The World health report : 2005 : make every mother and child count.

Publication date: 2005

Make every mother and child count The World Health Report 2005 World Health Organization ii Design: Reda Sadki Layout: Steve Ewart and Reda Sadki Figures: Christophe Grangier Photo retouching: Reda Sadki and Denis Meissner Printing coordination: Keith Wynn Printed in France This report was produced under the overall direction of Joy Phumaphi (Assistant Director-General, Family and Child Health), Tim Evans (Assistant Director-General, Evidence and Information for Policy) and Wim Van Lerberghe (Editor-in-Chief). The principal authors were Wim Van Lerberghe, Annick Manuel, Zoë Matthews and Cathy Wolfheim. Thomson Prentice was the Managing Editor. Valuable inputs (contributions, background papers, analytical work, reviewing, suggestions and criticism) were received from Elisabeth Aahman, Carla Abou-Zahr, Fiifi Amoako Johnson, Fred Arnold, Alberta Bacci, Rajiv Bahl, Rebecca Bailey, Robert Beaglehole, Rafael Bengoa, Janie Benson, Yves Bergevin, Stan Bernstein, Julian Bilous, Ties Boerma, Jo Borghi, Paul Bossyns, Assia Brandrup-Lukanov, Eric Buch, Flavia Bustreo, Meena Cabral de Mello, Virginia Camacho, Guy Carrin, Andrew Cassels, Kathryn Church, Alessandro Colombo, Jane Cottingham, Bernadette Daelmans, Mario Dal Poz, Catherine d’Arcangues, Hugh Darrah, Luc de Bernis, Isabelle de Zoysa, Maria Del Carmen, Carmen Dolea, Gilles Dussault, Steve Ebener, Dominique Egger, Gerry Eijkemans, Bjorn Ekman, Zine Elmorjani, Tim Ensor, Marthe Sylvie Essengue, David Evans, Vincent Fauveau, Paulo Ferrinho, Helga Fogstad, Marta Gacic Dobo, Ulf Gerdham, Adrienne Germain, Peter Ghys, Elizabeth Goodburn, Veloshnee Govender, Metin Gulmezoglu, Jean-Pierre Habicht, Sarah Hall, Laurence Haller, Steve Harvey, Peggy Henderson, Patricia Hernández, Peter Hill, Dale Huntington, Julia Hussein, Guy Hutton, Mie Inoue, Monir Islam, Christopher James, Craig Janes, Ben Johns, Rita Kabra, Betty Kirkwood, Lianne Kuppens, Joy Lawn, Jerker Liljestrand, Ornella Lincetto, Craig Lissner, Alessandro Loretti, Jane Lucas, Doris Ma Fat, Carolyn Maclennan, Ramez Mahaini, Sudhansh Malhostra, Adriane Martin Hilber, José Martines, Elizabeth Mason, Matthews Mathai, Dileep Mavalankar, Gillian Mayers, Juliet McEachren, Abdelhai Mechbal, Mario Merialdi, Tom Merrick, Thierry Mertens, Susan Murray, Adepeju Olukoya, Guillermo Paraje, Justin Parkhurst, Amit Patel, Vikram Patel, Steve Pearson, Gretel Pelto, Jean Perrot, Annie Portela, Dheepa Rajan, K.V. Ramani, Esther Ratsma, Linda Richter, David Sanders, Parvathy Sankar, Robert Scherpbier, Peelam Sekhri, Gita Sen, Iqbal Shah, Della Sherratt, Kenji Shibuya, Kristjana Sigurbjornsdottir, Angelica Sousa, Niko Speybroeck, Karin Stenberg, Will Stones, Tessa Tan-Torres Edejer, Petra Ten Hoope-Bender, Ann Tinker, Wim Van Damme, Jos Vandelaer, Paul Van Look, Marcel Vekemans, Cesar Victora, Eugenio Villar Montesinos, Yasmin Von Schirnding, Eva Wallstam, Steve Wiersma, Karl Wilhelmson, Lara Wolfson, Juliana Yartey and Jelka Zupan. Contributers to statistical tables were: Elisabeth Aahman, Dorjsuren Bayarsaikhan, Ana Betran, Zulfiqar Bhutta, Maureen Birmingham, Robert Black, Ties Boerma, Cynthia Boschi-Pinto, Jennifer Bryce, Agnes Couffinhal, Simon Cousens, Trevor Croft, David D. Vans, Charu C. Garg, Kim Gustavsen, Nasim Haque, Patricia Hernández, Ken Hill, Chandika Indikadahena, Mie Inoue, Gareth Jones, Betty Kirkwood, Joseph Kutzin, Joy Lawn, Eduardo Levcovitz, Edilberto Loaiza, Doris Ma Fat, José Martines, Elizabeth Mason, Colin Mathers, Saul Morris, Kim Mulholland, Takondwa Mwase, Bernard Nahlen, Pamela Nakamba-Kabaso, Agnès Prudhomme, Rachel Racelis, Olivier Ronveaux, Alex Rowe, Hossein Salehi, Ian Scott, U Than Sein, Kenji Shibuya, Rick Steketee, Rubén Suarez, Tessa Tan-Torres Edejer, Nathalie van de Maele, Tessa Wardlaw, Neff Walker, Hongyi Xu, Jelka Zupan, and many staff in WHO country offices, governmental departments and agencies, and international institutions. Valuable comments and guidance were provided by Denis Aitken and Michel Jancloes. Additional help and advice were kindly provided by Regional Directors and members of their staff. The report was edited by Leo Vita-Finzi, assisted by Barbara Campanini. Editorial, administrative and production support was provided by Shelagh Probst and Gary Walker, who also coordinated the photographs. The web site version and other electronic media were provided by Gael Kernen. Proofreading was by Marie Fitzsimmons. The index was prepared by Kathleen Lyle. Front cover photographs (clockwise from top left): L. Gubb/WHO; Pepito Frias/WHO; Armando Waak/WHO/PAHO; Carlos Gaggero/WHO/PAHO; Liba Taylor/WHO; Pierre Virot/WHO. Back cover photographs (left to right): Pierre Virot/WHO; J. Gorstein/WHO; G. Diez/WHO; Pierre Virot/WHO. This report contains several photographs from “River of Life 2004” – a WHO photo competition on the theme of sexual and reproductive health. WHO Library Cataloguing-in-Publication Data World Health Organization. The World health report : 2005 : make every mother and child count. 1.World health - trends 2.Maternal welfare 3.Child welfare. 4.Maternal health services - organization and administration. 5.Child health services - organization and administration 6.World Health Organization I.Title II.Title: Make every mother and child count. ISBN 92 4 156290 0 (NLM Classification: WA 540.1) ISSN 1020-3311 © World Health Organization 2005 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). 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Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland E-mail: whr@who.int Copies of this publication can be ordered from: bookorders@who.int The World Health Report 2005 iii contents Message from the Director-General xi Overview xiii Patchy progress and widening gaps – what went wrong? xiv Making the right technical and strategic choices xiv Moving towards universal coverage: access for all, with financial protection xvi Chapter summaries xix Chapter 1 Mothers and children matter – so does their health 1 The early years of maternal and child health 2 Where we are now: a moral and political imperative 3 Mothers, children and the Millennium Development Goals 7 Uneven gains in child health 8 The newborn deaths that went unnoticed 9 Few signs of improvement in maternal health 10 A patchwork of progress, stagnation and reversal 12 The numbers remain high 13 Chapter 2 Obstacles to progress: context or policy? 21 Context matters 22 Poverty undermines progress 22 The direct and indirect effects of HIV/AIDS 23 Conflicts and emergencies set systems back 24 The many faces of exclusion from care 25 Sources of exclusion 26 Patterns of exclusion 29 Different exclusion patterns, different challenges 30 Are districts the right strategy for moving towards universal coverage? 32 A strategy without resources 32 Have districts failed the test? 33 overview iv Chapter 3 Great expectations: making pregnancy safer 41 Realizing the potential of antenatal care 42 Meeting expectations in pregnancy 42 Pregnancy – a time with its own dangers 44 Seizing the opportunities 46 Critical directions for the future 47 Not every pregnancy is welcome 48 Planning pregnancies before they even happen 48 Unsafe abortion: a major public health problem 50 Dealing with the complications of abortion 51 Valuing pregnancy: a matter of legal protection 52 Chapter 4 Attending to 136 million births, every year 61 Risking death to give life 61 Skilled professional care: at birth and afterwards 65 Successes and reversals: a matter of building health systems 65 Skilled care: rethinking the division of labour 68 Care that is close to women – and safe 69 A back-up in case of complications 72 Rolling out services simultaneously 73 Postpartum care is just as important 73 Chapter 5 Newborns: no longer going unnoticed 79 The greatest risks to life are in its beginning 79 Progress and some reversals 82 No longer falling between the cracks 85 Care during pregnancy 86 Professional care at birth 86 Caring for the baby at home 88 Ensuring continuity of care 89 Planning for universal access 90 Benchmarks for supply-side needs 90 Room for optimism, reasons for caution 91 Closing the human resource and infrastructure gap 93 Scenarios for scaling up 93 Costing the scale up 98 Chapter 6 Redesigning child care: survival, growth and development 103 Improving the chances of survival 103 The ambitions of the primary health care movement 103 The successes of vertical programmes 103 Time for a change of strategy 105 Combining a wider range of interventions 105 Dealing with children, not just with diseases 107 Organizing integrated child care 108 The World Health Report 2005 v Households and health workers 109 Referring sick children 111 Bringing care closer to children 112 Rolling out child health interventions 112 The cost of scaling up coverage 115 From cost projections to scaling up 117 Chapter 7 Reconciling maternal, newborn and child health with health system development 125 Repositioning MNCH 125 Different constituencies, different languages 128 Sustaining political momentum 130 Rehabilitating the workforce 132 Not just a question of numbers 132 Recovering from the legacy of past neglect 134 Destabilization with the best of intentions 136 Tackling the salary problem 136 Financial protection to ensure universal access 137 Replacing user fees by prepayment, pooling and a refinancing of the sector 138 Making the most of transitory financial protection mechanisms 139 Generalizing financial protection 140 Channelling funds effectively 140 Statistical annex 149 Explanatory notes 149 Annex Table 1 Basic indicators for all WHO Member States 174 Annex Table 2a Under-five mortality rates: estimates for 2003, annual average percent change 1990–2003, and availability of data 1980–2003 182 Annex Table 2b Under-five mortality rates (per 1000) directly obtained from surveys and vital registration, by age and latest available period or year 186 Annex Table 3 Annual number of deaths by cause for children under five years of age in WHO regions, estimates for 2000–2003 190 Annex Table 4 Annual number of deaths by cause for neonates in WHO regions, estimates for 2000–2003 190 Annex Table 5 Selected national health accounts indicators: measured levels of expenditure on health, 1998–2002 192 Annex Table 6 Selected national health accounts indicators: measured levels of per capita expenditure on health, 1998–2002 200 Annex Table 7 Selected immunization indicators in all WHO Member States 204 Annex Table 8 Selected indicators related to reproductive, maternal and newborn health 212 overview vi Index 221 Figures Figure 1.1 Slowing progress in child mortality: how Africa is faring worst 8 Figure 1.2 Neonatal and maternal mortality are related to the absence of a skilled