultural changes toward gender equality, as well as creating a cadre of nationally educated gender experts that are ready to be employed in public and private sectors.

What we have accomplished so far?

In cooperation and partnership with UN Women and the Administrative Office of the President, Gender Responsive Budgeting Pilot Project has started in twelve ministries of Afghanistan.

Policy advisory support provided to key sector ministries to incorporate gender equality elements in their local governance policies, strategic plans and legislation.

Within our, Women's Economic Empowerment component, whole supply chain models for women's entrepreneurship together with cost-benefit and return on investment analysis tested and piloted. Unique business model developed in Kabul, namely Production, Demonstration and Training Center. These interventions allowed for 450 women from rural areas are being employed in Herat, Daikundi and Kabul provinces.

In partnership with Kabul University, twenty-two students (15 women, 7 men) were able to complete their Master's programme in gender and women's and graduate in October, 2017. New cohorts of students enrolled in 2018. This programme's objective is to create a pool of national gender experts.

Annually, around 150 religious leaders (mullahs) are trained on women's rights and gender equality. For the purpose of raising awareness and training, UNDP and the Ministry of Hajj and Religious Affairs have published together a book "Women's Rights in Islam" which is currently available in Dari (contact project staff to obtain a copy). The mullahs have been raising awareness among the public at their Friday sermons.

As part of the Youth-Mullah Volunteers Caravans initiative, 20 young leaders were mobilized in 2017 and have undergone extensive capacity building, leadership, gender equality and volunteerism training in Kabul city. These team leaders facilitated and conducted cascade trainings in their provinces (Balkh and Herat) to the peers thus enlarging the network to 49 active members as of end of 2017. More than 16,000 community members in Herat and Balkh provinces were reached by the network of volunteer advocates through dedicated awareness raising and behaviour changing campaigns on gender equality and women's rights as a key message.

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Enhancing Gender Equality and Mainstreaming in Afghanistan (EGEMA)

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This Project is a collaborative effort between the Afghan Government and UNDP Afghanistan. Its main purpose is to strengthen the Ministry of Women Affairs so that it can implement, monitor and report on national and international commitments that affect women.

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Women's rights and gender equality in Afghanistan

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Women's rights and gender equality in Afghanistan

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Below is the link to The Guardian's website with a range of different articles for you to add to your own knowledge to show some progress for women but also to contrast it with evidence that shows very little progress.

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Women's rights and gender equality + Afghanistan

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Will Singapore continue to put economic development before human rights?

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Will Singapore continue to put economic development before human rights?

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"Seldom has the death of a great Asian leader commanded as much appreciation in the West as the passing of Lee Kuan Yew," said Jerome Cohen, a human rights expert at New York University.

Beneath this, however, is a different reality; centralised control and limited freedoms, stated as necessary for economic growth.

That made some sense before, but today, in a more prosperous Singapore, the recent shutting down of independent media sites and the arrest of a teenager blogger over a YouTube video provide just two examples of the way in which Singaporean authorities aim to maintain forced harmony in the face of increasing social pressures from rising living costs and migration into the tiny island-nation.

"The dark side to Lee's legacy was always how basic human rights were sacrificed on the grounds of economic development," said Olof Blomqvist, Asia-Pacific spokesperson for Amnesty International.

"We had hoped that Singapore's next generation of leaders would usher in an era marked by respect for human rights, but unfortunately, we're seeing the opposite."

For 35 years, Lee was prime minister and faced almost no opposition, by design. As he once stated, "autocratic measures are needed for political stability, which together with rule-of-law, are essential for economic progress."

This meant curtailing press freedom, overactive use of the death penalty, and a judicial system that supported the People's Action Party (PAP, Lee's party) power.

Because the economy grew, citizens were mostly placid - but those who spoke out were the ones who suffered under a leadership with little tolerance for open debate and dissent.

"An impressive body of scholarship is already emerging concerning the achievements and shortcomings of Lee's distinctive and successful effort to coat Singapore's economic and social progress with the veneer of legitimacy that skillful manipulation of the 'rule of law' can confer upon an authoritarian and often arbitrary government," said Cohen.

Still, in many ways, it worked. Singapore's per-capital GDP has eclipsed numerous democratic countries, including the United States and its former colonial overlord, the United Kingdom.
Backlash
But not everything is rosy.

Living costs are rising faster than salaries. In fact, according to the Economist, in 2001 Singapore was only the 97th most expensive city in the world. Today, it ranks as number three, above New York, Paris, and Zurich.

Moreover, growing numbers of migrant workers are increasing pressures. According to the World Bank, from 2000 to 2010, Singapore's population grew by over one million, from 4.02 to 5.31 million, eclipsing growth from the previous decade.

"Newcomers - particularly Mainland Chinese - are commonly seen as uncouth and prone to objectionable behaviors," said Weiqiang Lin in a public statement for the Migration Policy Institute.

"Similarly, South Asian construction workers and Filipino domestic workers have also been singled out as targets of public backlash."

Immigration in particular was what led the PAP, to lose its iron grip on Parliament during the 2011, when it only won 60 per cent of votes - an unprecedented low point in its 57 years of continuous, uninterrupted rule.

According to Au Waipang, a Singaporean blogger who has faced government reprisals in the past, the recent moves to restrict free speech are tied to the PAP feeling insecure about its ability to hold power.

"The PAP brand is really quite toxic. So they resort to tilting the field, to shutting down opposing voices, and resurrecting the politics of fear," said Au.

This has led to the recent shutdown of independent media site The Real Singapore for violating the broad restrictions put in place by the Media Development Authority's licensing system last year, pointing to an ever more shrinking media space for criticism of the ruling authorities.

"Singapore's expansion of restrictions to the online space, as a platform increasingly used by citizens to get news and other information and participate in political discussions, is disturbing," said Au.

Now, this is extending to citizens too.

Singapore made headlines when Amos Yee, a 16-year-old Singaporean who posted a video to YouTube criticizing the recently deceased Lee last month, was arrested and tried as an adult for numerous charges.

"It is a travesty that a teenager could face jail time simply for posting a video on YouTube where he dares to criticize the former leader," said Blomqvist, adding that his conviction highlights the wide-ranging restrictions on freedom of expression in Singapore.

Elections will take place before the end of 2016, and Singaporeans will decide if PAP's current leader, Lee Kuan Yew's son, Lee Hsien Loong, deserves another term as prime minister.

The limited choices voters have, along with the growing restricted media environment, may foretell the continuation of Lee's legacy.

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Will Singapore continue to put economic growth before human rights?

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On the surface, it is a model country. With strong, consistent economic growth, a high standard of living, and a business environment free of the corruption that plagues its neighbours, Singapore is often cited as the right way to grow a country fast while avoiding ethnic and religious tensions, with credit given mostly to its longest-serving Prime Minister, Lee Kuan Yew, who passed away last month.

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What is happening to worldwide democracy?
How are individual continents changing in terms of democracy?

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Political rights and civil liberties around the world deteriorated to their lowest point in more than a decade in 2017, extending a period characterized by emboldened autocrats, beleaguered democracies, and the United States' withdrawal from its leadership role in the global struggle for human freedom.

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British troops breach Geneva Conventions in Iraq

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British troops breach Geneva Conventions in Iraq

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An article looking at how British troops breached the Geneva Conventions and what happened as a result.

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British troops breached Geneva conventions in Iraq, high court rules

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Court says soldiers subjected civilians to cruel and inhuman treatment, in cases that may determine handling of further claims

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Information about what constitutes war crimes, Serbian prosecutions, spotting war crimes, and the international court.

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The trial of former Bosnian Serb leader Radovan Karadzic at The Hague throws a renewed spotlight on the prosecution of war crimes.
But what exactly are war crimes? What body of laws do they refer to and who has the right to try a suspect for such crimes?

The concept of war crimes is a recent one. Before World War II, it was generally accepted that the horrors of war were in the nature of war.

But during World War II the murder of several million people - mainly Jews - by Nazi Germany, and the mistreatment of both civilians and prisoners of war by the Japanese, prompted the Allied powers to prosecute the people they believed to be the perpetrators of these crimes.

The Nuremberg trials in 1945 and 1946 led to 12 Nazi leaders being executed.

A similar process started in Tokyo in 1948. Seven Japanese commanders were hanged, though the Allies decided not to put Emperor Hirohito in the dock.

These trials were essentially the precedents for the cases that the modern-day tribunal in The Hague hears.

In addition, individual governments, feeling that justice has not been done, have acted on their own initiative.

This happened most famously in 1960, when Adolf Eichmann, a high-profile Nazi closely involved in the organisation of the concentration camps and the policies of the Holocaust, was tracked down in Argentina by Israeli agents.

He was kidnapped and taken to Israel where he was put on trial and subsequently hanged.

A more recent example was the 1987 trial of Klaus Barbie - a leading Nazi during the German occupation of France. Barbie was sentenced to life imprisonment.
Body of laws
At the heart of the concept of war crimes is the idea that an individual can be held responsible for the actions of a country or that nation's soldiers.

Genocide, crimes against humanity, mistreatment of civilians or combatants during war can all fall under the category of war crimes. Genocide is the most severe of these crimes.

The body of laws that define a war crime are the Geneva Conventions, a broader and older area of laws referred to as the Laws and Customs of War, and, in the case of the former Yugoslavia, the statutes of the International Criminal Tribunal in The Hague (ICTY).

Article 147 of the Fourth Geneva Convention defines war crimes as: "Wilful killing, torture or inhuman treatment, including... wilfully causing great suffering or serious injury to body or health, unlawful deportation or transfer or unlawful confinement of a protected person, compelling a protected person to serve in the forces of a hostile power, or wilfully depriving a protected person of the rights of fair and regular trial, ...taking of hostages and extensive destruction and appropriation of property, not justified by military necessity and carried out unlawfully and wantonly."

This, international lawyers say, is the basic definition of war crimes.

The statutes of The Hague tribunal say the court has the right to try suspects alleged to have violated the laws or customs of war in the former Yugoslavia since 1992. Examples of such violations are given in article 3:

Wanton destruction of cities, towns or villages, or devastation not justified by military necessity

Attack, or bombardment, by whatever means, of undefended towns, villages, dwellings, or buildings

Seizure of, destruction or wilful damage done to institutions dedicated to religion, charity and education, the arts and sciences, historic monuments and works of art and science

Plunder of public or private property.

The tribunal defines crime against humanity as crimes committed in armed conflict but directed against a civilian population. Again a list of examples is given in article 5:

Murder

Extermination

Enslavement

Deportation

Imprisonment

Torture

Rape

Persecutions on political, racial and religious grounds.

Genocide is defined by the tribunal as "acts committed with intent to destroy, in whole or in part, a national, ethnical, racial or religious group".

But the law on war crimes is continually evolving.

In February 2001, the tribunal in The Hague delivered a ruling that made mass systematic rape and sexual enslavement in a time of war a crime against humanity.

Mass rape, or rape used as a tool of war, was then elevated from being a violation of the customs of war to one of the most heinous war crimes of all - second only to genocide.
Spotting a war crime
It is not always easy to spot a war crime.

The displacement of civilians from their homes by an enemy army is not necessarily a war crime.

It can be argued that the displacement is being carried out for the protection of the civilians.

It only becomes a war crime if the expulsions can be proven to be part of campaign of ethnic cleansing or designed as a mass punishment of civilians.

Equally, is it a war crime for the air force of one country to bomb an enemy's television station because of the propaganda in the broadcasts?

Under the Geneva Conventions, this is not a war crime. Just about all aspects of a state's infrastructure - roads, bridges, power stations, factories - become legitimate targets if they might be put to military use.

Such attacks only become war crimes if the extent of collateral damage to civilians and civilian interests resulting from the attack would be excessive compared to the military advantage gained from the attack.
International court
International human rights groups have long called for a uniform and global legal system for dealing with war crimes and crimes against humanity.

Apart from the International Criminal Tribunal for the Former Yugoslavia, established in May 1993, an international tribunal was established in Arusha, Tanzania, for cases resulting from the atrocities carried out in Rwanda in 1994.

Another is trying former Liberian President Charles Taylor over war crimes committed during the civil war in neighbouring Sierra Leone.

Although these represent significant further steps in bringing those accused of war crimes to justice, they are, like Nuremberg and Tokyo, committed to dealing with war crimes in specific conflicts.

In July 2008, Surinam became the 107th country to join the International Criminal Court, set up in 2002 as a permanent tribunal to prosecute individuals for crimes against humanity.

The United States has refused to sign the treaty, arguing the court could be used to pursue politically motivated prosecutions. Other major powers including Russia, China and India have also refused.

The question of whether international courts of this kind are political - as defendants like Slobodan Milosevic argued - hangs over all international legal institutions.

In a sense it is true that the tribunals are political since the international political will to establish and fund them has to exist before they can get to work.

Critics of international courts often argue that international justice can only be truly legitimate when all war crimes, committed by any county, come under the jurisdiction of a single international court.

The BBC is not responsible for the content of external internet sites

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The trial of former Bosnian Serb leader Radovan Karadzic at The Hague throws a renewed spotlight on the prosecution of war crimes. But what exactly are war crimes? What body of laws do they refer to and who has the right to try a suspect for such crimes?

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Information about Radovan Karadzic's trial at the Hague as a result of Yugoslav wars.

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Editor's note: Radovan Karadzic was one of the dominant figures of the Bosnian war, serving as president of the "Serb Republic" in Bosnia from 1992 to 1995. The International Criminal Tribunal in The Hague on Thursday found him guilty of multiple crimes, including the slaughter of about 8,000 Muslim men and boys in the town of Srebrenica. NPR's Tom Gjelten covered the war in Bosnia, and Karadzic, for years. Given all that has happened in the last 20 years, many people will not recall the war in Bosnia. Remind us what happened.
Bosnia was one of the six republics that constituted Yugoslavia, an ethnically mixed country in southeast Europe. The Yugoslav president, Slobodan Milosevic, a Serb nationalist, helped stoke ethnic tensions in the country that led to its breakup.

Serb nationalists in Bosnia, led by Karadzic, created a separate "Serb Republic" in Bosnia and attempted to "cleanse" the territory under their control of Muslims and other non-Serbs. The subsequent war in Bosnia resulted in the death of about 100,000 people, mostly civilians. About two-thirds of the victims were Bosnian Muslims.
You covered the war for NPR. What were your experiences there?
Nothing I've done in more than 30 years as an NPR correspondent had a greater impact on me personally. I was in Sarajevo for weeks on end when it was besieged and under near constant shelling. More than 11,000 people died there.

At the time, it was the most dangerous place on the planet. I witnessed some of the infamous "ethnic cleansing" operations in Serb-held territory, when non-Serbs were rounded up and held under horrific conditions in detention camps or killed outright.