birth attendant 10 Figure 1.3 Changes in under-5 mortality rates, 1990–2003: countries showing progress, stagnation or reversal 14 Figure 1.4 Patterns of reduction of under-5 mortality rates, 1990–2003 14 Figure 1.5 Maternal mortality ratio per 100 000 live births in 2000 15 Figure 1.6 Neonatal mortality rate per 1000 live births in 2000 15 Figure 2.1 A temporary reversal in maternal mortality: Mongolia in the early 1990s 23 Figure 2.2 Levelling off after remarkable progress: DTP3 vaccine coverage since 1980 26 Figure 2.3 Different patterns of exclusion: massive deprivation at low levels of coverage and marginalization of the poorest at high levels 29 Figure 2.4 From massive deprivation to marginal exclusion: moving up the coverage ladder 30 Figure 2.5 Survival gap between rich and poor: widening in some countries, narrowing in others 31 Figure 3.1 Coverage of antenatal care is rising 42 Figure 3.2 The outcomes of a year’s pregnancies 49 Figure 3.3 Grounds on which abortion is permitted around the world 52 Figure 4.1 Causes of maternal death 62 Figure 4.2 Maternal mortality since the 1960s in Malaysia, Sri Lanka and Thailand 66 Figure 4.3 Number of years to halve maternal mortality, selected countries 68 Figure 5.1 Deaths before five years of age, 2000 80 Figure 5.2 Number of neonatal deaths by cause, 2000–2003 80 The World Health Report 2005 vii Figure 5.3 Changes in neonatal mortality rates between 1995 and 2000 81 Figure 5.4 Neonatal mortality in African countries shows stagnation and some unusual reversals 82 Figure 5.5 Neonatal mortality is lower when mothers have received professional care 88 Figure 5.6 The proportion of births in health facilities and those attended by medical doctors is increasing 92 Figure 5.7 The human resource gap in Benin, Burkina Faso, Mali and Niger, 2001 95 Figure 5.8 Cost of scaling up maternal and newborn care, additional to current expenditure 96 Figure 6.1 An integrated approach to child health 111 Figure 6.2 Proportion of districts where training and system strengthening for IMCI had been started by 2003 114 Figure 6.3 Cost of scaling up child health interventions, additional to current expenditure 116 Boxes Box 1.1 Milestones in the establishment of the rights of women and children 5 Box 1.2 Why invest public money in health care for mothers and children? 6 Box 1.3 A reversal of maternal mortality in Malawi 11 Box 1.4 Counting births and deaths 12 Box 2.1 Economic crisis and health system meltdown: a fatal cascade of events 22 Box 2.2 How HIV/AIDS affects the health of women and children 23 Box 2.3 Health districts can make progress, even in adverse circumstances 25 Box 2.4 Mapping exclusion from life-saving obstetric care 27 Box 2.5 Building functional health districts: sustainable results require a long-term commitment 34 Box 3.1 Reducing the burden of malaria in pregnant women and their children 44 Box 3.2 Anaemia – the silent killer 45 overview viii Box 3.3 Violence against women 47 Box 4.1 Obstetric fistula: surviving with dignity 64 Box 4.2 Maternal depression affects both mothers and children 65 Box 4.3 Screening for high-risk childbirth: a disappointment 69 Box 4.4 Traditional birth attendants: another disappointment 70 Box 4.5 Preparing practitioners for safe and effective practice 72 Box 5.1 Explaining variations in maternal, neonatal and child mortality: care or context? 83 Box 5.2 Sex selection 85 Box 5.3 Overmedicalization 94 Box 5.4 A breakdown of the projected costs of extending the coverage of maternal and newborn care 97 Box 6.1 What do children die of today? 106 Box 6.2 How households can make a difference 110 Box 6.3 A breakdown of the projected cost of scaling up 118 Box 7.1 International funds for maternal, newborn and child health 126 Box 7.2 Building pressure: the partnerships for maternal, newborn and child health 127 Box 7.3 MNCH, poverty and the need for strategic information 128 Box 7.4 Sector-wide approaches 129 Box 7.5 Rebuilding health systems in post-crisis situations 133 Box 7.6 Civil society involvement requires support 142 The World Health Report 2005 ix Tables Table 1.1 Neonatal and maternal mortality in countries where the decline in child mortality has stagnated or reversed 16 Table 2.1 Factors hindering progress 22 Table 4.1 Incidence of major complications of childbirth, worldwide 63 Table 4.2 Key features of first-level and back-up maternal and newborn care 71 Table 5.1 Filling the supply gap to scale up first-level and back-up maternal and newborn care in 75 countries (from the current 43% to 73% coverage by 2015 and full coverage in 2030) 96 Table 6.1 Core interventions to improve child survival 115 overview x The World Health Report 2005 xi Parenthood brings with it the strong desire to see our children grow up happily and in good health. This is one of the few constants in life in all parts of the world. Yet, even in the 21st century, we still allow well over 10 million children and half a million moth- ers to die each year, although most of these deaths can be avoided. Seventy million mothers and their newborn babies, as well as countless children, are excluded from the health care to which they are entitled. Even more numerous are those who remain without protection against the poverty that ill-health can cause. Leaders readily agree that we cannot allow this to continue, but in many countries the situation is either improving too slowly or not improving at all, and in some it is getting worse. Mothers, the newborn and children represent the well-being of a society and its potential for the future. Their health needs cannot be left unmet without harming the whole of society. Families and communities themselves can do a great deal to change this situation. They can improve, for example, the position of women in society, parenting, disease prevention, care for the sick, and uptake of services. But this area of health is also a public responsibility. Public health programmes need to work together so that all families have access to a continuum of care that extends from pregnancy (and even before), through childbirth and on into childhood, instead of the often fragmented services available at present. It makes no sense to provide care for a child while ignoring the mother’s health, or to assist a mother giving birth but not the newborn child. To ensure that all families have access to care, governments must accelerate the building up of coherent, integrated and effective health systems. This means tackling the health workforce crisis, which in turn calls for a much higher level of funding and better organization of it for these aspects of health. The objective must be health sys- tems that can respond to these needs, eliminate financial barriers to care, and protect people from the poverty that is both a cause and an effect of ill-health. The world needs to support countries striving to achieve universal access and finan- cial protection for all mothers and children. Only by doing so can we make sure that every mother, newborn baby and child in need of care can obtain it, and no one is driven into poverty by the cost of that care. In this way we can move not only towards the Millennium Development Goals but beyond them. message from the director-general LEE Jong-wook Director-General World Health Organization Geneva, April 2005 overview xii The World Health Report 2005 xiiioverview overview This year’s World Health Report comes at a time when only a decade is left to achieve the Millennium Development Goals (MDGs), which set internationally agreed devel- opment aspirations for the world’s population to be met by 2015. These goals have underlined the importance of improving health, and particularly the health of mothers and children, as an integral part of poverty reduction. The health of mothers and children is a priority that emerged long before the 1990s – it builds on a century of programmes, activities and experience. What is new in the last decade, however, is the global focus of the MDGs and their insistence on tracking progress in every part of the world. Moreover, the nature of the priority status of ma- ternal and child health (MCH) has changed over time. Whereas mothers and children were previously thought of as targets for well-intentioned programmes, they now increasingly claim the right to access quality care as an entitlement guaranteed by the state. In doing so, they have transformed maternal and child health from a technical concern into a moral and political imperative. This report identifies exclusion as a key feature of inequity as well as a key constraint to progress. In many countries, universal access to the care all women and children are entitled to is still far from realization. Taking stock of the erratic progress to date, the report sets out the strategies required for the accelerated improvements that are known to be possible. It is necessary to refocus the technical strategies developed within maternal and child health programmes, and also to put more emphasis on the importance of the often overlooked health problems of newborns. In this regard, the report advocates the repositioning of MCH as MNCH (maternal, newborn and child health). The proper technical strategies to improve MNCH can be put in place effectively only if they are implemented, across programmes and service providers, throughout pregnancy and childbirth through to childhood. It makes no sense to provide care for a child and ignore the mother, or to worry about a mother giving birth and fail to pay attention to the health of the baby. To provide families universal access to such a continuum of care requires programmes to work together, but is ultimately dependent on extending and strengthening health systems. At the same time, placing MNCH at the core of the drive for universal access provides a platform for building sustainable health systems where existing structures are weak or fragile. Even where the MDGs will not be fully achieved by 2015, moving towards universal access has the potential to transform the lives of millions for decades to come. xiv The World Health Report 2005 PATCHY PROGRESS AND WIDENING GAPS – WHAT WENT WRONG? Each year 3.3 million babies – or maybe even more – are stillborn, more than 4 million die within 28 days of coming into the world, and a further 6.6 million young children die before their fifth birthday. Maternal deaths also continue unabated – the annual total now stands at 529 000 often sudden, unpredicted deaths which occur during preg- nancy itself (some 68 000 as a consequence of unsafe abortion), during childbirth, or after the baby has been born – leaving behind devastated families, often pushed into poverty because of the cost of health care that came too late or was ineffective. How can it be that this situation continues when