I interviewed some survivors from Srebrenica, mostly women, who shared stories of what they had been through. For many in the West, the mass killings and concentration camps were reminiscent of what happened under the Nazis and made a mockery of the "never again" pledge that followed World War II.
The U.N. war crimes tribunal was established in 1993. Why have these prosecutions taken so long?
The first conviction came only in 2000. Karadzic was arrested in 2008, so his prosecution and trial took eight years and concluded more than 20 years after the crimes for which he was held responsible. His is the first high-profile conviction.

Milosevic was arrested in 2001 but died in custody before his trial was complete. Ratko Mladic, the commander of the Bosnian Serb Army, was arrested in 2011, and his trial is continuing. By contrast, the war crimes trials at Nuremberg, after World War II, were completed in a matter of months.

In addition to the Srebrenica killings, what else was Karadzic charged with?

He was also tried on genocide charges with regard to killings in seven other Bosnian towns, but the court found insufficient evidence in those cases to convict him.

He was, however, found guilty of nine other counts, including five counts of "crimes against humanity" for such things as murder, deportation and forced population transfers, and four other counts of violating the customary laws of war as set down in the Geneva Conventions.

Of special importance in those cases was the Sarajevo shelling and the taking of United Nations peacekeepers as hostages in an effort to thwart airstrikes against his forces. He has already indicated he intends to appeal his convictions.
What lessons can we take from this case?
First and foremost is that victims of war crimes have to be patient in their expectation that justice will be served. The process is maddeningly slow. Leaders of the opposition forces in Syria say they hope the Karadzic trial will lead to similar prosecutions and convictions of Syrian war criminals, but they are likely to be in for a long wait.
Did you ever meet Karadzic during your time in Bosnia?
Yes I did, on more than one occasion. He was a garrulous but strange figure, oblivious to the human suffering for which his forces were responsible, especially in Sarajevo. It was his hometown, and it seemed like everyone there had some recollection of him. He had a thick head of hair which he brushed back in these big swoops.

Before the war, he worked as a psychiatrist, and at one time he was hired by the Sarajevo soccer club to instill a "winning attitude" in the team. He also considered himself a poet and often told people he was destined to be one of the two or three greatest poets writing in the Serbian language. This was an example of his narcissism, rather than his ability as a poet.

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Two Decades After The War, A Genocide Conviction For Radovan Karadzic

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Editor's note: Radovan Karadzic was one of the dominant figures of the Bosnian war, serving as president of the "Serb Republic" in Bosnia from 1992 to 1995. The International Criminal Tribunal in The Hague on Thursday found him guilty of multiple crimes, including the slaughter of about 8,000 Muslim men and boys in the town of Srebrenica.

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An article to help you evaluate the success of the MDGs.

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Did the United Nation's millennium development goals (MDGs) make any difference? Perhaps no question is more important for assessing the results of global policy cooperation between 2000 and 2015.

But this is a difficult question to answer, because pathways of cause and effect are difficult to discern. In our study we examined which trajectories changed, for better or worse, and to what scale of human consequence. Here we highlight three key findings.

At least 21 million extra lives were saved due to accelerated progress

Our results show that the clearest victories during the MDG era were in matters of life and death. We calculate the number of lives saved beyond "business-as-usual" pre-MDG trends on child mortality, maternal mortality, HIV/Aids, and tuberculosis. We also look at malaria, which is predominantly a subset of child mortality. These indicators show evidence of major accelerations in rates of progress during the 2000s, with the exception of maternal mortality, which experienced more modest acceleration.

The upshot is that somewhere between 21-29 million more people are alive today than would have been the case if countries had continued their pre-MDG rates of progress. (The range depends mainly on whether we use child mortality trends from 1990-2000 or 1996-2001 as the pre-MDG reference period.)

As shown in the graph below, approximately two-thirds of the lives saved were in sub-Saharan Africa, around a fifth were in China and India, and the remainder were in the rest of the developing world. Between 8.8 to 17.3 million of the lives were saved due to faster progress on child mortality; 8.7 million due to expanded treatment for HIV/Aids, 3.1 million due to declines in TB deaths, and approximately half a million due to improvements in maternal mortality.

Embed link - Millions of lives saved by the millennium development goals - lower limit calculation

Some successes more impressive than others

One of the core tensions in assessing outcomes over the MDG period is to distinguish between the amount of progress achieved and changes in the rate of progress.

For example, the UN celebrated improved access to drinking water as an early MDG success. But were countries already on course to achieve this as of 2000? We conducted many tests for differences in mean rates of progress and found that trends varied considerably across issues and geographies. Positive changes were concentrated in sub-Saharan Africa and low-income countries (as classified by the World Bank in 2000).

The graph below shows our estimate of the number of lives improved, or not, due to changes in trends on a range of indicators. One positive result here is that as many as 471 million extra people have been lifted out of extreme poverty as of 2013 (the most recent year with available data), compared to 1990s trends. As many as 111 million more people also completed primary school, although official data don't allow us to break that number down by the same geographic groupings, so it's not included in the graph.

Meanwhile, for water and undernourishment, accelerations in the majority of developing countries were outweighed by slowdowns in the rate of progress in many populous countries, which generated negative overall numbers for our estimate of incremental lives improved. For sanitation, the aggregate figures are only modestly positive.

Embed links - Aggregated number of lives improved

Low-income countries accelerated more than middle-income countries

Our findings highlight a major difference in trends among low-income countries (LICs) versus middle-income countries (MICs).

The graph below illustrates this by plotting average (population-weighted) rates of progress for both LICs and MICs, when excluding India and China from the respective calculations. The vertical axis shows how much each group's annual rate of progress changed before and after 2000: a ratio of 1 indicates no change, a ratio of 2 indicates a doubling in the rate of progress, and so forth. The horizontal axis measures each group's relative amount of progress toward eliminating its respective problems from 1990 to 2015.

The LICs are all somewhat above and to the left of MICs in the chart, indicating more acceleration but smaller relative gains. Meanwhile MICs tended to see larger relative gains but less acceleration, since they were already achieving steady progress prior to 2000.

So what does this mean for the SDGs?

Our estimates draw from available data at the time of writing, so results may be updated as future data revisions are released. In the meantime, the findings dispel some common myths about the MDGs.

They show that, especially on matters of life and death, 2015 outcomes were not on track to happen anyhow. Some shifts were dramatic, and Africa was responsible for many of the greatest incremental gains, not simply China and India.

However, outcomes on basic needs were mixed. The diversity of trends prompts clear questions of why: What differences in public and private action led to such different results across geographies and issues?

Answering such questions is crucial if the world is going to have a shot at achieving the UN's ambitious sustainable development goals for 2030.
An earlier version of this blogpost was first published by Brookings. Join our community of development professionals and humanitarians. Follow @GuardianGDP on Twitter. Join the conversation with the hashtag #Dev2030.

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How successful were the millennium development goals?

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As the world embarks on new development goals, there is still confusion about the success of the MDGs. But our calculations show that at least 21 million lives were saved

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How does healthcare funding vary around the world?

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How does healthcare funding vary around the world?

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Visual and clear article looking at the different types of healthcare funding and pros and cons of them, with specific country examples for each.

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What is it?

Tax revenues are collected to fund health care.

How does it work in principle?

Tax-funded models typically seek to pool risk across large populations and make health services available on a universal basis.

Taxes vary according to:

how they are levied: direct taxes are levied on individuals, households and companies by the government (eg, Income Tax, Corporation Tax), whereas indirect taxes are applied on the manufacture or sale of goods and services (eg, Value Added Tax, import/export taxes)

who is raising them: taxes raised by central government may be used to finance national spending on health care; taxes raised by local government may be used for spending on health care in a specific region or local area

whether they are raised for general purposes or earmarked for a specific use - the latter is known as a hypothecated or earmarked tax (see box).

How is this model applied in practice?

Australia, Canada, New Zealand and the Nordic countries are some of the other countries that rely mainly on general taxation to fund health care. However, no country relies on general taxation alone; they may also have user charges or elements of private insurance. For example, in Canada, about 70 per cent of health spending is publicly funded though taxation, with the remaining 30 per cent largely accounted for by out-of-pocket spending (costs borne directly by patients) (14.6 per cent) and private health insurance (12.2 per cent) (Canadian Institute for Health Information 2016). 1

Methods of levying tax vary considerably between different countries, particularly whether they are raised by central or local government. In Sweden, for example, public funding for health care comes from both central and local taxation. In 2013, local taxes accounted for 68 per cent of county councils' total revenues, 18 per cent came from subsidies and national government grants financed by national income taxes and indirect taxes (Mossialos et al 2016).

The pros and cons of this model vary depending on the taxes used to raise funding, but some general implications are as follows.

Glossary

Regressive: A regressive tax on incomes is one in which the average rate of tax falls as income rises - ie, the percentage of your income taken in tax falls as you become richer

Progressive: A progressive tax on incomes is one in which the average rate of tax rises as income rises - ie, the percentage of your income taken in tax rises as you become richer

Private health insurance (PHI)

What is it?

Individuals (or employers on their behalf) take out health care insurance policies from private organisations.

How does it work in principle?

Policy-holders contribute on a regular basis. The level of contribution is based on their risk of requiring health care, which can be assessed in several ways:

individual risk, which may take into account age, family history and the existence of pre-existing medical conditions

community risk, for example, where contributions are estimated as an average across a geographically defined area and all members of the community pay the same premium

group risk, typically estimated across employees of a single firm or occasionally a single industry; again, all members of the group pay the same premium (Mossialos et al 2002).

Contributions are collected by private insurers. The benefits package may vary between insurers, enabling people to choose according to their means, needs and preferences.

How is this model applied in practice?

The use of private insurance varies greatly. Broadly speaking, there are five different ways in which private insurance can be used: as the dominant form of cover; as duplicate cover; as complementary cover; as supplementary cover; and as substitutive cover.

Dominant or primary cover

In the United States, PHI is the dominant form of health cover for most of the population. In some countries (eg, Switzerland) PHI is mandatory. However, as with tax-funded models and social health insurance, countries that use PHI as a dominant form also rely on other sources of funding (for example, see box on US).

Duplicate - or 'double' cover

In other countries (eg, in the UK, Portugal, Spain), PHI is largely taken out by individuals in higher income groups, to allow quicker access to services or increased choice of provider. This form of PHI does not exempt people from paying into the publicly funded health system. Arguments that the privately insured are 'paying twice' and are making less use of public services can lead to advocacy for tax relief for PHI (see box).

Complementary - or 'additional' cover

In some countries, PHI is used to complement government/social insurance schemes by covering the costs of publicly funded services that incur user charges. For example, in France complementary insurance is held by approximately 85 per cent of the population to cover the cost of statutory user charges.

Supplementary cover

This form of PHI provides coverage for health services that are excluded from government/social insurance schemes. In Canada, for example, private supplementary health insurance provides coverage for the cost of prescription drugs (only medication administered in hospital is covered by public funding), dental care, optical care and other goods and services not covered by the public system.

Substitutive - or 'alternative' cover

Finally, in some countries, people are permitted to opt out of government health coverage or statutory social insurance schemes and purchase PHI as an alternative. In Germany, for instance, people who earn over a certain amount can choose to purchase private health insurance instead of social health insurance. However, this type of opt-out needs to be carefully managed to ensure the statutory scheme remains equitable and financially viable.

Social health insurance (SHI)

What is it?

Typically, employees and employers pay contributions to cover a defined package of services (Wagstaff 2010). This system was introduced under Chancellor Bismarck in 19th century Germany.

How does it work in principle?

In classic social insurance models, members (normally employees) contribute a proportion of their salary, with the level of contribution related to income rather than risk of illness. Employee contributions are typically matched by employers. For example, in Germany, the basic flat social health insurance contribution rate in 2016 amounts to 14.6 per cent of an employee's gross income (with an annual upper limit of €52,200), shared equally between employer and employee. Those earning above €57,600 per year can opt out of the social health insurance system and purchase private insurance instead (Federal Ministry of Labour and Social Affairs 2016).

Contributions are often collected by independent bodies, usually known as insurers or 'sickness funds', which are responsible for paying providers of health and care services.

There may be a single fund or several funds covering different sectors of the population and these are usually publicly run. In some countries, privately run insurers can compete; where this happens, mechanisms may exist to pool risks and costs between funds. Members may or may not have a choice of which fund they join. The defined package of health benefits may also vary between funds, but there is usually a standard regulated basic package.

How is this model applied in practice?

The way that social health insurance schemes operate varies widely from one country to another.

In most countries, the statutory scheme does not raise sufficient funds and is subsidised by other means (see below). In France, for example, additional funds are raised via general taxation (income tax) and 'sin taxes' on alcohol and tobacco. France also requires co-payments at the point of access that are capped. Co-payments also apply in Germany - eg, for each day of an inpatient stay - and are capped at 2 per cent of household income, or less for certain groups that meet the criteria (Robertson et al 2014).

As social health insurance is often based on employment, countries operating this model have to find ways (including general taxation and other sources such as statutory pension funds) to provide cover for those not in employment. For example, the Japanese health insurance scheme has several options to ensure universal cover is provided: employees of large firms are required to sign up to SHI; employees at smaller firms are given cover through the Japan Health Insurance Association; those who are not covered by either of these are covered by a government scheme.

What is it?

User charging involves individuals paying for some or all of their medical care out of their own pocket.

How do user charges work in principle?

In their purest form, user charges rely on patients paying the cost of care. In most European and OECD countries, these charges make up only a small proportion of expenditure. However, user charges often form a large part of the way health care is financed in developing countries (Gottret et al 2006). In India, for example, more than 70 per cent of total health expenditure is accounted for by user fees (Mossialos et al 2016).

How are user charges applied in practice?

Health care costs can be catastrophically expensive for people with severe or long-term illness, so very few countries rely solely on user charges to cover health care costs, instead developing alternative financing models that allow risks and costs to be pooled across large groups of people.

However, most countries rely on user charges to some extent. An OECD survey of 29 member states in 2010 found that all had some form of co-payment or charge for pharmaceuticals and 20 had some form of payment for a GP visit and half had some form of charge for hospital treatment (Paris et al 2010). Some countries allow charges for non-clinical services that do not affect health outcomes. For example, the NHS in England allows hospitals to charge inpatients for use of bedside entertainment systems.

User charges also apply where individuals seek private care for services or treatments not covered by a national scheme or insurer, or where access may be limited (eg, paying privately for an operation to avoid having to wait).

In practice, many European countries use exemptions to ensure that individuals less able to pay are not discouraged (or prevented) from seeking care when they need it. Often these exemptions apply to people on lower incomes, children or older people, or people with long-term conditions or a disability. Introducing these exemptions makes the administration of schemes more complex, and will limit the money such charges can raise.

In Italy, out-of-pocket spending accounted for 18 per cent of total health spending in 2013 - comprising spending on services not covered by the public system and co-payments for some services, including pharmaceuticals, specialist visits and some diagnostic testing (Mossialos et al 2016). Various exemptions are in place: for pregnant women (for treatment related to pregnancy), prisoners, people with severe disability or long-term conditions, and those over the age of 65 and under the age of 6 who live in households with a gross income below a nationally defined threshold (Mossialos et al 2016).