the causes of these deaths are largely avoidable? And why is it still necessary for this report to emphasize the impor- tance of focusing on the health of mothers, newborns and children, after decades of priority status, and more than 10 years after the United Nations International Confer- ence on Population and Development put access to reproductive health care for all firmly on the agenda? Although an increasing number of countries have succeeded in improving the health and well-being of mothers, babies and children in recent years, the countries that started off with the highest burdens of mortality and ill-health made least progress during the 1990s. In some countries the situation has actually worsened, and worry- ing reversals in newborn, child and maternal mortality have taken place. Progress has slowed down and is increasingly uneven, leaving large disparities between countries as well as between the poor and the rich within countries. Unless efforts are stepped up radically, there is little hope of eliminating avoidable maternal and child mortality in all countries. Countries where health indicators for mothers, newborns and children have stag- nated or reversed have often been unable to invest sufficiently in health systems. The health districts have had difficulties in organizing access to effective care for women and children. Humanitarian crises, pervasive poverty, and the HIV/AIDS epidemic have all compounded the effect of economic downturns and the health workforce crisis. With widespread exclusion from care and growing inequalities, progress calls for mas- sively strengthened health systems. Technical choices are still important, though, as in the past programmes have not always pursued the best approaches to make good care accessible to all. Too often, programmes have been allowed to fragment, thus hampering the continuity of care, or have failed to give due attention to professionalizing services. Technical experi- ence and the successes and failures of the recent past have shown how best to move forward. MAKING THE RIGHT TECHNICAL AND STRATEGIC CHOICES There is no doubt that the technical knowledge exists to respond to many, if not most, of the critical health problems and hazards that affect the health and survival of mothers, newborns and children. The strategies through which households and health systems together can make sure these technical solutions are put into action for all, in the right place and at the right time, are also becoming increasingly clear. Antenatal care is a major success story: demand has increased and continues to increase in most parts of the world. However, more can be made of the considerable potential of antenatal care by emphasizing effective interventions and by using it as a platform for other health programmes such as HIV/AIDS and the prevention and treat- ment of sexually transmitted infections, tuberculosis and malaria initiatives, and family xvoverview planning. Health workers, too, can make more use of antenatal care to help mothers prepare for birthing and parenting, or to assist them in dealing with an environment that does not always favour a healthy and happy pregnancy. Pregnant women, adoles- cents in particular, may be exposed to violence, discrimination in the workplace or at school, or marginalization. Such problems need to be dealt with also, but not only, by improving the social, political and legal environments. A case in point is how societies face up to the problem of the many millions of unintended, mistimed and unwanted pregnancies. There remains a large unmet need for contraception, as well as for more and better information and education. There is also a real need to facilitate access to responsive post-abortion care of high quality and to safe abortion services to the fullest extent allowed by law. Attending to all of the 136 million births every year is one of the major challenges that now faces the world’s health systems. This challenge will increase in the near future as large cohorts of young people move into their reproductive years, mainly in those parts of the world where giving birth is most dangerous. Women risk death to give life, but with skilled and responsive care, at and after birth, nearly all fatal outcomes and disabling sequelae can be averted – the tragedy of obstetric fistulas, for example – and much of the suffering can be eased. Childbirth is a central event in the lives of families and in the construction of communities; it should remain so, but it must be made safe as well. For optimum safety, every woman, without exception, needs professional skilled care when giving birth, in an appropriate environment that is close to where she lives and respects her birthing culture. Such care can best be provided by a registered midwife or a health worker with midwifery skills, in decentralized, first-level facilities. This can avert, contain or solve many of the life-threatening problems that may arise during childbirth, and reduce maternal mortality to surprisingly low levels. Skilled midwifery professionals do need the back-up only a hospital can provide, however, for women with problems that go beyond the competency or equipment available at the first level of care. All women need first-level maternal care and back-up care is only necessary for a minority, but to be effective both levels need to work in tandem and both must be put in place simultaneously. The need for care does not stop as soon as the birth is over. The hours, days and weeks that follow birth can be dangerous for women as well as for their babies. The welcome emphasis, in recent years, on improving skilled attendance at birth should not divert attention from this critical period, during which half of maternal deaths oc- cur as well as a considerable amount of illness. There is an urgent need to develop effective ways of organizing continuity of care during the first weeks after birth, when health service responsibilities are often ill-defined or ambiguous. The postpartum gap in providing care for women is also a postnatal gap. Although the picture of the unmet need in caring for newborns is still very incomplete, it shows that the health problems of newborns have been unduly neglected and underesti- mated. Newborn babies seem to have fallen between the cracks of safe motherhood programmes on one side and child survival initiatives on the other. Newborn mortality is a sizeable proportion of the mortality of children under five years of age. It has become clear that the MDG for child mortality will not be reached without substantial advances for the newborn. Although modest declines in neonatal mortality have oc- curred worldwide (for example, vaccination is well on the way to eliminating tetanus as a cause of neonatal death), in sub-Saharan Africa some countries have seen reversals that are both unusual and disturbing. xvi The World Health Report 2005 Progress in newborn health does not require expensive technology. It does however require health systems that provide continuity of care starting from the beginning of pregnancy (and even before) and continuing through professional skilled care at birth into the postnatal period. Most crucially, there is a need to ensure that the delicate and often overlooked handover between maternal and child services actually takes place. Newborns who are breastfed, loved and kept warm will mostly be fine, but problems can and do occur. It is essential to empower households – mothers and fathers in particular – so that they can take good care of their babies, recognize dangers early, and get professional help immediately when difficulties arise. The greatest risks to life are in its beginning, but they do not disappear as the newborn grows into an infant and a young child. Programmes to tackle vaccine- preventable diseases, malnutrition, diarrhoea, or respiratory infections still have a large unfinished agenda. Immunization, for example, has made satisfactory progress in some regions, but in others coverage is stagnating at levels between 50% and 70% and has to find a new momentum. These programmes have, however, made such inroads on the burden of ill-health that in many countries its profile has changed. There is now a need for more integrated approaches: first, to deal efficiently with the changing spectrum of problems that need attention; second, to broaden the focus of care from the child’s survival to its growth and development. This is what is needed from a public health point of view; it is also what families expect. The Integrated Management of Childhood Illness (IMCI) combines a set of effective interventions for preventing death and for improving healthy growth and develop- ment. More than just adding more subsets to a single delivery channel, IMCI has transformed the way the health system looks at child care – going beyond the mere treatment of illness. IMCI has three components: improving the skills of health workers to treat diseases and to counsel families, strengthening the health system’s support, and helping households and communities to bring up their children healthily and deal with ill-health when it occurs. IMCI has thus moved beyond the traditional notion of health centre staff providing a set of technical interventions to their target population. It is bringing health care closer to the home, while at the same time improving refer- ral links and hospital care; the challenge now is to make IMCI available to all families with children, and create the conditions for them to avail themselves of such care whenever needed. MOVING TOWARDS UNIVERSAL COVERAGE: ACCESS FOR ALL, WITH FINANCIAL PROTECTION There is a strong consensus that, even if all the right technical choices are made, maternal, newborn and child health programmes will only be effective if together, and with households and communities, they establish a continuum of care, from pregnancy through childbirth into childhood. This continuity requires greatly strengthened health systems with maternal, newborn and child health care at the core of their develop- ment strategies. It is forcing programmes and stakeholders with different histories, interests and constituencies to join forces. The common project that can pull together the different agendas is universal access to care. This is not just a question of fine- tuning advocacy language: it frames the health of mothers, babies and children within a broader, straightforward political project, responding to society’s claim for the pro- tection of the health of its citizens and for access to care – a claim that is increasingly seen as legitimate. The magnitude of the challenge of scaling up services towards universal access, however, should not be underestimated. xviioverview Reaching all children with a package of essential child