In Norway - where co-payments are used for GP and specialist visits, physiotherapy visits, prescription drugs and some diagnostics - annual caps for out-of-pocket expenditure are set nationally. Above this, fees are waived, and exemptions are also in place. In New Zealand, co-payments are required for most GP services and some nursing services provided in GP clinics. The average co-payment for a GP consultation ranges from NZD15-45 (around £8-25), although this is capped at NZD17.50 (around £10) per visit for people living in low-income areas (Mossialos et al 2016).

A variant of having users pay for their own healthcare is Medical Savings Accounts. Usually mandatory, individuals (and in some cases, their employers) make regular savings into funds which they then use to pay for care when they or their family members need it. The most widely known example is Singapore, although even here it is only one of a number of payment systems. Other funding streams used to supplement it in Singapore include direct subsidies to hospitals, voluntary back-up insurance to cover high health care costs and a government-funded safety net for low-income people (McKee 2013).

Conclusion

No country (the UK included) relies on a single source of funding for health care. Countries typically use one of the three main funding models as the principal way of paying for health care alongside elements of the others. All countries make use of user charges to pay for a proportion of overall costs.

The precise combination of funding sources in use develops over time based on a country's context, history and social values. Whatever model is used, debates about its effectiveness and efficiency are inevitable.

However, there is no evidence that one funding model or particular mix of funding mechanisms is inherently superior to others. As the OECD concluded, 'There is no health care system that performs systematically better in delivering cost-effective health care' (OECD 2010). This, plus the high costs associated with any transition, means that developed countries rarely make major changes to their established primary way of paying for health care.

Regardless of how health care is funded, all countries face similar challenges - namely, how to meet rising demand for services and transform care in response to an ageing population and changing patterns of disease. This is leading to increased pressures on services and funding challenges in countries around the world.

For the sake of simplicity, we have limited this analysis to health care; however, it is important to note that most countries face similar challenges in funding social care. As we have argued elsewhere, any debate about how to fund the NHS in future must go hand in hand with discussion about how to pay for social care, with the aim of creating a single ringfenced budget for health and social care (Commission on the Future of Health and Social Care in England 2014a).

Our thanks to Loraine Hawkins (Health Systems, Finance and Governance Consultant​, and Visiting Fellow at The King's Fund) for her contribution to this report alongside the authors.

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Commission on the Future of Health and Social Care in England (2014a). A new settlement for health and social care: final report. London: The King's Fund. Available at: www.kingsfund.org.uk/publications/new-settlement-health-and-social-care (accessed on 3 March 2017).

Commission on the Future of Health and Social Care in England (2014b). A new settlement for health and social care: interim report. London: The King's Fund. Available at: www.kingsfund.org.uk/publications/new-settlement-health-and-social-care-interim (accessed on 28 February 2017).

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Tax revenues are collected to fund health care. Tax-funded models typically seek to pool risk across large populations and make health services available on a universal basis.

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Why is the USA falling behind in education despite spending the most?

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Why is the USA falling behind in education despite spending the most?

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Why is the USA falling behind? A look at how the US system is flawed, but also comparing to other countries: Canada, Finland, Germany, South Korea

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The US spends more on education than other countries. Why is it falling behind?

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Spending per student exceeds the OECD average but the likes of Finland and South Korea get better results. What can the US learn from them?

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How does US healthcare compare to other countries.

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How does US healthcare compare to other countries.

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A look at US healthcare spending and how it compares to France and Japan. Range of facts and specific evidence you can use in your exam answers.

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How much is good health care worth to you? $8,233 per year? That's how much the U.S. spends per person.

Worth it?

That figure is more than two-and-a-half times more than most developed nations in the world, including relatively rich European countries like France, Sweden and the United Kingdom. On a more global scale, it means U.S. health care costs now eat up 17.6 percent of GDP.

A sizable slice of Americans - including some top-ranking politicians - say the cost may be unfortunate but the U.S. has "the best health care in the world."

But let's consider what 17 cents of every U.S. dollar is purchasing. According to the most recent report from the Organization for Economic Co-operation and Development (OECD) - an international economic group comprised of 34 member nations - it's not as much as many Americans expect.

In the United States:

There are fewer physicians per person than in most other OECD countries. In 2010, for instance, the U.S. had 2.4 practicing physicians per 1,000 people - well below below the OECD average of 3.1.

The number of hospital beds in the U.S. was 2.6 per 1,000 population in 2009, lower than the OECD average of 3.4 beds.

Life expectancy at birth increased by almost nine years between 1960 and 2010, but that's less than the increase of over 15 years in Japan and over 11 years on average in OECD countries. The average American now lives 78.7 years in 2010, more than one year below the average of 79.8 years.

There's a bright side, to be sure. The U.S. leads the world in health care research and cancer treatment, for instance. The five-year survival rate for breast cancer is higher in the U.S. than in other OECD countries and survival from colorectal cancer is also among the best, according to the group.

This week on the PBS NewsHour broadcast, health correspondent Betty Ann Bowser will explore one hospital system's unusual approach to improving performance while reducing costs - one based on Toyota's assembly line model for manufacturing cars. The concept is pretty simple: If waste is rooted out of the "assembly line process," the result will be better cars (or health outcomes, in this case) and lowered costs. At Virginia Mason Medical Center in Seattle, top officials decided that hospital "waste" can look like anything from unnecessary tests to elaborate waiting rooms to poorly designed floor plans. Tune in for the full report.

In the meantime, for a more detailed update on where the U.S. stands apart from its global peers, we spoke to Mark Pearson, head of Division on Health Policy at OECD.
NewsHour: Let's start broadly. Where does the U.S. health care spending stand relative to other OECD countries?
Pearson: Whether measured relative to its population or its economy, the United States spends by far the most in the world on health care.

The U.S. spent $8,233 on health per person in 2010. Norway, the Netherlands and Switzerland are the next highest spenders, but in the same year, they all spent at least $3,000 less per person. The average spending on health care among the other 33 developed OECD countries was $3,268 per person.

The U.S. is a very rich country, but even so, it devotes far more of its economy - 17.6 percent of GDP in 2010 - to health than any other country. The Netherlands is the next highest, at 12 percent of GDP, and the average among OECD countries was almost half that of the U.S., at 9.5 percent of GDP.
NewsHour: What are Japan and France doing, for instance, to keep down their costs?
Pearson: France and Japan demonstrate that it is possible to have cost-containment at the same time as paying physicians using similar tools to those used in the U.S. There are three key things that stand out when you compare these countries to the U.S.:

They use a common fee schedule so that hospitals, doctors and health services are paid similar rates for most of the patients they see. In the U.S., how much a health care service gets paid depends on the kind of insurance a patient has. This means that health care services can choose patients who have an insurance policy that pays them more generously than other patients who have lower-paying insurers, such as Medicaid.

They are flexible in responding if they think certain costs are exceeding what they budgeted for. In Japan, if spending in a specific area seems to be growing faster than projected, they lower fees for that area. Similarly, in France an organization called CNMATS closely monitors spending across all kinds of services and if they see a particular area is growing faster than they expected (or deem it in the public interest), they can intervene by lowering the price for that service. These countries also supplement lowering fees with other tools. For example, they monitor how many generic drugs a physician is prescribing and can send someone from the insurance fund to visit physicians' offices to encourage them to use cheaper generic drugs where appropriate. In comparison, U.S. payment rates are much less flexible. They are often statutory and Medicare cannot change the rates without approval by Congress. This makes the system very inflexible for cost containment.

There are few methods for controlling rising costs in private insurance in the U.S. In running their business, private health insurers continually face a choice between asking health care providers to contain their costs or passing on higher costs to patients in higher premiums. Many of them find it hard to do the former.

NewsHour: Are there particular areas of care where the U.S. spends more? What are some successful models other countries are employing to keep costs down in those areas?
Pearson: Spending on almost every area of health care is higher in the United States than in other countries. For example, nearly $900 per person per year goes on administrative costs. This is far higher than in, say, France, which spends $300 per person, but which also has a system in which health care services are reimbursed in a similar way to the U.S.

In part, higher costs are also because the U.S. has been slow to embrace the advantages of information and communications technology in improving the administration of its system and in cutting down on waste. In Sweden, for example, all drug prescribing is done electronically - a message is sent directly from the doctor's office to the pharmacy. Not only does this cut down on medical errors, it is also thought to save 1-2 hours of work by the pharmacists per day.
NewsHour: For hospital care in particular, how much more does the U.S. spend? Do we know why it's more? What might the U.S. learn from other OECD nations in this area?
Pearson: A large amount of higher overall hospital spending in the U.S. can be explained by services costing more in U.S. hospitals rather than because U.S. hospitals are delivering more services. When we look across a broad range of hospital services (both medical and surgical), the average price in the United States is 85 percent higher than the average in other OECD countries. To put this in perspective, a hospital stay in the United States costs over $18,000 on average. The countries that come closest to spending as much - Canada, the Netherlands, Japan - spend between $4,000 and $6,000 less per stay. Across OECD countries, the average cost of a hospital stay is about one-third that of the U.S., at $6,200.

As we have previously said, many OECD countries use strong regulation to set prices that hospitals can charge for different services, and some of them even set budgets for how much hospitals can spend. The quality of care delivered in hospitals in these countries are comparable to that in the U.S., and universities are still able to attract the best students to medicine.

If strict price control is not a path that the U.S. wishes to follow, an interesting example that the U.S. could learn from is Switzerland, where the national government provides a ranking of hospital services from most expensive to least expensive. Groups of insurers and hospitals across different regions then use the national government's ranking to negotiate what prices they ought to pay across the board.

Such an approach still leaves room for differences in prices across regions and states, but it could help smooth out some of the huge differences you see in prices paid for the same services delivered in the same hospital, depending on whether a patient is on Medicare, Medicaid or their own health insurer.
NewsHour: What about specific procedures? Why is the cost of a hip replacement in the U.S. double what it costs in Germany, for instance?
Pearson: The table below gives some examples of the prices of some common procedures in the United States compared with some of the countries with the best quality health systems in the world. It shows that:

A coronary bypasses costs between nearly 50 percent more than in Canada, Australia and France, and are double the price in Germany.

Hip and knee replacements are generally cheaper in other countries than the U.S.

PTCAs (coronary angioplasty) are much more expensive in the United States than elsewhere.

It is difficult to untangle precisely why prices are higher in the U.S., but two things are apparent: U.S. physicians get higher incomes than in other countries and the U.S. uses more expensive diagnostic procedures. More generally, with so many different kinds of insurance, no one organization has a strong incentive to cut out wasteful practices and ensure that all Americans get value for the very high levels of expenditure incurred when they are sick.
NewsHour: The U.S. system is known for over-testing and over-treating, everything from CT scans and MRIs, knee replacements to coronary bypasses. How severe is the over-testing and why is it occurring? Are there mechanisms in place to prevent this in other OECD countries?
Our data suggests that the U.S. does do more tests than other OECD countries. The U.S. did 100 MRI tests and 265 CT tests for every 1000 people in 2010 - more than twice the average in other OECD countries. It does more tonsillectomies and more knee replacements than any other OECD country. It also has more Caesarean sections and coronary bypass procedures than in most other countries.

These procedures and the use of expensive diagnostic tests are all subject to physician opinion on whether they are desirable or not. The fact that U.S. physicians decide that more procedures and tests are desirable compared to their peers in other countries could be due to a few different things, such as:

A fear of litigation that sees physicians test for everything so that they cannot be blamed for not having covered all bases

Payments that mean that physicians get paid more if they do more interventions, regardless of medical necessity.

Because patients ask for more tests and services. It is often comforting to feel that medical problems are being diagnosed or treated, regardless of whether they are medically necessary. As these services are often paid for by insurance policies, the immediate cost of extra treatment for a patient is often zero or very low.

It is often argued that differences in testing could reflect differences in patients' needs between and within countries. However, research at the Dartmouth Institute has documented that there are large variations in medical practice across different regions in the United States which cannot be explained by differences in population structure or differences in illness. They found that the rate of coronary bypass was five times greater in certain hospital referral regions in the United States than others between 2003 and 2007. Similarly, regional variations in hip and knee replacement are substantial, with the rates four to five times higher in some regions compared with others in 2005-06.

Some OECD countries have seen their medical profession and health policy makers develop 'clinical guidelines' to promote a more rational use of MRI and CT exams. In the United Kingdom, since the creation of the Diagnostic Advisory Committee by the National Institute for Health and Clinical Excellence (NICE), a number of guidelines have been issued on the appropriate use of MRI and CT exams for different purposes
NewsHour: Is the U.S. doing less than other countries in some instances?
Pearson: It is likely that this is happening in some instances. The U.S. has fewer physicians and fewer physician consultations relative to its population. The U.S. also has fewer hospital beds for its population size and shorter average stays in hospital relative to other countries. Indeed, the lower numbers of physicians could help explain why they cost more; there is less competition for patients.

Having fewer hospital beds and shorter hospital stays can also be a good thing - a sign that wasteful overuse of hospitals is being avoided in the U.S. system. Medicare in the U.S. has long pioneered how hospitals are paid, by providing a fixed amount for a patient with a particular condition. This means that hospitals have an incentive to treat patients as quickly as possible and it also demonstrates how broader reform in the U.S. could potentially have large effects on costs.
NewsHour: Where is the U.S. getting value for its health care dollar?
Pearson: If insured, waiting times for U.S. patients are among the lowest in OECD countries. Relatively fewer patients (just 20 percent) wait more than four weeks for a specialist appointment or more than four months for elective surgery (7 percent).

U.S. patients also benefit from better cancer outcomes. OECD Health Data shows that the five-year survival rate for breast cancer is higher in the U.S. than in other OECD countries (89.3 percent compared to an OECD average of 83.5 between 2004 and 2009); survival from colorectal cancer is also among the best (64.5 percent compared to an OECD average of 59.9 percent, 2004-09).

Most obviously, the U.S. leads the world in health care research. Along with the FDA's comparatively shorter drug approval processes, this means that cutting-edge drugs and treatments are available more quickly to American patients than elsewhere. The average time from first (worldwide) launch of a new drug to use is 1.3 years in the U.S., the lowest of all OECD countries. The U.S. is also trialing more new procedures and treatments, with the National Institutes of Health currently registering 119,469 clinical trials underway in the U.S., vastly more than any other OECD country.

The U.S. has also led the way on safer hospitals and health care quality, with programs such as the Institute of Healthcare Improvement's 100,000 Lives campaign triggering far-reaching cultural shifts in the several thousand hospitals and clinical facilities that signed. Innovative centers such as the Mayo Clinic and Johns Hopkins that bring laboratory research and clinical practice together have also benefited patients enormously.