health interventions neces- sary to comply with and even go beyond the MDGs is technically feasible within the next decade. In the 75 countries that account for most of child mortality this will require US$ 52.4 billion, in addition to current expenditure, of which US$ 25 billion represents additional costs for human resources. This US$ 52.4 billion corresponds to an increase as of now of 6% of current median public expenditure on health in these countries, rising to 18% by 2015. In the 21 countries facing the greatest constraints and where a long lead time is likely, current public expenditure on health would have to grow by 27% as of 2006, rising to around 76% in 2015. For maternal and newborn care, universal access is further away. It is possible to envisage various scenarios for scaling up services, taking into account the specific cir- cumstances in each of the same 75 countries. At present, some 43% of mothers and newborns receive some care, but by no means the full range of what they need even just to avoid maternal deaths. Adding up the optimistic – but also realistic – scenarios for each of the 75 countries gives access to a full package of first-level and back-up care to 101 million mothers (some 73% of the expected births) in 2015, and to their babies. If these scenarios were implemented, the MDG for maternal health would not be reached in every country, but the reduction of maternal and perinatal mortality globally would be well on the way. The costs of implementing these 75 country sce- narios would be in the region of US$ 39 billion additional to current expenditure. This corresponds to a growth of 3%, in 2006, rising to 14% over the years, of current me- dian public expenditure on health in these countries. In the 20 countries with currently the lowest coverage and facing the greatest constraints, current public expenditure on health would have to grow by 7% in 2006, rising to 43% in 2015. Putting in place the health workforce needed for scaling up maternal, newborn and child health services towards universal access is the first and most pressing task. Making up for the staggering shortages and imbalances in the distribution of health workers in many countries will remain a major challenge for years to come. The extra work required for scaling up child care activities requires the equivalent of 100 000 full-time multipurpose professionals, supplemented, according to the sce- narios that have been costed, by 4.6 million community health workers. Projected staffing requirements for extending coverage of maternal and newborn care assumes the production in the coming 10 years of at least 334 000 additional midwives – or their equivalents – as well as the upgrading of 140 000 health professionals who are currently providing first-level maternal care and of 27 000 doctors who currently do not have the competencies to provide back-up care. Without planning and capacity-building, at national level and within health districts, it will not be possible to correct the shortages and to improve the skills mix and the working environment. Planning is not enough, however, to put right disruptive histories that have eroded workforce development. After years of neglect there are problems that require immediate attention: first and foremost is the nagging question of the remuneration of the workforce. In many countries, salary levels are rightfully considered unfair and insufficient to provide for daily living costs, let alone to live up to the expectations of health profes- sionals. This situation is one of the root causes of demotivation, lack of productivity and the various forms of brain-drain and migration: rural to urban, public to private and from poorer to richer countries. It also seriously hampers the correct functioning of services as health workers set up in dual practice to improve their living conditions or merely to make ends meet – leading to competition for time, a loss of resources for xviii The World Health Report 2005 the public sector, and conflicts of interest in dealing with their clients. There are even more serious consequences when health workers resort to predatory behaviour: finan- cial exploitation may have catastrophic effects on patients who use the services, and create barriers to access for others; it contributes to a crisis of trust in the services to which mothers and children are entitled. There is an urgent need to invent and deploy a whole range of measures to break the vicious circle, and bring productivity and dedication back to the level the popula- tion expects and to which most health workers aspire. Among these, one of the most challenging is rehabilitating the workforce’s remuneration. Even a modest attempt to do so, such as doubling or even tripling the total workforce’s salary mass and benefits in the 75 countries for which scenarios were developed, might still be insufficient to attract, retain and redeploy quality staff. But it would correspond to an increase of 2% rising, over 10 years, to 17% of current public expenditure on health, merely for payment of the MNCH workforce. Such a measure would have political and macro- economic implications and is something that cannot be done without a major effort, not only by governments but by international solidarity as well. On the eve of a decade that will be focused on human resources for health, this will require a fundamental debate, in countries as well as internationally, on the volume of the funds that can be allocated and on the channelling of these funds. This is all the more important because rehabilitating the remuneration of the workforce is only one part of the answer: estab- lishing an atmosphere of stability and hope is also needed to give health professionals the confidence they need to work effectively and with dedication. At the same time, ensuring universal access is not merely a question of increasing the supply of services and paying health care providers. For services to be taken up, financial barriers to access have to be eliminated and users given predictable financial protection against the costs of seeking care, and particularly against the catastrophic payments that can push households into poverty. Such catastrophic payments occur wherever user charges are significant, households have limited ability to pay, and pooling and prepayment is not generalized. To attain the financial protection that has to go with universal access, countries throughout the world have to move away from user charges, be they official or under-the-counter, and generalize prepayment and pooling schemes. Whether they choose to organize financial protection on the basis of tax-generated funds, through social health insurance or through a mix of schemes, two things are important: first, that ultimately no population groups are excluded; second, that maternal and child health services are at the core of the health entitlements of the population, and that they be financed in a coherent way through the selected system. While it can take many years to move from a situation of a limited supply of services, high out-of-pocket payments and exclusion of the poorest to a situation of universal access and financial protection, the extension of health care supply networks has to proceed in parallel with the construction of such insurance mechanisms. Financing is the killer assumption underlying the planning of maternal, newborn and child health care. First, increased funding is required to pay for building up the supply of services towards universal access. Second, financial protection systems have to be built at the same time as access improves. Third, the channelling of increased funds, both domestic and international, has to guarantee the flexibility and predictability that make it possible to cope with the principal health system constraints – particularly the problems facing the workforce. Channelling increased funding flows through national health insurance schemes – be they organized as tax-based, social health insurance, or mixed systems – offers the best avenue to meet these three challenges simultaneously. It requires major capacity- xixoverview building efforts, but it offers the possibility of protecting the funding of the workforce in public sector and health sector reform policies and in the forums where macroeco- nomic and poverty-reduction policies are decided. It offers the possibility of tackling the problem of the remuneration and the working conditions of health workers in a way that gives them long-term, credible prospects, which traditional budgeting or the stopgap solutions of project funding do not offer. While the financing effort seems to be within reasonable reach in some countries, in many it will go beyond what can be borne by governments alone. Both countries and the international community will need to show a sustained political commitment to mobilize and redirect the considerable resources that are required, to build the in- stitutional capacity to manage them, and to ensure that maternal, newborn and child health remains at the core of these efforts. This decade can be one of accelerating the move towards universal coverage, with access for all and financial protection. That will ensure that no mother, no newborn, and no child in need remains unattended – because every mother and every child counts. CHAPTER SUMMARIES Chapter 1. Mothers and children matter – so does their health This chapter recalls how the health of mothers and children became a public health priority during the 20th century. For centuries, care for mothers and young children was regarded as a domestic affair, the realm of mothers and midwives. In the 20th century this purely domestic concern was transformed into a public health priority. In the opening years of the 21st century, the MDGs place it at the core of the struggle against poverty and inequality, as a matter of human rights. This shift in emphasis has far-reaching consequences for the way the world responds to the very uneven progress in different countries. The chapter summarizes the current situation regarding the health of mothers, new- borns and children. Most progress has been made by countries that were already in a relatively good position in the early 1990s, while countries that started with the highest mortality rates are also those where improvements have been most disap- pointing. Globally, mortality rates in children under five years of age fell throughout the latter part of the 20th century: from 146 per 1000 live births in 1970 to 79 in 2003. Towards the turn of the millennium, however, the overall downward trend started to falter in some parts of the world. Improvements continued or accelerated in the WHO Regions of the Americas, South-East Asia and Europe, while the African, Eastern Mediter- ranean and Western Pacific Regions experienced a slowing down of progress. In 93 countries, totalling 40% of the world population, under-five mortality is decreasing fast. A further 51 countries, with 48% of the world population, are making slower progress: they will only reach the MDGs if improvements are accelerated significantly. Even more worrying are the 43 countries that contain the remaining 12% of the world population, where under-five mortality was high or very high to start with and is now stagnating or reversing. Reliable data on newborns are only recently becoming available and are more dif- ficult to interpret. The most recent estimates show that newborn mortality is consid- erably higher than usually thought and accounts for 40% of under-five deaths; less than 2% of newborn deaths currently occur in high income countries. The difference between rich and poor countries seems to be widening. xx The World Health Report 2005 Over 300 million women in the world currently suffer from long-term or short-term illness brought about by pregnancy or childbirth. The 529 000 annual maternal deaths, including 68 000 deaths attributable to unsafe abortion, are even more unevenly spread than newborn or child deaths: only 1% occur in rich countries. There is a sense of progress, backed by the tracking of indicators that show increases in the uptake of care during pregnancy and childbirth in all regions except sub-Saharan Africa during the 1990s, but the overall picture shows no spectacular improvement, and the lack of reliable information on the fate of mothers in many countries – and on that of their newborns – remains appalling. Chapter 2. Obstacles to progress: context or policy? This chapter seeks to explain why progress in maternal and child health has appar- ently stumbled so badly in many countries. Slow progress, stagnation and reversal are clearly related to poverty, to humanitarian crises, and, particularly in sub-Saharan Africa, to the direct and indirect effects of HIV/AIDS. These operate, at least in part, by fuelling or maintaining exclusion from care. In many countries numerous women and children are excluded from even the most basic health care benefits: those that are important for mere survival. The specific causes, manifestations and patterns of exclusion vary from country to country. Some countries show a pattern of marginal exclusion: a majority of the population enjoys access to service networks, but substantial groups remain excluded. Other countries, often the poorest ones, show a pattern of massive deprivation: only a small minority, usually the urban rich, enjoys reasonable access, while an overwhelm- ing majority is excluded. These countries have low density, weak and fragile health systems. The policy challenges vary according to the different patterns of exclusion. Many countries have organized their health care systems as health districts, with a back- bone of health centres and a referral district hospital. These strategies have often been so under-resourced that they failed to live up to expectations. The chapter argues that the health district model still stands as a rational way for governments to organize decentralized health care delivery, but that long-term commitment and investment are required to obtain sustained results. Chapter 3. Great expectations: making pregnancy safer This chapter reviews the three most important ways in which the outcomes of preg- nancies can be improved: providing good antenatal care, finding appropriate ways of preventing and dealing with the consequences of unwanted pregnancies, and improv- ing the way society looks after pregnant women. Antenatal care is a success story: coverage throughout the world increased by 20% during the 1990s and continues to increase in most parts of the world. Concern for a good outcome of pregnancy has made women the largest group actively seeking care. Antenatal care offers the opportunity to provide much more than just pregnancy- related care. The potential to promote healthy lifestyles is insufficiently exploited, as is the use of antenatal care as a platform for programmes that tackle malnutrition, HIV/AIDS, sexually transmitted infections, malaria and tuberculosis and promote fam- ily planning. Antenatal consultations are the ideal occasion to establish birth plans that can make sure the birth itself takes place in safe circumstances, and to help mothers prepare for parenting. xxioverview The chapter sets out critical directions for the future, including the need to improve the quality of care and to further increase coverage. Even in societies that value pregnancy highly, the position of pregnant women is not always enviable. In many places there is a need to improve the social, political and legal environments so as to tackle the low status of women, gender-based violence, discrimination in the workplace or at school, or marginalization. Eliminating sources of social exclusion is as important as providing antenatal care. Unintended, mistimed or unwanted pregnancies are estimated to number 87 million per year. There remains a huge unmet need for investment in contraception, informa- tion and education to prevent unwanted pregnancy, though no family planning policy will prevent it all. More than half of the women concerned, 46 million per year, resort to induced abortion: that 18 million do so in unsafe circumstances constitutes a major public health problem. It is possible, however, to avoid all of the 68 000 deaths as well as the disabilities and suffering that go with unsafe abortions. This is not only a ques- tion of how a country defines what is legal and what is not, but also of guaranteeing women access, to the fullest extent permitted by law, to good quality and responsive abortion and post-abortion care. Chapter 4. Attending to 136 million births, every year This chapter analyses the major complications of childbirth and the main causes of maternal mortality. Direct causes of maternal mortality include haemorrhage, infec- tion, eclampsia, obstructed labour and unsafe abortion. Childbirth is a moment of great risks, but in many situations over half of maternal deaths occur during the postpartum period. Effective interventions exist to avoid most of the deaths and long-term dis- abilities attributable to childbirth. The history of successes in reducing maternal and newborn mortalities shows that skilled professional care during and after childbirth can make the difference between life and death for both women and their newborn babies. The converse is true as well: a breakdown of access to skilled care may rapidly lead to an increase of unfavourable outcomes. All mothers and newborns, not just those considered to be at particular risk of de- veloping complications, need skilled maternal and neonatal care: close to where and how they live, close to their birthing culture, but at the same time safe, with a skilled professional able to act immediately when complications occur. Such birthing care can best be provided by a registered midwife or a professional health worker with equivalent skills, in midwife-led facilities. These professionals can avert, contain or solve many of the largely unpredictable life-threatening problems that may arise dur- ing childbirth and thus reduce maternal mortality to surprisingly low levels. But they do need the back-up only a hospital can provide to help mothers who present problems that go beyond their competency or equipment. All women need first-level maternal care, and only in a minority of cases is back-up care necessary, but to be effective both need to work in tandem, and have to be extended simultaneously. In many coun- tries uptake of postpartum care is even lower than of care at childbirth. This is an area of crucial importance with much scope for improvement. Chapter 5. Newborns: no longer going unnoticed Until recently, there has been little real effort to tackle the specific health problems of newborns. A lack of continuity between maternal and child health programmes has allowed care of the newborn to fall through the cracks. xxii The World Health Report 2005 Each year nearly 3.3 million babies are stillborn, and over 4 million more die within 28 days of coming into the world. Deaths of babies during this neonatal period are as nu- merous as those in the following 11 months or those among children aged 1–4 years. Skilled professional care during pregnancy, at birth and during the postnatal period is as critical for the newborn baby as it is for its mother. The challenge is to find a better way of establishing continuity between care during pregnancy, at birth, and when the mother is at home with her baby. While the weakest link in the care chain is skilled attendance at birth, care during the early weeks of life is also problematic because professional and programmatic responsibilities are often not clearly delineated. The chapter presents a set of benchmarks for the needs in human resources and service networks to provide first level and back-up maternal and newborn care to all. In many countries there are major shortages in facilities and, crucially, human resources. Using a set of scenarios to scale up towards universal access to both first- level and back-up maternal and newborn care in 75 countries, it seems realistic for coverage to increase from its present 43% (with a limited package of care) to around 73% (with a full package of care) in 2015. Implementing these scenarios would cost US$ 1 billion in 2006, increasing, as coverage expands, to US$ 6 billion in 2015: a total of US$ 39 billion over ten years, in addition to present expenditure on maternal and newborn health. This corresponds to an extra outlay of around US$ 0.22 per inhabitant per year initially, increasing to US$ 1.18 in 2015. A preliminary estimate of the potential impact of this scaling up suggests a reduction of maternal mortality, in these 75 countries, from a 2000 aggregate level of 485 to 242 per 100 000 births, and of neonatal mortality from 35 to 29 per 1000 live births by 2015. Chapter 6. Redesigning child care: survival, growth and development Increased knowledge means that technically appropriate, effective interventions for reducing child mortality and improving child health are available. It is now necessary to implement them on a much larger scale. This chapter explains how in the 1970s and 1980s vertical programmes have undeniably allowed fast and significant results. The Expanded Programme on Immunization and initiatives to implement oral rehydration therapy, for example, with a combination of state-of-the-art management and simple technologies based on solid research, were adopted and promoted to great effect. For all their impressive results, however, the inherent limitations of vertical approaches became apparent. At