The size and diversity of the U.S. system has also provided room for more experimentation to try and find better ways to deliver health care. Examples that the world is watching at the moment include Accountable Care Organisations, which seek to better manage risk-sharing by giving providers flexibility to coordinate and deliver health care while holding them accountable for costs and outcomes and the Medical Home model, which seeks to coordinate care and better engage patients and families, using health coaches, care transition pathways and other interventions to reduce expensive re-hospitalizations. Unfortunately, while the U.S. is better at trying out such innovations on a relatively small scale, it then struggles to roll out successful innovations nationally.
NewsHour: Are there particular areas the U.S. is doing poorly compared to other OECD countries?
Overall, the life expectancy of a U.S. citizen, at 78.2 years, is shorter than the average among OECD countries of 79.5 years and there are a number of specific areas where U.S. health care is weak when compared with other countries.

The U.S. needs stronger policies in tackling lifestyles that lead to poor health. While many states are making efforts to reduce smoking, there are fewer policies to tackle the harmful use of alcohol in the U.S. than you would find in other OECD countries, such as higher taxes on alcohol or minimum prices.

The U.S. could certainly do a lot more on obesity. It's a big risk factor for poor health in the U.S., more so than you find in other OECD countries. Adult overweight and obesity rates are the highest in the OECD, and have kept growing even in the last couple of years, while they have nearly stabilised in some other OECD countries, such as England, France and Italy. Child overweight and obesity rates are also very high, but they have been relatively stable over the past 10 years. The slides below show that the U.S. does poorly both in terms of diet and physical activity, even in comparison with other high-obesity countries, across all age groups.

The first lady's "Let's move" campaign is great, but it cannot achieve a lot if it isn't supported by other measures. Support for physician counseling and programs to help encourage healthier lifestyles vary widely with different insurance arrangements. The U.S. has a national program to cover breast and cervical cancer screening for low-income women, why not have one to cover lifestyle counseling for low-income people? Advertising regulation is left to the food and beverage industry (e.g. the IFBA "Pledges") and this is not likely to have a major impact.

In terms of health care services, the biggest areas of concern are the quality of primary care services and coordination of care for long-term conditions. Asthma, a condition readily managed by general practitioners in the community, should require hospital admission on very few occasions. In the U.S. however, hospital admission rates for asthma are more than double the OECD average (120.6 per 100,000 population compared to an OECD average of 51.8, 2009).

A similar picture emerges for chronic obstructive pulmonary disease (230 admissions per 100,000 population compared to an OECD average of 198, 2009). These outcomes can be improved through better health care. In a Commonwealth Fund survey of seven nations (Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States), 16 percent of American patients reported delays in being notified about an abnormal test result (the highest proportion reported) and only 75 percent of primary care physicians reported often or always receiving correspondence from specialists after referral suggesting systemic problems with care coordination.
Editor's Note: Tune in to the PBS NewsHour on Wednesday for health correspondent Betty Ann Bowser's full report on Virginia Mason Medical Center's Toyota-inspired approach to improving care and bringing down costs. All week on the NewsHour's health page, we'll continue to explore why the U.S. health care system is so expensive and what can be done to fix it.
Tuesday: What steps can you take to make your next hospital stay safer and cheaper? Hari Sreenivasan talks with Elizabeth Bailey, author of "The Patient's Checklist: 10 Simple Hospital Checklists to Keep You Safe, Sane and Organized."

Wednesday: We illustrate what the U.S. could buy with the $750 billion wasted in American health care each year, and, in a separate post, our partners at Kaiser Health News examine the "Top 7 Drivers of U.S. Health Care Costs."

Thursday: In a "Reporter's Notebook," Betty Ann Bowser examines Virginia Mason's decision to eliminate a staple of the American hospital: the waiting room.

Friday: What inefficiencies have you seen in the U.S. health care system? We share some of the first-person accounts submitted by NewsHour viewers.

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Health Costs: How the U.S. Compares With Other Countries

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How much is good health care worth to you? $8,233 per year? That's how much the U.S. spends per person. Worth it? That figure is more than two-and-a-half times more than most developed nations in the world, including relatively rich European countries like France, Sweden and the United Kingdom.

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An article with excellent statistics to use in your answers looking at education spending around the world; the history of education spending in France and the USA; how education spending differs between developed and developing nations.

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In most countries basic education is nowadays perceived not only as a right, but also as a duty - governments are typically expected to ensure access to basic education, while citizens are often required by law to attain education up to a certain basic level.

This was not always the case: the advancement of these ideas began in the mid 19th century, when most of today's industrialized countries started expanding primary education, mainly through public finances and government intervention. Data from this early period shows that government funds to finance the expansion of education came from a number of different sources, but specifically taxes at the local level played a crucial role. The historical role of local funding for public schools is important to help us understand changes - or persistence- in regional inequalities.

The second half of the 20th century marked the beginning of education expansion as a global phenomenon. Available data shows that by 1990 government spending on education as a share of national income in many developing countries was already close to the average observed in developed countries.

This global education expansion in the 20th century resulted in a historical reduction in education inequality across the globe: in the period 1960-2010 education inequality went down every year, for all age groups and in all world regions. Recent estimates of education inequality across age groups suggest that further reductions in schooling inequality are still to be expected within developing countries.

Recent cross-country data from UNESCO tells us that the world is expanding government funding for education today, and these additional public funds for education are not necessarily at the expense of other government sectors. Yet behind these broad global trends there is substantial cross-country - and cross-regional - heterogeneity. In high-income countries, for instance, households shoulder a larger share of education expenditures at higher education levels than at lower levels - but in low-income countries this is not the case. Malawi is a stark example: tertiary education is almost completely subsidised by the state, yet household contribute almost 20% of the costs of primary education.

Following the agreement of the Millennium Development Goals, the first decade of the 21st century saw an important increase in international financial flows under the umbrella of development assistance. Recent estimates show that development assistance for education has stopped growing since 2010, with notable aggregate reductions on flows going to primary education. These changes in the priorization of development assistance for education across levels and regions, can have potentially large distributional effects, particularly within low income countries that depend substantially on this source of funding for basic education.

When analysing correlates, determinants and consequences of education consumption, the macro data indicates that national expenditure on education does not explain well cross-country differences in learning outcomes. This is indicative of a complex 'education production function' whereby for any given level of expenditure, output achieved depends crucially on the input mix.

Available evidence specifically on the importance of school inputs to produce education, suggests that learning outcomes may be more sensitive to improvements in the quality of teachers, than to improvements in class sizes. Regarding household inputs, the recent experimental evidence suggests that interventions that increase the benefits of attending school (e.g. conditional cash transfers) are particularly likely to increase student time in school; and that those that incentivise academic effort (e.g. scholarships) are likely to improve learning outcomes.

Policy experiments have also shown that pre-school investment in demand-side inputs leads to large positive impacts on education - and other important outcomes later in life. The environment that children are exposed to early in life, plays a crucial role in shaping their abilities, behavior and talents.

Interactive charts on Education Spending

Historical perspective on financing education

Governments around the world are nowadays widely perceived to be responsible for ensuring the provision of accessible quality education. This is a recent social achievement. The advancement of the idea to provide education for more and more children only began in the mid 19th century, when most of today's industrialized countries started expanding primary education. The following visualization, plotting public expenditure on education as a share of Gross Domestic Product (GDP) for a number of early-industrialized countries, shows that this expansion took place mainly through public funding. Our entry on Primary Education and Schools provides details regarding how this expansion in funding materialized in better education outcomes for these countries.

Public schools in the US currently educate more than 90% of all children enrolled in elementary and secondary schools.

This is the result of a process of education expansion that relied heavily on public funding, particularly from local governments. The visualization shows the sources of revenues for public schools in the US over the last 120 years. As it can be seen, states and localities are - and have always been - the main sources of funding for public primary education in the US. In fact, we observe three broad periods in this graph: there is first a period of stable revenues until 1920, then a period of sharp growth and decline during the interwar years, and then a period of substantial growth since the second world war, slowing down in the 1970s. In all these periods, federal funding was always very small, as can be seen when changing the visualisation from 'absolute' to 'relative'. Disaggregated data from the last couple of decades gives further insights into the specific sources of local revenues for schools in the US: the largest part comes from property taxes (about 80% of local revenues came from property taxes in 2013), while only a very small part comes from fees and donations (private funding for public schools, which is considered a local revenue, amounted to less than 2% of total public school revenues in 2013). This heavily decentralised system relying on property taxes has the potential of creating large inequalities in education, since public schools in affluent urban areas are able to raise more funding from local revenues. Indeed, a significant part of the debate on education inequalities in the US today focuses on the importance of increasing progressive federal spending to reduce inequalities in public school funding.

The case of the US above shows that funding for public schools has been historically a responsibility of local governments. In other countries, such as France, the expansion of public education also took place initially with resources from local governments, but relatively quickly the fiscal burden was shifted to the national level. In France this transition was associated with a sharp jump towards universal access and a concomitant reduction in regional inequalities. The following visualization from Lindert (2004) provides evidence of the French experience. As we can see there are three distinct periods: education spending was initially low and mainly private, then in 1833 funding began growing with local resources after the introduction of a law liberating communes to raise more local taxes for schools, and finally in 1881 the national government took over most of the financial responsibility after the introduction of a new law that abolished all fees and tuition charges in public elementary schools. In the source book, Lindert (2004) provides further evidence of how this transition towards centrally funded public education reduced north-south inequalities in France.

A comparison of expenditure between public and private education institutions is helpful to contextualize the role the public sector played in the process of education expansion in industrialized countries. The following graph does this using data from the National Center for Education Statistics in the US. It shows that during the years 1950-1970 - a period of substantial growth in education expenditure in the US - expenditure grew specifically in the public sector.

The second half of the 20th century marked the beginning of education expansion as a global phenomenon. The visualization, using data from Szirmai (2005), shows government expenditure on education as a share of national income for a selection of low and middle-income countries, together with the corresponding average for high-income countries, for the period 1960-2010. As it can be seen, by 1990 government spending on education in many developing countries was already close to the average observed in developed countries.

It is important to point out that the remark above makes reference to convergence in expenditure relative to income. To the extent that low-income countries remain poorer than high-income countries, gaps in levels of expenditure per pupil are persistently large. Indeed, cross-country heterogeneity in education expenditure per pupil is currently much higher than heterogeneity in expenditure as share of GDP. One factor contributing to the slower convergence of expenditure per pupil in real terms is the fact that teachers' salaries - the main component of education expenditure - are much higher in high-income countries, because labour has a higher opportunity cost in these countries. In general, the opportunity cost of labour is a key variable that governments in developing countries should factor in when deciding whether to expand education now, rather than later.

An important consequence of the global education expansion is a reduction in education inequality across the globe. The following visualization shows this through a series of graphs plotting changes in the Gini coefficient of the distribution of years of schooling across different world regions. The Gini coefficient is a measure of inequality and higher values indicate higher inequality - you can read about the definition and estimation of Gini coefficients in our entry on income inequality. The time-series chart shows inequality by age group. It can be seen that as inequality is falling over time, the level of inequality is higher for older generations than it is for younger generations. We can also see that in the reference period education inequality went down every year, for all age groups and in all world regions.

Have gains from historical education expansion fully materialized? The breakdown by age gives us a view into the future: as the inequality is lower among today's younger generations, we can expect the decline of inequality to continue in the future. Thus, further reductions in education inequality are still to be expected within developing countries; and if the expansion of global education can be continued, we can speed up this important process of global convergence.

The experience of South Korea shows that it is possible to reduce education inequality rapidly across all levels of education. The following visualization show two graphs comparing the concentration of years of education in South Korean between the years 1970 and 2010. To be precise, each of these graphs shows an education Lorenz curve: a plot showing the cumulative percentage of the schooling years across all levels of education on the vertical axis, and the cumulative percentage of the population on the horizontal axis. As it can be seen, in 2010 education was much less concentrated than in 1970, not only because there was a smaller share of individuals without schooling (shown along the bottom of the chart), but also because there was a smaller share of individuals concentrating large proportions of school-years at higher levels of education. Indeed, in only 40 years South Korea was able to double the mean years of schooling (from 6 to 12 years) and at the same time get remarkably close to the 45-degree line marking the hypothetical scenario of perfect equality of schooling. In other entries we show that in this same period South Korea increased drastically its GDP per capita while significantly improving health outcomes, such as child mortality.

Financing of education across the world

The last two decades have seen a small but general increase in the share of income that countries devote to education. The following chart plots trends in public expenditure on education as a share of GDP. As usual, a selection of countries is shown by default, but other countries can be added by clicking on the relevant option at the top of the chart. Although the data is highly irregular due to missing observations for many countries - an issue we discuss in more detail in our section on Data Quality below -, we can still observe a broad upward trend for the majority of countries. Specifically, it can be checked that of the 88 countries with available data for 2000/2010, three-fourths increased education spending as a share of GDP within this decade. As incomes - measured by GDP per capita - are generally increasing around the world, this means that the total amount of global resources spent on education is also increasing in absolute terms.

You can explore the trends by education level in these interactive charts:

The above-mentioned growth in overall government expenditure on education as a share of GDP cannot be entirely attributed to a wide-spread change in the prioritization of education spending within domestic budgets. The following visualization shows government expenditure on education as a share of total government expenditure. In this case the available data does not suggest a discernible global pattern. For instance, of the 36 countries with available data for 2000 to 2010, only around half increased spending on education relative to the other sectors. The data does suggest, however, that there is large and persistent cross-country heterogeneity in the relative importance of education vis-a-vis other sectors, even within developing countries. For example, in 2011 education accounted for about 8% of government spending in the Central African Republic, while it accounted for about 30% in Ghana.

Generally speaking, countries that spend a large share of their income on education also tend to prioritize education highly within their budgets. The following visualization presents a snapshot of government spending on education around the world for the year 2016. Specifically, this graph plots government expenditure on education as a share of GDP in the vertical axis, and government expenditure on education as a share of total government expenditure in the horizontal axis. Each dot on this chart represents a different country, with the assigned colors denoting different world regions. As we can see, there is a positive correlation, but regional differences are stark: for almost every level of spending as a share of GDP along the horizontal axis, European countries (marked in light orange) spend a smaller budget share on education.

In comparison to countries where education started expanding later, European countries tend to assign relatively more of their government education budgets to the secondary and tertiary levels, while at the same time devoting relatively less of their general government budgets to education as a whole. This can be appreciated in the following visualization, where the priorization of primary education (i.e. the share of primary education within the education budget) is plotted against the overall priorization of education (i.e. the share of education within the entire government budget). It can be seen that European countries (marked again in light orange) are mostly located in the bottom-left. And there is a weak positive correlation between the variables, both across all countries and across European countries.