the same time, it became clear that a more comprehensive approach to the needs of the child was desirable, both to improve outcomes and to respond to a genuine demand from families. The response was to package a set of simple, affordable and effective interventions for the combined management of the major childhood illnesses and malnutrition, under the label of Integrated Management of Childhood Illness (IMCI). IMCI combined interventions designed to prevent deaths, taking into account the changing profile of mortality causes, but it also comprised of interventions and approaches to improve children’s healthy growth and development. More than just adding extra programmes to a single delivery channel, IMCI has gone a step further and has sought to transform the way the health system looks at child care, spanning a continuum of care from the family and community to the first-level health facility and on to referral facilities, with an emphasis on counselling and problem- solving. Many children still do not benefit from comprehensive and integrated care. As child health programmes continue to move towards integration it is necessary to progress towards universal coverage. Scaling up a set of essential interventions to full xxiiioverview coverage would bring down the incidence and case fatality of the conditions causing children under five years of age to die, to a level that would permit countries to move towards and beyond the MDGs. This will not be possible without a massive increase of expenditure on child health. Implementing scenarios to reach full coverage in 75 countries would cost US$ 2.2 billion in 2006, increasing, as coverage expands, to US$ 7.8 billion in 2015: a total of US$ 52.4 billion over 10 years, in addition to present expenditure on child health. This corresponds to an extra outlay of around US$ 0.47 per inhabitant per year initially, expanding to US$ 1.48 in 2015. Chapter 7. Reconciling maternal, newborn and child health with health system development This last chapter looks at the place of maternal, newborn and child health within the broader context of health system development. Today, the maternal, newborn and child health agendas are no longer discussed in purely technical terms, but as part of a broader agenda of universal access. This frames it within a straightforward political project: responding to society’s demand for the protection of the health of citizens and access to care, a demand that is increasingly seen as legitimate. Universal access requires a sufficiently dense health care network to supply services. The critical challenge is to put in place the health workforce required for scaling up. The most visible features of the health workforce crisis in many countries are the staggering shortages and imbalances in the distribution of health workers. Filling these gaps will remain a major challenge for years to come. Part of the problem is that sustainable ways have to be devised of offering competitive remuneration and incentive packages that can attract, motivate and retain competent and productive health workers. In many of the countries where progress towards the MDGs is disappointing, very substantial increases in the remuneration packages of health personnel are urgently needed, a challenge of a magnitude that many poor countries cannot face alone. Universal access, however, is more than deploying an effective workforce to supply services. For health services to be taken up, financial barriers to access have to be reduced or eliminated and users given predictable protection against the costs of seeking care. The chapter shows that by and large the introduction of user fees is not a viable answer to the underfunding of the health sector, and institutionalizes exclusion of the poor. It does not accelerate progress towards universal access and financial protection; this can be guaranteed only through generalized prepayment and pooling schemes. Whichever system is adopted to organize these schemes, two things are important. First, ultimately no population groups should be excluded; second, maternal, newborn and child health services should be at the core of the set of services to which citizens are entitled and which are financed in a coherent way through the selected system. With time, most countries move towards universal coverage, widening prepayment and pooling schemes, in parallel with the extension of their health care supply networks. This also has consequences for the funding flows directed towards maternal, newborn and child health. In most countries, financial sustainability for maternal, newborn and child health can best be achieved in the short and middle term by looking at all sources of funding: external and domestic, public and private. Channelling funds towards generalized insurance schemes that both fund the expansion of health care networks and provide financial protection, offers most guarantees for sustainable financing of maternal, newborn and child health and of the health systems on which it depends. 1 chapter one mothers and children matter – so does their health The healthy future of society depends on the health of the children of today and their mothers, who are guardians of that future. However, despite much good work over the years, 10.6 million children and 529 000 mothers are still dying each year, mostly from avoidable causes. This chapter assesses the current status of maternal and child health programmes against their historical background. It then goes on to examine in more detail the patchwork of progress, stagnation and reversals in the health of mothers and children worldwide and draws attention to the previously underestimated burden of newborn mortality. Most pregnant women hope to give birth safely to a baby that is alive and well and to see it grow up in good health. Their chances of doing so are better in 2005 than ever before – not least because they are becoming aware of their rights. With today’s knowledge and technol- ogy, the vast majority of the problems that threaten the world’s moth- ers and children can be prevented or treated. Most of the millions of untimely deaths that occur are avoidable, as is much of the suffering that comes with ill-health. A mother’s death is a tragedy unlike others, because of the deeply held feeling that no one should die in the course of the normal process of reproduction and because of the devasta- ting effects on her family (1). In all cultures, families and communities acknowledge the need to care for mothers and children and try to do so to the best of their ability. An increasing number of countries have succeeded in improving the health and well-being of mothers, babies and children in recent years, with noticeable results. However, the countries with the highest burden of mortality and ill-health to start with made little progress during the 1990s. In some, the situ- ation has actually worsened in recent years. Progress has therefore been patchy and unless it is accelerated significantly, there is little hope of reducing maternal mortality by three quarters and child mortality by two thirds by the target date of 2015 – the targets set by the Millennium Declaration (2, 3). In too many countries the health of mothers and chil- dren is not making the progress it should. The reasons for this are complex and vary from one country to an- other. They include the familiar, persistent enemies of health – poverty, inequality, war and civil unrest, and the destructive influence of HIV/AIDS – but also the failure to The World Health Report 20052 translate life-saving knowledge into effective action and to invest adequately in public health and a safe environment. This leaves many mothers and children, particularly the poorest among them, excluded from access to the affordable, effective and re- sponsive care to which they are entitled. For centuries, care for childbirth and young children was regarded as a domestic affair, the realm of mothers and midwives. In the 20th century, the health of mothers and children was transformed from a purely domestic concern into a public health priority with corresponding responsibilities for the state. In the opening years of the 21st century, the Millennium Development Goals place it at the core of the struggle against poverty and inequality, as a matter of human rights. This shift in emphasis has far-reaching consequences for the way the world responds to the very uneven progress in different countries. THE EARLY YEARS OF MATERNAL AND CHILD HEALTH The creation of public health programmes to improve the health of women and chil- dren has its origins in Europe at the end of the nineteenth century. With hindsight, the reasons for this concern look cynical: healthy mothers and children were seen by governments at that time to be a resource for economic and political ambitions. Many of Europe’s politicians shared a perception that the ill-health of the nation’s children threatened their cultural and military aspirations (4). This feeling was particularly strong in France and Britain, which had experienced difficulties in recruiting soldiers fit enough for war. Governments saw a possible solution in the pioneering French experiments of the 1890s, such as Léon Dufour’s Goutte de lait (drop of milk) clinics and Pierre Budin’s Consultations de nourrissons (infant welfare clinics) (5). These programmes offered a scientific and convincing way to produce healthy children who would become productive workers and robust soldiers. The programmes also increas- ingly found support in the emerging social reform and charitable movements of the time. As a result, all industrialized countries and their colonies, as well as Thailand and many Latin American countries, had instituted at least an embryonic form of maternal and infant health services by the onset of the 20th century (6). The First World War ac- celerated the movement. Josephine Baker, then Chief of the Division of Child Hygiene of New York, summed it up as follows: One of the first maternal and child health clinics, in the late 19th century, was ‘L’Œuvre de la goutte de lait’: Dr Variot’s consultation at the Belleville Dispensary, Paris. 