The following visualization shows the percentage of total education expenditures contributed directly by households in 15 high income countries and 15 low/middle income countries (most recent data available on 2014). The top chart in this figure, corresponding to high income countries, shows a very clear pattern: households contribute the largest share of expenses in tertiary education, and the smallest share in primary education. Roughly speaking, this pattern tends to be progressive, since students from wealthier households are more likely to attend tertiary education, and those individuals who attend tertiary education are likely to perceive large private benefits (more on this in our entry on Skill Premium). In contrast, the bottom chart shows a very different picture: in several low-income countries households contribute proportionally more to primary education than to higher levels. Malawi is a notable case in point - tertiary education is almost completely subsidised by the state, yet household contribute with almost 20% of the costs in primary education. Such distribution of private household contributions to education is regressive.

Recent funding structures in OECD countries

We have already mentioned that those countries that pioneered the expansion of primary education in the 19th century - all of which are current OECD member states - relied heavily on public funding to do so. Today, public resources still dominate funding for the primary, secondary and post-secondary non-tertiary education levels in these countries. While in the last decade the share of public funding for these levels of education has decreased slightly, the broad pattern is remarkably stable. The visualization presents OECD-average expenditure on education institutions by source of funds. By clicking on the option labeled 'relative' you can see the corresponding share of each source: private funding went up from 7.9% in 2000, to 9.4% in 2012. The role of public funding for other levels of education is however quite different. At the tertiary level public sources account for less than 70% of funding on average (2012 figures). Below we provide evidence of the pre-school level.

High-income countries tend to have better developed pre-primary education systems than lower-income countries. However, within high-income countries there is substantial heterogeneity in the extent to which pre-primary education is publicly financed. The visualization presents expenditure on pre-primary educational institutions as a share of GDP across the OECD. As it can be seen, publicly funded pre-primary education tends to be more strongly developed in the European than the non-European countries of the OECD. In fact, the OECD reports that in Europe the concept of universal access to education for 3-6 year-olds is generally accepted: most countries in this region provide all children with at least two years of free, publicly funded pre-primary education in schools before they begin primary education.

The largest part of funding devoted to education in OECD countries goes to finance current expenditures, mainly compensation of staff - specifically, teachers. The following two charts, taken from the OECD's report Education at a Glance (2015), highlight the labour-intensive nature of education. In the lower levels of education (i.e. primary, secondary and post-secondary non-tertiary) the share of current expenditure is very large and exhibits little cross-country variation - between 90 and 97 percent of total expenditure corresponds to current expenditure across all of the OECD countries. In higher levels of education (i.e. tertiary) there is more cross-country variation, but current expenditure still dominates by a large margin across all countries.

In the figures above we noted the importance of current expenditure in the production of education. The following table provides further details regarding the type of expenditures that comprise current spending. Specifically, this chart shows a breakdown of expenditure for tertiary-level institutions in the US (public and private), during the period 1980-1997. It shows that instruction accounts for almost half of expenditure; and while there are some small differences across sectors, there is a fair amount of stability in expenditures across time. This serves as a benchmark for lower education levels, where instruction takes an even larger share of expenditure.

Following the agreement of the Millennium Development Goals, the first decade of the 21st century saw an important increase in international financial flows under the umbrella of development assistance (often also called development aid, or simply 'aid'). The following chart shows total OECD development assistance flows for education by level, in constant 2013 US dollars, for the period 2002-2013. As it can be seen, there are two distinct periods: in 2003-2010 flows for education increased substantially, more than doubling in real terms across all levels of education; and in the years 2010-2013 funding for basic education decreased, while funding for secondary and post-secondary education remained relatively constant. For many low income countries, where development assistance contributes a substantial share of funding for education, this marked change in trends is important. As a reference, in 2012 development assistance accounted for more than 20 percent of all domestic spending on basic education in recipient low-income countries.

The recent reductions in development assistance funds for primary education have been coupled with important changes in regional priorities. Specifically, the share of development assistance for primary education going to sub-Saharan Africa has been decreasing sharply since the agreement of the Millennium Development Goals. The following chart shows this: sub-Saharan Africa's share in total aid to primary education declined from 52 percent in 2002 to 30 percent in 2013, while the continent's share in the total number of out-of-school children rose from 46 percent to 57 percent. This pattern is something specific to the education sector within the broader development assistance landscape: in the healthcare sector the overall slowdown of flows started a couple of years later, was less abrupt, and affected proportionally less the sub-Saharan countries. Indeed, recent studies further highlight that development assistance for education is significantly different to assistance for healthcare in other ways: the education sector attracts less earmarked funding through multilaterals, and includes a smaller proportion of resources that developing governments can directly control for programming.

You can read more about development assistance for healthcare in our entry on Financing Healthcare.

In the Historical Perspective section above, we mentioned that public spending on education has translated, in the long run, into lower inequality in education outcomes across most of the world. But for any given country, with a determined income distribution and demographic structure, the extent to which public spending on education contributes to reduce inequality depends crucially on the way in which spending is focused across education levels. The recent UNICEF report The Investment Case for Education and Equity shows that in low income countries, on average 46 percent of public resources are allocated to the 10 percent of students who are most educated - while this figure goes down to 26 and 13 percent in lower-middle and upper-middle income countries respectively. The following visualization shows further details on the concentration of public spending across different countries. The vertical axis shows the percentage of public education resources going to the 10% most educated or 10% least educated students - as we can see expenditure is heavily concentrated at the top in many low income countries.

The earlier remarks about trends in international education financing flows (namely that aid is very important in low-income countries, and that a relatively low and shrinking share of aid is going to primary levels), suggest that inequality in public spending will worsen in low income countries. Yet development assistance priorities have a scope for changing this.

What determines educational finance?

The big picture

One of the reasons to justify government intervention in the market for education, is that education generates positive externalities. This essentially means that investing in education yields both private and social returns. Private returns to education include higher wages and better employment prospects. Social return include pro-social behaviour (e.g. volunteering, political participation) and interpersonal trust. The following chart uses OECD results from the Survey of Adult Skills to show how self-reported trust in others correlates with educational attainment. More precisely, this chart plots the percentage-point difference in the likelihood of reporting to trust others, by education level of respondents. Those individuals with upper secondary or post-secondary non-tertiary education are taken as the reference group, so the percentage point difference is expressed in relation to this group. As we can see, in all countries those individuals with tertiary education were by far the group most likely to report trusting others. And in almost every country, those with post-secondary non-tertiary education were more likely to trust others than those with primary or lower secondary education. The OECD's report Education at a Glance (2015) provides similar descriptive evidence for other social outcomes. The conclusion is that adults with higher qualifications are more likely to report desirable social outcomes, including good or excellent health, participation in volunteer activities, interpersonal trust, and political efficacy. And these results hold after controlling for literacy, gender, age and monthly earnings.

Education outcomes are typically measured via 'quantity' output (e.g. years of schooling) and 'quality' output (e.g. learning outcomes, such as test scores from the Programme for International Student Assessment - PISA). The following visualization presents three scatter plots using 2010 data to show the cross-country correlation between (i) education expenditure (as a share of GDP), (ii) mean years of schooling, and (iii) mean PISA test scores. At a cross-sectional level, expenditure on education correlates positively with both quantity and quality measures; and not surprisingly, the quality and quantity measures also correlate positively with each-other. But obviously correlation does not imply causation: there are many factors that simultaneously affect education spending and outcomes. Indeed, these scatterplots show that despite the broad positive correlation, there is substantial dispersion away from the trend line - in other words, there is substantial variation in outcomes that does not seem to be captured by differences in expenditure.

The following visualization presents the relationship between PISA reading outcomes and average education spending per student, splitting the sample of countries by income levels. It shows that income is an important factor that affects both expenditure on education and education outcomes: we can see that above a certain national income level, the relationship between PISA scores and education expenditure per pupil becomes virtually inexistent. Several studies with more sophisticated econometric models corroborate the fact that expenditure on education does not explain well cross-country differences in learning outcomes. You can read more about test scores and learning outcomes in our entry on Quality of Education.

The fact that expenditure on education does not explain well cross-country differences in learning outcomes is indicative of the intricate nature of the process through which such outcomes are produced. Borrowing the terms from the economics literature, the following 'production function' provides a conceptual framework to think about the determinants of learning outcomes:

where A is skills learned (achievement), s is years of schooling, Q is a vector of school and teacher characteristics (quality), C is a vector of child characteristics (including "innate ability"), H is a vector of household characteristics, and I is a vector of school inputs under the control of households, such as children's daily attendance, effort in school and in doing homework, and purchases of school supplies.

This conceptualization highlights that, for any given level of expenditure, the output achieved will depend on the input mix. And consequently, this implies that in order to explain education outcomes, we must rely on information about specific inputs. In the following sections we explore evidence regarding the returns to household inputs (i.e. different elements of Q) and demand-side inputs (i.e. elements of C,H and I).

School inputs

A vast number of studies have tried to estimate the impact of classroom resources on learning outcomes. The following table summarizes results from the systematic review in Hanushek (2006). In this table, the left-hand side summarizes results from econometric studies focusing on developing countries, while the right-hand side presents evidence from the US (where studies have concentrated extensively). We can see that for all listed inputs and across all countries, the share of studies that have found a positive effect is small - in fact, the majority of studies find either no effect, or a negative effect. This clearly does not mean that these classroom resources are not important, but rather that it is very difficult to know with confidence when and where they are a binding constraint to improve learning outcomes. A first conclusion, therefore, seems to be that context and input mix are fundamental to improving outcomes - even in developing countries where the expected returns to additional resources is large across the board.

Taking the ratio of positive to negative effects detected in the literature as a proxy for what tends to work best, we can derive a second conclusion from the table: spending more resources on better teachers (i.e. improving teacher experience and teacher education) tends to work better to improve learning outcomes than simply increasing the number of teachers per pupil. And this seems to be true both in developed and developing countries. This last conclusion is consistent with the main message from the OECD's report Does money buy strong performance in PISA?, which points out that countries that prioritised the quality of teachers over class sizes performed better in PISA tests.

And it is also consistent with a recent high-quality study on the impact of teacher quality on test scores using data from the US, which suggests that improvements in teacher quality can causally raise students' test scores (evidence from Chetty et al. (2014) - see our entry on Quality of Education for a discussion of their results).

Education in low-income countries is particularly difficult because there is substantial heterogeneity in the degree of preparation that children have when they enter school - much more so than in high-income countries. Recent evidence from policy 'experiments' in developing countries suggests remedial teaching, in the form of assistants teaching targeted lessons to the bottom of the class, can yield substantial improvements in learning outcomes. The following visualization summarizes the effects of four different policy treatments within the so-called Teacher Community Assistant Initiative (TCAI) in Ghana - this is an initiative that evaluated four different such remedial teaching interventions.

The units in this figure are standard deviations of test results. The first two sets of estimates correspond to the test-score impacts of enabling community assistants to provide remedial instruction specifically to low-performing children, either during school, or after school. The third set of estimates corresponds to test-score impacts of providing a community assistant and reducing class size, without targeting instruction to low-performing pupils. And the last set of results corresponds to testing the effect of training teachers to provide small-group instruction targeted at pupils' actual learning levels.

As we can see, while all interventions had a positive effect, the lowest impacts - across all tests - come from the non-targeted 'normal curriculum' intervention that reduced class sizes, and from the intervention that provided training to teachers on how to engage in targeted remedial teaching themselves. This suggests that the improvements in outcomes were caused by the combination of targeted instruction and TCAs who, unlike teachers, were specifically dedicated to this purpose. These results are consistent with findings from across Africa, suggesting that teaching at the right level causes better learning outcomes in a cost-effective way (see Glewwe and Muralidharan 2016 for further details on this evidence).

We have already made the point that the bulk of education expenditure goes specifically towards financing teachers. And we have also pointed out that improving teacher quality may be a particularly good instrument to improve teaching outcomes. This leads to a natural question: are pay-for-performance teacher contracts an effective instrument to improve learning outcomes? A growing body of literature in the economics of education has started using randomized control trials (i.e. policy 'experiments') to answer this question. Glewwe and Muralidharan (2016) provide the following account of the available evidence:

"Results suggest that even modest changes to compensation structures to reward teachers on the basis of objective measures of performance (such as attendance or increases in student test scores) can generate substantial improvements in learning outcomes at a fraction of the cost of a "business as usual" expansion in education spending. However, not all performance pay programs are likely to be effective, so it is quite important to design the bonus formulae well and to make sure that these designs reflect insights from economic theory."

The conclusion is that well-designed pay-for-performance contracts are a cost-effective instrument to boost test scores; but this does not mean that they are necessarily effective at achieving other - perhaps equally important - objectives of time spent in school. In simple words, it is possible that pay-for-performance yields 'teaching to the test'. Alternative incentive mechanisms, such as community-based monitoring of teachers, have been proposed as an alternative. Glewwe and Muralidharan (2016) also provide a review of the - somewhat limited - available evidence on such alternative incentive mechanisms.

Household inputs

Demand-side inputs are as important as supply-side inputs to produce education. Attending school and exerting effort are perhaps the most obvious examples: without these inputs even the best endowed schools will fail to deliver good outcomes. The table summarizes information on different demand-side investments that have shown to successfully improve quality and quantity outcomes. More precisely, this table gathers evidence from randomized control trials in developing countries, as per the review in Glewwe and Muralidharan (2016). The reported figures correspond to positive/negative significant/insignificant estimates across a set of available experimental studies (bear in mind some studies estimate more than one effect - e.g. by measuring outcomes at several points in time). As we can see, the evidence suggests interventions that increase the benefits of attending school - such as conditional cash transfers - are likely to increase student time in school. And those that increase the benefits of higher effort and better academic performance - such as merit scholarships - are likely to improve learning outcomes (see Glewwe and Muralidharan 2016 for further details on the underlying policy interventions, plus further evidence and discussion of results).

In many low-income countries, health problems are an important factor preventing children from attending school. The following visualization presents a comparison of the impact that a number of different health interventions have achieved in different countries - together with some non-health-related interventions that serve as reference. The height of each bar in this graph reflects the additional school years achieved per hundred dollars spent on the corresponding intervention; so these estimates can be interpreted as a measure of how cost-effective the different interventions are.

We see that treating children for intestinal worms (labeled 'deworming' in the chart) led to an additional 13.9 years of education for every $100 spent in Kenya; while a program targeting anaemia (labeled 'iron fortification') led to 2.7 additional years per $100 in India. These interventions seem to be much more cost-effective to improve test scores than conditional cash transfers, free school uniforms, or merit scholarships (further details on all interventions available from Dhaliwal et al. 2012). Of course, ranking these interventions is not trivial since most programmes achieve multiple outcomes - indeed, we have already discussed that remedial teaching is generally effective to increase test-scores, although here we see a particular instance where it had no impact on school attendance. Nevertheless, health interventions seem to be particularly interesting, since they lead to substantial achievements in both education and health outcomes (for a recent analysis of the literature on the impacts of mass deworming see Croke et al. 2016).