3mothers and children matter – so does their health “It may seem like a cold-blooded thing to say, but someone ought to point out that the World War was a back-handed break for children . As more and more thousands of men were slaughtered every day, the belligerent nations, on whatever side, began to see that new human lives, which could grow up to replace brutally extinguished adult lives, were extremely valuable national assets. [The children] took the spotlight as the hope of the nation. That is the handsomest way to put it. The ugliest way – and, I suspect, the truer – is to say flatly that it was the military usefulness of human life that wrought the change. When a nation is fighting a war or preparing for another . it must look to its future supplies of cannon fodder” (7). Caring for the health of mothers and children soon gained a legitimacy of its own, beyond military and economic calculations. The increasing involvement of a variety of authorities – medical and lay, charitable and governmental – resonated with the rising expectations and political activism of civil society (1). Workers’ movements, women’s groups, charities and professional organizations took up the cause of the health of women and children in many different ways. For example, the International Labour Organization proposed legal standards for the protection of maternity at work in 1919; the New York Times published articles on maternal mortality in the early 1930s; and in 1938 the Mothers’ Charter was proclaimed by 60 local associations in the United King- dom. Backed by large numbers of official reports, maternal and child health became a priority for ministries of health. Maternal and child health programmes became a public health paradigm alongside that of the battle against infectious diseases (8). These programmes really started to gain ground after the Second World War. Global events precipitated public interest in the roles and responsibilities of governments, and the Universal Declaration of Human Rights in 1948 by the newly formed United Nations secured their obligation to provide “special care and assistance” for mothers and children (9). This added an international and moral dimension to the issue of the health of mothers and children, representing a huge step forward from the political and economic concerns of 50 years earlier. One of the core functions assigned to the World Health Organization (WHO) in its Constitution of 1948 was “to promote maternal and child health and welfare” (10). By the 1950s, national health plans and policy documents from development agencies invariably stressed that mothers and children were vulnerable groups and therefore priority “targets” for public health action. The notion of mothers and children as vul- nerable groups was also central to the primary health care movement launched at Alma-Ata (now Almaty, Kazakhstan) in 1978. This first major attempt at massive scal- ing up of health care coverage in rural areas boosted maternal and child health pro- grammes by its focus on initiatives to increase immunization coverage and to tackle malnutrition, diarrhoea and respiratory diseases. In practice, child health programmes were usually the central – often the only – programmatic content of early attempts to implement primary health care (11). WHERE WE ARE NOW: A MORAL AND POLITICAL IMPERATIVE The early implementation of primary health care often had a narrow focus, but among its merits was the fact that it laid the groundwork for linking health to development and to a wider civil society debate on inequalities. The plight of mothers and children soon came to be seen as much more than a problem of biological vulnerability. The 1987 Call to Action for Safe Motherhood explicitly framed it as “deeply rooted in the adverse social, cultural and economic environments of society, and especially the environment © Archives de l’Assistance Publique – Hôpitaux de Paris The World Health Report 20054 that societies create for women” (12). Box 1.1 recalls some important milestones in establishing the rights of women and children. In this more politicized view, women’s relative lack of decision-making power and their unequal access to employment, finances, education, basic health care and other resources are considered to be the root causes of their ill-health and that of their chil- dren. Poor nutrition in girls, early onset of sexual activity and adolescent pregnancy all have consequences for well-being during and after pregnancy for both mothers and children. Millions of women and their families live in a social environment that works against seeking and enjoying good health. Women often have limited exposure to the education, information and new ideas that could spare them from repeated childbearing and save their lives during childbirth. They may have no say in decisions on whether to use contraception or where to give birth. They may be reluctant to use health services where they feel threatened and humiliated by the staff, or pressured to accept treatments that conflict with their own values and customs (13). Poverty, cul- tural traditions and legal barriers restrict their access to financial resources, making it even more difficult to seek health care for themselves or for their children. The unfair- ness of this situation has made it obvious that the health of mothers and children is an issue of rights, entitlements and day-to-day struggle to secure these entitlements. The shift to a concern for the rights of women and children was accelerated by the International Conference on Population and Development, held in Cairo, Egypt, in Child health programmes were central to early attempts to implement primary health care. Here a community nurse in Thailand watches as a mother weighs her baby. W HO Archives: W HO12, SEARO 211 5mothers and children matter – so does their health Box 1.1 Milestones in the establishment of the rights of women and children In the 20th century several international treaties came into being, holding signatory countries accountable for the human rights of their citizens. Over the past two decades United Nations bodies, as well as international, regional and national courts, have increasingly focused on the human rights of mothers and children. The Universal Declaration of Human Rights states that “motherhood and childhood are entitled to special care and assistance”. The Declaration of the Rights of the Child. The Convention on the Elimination of All Forms of Dis- crimination Against Women enjoins States parties to ensure appropriate maternal health services. At the United Nations World Summit on Children govern- ments declare their “joint commitment . to give every child a better future”, and recognize the link between women’s rights and children’s well-being. The United Nations Human Rights Committee expresses concern over high rates of maternal mortality. The United Nations United Nations Human Rights Commit- tee rules that, when abortion gives rise to a criminal penalty even if a woman is pregnant as a result of rape, a woman’s right to be free from inhuman and degrading treatment might be violated. The United Nations Committee on the Rights of the Child states that adolescent girls should have access to information on the impact of early marriage and early pregnancy and have access to health services sensitive to their needs and rights. The United Nations Committee on the Rights of the Child adopts its General Comment on HIV/AIDS and that on the Rights of the Child. The United Nations Committee Against Torture calls for an end to the extraction of confessions for prosecution purposes from women seeking emergency medical care as a result of illegal abortion. The United Nations Special Rapporteur on the Right to Health reports that all forms of sexual violence are inconsistent with the right to health. The General Conference of the International Labour Organi- zation adopts the Maternity Protection Convention. The International Covenant on Economic, Social and Cul- tural Rights recognizes the right to the highest attainable stan- dard of physical and mental health. The Convention on the Rights of the Child guarantees chil- dren’s right to health. States commit themselves to ensuring appropriate maternal health services. The United Nations International Conference on Popula- tion and Development and the United Nations Fourth World Conference on Women affirm women’s right of access to appropriate health care services in pregnancy and childbirth. The United Nations Committee on Economic, Social and Cultural Rights states that measures are required to “improve child and maternal health, sexual and reproductive health ser- vices”. The United Nations Commission on Human Rights, states that sexual and reproductive health are integral elements of the right to health. The United Nations Sub-Commission on the Promotion and Protection of Human Rights adopts a resolution on “harmful traditional practices affecting the health of women and the girl child”. 1948 1952 1959 1966 1981 1990 1993 1996 1994 2000 1995 2003 2003 2004 2004 1989 The World Health Report 20056 1994. The conference produced a 20-year plan of action that focused on universal access to reproductive health services (of which maternal and child health care be- came a subset), which was grounded in individual choices and rights. This change in perspective is important, because it alters the rationale for investing in the health of mothers and children. Today, more is known than ever before about what determines the health of women and children and about which interventions bring about improvements most cost- effectively. This knowledge makes investment more successful, and withholding care even less acceptable. The health of mothers and children satisfies the classical criteria for setting public health priorities (see Box 1.2). Compelling as these arguments may be, however, they miss two vital points. birth-weight children in turn are at greater risk of dying and of suffering from infections and growth retardation (25) , have lower scores on cognitive tests (26–28) and may be at higher risk of developing chronic diseases in adulthood(29, 30 ). Healthy children are at the core of the formation of human capital. Child illnesses and malnutrition reduce cognitive development and intellectual performance(31–33), school enrolment and attendance (34, 35), which impairs f inal educat ional achievement. Intrauterine growth retardation and malnutri- tion during early childhood have long-term effects on body size and strength(36, 37) with implications for productivity in adulthood. In addition, with the death or illness of a woman, society loses a member whose labour and activities are essential to the life and cohesion of families and communities. Healthy mothers have more time and are more available for the social interaction and the creation of the bonds that are the prerequisite of social capital. They also play an important social role in caring for those who are ill. The economic costs of poor maternal and child health are high (38) ; substantial savings in future expenditure are likely through family planning programmes (39, 40) and interventions that improve maternal and child health in the long term. Consequent gains in human and social capital translate into long-term economic benefits (41). There is evidence of economic returns on investment in immunization (42) , nutrition