The environment that children are exposed to early in life, plays a crucial role in shaping their abilities, behavior and talents. To a great extent, this is what drives large and remarkably persistent gaps in the education achievement between individuals in the same country, but in different socioeconomic environments. Cunha et al. (2006) provide a detailed account of the theory and evidence behind this claim, and discuss its implications for the design of education policies. In the chart we see the impacts from the Perry Preschool Program - a flagship experimental intervention study, designed to test the impact of pre-school education on subsequent education outcomes. The chart shows disadvantaged children participating in the pre-school program (the 'treatment group') had higher grades and were more likely to graduate from high school than the reference control group. Moreover, they spent substantially less time in special education. Other programs have similarly shown evidence of very large and persistent returns to early education interventions.

Relationship between sources

The main source of data on international education expenditure is UNESCO's Institute for Statistics (UIS). The same data is also then published by the World Bank ( World Bank EdStats and World Development Indicators) and Gapminder. It is also the main source of education data for most UN reports - such as the EFA Global Monitoring Report (UNESCO), the Human Development Report (UNDP), the State of the World's Children report (UNICEF) and the Millennium Development Goals (UN).

The UIS database is produced mainly from yearly national reports, but it also relies on reports from international organizations.

Specifically, countries in the European Union, or members of the OECD, have richer data, since they collect information through the UIS-OECD-Eurostat (UOE) survey, which is more detailed than the UIS survey (see more at FAQ-UIS)

Another, related but different source of education expenditure data, is the International Food Policy Research Institute (IFPRI), which publishes the Statistics of Public Expenditure for Economic Development (SPEED). This source relies primarily on data from the International Monetary Fund (IMF).

Definitions

In the UIS database, government expenditure on education includes spending by local/municipal, regional and national governments, on public and private educational institutions, education administration, and subsidies for private entities (students/households and other privates entities). This information is then reported by level of education, and typically as a share of national income (GDP) or as a share of total public expenditure. In principle, expenditure on pre-primary levels as well as expenditure sourced with transfers from international sources to government, are included. In practice, however, many countries under report these specific figures.

Measurement limitations

The UIS has been maintained since 1999 with the intent of providing comparable expenditure figures across countries and time, and its estimates rely on reports submitted by ministries and national statistics offices. Since reporting is delegated typically to ministries of education, in some instances data on total public expenditure on education fails to represent spending by other ministries that also have budgets for education. Additionally, since not all countries have (or update) national education accounts, the UIS attempts to generate estimates and impute missing data using information from national publications, official websites and other sources. However, the UIS dataset has several missing observations, particularly for years prior to 2010.

To gauge the extent to which UIS data is reliable, the following visualization shows the proportions of regular and irregular data that countries make available (where 'Regular' means data is available at least once every 3 years; and 'Irregular' means data is available less frequently than every 3 years). As can be seen, the picture is not particularly encouraging: less than half of the countries reported regularly data on total government expenditure on education over the reference period.

Apart from the above-mentioned issues regarding the availability of data, comparing education financing between different countries can be challenging because the way that expenses are categorized is not always consistent. This can be particularly difficult when it comes to expenses that could potentially be classified as education or non-education-related, like teaching hospitals or transportation. While this issue is not as significant in other sectors like healthcare, it still presents some difficulties. For a further discussion of these issues see the UIS data collection manual .

Long-run estimates of education financing

As it has been mentioned, the earliest data on financing of education dates back to the late 19th century, when today's industrialized countries began expanding their education systems. The main sources here are academic publications.

Data Source: Lindert, Peter H. "The rise of social spending, 1880-1930." Explorations in Economic History 31, no. 1 (1994)

Description of available measures: Public Education Expenditure as percent of GDP

Time span: Selected years in the late 19th century

Geographical coverage: Selection of high-income countries

Data Source: Flora, Peter et al. 1983. State, Economy and Society in Western Europe, 1815-1975. Frankfurt: Campus Verlag

Description of available measures: Central government expenditure by sectors, as percent of GDP and as percent of total expenditure.

Time span: 1815-1975

Geographical coverage: Western Europe

Link: Available online from http://gpih.ucdavis.edu/Government.htm/

Data Source: Tanzi, Vito, and Ludger Schuknecht. Public spending in the 20th century: A global perspective. Cambridge University Press, 2000.

Description of available measures:

Public Health Expenditure as percent of GDP

Health Insurance Coverage as percent of labour force

Time span: 1910-1994

Geographical coverage: Selection of high-income countries

Data publisher: Adam Szirmai, (2015) The Dynamics of Socio-Economic Development, www.dynamicsofdevelopment.com

Data source: Different sources, but mainly UIS after 2000, and selected UNESCO yearbooks prior 2000

Description of available measures:

Gross enrolment ratios by educational level, country and region

Net enrolment ratios by region

Highest diploma obtained (as percentage of 25+ age bracket)

Average years of education of the population of 25 years and over

Government expenditure per pupil in selected countries, 1965-2010

Government expenditure on education as a percentage of gross national product

Cognitive performance of developing countries

Illiterates as a Percentage of the Population of 15 years and over

Time span: Selected years in the second half of 20th century (periodic updates online)

Geographical coverage: Selected low and middle income countries

Long-run country-specific statistics on education financing

Country-specific statistics are another important source of long-run data on education spending. Two references we used in this entry are the U.S. Bureau of the Census and the U.S. National Center for Education Statistics.

Data Source: (a) Historical Statistics of the United States Colonial Times to 1970 (1929-1970); and (b) US Census Statistical Abstract 1990 (1970-1990). Both published by the US Bureau of the Census

Description of available measures: Total education expenditure, disaggregated by private and public spending, with further details on specific types of expenditure (figures mainly expressed in current prices)

Time span: 1929-1990

Geographical coverage: U.S.

Data Source: National Center for Education Statistics (NCES) - Digest of Education Statistics

Description of available measures: Information on a variety of subjects in the field of education statistics, including the number of schools and colleges, teachers, enrollments, and graduates, in addition to educational attainment, finances, federal funds for education, libraries, and international education.

Time span: Since 1970

Geographical coverage: U.S.

Data Source: UIS based on reports from ministries, national statistics offices and international agencies

Description of available measures:

Out-of-school children

Entry

Participation

Progression

Completion

Literacy

Educational attainment

International student mobility in tertiary education

Human resources

Financial resources

School resources and teaching conditions (Africa only)

Adult education (Latin America and the Caribbean only)

Disparities in teacher's training, deployment, characteristics and working conditions at sub-national level (East and South West Asia only)

Time span: 1970-2015 for some variables, but most variables available since 1998

Geographical coverage: Global by Country

Link: http://data.uis.unesco.org

Another important source is the OECD - this is arguably the most comprehensive database in terms of variables and regularity of observations. This is the source used for the OECD's periodic report Education at a Glance.

Data Source: OECD based on reports from member countries

Description of available measures:

Graduation and entry rates

Graduates and entrants by field

Profile of graduates and entrants

Student-teacher ratio and average class size

Distribution of teachers by age and gender

Enrolment rate by age

Share of enrolment by type of institution

Share of enrolment by gender, programme orientation and mode of study

Share of international students enrolled by field of education

Share of international students enrolled by country of origin

Transition from school to work

Educational attainment and labour-force status

Educational finance indicators

Time span: 1960-2015 for some variables, though substantial missing values prior 1990

Geographical coverage: OECD countries

Link: http://stats.oecd.org

Yet another relevant source of internationally comparable expenditure statistics is IFPRI's Statistics of Public Expenditure for Economic Development. This dataset relies mainly on IMF statistics.

Data Source: IFPRI, from multiple dats sources, but mainly IMF statistics

Description of available measures:

Education expenditure in 2005 $ppp

Education expenditure in 2005 US$

percentage of education expenditure in total gdp

per capita education expenditure in 2005 $ppp

percentage of education expendtiure in total expenditure

Time span: 1980-2012

Geographical coverage: 67 countries across all continents

Link: https://www.ifpri.org/publication/statistics-public-expenditures-economic-development-speed

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How is education financed? How much do we spend on it? What are the returns?

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Somalia - a country suffering the debts of its predecessors and unable to move forward.

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Somalia - a country suffering the debts of its predecessors and unable to move forward.

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An interesting article that looks at how Somalia is ineligible for new World Bank funding because of its debts accrued in the 1980's. Good evidence for assessing whether the WB and IMF help or hinder development.

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World Bank and IMF, put your money where your mouth is on Somalia

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The institutions should match fine words about eradicating poverty with action to help one of the world's most fragile states

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Are the IMF and World Bank's policies the problem?

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Are the IMF and World Bank's policies the problem?

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An article which looks at the fundamental issues of SAPs and reducing public spending as the key problem with the IMF and WB. Specific example of Ghana to develop your own knowledge.

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The World Bank and the IMF won't admit their policies are the problem

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Those who run the global economy realise it could blow up at any time, but are carrying on regardless

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World Bank and IMF helping or hindering development in developing countries?

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World Bank and IMF helping or hindering development in developing countries?

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An journal article which looks at the IMF and World Bank in detail, giving specific examples throughout.
Synoptic links to globalisation and superpowers too.

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Reality check: does the UK really spend half of what the US does on healthcare?

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Reality Check: Does UK spend half as much on health as US?

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The claim: The NHS costs half as much as the US health system, and cares for the whole population. Reality Check verdict: If you look at every penny spent on health by anyone in the country, then the UK spends about half as much on health as the US does.

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Research produced by the Australian government comparing life expectancy of indigenous and non-indigenous populations and the specific strategies being used to close the gap

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UNICEF statistics on infant and maternal mortality

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UNICEF statistics on infant and maternal mortality

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Can be used to provide up to date statistics for both the DRC and Algeria.

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Legal framework for birth registration
Law No. 87-010 (1 August 1987), as amended by Law No. 16/008 (15 July 2016) on the Family Code

Legal informant to register a birth
Father or mother, Ascendants and relatives, Those present at the birth;

The declaration may be made by a mandatory bearer of a written power of attorney, even under private seal, of the father or the mother (Family Code, article 117).

Requirements for birth registration
Presentation of the medical certificate of birth;

For the registration, the presence and consent of one of the parents (father or mother) is sufficient. Registration can also be done by ascendants, close relatives or any person present at the birth. Another person designated as having a power of attorney in writing and signed by the parents may make the declaration of the child on behalf of the parents to the registry office.

Information collected
Regarding the child: Name, Sex, Date of birth, Date of registration, Place of occurrence, Place of registration

Regarding the mother of the child: Date of birth or age, Place of usual residence, Date of birth or age, Place of usual residence, Occupation, Nationality

Regarding the father of the child: Date of birth or age, Place of usual residence, Date of birth or age, Place of usual residence, Occupation, Nationality

Data sources: Information on civil registration systems was compiled over a period from December 2016 to November 2017 using the existing relevant legal frameworks and in consultation with CRVS experts, officials within the relevant national institutions, and UNICEF country offices. All reasonable precautions have been taken by UNICEF to verify this country profile; updates will be made to reflect changes in policy and implementation and/or new information.

Legal framework for marriage registration
Law No. 87-010 (1 August 1987), as amended by the Law No. 16/008 (15 July 2016) on the Family Code

Requirements for marriage registration
Husband's presence at registration, Wife's presence at registration, Proof of wife's age, Proof of husband's age, Witness to the marriage, Affidavit attested by magistrate, public notary, etc.

The Registrar of Civil Status requires the delivery of the following documents:

- An extract of the birth certificate of each spouse;
- Copies of the acts granting exemptions in the cases provided for by law;

- Where applicable, copies of the deeds acknowledging the consent of the parents or guardian, or written proxies

(Family Code, article 373)

Information collected
Regarding the spouses: Date of birth or age of bride, Place of usual residence of bride, Date of birth or age of groom, Place of usual residence of groom, occupation and nationality of spouses

Regarding the marriage: Date of occurrence, Date of registration, Place of occurrence, Place of registration

(Family Code, article 392)

Download sample marriage registration form
Data sources: Information on civil registration systems was compiled over a period from December 2016 to November 2017 using the existing relevant legal frameworks and in consultation with CRVS experts, officials within the relevant national institutions, and UNICEF country offices. All reasonable precautions have been taken by UNICEF to verify this country profile; updates will be made to reflect changes in policy and implementation and/or new information.

Legal framework for death registration
Law No. 87-010 (1 August 1987), as amended by Law No. 16/008 (15 July 2016) on the Family Code

Information collected
The death certificate states:

- Time, if any, day, month, year and place of death, name, date and place of birth, sex, nationality, occupation and domicile or residence of the deceased;

- Name, age, nationality, occupation and domicile or residence of the deceased's father and mother, if possible;

- Name, age, nationality, occupation and domicile or residence of the spouse, if the deceased was married;

- Name, age, nationality, occupation and domicile or residence of the declarant.

As far as possible, mention is made of the death in the margin of the deceased's birth certificate.

(Family Code, article 134)

Information collected in case of fetal death
Sex of the child, Name, age, nationality, occupation and domicile of the father and mother, Day, month, year and place of confinement

When an infant is declared stillborn, the declaration is entered into the death registry and not into the birth registry. The act mentions only that the child was declared lifeless without there being a presumption on the point of knowing whether the child lived or not. (Family Code, article 123)

Download sample death registration form
Data sources: Information on civil registration systems was compiled over a period from December 2016 to November 2017 using the existing relevant legal frameworks and in consultation with CRVS experts, officials within the relevant national institutions, and UNICEF country offices. All reasonable precautions have been taken by UNICEF to verify this country profile; updates will be made to reflect changes in policy and implementation and/or new information.

Since its inception in 1995, the Multiple Indicator Cluster Surveys, known as MICS, has become the largest source of statistically sound and internationally comparable data on women and children worldwide. In countries as diverse as Costa Rica, Mali and Qatar, trained fieldwork teams conduct face-to-face interviews with household members on a variety of topics - focusing mainly on those issues that directly affect the lives of children and women.

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Democratic Republic of the Congo - UNICEF DATA

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Legal framework for birth registration Law No. 87-010 (1 August 1987), as amended by Law No. 16/008 (15 July 2016) on the Family Code Legal informant to register a birth Father or mother, Ascendants and relatives, Those present at the birth; The declaration may be made by a mandatory bearer of a written power of attorney, even under private seal, of the father or the mother (Family Code, article 117).

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How decades of conflict have led to a mistrust of officials, leading to the second largest Ebola outbreak in history.

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How decades of conflict have led to a mistrust of officials, leading to the second largest Ebola outbreak in history.

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An interview with the chief of the WHO on why the Ebola crisis in the DRC is so difficult to manage.

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GENEVA - An Ebola epidemic that experts are calling " exceptionally dangerous " is unfolding in the Democratic Republic of Congo.

So far, there have been more than 420 cases and 240 deaths, which makes it the largest outbreak of Ebola since the 2014-2016 West Africa outbreak that killed 11,000. It's also the second-largest Ebola outbreak on record.

Humans have tangled with the Ebola virus for centuries with deadly results. But until five months ago, Ebola had never emerged in an active war zone.

On August 1, the World Health Organization declared an Ebola outbreak in the Democratic Republic of the Congo. The virus had started spreading in cities in North Kivu, an unstable province in the Central African country, where fighting among multiple rebel and militia groups has repeatedly interrupted the painstaking work of health workers who came to respond to the outbreak.

Even though Ebola responders have never had so many tools at their disposal to fight the virus - experimental vaccines and treatments that have shown promise - the incidence of the disease has more than doubled since September. Even worse, many of the newly diagnosed cases cannot be linked to other known cases. That means there are still people spreading the disease whom health officials have not yet identified.

Due to the ongoing conflict in the region, the US government has decided it's too dangerous to allow its top Ebola experts to work at the outbreak's epicenter. The US has maintained this stance despite outcry from public health officials who say the US isn't doing enough to help.

To unpack how the outbreak got so bad, and what the WHO needs right now, I sat down with Peter Salama, the head of the new Health Emergencies Program at the WHO. His team was created in 2016 as a direct response to the WHO's fumbling of the West Africa Ebola outbreak. This year alone, he's helped the organization respond to 50 health emergencies in 47 countries.

But the Ebola outbreak in DRC is something different, Salama said. Sitting in his office in Geneva, in front of a map of DRC - which he keeps in front of him "to remind me I need to keep focused on this on a minute basis" - he walked me through the extraordinary complexity of trying to quash an Ebola outbreak in a war zone and why the WHO could use the world's best Ebola minds right now. Our conversation has been edited for length and clarity.

The Ebola response could use US experts

Julia Belluz

The US pulled its Centers of Disease Control and Prevention workers out of Beni, the outbreak epicenter. They decided it was too dangerous for America's best Ebola experts to be there - and it sounds like they are not coming back anytime soon. Could the US be doing more? Does the WHO need those experts now?

Peter Salama

As we go more and more into the outbreak, it taxes all of our capacities, so we have to give staff an opportunity to take a short break at some point and refresh. We have to look at rotating staff - because people are working 20 hours a day here in Geneva and [in DRC]. We don't want people so exhausted they burn out. So we need people. We have people coming in and for some countries, not just the US, they do have security concerns.

Julia Belluz

But I understand Canada, the UK, even nonprofits with US personnel, are sending people, and you have hundreds of WHO officials deployed. Is the US government an outlier?

Peter Salama

The US government is the main country that has had constraints. But others have asked a lot of questions, need reassurance, and are limited in their responders.

Julia Belluz

What kind of people do you need at this point?

Peter Salama

Some of the key areas where it's not easy to find people are the most senior viral hemorrhagic epidemiologists, the people who are specialized in viral hemorrhagic fevers. [We need] medical logisticians but not just general logisticians - it's people who know how to set up the cold chain at negative 60 to 80 degrees Celsius [to keep the vaccine cold] and ensure its integrity right through to Beni. So it's not just the average humanitarian worker we need.

Julia Belluz

What about money? The health emergency fund at WHO has never gotten the $100 million from donors, including the US, it requested. How do you operate in this constant state of underfunding?

Peter Salama

We asked for $100 million initial capital when we started three years ago. We never got to $100 million. But because it's constantly used and constantly replenished, it's not the end of the world. In the last two years, we've used around $60 million to respond to 70 events. This year, we've received almost $40 million with additional pledges. So it's been well supported.

I'd like to get to some more formal system in place whereby, for example, the G20 country says we guarantee this fund, because it is so important for global security, will never fall below $50 million. That's where I'd like to get to.

What makes this outbreak different from all the rest

Julia Belluz

DRC had seen nine Ebola outbreaks since the virus was discovered in 1976. What makes this 10th outbreak different?

Peter Salama

It's an outbreak I describe as a perfect storm - a combination of this deadly disease in one of the most difficult, protracted crises we have around the world.

In North Kivu, there's a long civil conflict, the proximity to numerous international borders - Uganda, Rwanda, and South Sudan - and a population that's constantly on the move with 1 million displaced people out of the [6] million residents. It's also a population that's highly traumatized, especially in and around Beni [the outbreak epicenter]. People have been subject to an enormous number of severe attacks consistently since 2014 but dating back to even the Rwandan genocide [in 1994].

That population is so traumatized that everything for them is viewed through the lens of distrust of authority, physical insecurity, and the inability of the world to protect them. These viruses manage to exploit social vulnerabilities and fault lines. That's what we're seeing in this Ebola outbreak starkly.

Julia Belluz

One reason that's been cited for the ongoing Ebola spread is the mistrust brought on by this violence and instability in North Kivu - that it contributes to the spread of Ebola when people won't go to treatment centers or work with responders. What is the WHO doing to overcome that?

Peter Salama

The most important thing we can do is understand what community perceptions and behaviors are related to the outbreak. We have sociologists and anthropologists - both local and international - working closely with WHO. So we ask them questions we want to know.

For example, when we first went into North Kivu, we wanted to understand more about the political economy. It's a mineral-rich part of DRC: 60 percent of the world's cobalt, the critical ingredient for electric car batteries. The mineral wealth has a lot to do with why it's so unstable. The anthropologists gave us an initial briefing, to help frame the response from WHO.

Since then, we've asked them more mundane but critical questions - about key burial practices, the ongoing perception of the Ebola response. Some of the feedback we got was fascinating. Everyone assumed, this being the 10th outbreak of Ebola in DRC, that there would be a high knowledge and awareness about Ebola. But the level of awareness was abysmal, including among health care workers.

Julia Belluz

There was an interesting Lancet study a little while back showing that people in DRC trust the Ebola vaccine but would not send their family to treatment centers. Is that still the case?

"We have 300 staff, and every night I lose sleep thinking about the fact they are in the line of fire"

Peter Salama

The awareness and knowledge [about Ebola treatment is changing]. There's a much more sophisticated understanding of how this Ebola response fits in with populations' concerns around protection and security. The constant refrain has been, "Look, we think the Ebola response is really important and support it as a community, but we want you to give at least equal if not more attention to our physical protection and security. We don't want to survive Ebola to die from physical violence." The women's groups, the youth groups - they are very articulate about that. They are sending a message to the international community.

Julia Belluz

That seems like a much bigger challenge than your unit or the WHO can address.

Peter Salama

We have 300 staff, and every night I lose sleep thinking about the fact they are in the line of fire. Two weekends ago, a there was a huge incident in Beni. There were bullet holes through several of our staff's walls. They were sending us pictures. We temporarily moved staff who were feeling the effects of being in the line of fire. An ordnance landed on their guesthouse. It didn't explode, but if it did, they probably would have all died.

Julia Belluz

This violence and insecurity - would you still say that's the major impediment to getting this outbreak under control?

Peter Salama

The key challenge here has always been this conflation of really violent security incidences and constant attacks. Beni, the epicenter, has had more than 20 serious attacks since the outbreak was declared on August 1, so it's constant. On the other hand, we know that it is a vicious cycle with the community mistrust. So they go together.

Julia Belluz

But people are accepting the vaccine?

Peter Salama

When you look at the ring vaccination, you find a confirmed case and the contacts around the case and vaccinate them. We have done maybe 240 rings around confirmed cases. With over 90 percent of those rings, we are achieving between 95 and 100 percent of coverage. So there's overwhelming acceptance.

But what comes up more so is people questioning why the vaccine is not being used on a much wider scale - so they are not understanding this ring vaccination strategy.

It's not an easy question to answer. We have to explain that it's a specific strategy that worked for the eradication of a disease [smallpox], and it's worked in previous Ebola responses. Also, we don't have a licensed product and we have a limited quantity, so we have to use a vaccination strategy that conserves the vaccine.

We don't vaccinate the majority of our staff. They aren't at imminent risk if they don't participate in burial work or clinical care. So I haven't been vaccinated because I don't do direct clinical care.

The promise of new Ebola drugs and vaccines

Julia Belluz

WHO is now giving out the vaccine preventively in Uganda - but given all that you've described, it's surprising it hasn't already spread across borders.

Peter Salama

There's been a lot of firsts in this outbreak response, things that have never been done before. One of them is the use of this experimental Ebola vaccine at this scale. We have more than 37, 000 people vaccinated.

We know vaccination is having an important impact. In [outbreaks], we talk about something called the reproductive number [or the number of people one sick person can infect]. Even for Beni, the reproductive number is 1. When Ebola is really hot, it can get up to 2 to 4.

Testing the limits of our Ebola knowledge

Julia Belluz

A lot of observers are talking about this Ebola outbreak as the major test for your health emergencies unit. Has it caused you to rethink how you're working or structured?

Peter Salama

This is probably the biggest test of any public health institution or knowledge in terms of an Ebola outbreak. This is the most difficult context we've seen, and we have people who have been involved in Ebola since the '80s. So it's a test for everyone, including WHO.

We are very confident we have the right people and systems. The issue really is the context - an outbreak that's this volatile requires us to revise strategies regularly. We are keeping open and making sure we listen to experts from various advisory groups.

We are using that [advice] to continue to challenge any assumptions and revise our strategies. There won't be one point in time when we say, "Let's change everything and start again."

We know these strategies - traditional public health measures and breakthroughs like vaccines and therapeutics - will help us stop the outbreak. But the minimum requirement from this point on, according to the epidemic curve, is that it will take six months minimum [to stop the outbreak].

The tension elections in DRC bring

Julia Belluz

This month, there are elections coming up in DRC. This is a moment of real tension given the fraught political environment. Is there a concern that the elections could hamper the response, and what is WHO doing about it?

Peter Salama

The elections are scheduled for December 23, and we are very vigilant in trying to ensure that Ebola is not used as a political issue in the context of the elections.

It's difficult - we have to engage all the community leaders, whether it's the governor of Kivu, the mayor of Beni, opposition parties - to ensure everybody understands this is off the table. We don't want to use Ebola for that purpose. So far, they've been receptive to that. But it's a constant awareness-raising and education process. It's important to have the community behind us on this.

Julia Belluz

I remember learning early on as a health reporter that Ebola was a virus no one thought would go epidemic because it was so hard to transmit - people got so sick and died so fast. But that was knowledge from rural outbreaks, and since it's been showing up in urban areas, we've seen Ebola's true, deadly potential. What's the big takeaway here from an outbreak response point of view?

Peter Salama

In the last two years since I have been here, 80 percent of our major outbreaks have been in conflict-affected areas. This is the issue of the future.

The issue of urban outbreaks of high-threat pathogens is really an issue of our generation. I don't think we've fully grappled with that. Now with yellow fever, plague, with Ebola, we are starting to see these patterns. All bets are off [in terms of] thinking we know about the transmission of diseases because of what happened in rural outbreaks in the past. It's completely different now.

Clarification, December 2: We updated the headline to more accurately reflect the current status of the outbreak.

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Why the Ebola outbreak in DRC is so difficult to contain

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GENEVA - An Ebola epidemic that experts are calling " exceptionally dangerous " is unfolding in the Democratic Republic of Congo. So far, there have been more than 420 cases and 240 deaths, which makes it the largest outbreak of Ebola since the 2014-2016 West Africa outbreak that killed 11,000.

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What is happening to life expectancy in the UK?

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What is happening to life expectancy in the UK?

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A piece of research that looks at key trends, reasons for these trends and why our increasing life expectancy trend has slowed.

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How has life expectancy changed over time?

Mortality rates in England and Wales have declined steadily since the 19th century, leading to a long-term rise in life expectancy 1 for both males and females (Figure 1). Males born in 1841 could expect to live to only 40.2 years and females to 42.2 years, mainly because of high mortality rates in infancy and childhood. Improvements in nutrition, hygiene, housing, sanitation, control of infectious diseases and other public health measures reduced these high rates, increasing life expectancy at birth to 55 years for males and 59 years for females by 1920.

The 20th century saw further dramatic improvements in life expectancy resulting from public health measures such as childhood immunisations, the introduction of universal health care, medical advances (such as in treatment of heart disease and cancer) and lifestyle changes, including a decline in smoking. By 2016 life expectancy at birth had increased to 79.5 years for males and 83.1 years for females (Figure 2).

The effect on healthy life expectancy

Healthy life expectancy 2 has also increased, but not at the same rate as life expectancy, so more years are spent in poor health. Although an English male could expect to live 79.5 years in 2014-16, his average healthy life expectancy was only 63.3 years - ie, he would have spent 16.2 of those years (20 per cent) in 'not good' health.

An English female could expect to live 83.1 years, of which 19.2 years (23 per cent) would have been spent in 'not good' health. And although females live an average of 3.6 years longer than males, much of that time is spent in poor health - they experience only 0.6 more years of good health than men. Rates of disability-free life expectancy are similar to those for healthy life expectancy. Although we focus here mainly on overall life expectancy, further data on healthy and disability-free life expectancy, including for local areas, is available from the Office for National Statistics.

What's the difference in life expectancy between males and females?

Women have always lived longer than men, but the gender gap in 1841 was relatively small (two years) because of the high prevalence in the 19th century of diseases that killed men and women indiscriminately. In the late 19th and early 20th centuries the gender gap started to widen, peaking at 6.3 years by 1971 (see Figure 1 - the difference between male and female life expectancy is the gender gap).

Reasons for the widening gender gap included poor working conditions and rate of smoking for men in contrast to improved life chances for women, for example, lower risk of dying in labour and from tuberculosis, which affected women more than men. The gender gap has decreased since the 1970s, although in 2016 it was nearly double (3.6 years) what it was in 1841 (see Figure 2).

Inequalities in life expectancy

People living in more affluent areas live significantly longer than people living in deprived areas. In 2014-16, males living in the least deprived 10 per cent of areas in England and Wales could expect to live almost a decade (9.3 years) longer than males living in the 10 per cent most deprived areas, and for females the gap was 7.4 years. The gap in healthy life expectancy at birth is even greater - about 19 years for both males and females, and those living in the most deprived areas spend nearly a third of their lives in poor health, compared with only about a sixth for those in the least deprived areas.

Socio-economic inequalities in life expectancy are also widening in both sexes, as a result of greater gains in life expectancy in less deprived populations. Between 2011-13 and 2014-16, the difference in life expectancy between the most and least deprived widened by 0.3 years among males and 0.4 years among females, and life expectancy among the most deprived females fell over this period.

While mortality rates have declined everywhere over time, there is a persistent north-south divide in life expectancy and healthy life expectancy, with people residing in southern regions of England on average living longer and with fewer years in poor health than those living further north. For example, in 2014-16, life expectancy for males was lowest in Blackpool and Manchester and highest in Kensington and Chelsea and East Dorset, with a difference of about nine years. For females, life expectancy was again lowest in Blackpool and Manchester and highest in Camden and Kensington and Chelsea, with a difference of about seven years.

The slowdown in mortality improvements after 2010

2010 marked a turning point in long-term mortality trends, with improvements tailing off after decades of steady decline - in both males and females, and at younger and older ages. In the 100 years to 2010-12, life expectancy increased by nearly three years every decade, but between 2011 and 2016 it increased by only 0.4 years for males and 0.2 years for females.

2015 was an exceptional year when life expectancy fell across virtually all of Europe. The age-standardised mortality rate 3 in England and Wales in 2015 increased by 3 per cent for males and 5 per cent for females over 2014, leading to a fall in life expectancy. Most of the 'excess' deaths occurred early in the year and among people aged 75+.

Although life expectancy has picked up in 2016 and 2017, the Office for National Statistics announcement that the mortality rate in quarter one of 2018 was higher than in any quarter since 2009 prompted the Department of Health and Social Care to ask Public Health England to undertake a review of mortality trends in England and Wales.

How does the UK compare with other European countries?

Life expectancy at birth in 2016 varied by 11.5 years across the EU for males and by almost 8 years for females. Generally, western and southern European countries had higher life expectancies than central and eastern European countries. Women outlive men in all countries.

In 2016 the UK ranked 10th among the 28 EU countries for male life expectancy, but only 17th and below the EU average for females (Figures 3 and 4), with Denmark being the only west European country to have lower female life expectancy. For males in the UK, life expectancy was 1.6 years shorter than the highest seen in the EU (Italy) and for females it was 3.3 years shorter than the highest (Spain).

As in the UK, since 2011 improvements in mortality, and therefore life expectancy, have slowed in many countries in Europe and beyond, and more so in females than males. A recent report shows that compared with 2005-10, during 2011-16 improvements in life expectancy slowed in most of 20 countries examined, including the USA, Canada and Australia; for females the UK showed the greatest slowdown and for males the UK had the second greatest slowdown (after the USA). However, the UK experienced greater improvements than most countries during the earlier period, 2005-10. Some countries (including Japan, Denmark, Italy) did not experience a slow down, with greater improvements in 2011-16 than in the preceding period.

As in the UK, many EU countries also reported increased mortality in 2015 that again disproportionately affected older people and older women more than older men. Compared with 2014, in 2015 life expectancy at birth fell in 23 of the 28 EU countries for females and in 16 EU countries for males. This suggests that the factors causing the increased deaths in England in 2015 also affected many other countries.

Flu caused excess deaths in some winters in both the UK and in Europe, especially among older people and women, as reported by official agencies, and spikes in winter mortality rates show similar patterns across several European countries.

Why have improvements in life expectancy slowed down?

The reasons for the slowdown in mortality improvements in the UK, and why the slowdown has been greater than in many other countries, are unclear and hotly debated.

Several studies have attributed both the 2015 fall in life expectancy and the tailing off of mortality improvements after 2010 to the consequences of austerity-driven constraints on health, social care and other public spending and their impact on services [refs 1-6]. These studies are often based on statistical associations, for example, between mortality trends and the slowdown in spending on health and social care, increased waiting times, rising numbers of delayed discharges from hospital and cuts in welfare benefits.

Others question the methods and findings of the research. While acknowledging that austerity could have had negative consequences on the quality of care, they suggest that the statistical associations don't prove causality and that many other factors, such as the growing complexity of medical conditions in an ageing population, could contribute towards those extra deaths [refs 7-9].

The recent report by the Office for National Statistics showing that the UK has had the lowest rate of improvement in life expectancy since 2011 among western nations other than the USA has added to claims that austerity is the only credible explanation. Some European countries such as Greece, Spain, Portugal and Ireland also experienced austerity-related cuts in public expenditure after the 2008 recession, and they show less slowing of mortality improvements than the UK. There have been calls for the government to undertake an urgent investigation [refs 10-11], and there is now a review of mortality trends in England and Wales by Public Health England under way.

What do we know?

There are some specific changes impacting on different age groups that we know about. For example, flu has been shown to cause extra deaths, especially among older people, and a slowing in the decline in mortality rates for circulatory diseases (such as heart attack and stroke) since 2011 has been a major factor in slowing mortality improvements for people aged 55 and over in all the UK countries. These different factors, and the effects of other changes occurring concurrently such as falling smoking rates and rising levels of obesity and dementia, need to be estimated and disentangled to understand their contribution to overall life expectancy. We also need to understand why these changes are taking place. Given that many of these trends are occurring also in many other countries, it is important to also learn from them.

It's likely that there are several factors contributing to the slowing of improvements in mortality, and hence life expectancy, in this country, but disentangling their effects is complex. For now, the causes of the slowdown in mortality improvements remain unclear but several agencies and researchers are undertaking further investigations to try to understand what's causing it. Given that life expectancy is lower in the UK than in many European countries, especially in females, and that improvements here are weaker, it's important to establish what's happening, why and what can be done to reverse these trends.

We're working with the Health Foundation to investigate mortality trends in the UK and the potential causes for the slowing of mortality improvements. This includes research commissioned by the Health Foundation from the London School of Economics and Political Science, which we will jointly oversee.

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What is happening to life expectancy in the UK?

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How has life expectancy changed over time? Mortality rates in England and Wales have declined steadily since the 19th century, leading to a long-term rise in life expectancy 1 for both males and females (Figure 1). Males born in 1841 could expect to live to only 40.2 years and females to 42.2 years, mainly because of high mortality rates in infancy and childhood.

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Why are the Bolivian's turning against Evo Morales?

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Why are the Bolivian's turning against Evo Morales?

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People who once voted for him in numbers are now turning against him as he changes the constitution again to allow him to run for a 4th term.

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U NLIKE OTHER Latin American presidents with authoritarian leanings, Evo Morales has dominated his country less through coercion than through consent. Bolivia's economy has grown by an average of nearly 5% a year during his 13 years in power, double the Latin American average. Although it remains South America's poorest country, extreme poverty has fallen by more than half, according to the World Bank. Indigenous and mestizo Bolivians, a majority of the population, have made social and economic progress under the first president with indigenous roots. In 2017 he celebrated those achievements by building a museum in his home town whose collection features portraits of himself.

Mr Morales, a former leader of a coca-growers' union, has won three elections fairly and by large margins. He hopes to win a fourth in October. But his attempts to prolong his presidency have become increasingly high-handed. He has tightened his hold over the supposedly independent electoral commission. The government has leaned on the press, for example by withdrawing advertising from critical newspapers. Although Mr Morales might win a fair election in October, many Bolivians are worried that he will hold on to office whatever the vote. That fear has provoked a backlash, which has given heart to a divided opposition.
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Mr Morales's candidacy is itself a cheat. On December 4th the supreme electoral tribunal granted his petition to be allowed to run for a fourth consecutive term. This builds on a ruling in 2017 by the constitutional court, which is as tame as the electoral authority, that all elected officials are entitled to run for re-election as many times as they want. Both decisions contradict the constitution adopted in 2009, which says that office-holders may not serve more than two consecutive terms. The rulings also flout the result of a referendum that Mr Morales held in February 2016, in which a narrow majority voted that he should not be able to seek re-election.

On January 27th Bolivia will hold its first-ever primaries to select presidential candidates for each party, under a law passed last August. The opposition denounces them as a device for giving Mr Morales's candidacy a spurious legitimacy.

The grassroots 21 F movement, named after the date in February when the referendum was held, has staged strikes and demonstrations since the constitutional court's ruling. Its members are mostly from the middle class, which has grown during Mr Morales's presidency and is now the largest socio-economic group, according to Captura, a consultancy. "Evo should leave power because he lost a referendum," says Eli Peredo, a psychologist who took part in a march on December 6th in La Paz, Bolivia's seat of government. The institutions he now threatens "were set up under a constitution that he was instrumental in bringing to life", she points out.

Some indigenous and social movements that once supported Mr Morales are having doubts. The government "has no right to violate the constitution," says Cristóbal Huanca, an Aymara indigenous leader from a village near Oruro, south of La Paz. The government "treats us as though we are right-wing enemies if we disagree with him," he says. Mr Morales's foes are also indignant about corruption, an old problem that he has failed to control.

Protests late last year turned violent. A woman died on December 6th in the northern city of Riberalta when she fell after challenging anti-government demonstrators who had forced shops to shut down. On December 11th the electoral tribunal's regional headquarters and a branch of the government-owned telephone company were destroyed in Santa Cruz, an anti-Morales stronghold. The government blamed the demonstrators, mostly university students. Some witnesses claim that government agents had provoked the vandalism. After a lull, protests may well resume soon.

21 F avoids aligning itself with any political party. But Mr Morales's rivals for the presidency hope to turn its anger into votes. The politician with the best chance of unseating him is Carlos Mesa, a centrist former president. In 2003, when he was Bolivia's vice-president, he broke with the then-president, Gonzalo Sánchez de Lozada, over Mr Sánchez's suppression of protests against the export of natural gas. That earned Mr Mesa, a historian and journalist by profession, popular respect. Some polls suggest he could beat Mr Morales.

But many Bolivians regard Mr Mesa as a representative of the white ruling class, whose political hegemony Mr Morales ended. The opposition, which spans the political spectrum, has so far failed to unite behind him. Six other candidates plan to challenge Mr Morales. Some have called for a boycott of this month's primaries.

The president has reserves of strength. He is the left's only leader of national stature. His party, the Movement towards Socialism, remains powerful in rural areas. Luis Paredes, a bus driver and coffee farmer who has prospered under Mr Morales, worries about slipping backwards if he loses. The president is not a dedicated democrat, Mr Paredes admits. But "frankly, making sure I have a stable income is more important to me than respecting the constitution", he says. Mr Morales is sure to exploit that sentiment.

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The movement to stop Bolivia's President Evo Morales

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UNLIKE OTHER Latin American presidents with authoritarian leanings, Evo Morales has dominated his country less through coercion than through consent. Bolivia's economy has grown by an average of nearly 5% a year during his 13 years in power, double the Latin American average.

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How a President who came to power, overhauled the constitution to enhance the rights of indigenous people, has lost his way.

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Evo Morales's rise from the humblest of origins to the Bolivian presidency has been remarkable. Since taking office five years ago, this son of subsistence farmers has won himself fame, bolstered his support, and filled ordinary Bolivians with pride through his unabashed defense of indigenous rights, his refusal to compromise at the United Nations climate change conference in Copenhagen, and, more broadly, his willingness to thumb his nose at states far larger and more powerful than his own. When the country adopted a new constitution (largely of Morales's making) that enhanced rights for the environment and native peoples in 2009, the leader in La Paz officially turned his charging rhetoric into concrete results. In the space of just a few years, Morales convinced Bolivians, and not just the traditional elites, that their government can serve their interests and make a difference on the world stage.

All this makes the developments of the last month that much more confusing -- and surprising. Many in Bolivia today are asking what went wrong. How is it that, just a year after ushering in a new law that gave unprecedented rights to what he calls "Mother Earth," Morales fought to build a freeway through a national park, trampling on protected indigenous territory? Could it really be that, after protests erupted, the first indigenous president in the history of South America violently repressed the very people who were instrumental in granting him that honor in the first place, leaving more than 100 injured?

In fact, he did both, which has caused a political crisis in La Paz and undermined his comfortable grip on power. The explanation for Morales's confusing turnaround lies in something that Bolivian dissidents have been complaining about for a while now. The leader's intransigence -- the exact quality that helped him remake Bolivia -- now threatens to undermine his administration.

To be fair, there are many reasons for Morales's about-face. His constituents push for inconsistent agendas -- many of them want both development and conservation,

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The Rise and Fall of Bolivia's Evo Morales

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Evo Morales's rise from the humblest of origins to the Bolivian presidency has been remarkable. Since taking office five years ago, this son of subsistence farmers has won himself fame, bolstered his support, and filled ordinary Bolivians with pride through his unabashed defense of indigenous rights, his refusal to compromise at the United Nations climate change conference in Copenhagen, and, more broadly, his willingness to thumb his nose at states far larger and more powerful than his own.

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The Taliban say they will rule Afghanistan according to Sharia, or Islamic law.

The militant Islamist group have taken control after the departure of US and allied forces from the country.

What have the Taliban said?

In the first press briefing after taking power, a Taliban spokesman said issues such as the media and women's rights would be respected "within the framework of Islamic law", but the group has not yet provided any details of what that will mean in practice.

The Taliban have been known for their strict interpretation of Sharia, including punishments such as public executions of convicted murderers and adulterers.

What is Sharia?

Sharia is Islam's legal system.

It is derived from the Quran, Islam's holy book, as well as the Sunnah and Hadith - the deeds and sayings of the Prophet Muhammad.

Where an answer cannot be derived directly from these, religious scholars may give rulings as guidance on a particular topic or question.

In Arabic, Sharia literally means "the clear, well-trodden path to water".

Sharia acts as a code for living that all Muslims should adhere to, including prayers, fasting and donations to the poor.

It aims to help Muslims understand how they should lead every aspect of their lives according to God's wishes.

What does this mean in practice?

Sharia can inform every aspect of daily life for a Muslim.

For example, a Muslim wondering what to do if their colleagues invite them to the pub after work may turn to a Sharia scholar for advice to ensure they act within the legal framework of their religion.

Other areas of daily life where Muslims may turn to Sharia for guidance include family law, finance and business.

How are rulings made?

Like any legal system, Sharia is complex and its practice is entirely reliant on the quality and training of experts.

Islamic jurists issue guidance and rulings. Guidance that is considered a formal legal ruling is called a fatwa.

There are five different schools of Islamic law. There are four Sunni schools: Hanbali, Maliki, Shafi'i and Hanafi, and one Shia school, Jaafari.

The five schools differ in how literally they interpret the texts from which Sharia law is derived.

Interpretation of Islamic law is also nuanced according to local culture and customs, which means Sharia may look quite different in different places.

What are some of the tough punishments?

Islamic scholars says Sharia is mainly a code of ethical conduct and about worship and charity but a part of it deals with crime.

Sharia law divides offences into two general categories: "hadd" offences, which are serious crimes with set penalties, and "tazir" crimes, where the punishment is left to the discretion of the judge.

Hadd offences include theft, which under the strictest interpretations of Sharia, can be punishable by amputating the offender's hand.

There are many safeguards and a high burden of proof in the application of hadd penalties. But experts say that often doesn't happen in practice.

Some countries where Islamic law is applied adopt or enforce such punishments for hadd offences, and surveys have suggested attitudes of Muslims to harsh penalties for such offences vary widely.

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What is Sharia law? What does it mean for women in Afghanistan?

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The Taliban say they will rule Afghanistan according to Sharia, or Islamic law. The militant Islamist group have taken control after the departure of US and allied forces from the country. What have the Taliban said?

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How Castro chose to prioritise health over economic development and why doctors now earn so much on foreign missions for Cuba.

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How Doctors Became Cuba's Biggest Export

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The Communist country has been sending doctors abroad since 1963, bringing in billions of dollars each year.