programmes (41, 43), interventions to reduce low birth weight (36), and integrated health and social development programmes (44, 45). Maternal and child health programmes are also prime candidates for public funding because they produce public goods. Although many Modern states guarantee health entitlements for mothers, newborns and children that are grounded in human rights conventions. Ensur- ing them access to care has become a moral and political imperative, which also has a strong rational basis. From a public health point of view an important criterion for priority setting and public funding is that cost-effective intervention packages exist. Such packages are well documented in the case of maternal and child health (14, 15). But cost-effectiveness is only one of the criteria for public investment. Others commonly used include: the generation of positive externalities; the production of public goods and the rule of rescue; and the potential to increase equity and avoid catastrophic expenditure (16). Any of these criteria can be a sufficient condition for public investment on its own. When more than one is present, as in maternal and child health interventions, the case for public funding is even stronger. Health care for mothers and children produces obvious positive externalities through vaccination or the treatment of the infectious diseases of childhood, and through the im- proved child health that follows improvement of maternal health. There has been lit tle systematic research on the human, social and economic capital generated by improving the health of mothers and children, but the negative externalities of ill-health are clear. The health of mothers is a major determinant of that of their children, and thus indirectly af fects the formation of human capital. Motherless children die more frequently, are more at risk of becoming malnourished and less likely to enrol at school(17, 18). The babies of ill or undernourished pregnant women are more likely to have a low birth weight(19–21) and impaired development(19, 22–24). Low- maternal and child health interventions can be classified as private goods, a comprehensive programme also includes components such as information on contraception, on sexual health and rights, on breastfeeding and child care, that are obvious public goods. Moreover, the rule of rescue, which gives priority to interventions that save lives, applies to many maternal and child health interventions. Finally, public funding for maternal and child health care is justified on grounds of equity. Motherhood and childhood are periods of particularly high vulnerability that require “special care and assistance” (19) ; they are also periods of high vulnerability because women and children are more likely to be poor. Although systematic documentation showing that they are overrepresented among the poor is scarce (46) , women are more likely to be unemployed, to have lower wages, less access to education and resources and more restricted decision-making power, all of which limit their access to care. Public investment in maternal and child health care is justified in order to correct these inequities. In addition, where women and children represent a large proportion of the poor, subsidizing health services for them can be an effective strategy for income redistribution and poverty alleviation (14). Ill-health among mothers and children, and particularly the occurrence of major obstetric problems, is largely unpredictable and can lead to catastrophic expenditures (47) that may push households into poverty. The risk of catastrophic expenditures is often a deterrent for the timely uptake of care – a major argument, technically and politically, for public investment. Box 1.2 Why invest public money in health care for mothers and children? 7mothers and children matter – so does their health First, children are the future of society, and their mothers are guardians of that future. Mothers are much more than caregivers and homemakers, undervalued as these roles often are. They transmit the cultural history of families and communities along with social norms and traditions. Mothers influence early behaviour and estab- lish lifestyle patterns that not only determine their children’s future development and capacity for health, but shape societies. Because of this, society values the health of its mothers and children for its own sake and not merely as a contribution to the wealth of the nation (48). Second, few consequences of the inequities in society are as damaging as those that affect the health and survival of women and children. For governments that take their function of reducing inequality and redistributing wealth seriously, improving the living conditions and providing access to health care for mothers and children are good starting points. Improving their health is at the core of the world’s push to reduce poverty and inequality. MOTHERS, CHILDREN AND THE MILLENNIUM DEVELOPMENT GOALS In his report to the Millennium Summit, the Secretary-General of the United Nations, Kofi Annan, called on “the international community at the highest level – the Heads of State and Government convened at the Millennium Summit – to adopt the target of halving the proportion of people living in extreme poverty, and so lifting more than 1 billion people out of it, by 2015” (49). He further urged that no effort be spared to The health of mothers and children is now seen as an issue of rights, entitlements and day-to-day struggle to secure these entitlements. Rafiqur Rahm an/Reuters The World Health Report 20058 reach this target by that date in every region, and in every country. The Millennium Declaration (50), coming after a decade of “unprecedented stagnation and deteriora- tion” (51), set out eight specific Millennium Development Goals (MDGs), each with its numerical targets and indicators for monitoring progress. The MDGs galvanized coun- tries and the international community in a global partnership that, for the first time, articulated a commitment by both rich and poor countries to tackle a whole range of dimensions of poverty and inequality in a concerted and integrated way. The health agenda is very much in evidence in the MDGs: it is explicit in three of the eight goals, eight of the 18 targets, and 18 of the 48 indicators. This emphasis on health reflects a global consensus that ill-health is an important dimension of poverty in its own right. Ill-health contributes to poverty. Improving health is a condition for poverty alleviation and for development. Sustainable improvement of health depends on successful poverty alleviation and reduction of inequalities. It is no accident that the formulation of the MDG targets and indicators reveals the special priority given to the health and well-being of women, mothers and children. Mother and child health is clearly on the international agenda even in the absence of universal access to reproductive health services as a specific Millennium Develop- ment Goal. Globally, we are making progress towards the MDGs in maternal and child health. Success is overshadowed, however, by the persistence of an unacceptably high mortality and the increasing inequity in maternal and child health and access to health care worldwide. UNEVEN GAINS IN CHILD HEALTH Being healthy means much more than merely surviving. Nevertheless, the mortality rates of children under five years of age provide a good indicator of the progress made – or the tragic lack of it. Under-five mortality rates fell worldwide throughout the latter part of the 20th century: from 146 per 1000 in 1970 to 79 per 1000 in 2003. Since 1990, this rate has dropped by about 15%, equating to more than two million lives Figure 1.1 Slowing progress in child mortality: how Africa is faring worst Mo rta lity ra te of ch ild re n u nd er 5 ye ar s o f a ge pe r 1 00 0 liv e b irt hs 0 50 100 150 200 250 1970 1980 1990 2000 2003 Africa Eastern Mediterranean World South-East Asia South-East Asia without India Western Pacific Western Pacific without China Americas Europe 9mothers and children matter – so does their health saved in 2003 alone. Towards the turn of the millennium, however, the overall down- ward trend was showing signs of slowing. Between 1970 and 1990, the under-five mortality rate dropped by 20% every decade; between 1990 and 2000 it dropped by only 12% (see Figure 1.1). The global averages also hide important regional differences. The slowing down of progress started in the 1980s in the WHO African and Western Pacific Regions, and during the 1990s in the Eastern Mediterranean Region. The African Region started out at the highest levels, saw the smallest reductions (around 5% by decade between 1980 and 2000) and the most marked slowing down. In contrast, progress continued or accelerated in the WHO Region of the Americas, and the South-East Asia and European Regions. The result is that the differences between regions are growing. The under-five mor- tality rate is now seven times higher in the African Region than in the European Region; the rate was “only” 4.3 times higher in 1980 and 5.4 times higher in 1990. Child deaths are increasingly concentrated in the African Region (43% of the global total in 2003, up from 30% in 1990). As 28% of child deaths still occur in South-East Asia, two of the six WHO regions – Africa and South-East Asia – account for more than 70% of all child deaths. Looking at it another way, more than 50% of all child deaths are concentrated in just six countries: China, the Democratic Republic of the Congo, Ethiopia, India, Nigeria and Pakistan. The fortunes of the world’s children have also been mixed in terms of their nutritional status. Overall, children today are better nourished: between 1990 and 2000 the global prevalence of stunting and underweight declined by 20% and 18%, respec- tively. Nevertheless, children across southern and central Asia continue to suffer very high levels of malnutrition, and throughout sub-Saharan Africa the numbers of children who are stunted and underweight increased in this period (52). THE NEWBORN DEATHS THAT WENT UNNOTICED If further progress is to be made in reducing child mortality, increased efforts are needed to bring about a substantial reduction in deaths among newborns. The first global estimates of neonatal mortality, dating from 1983 (53), were derived using historical data and are generally considered to give only a rough indication of the magnitude of the problem. More rigorous estimates became available for 1995 and for 2000. These are based on national demographic surveys as well as on statistical models. The new estimates show that the burden of newborn mortality is considerably higher than many people realize. Each year, about four million newborns die before they are four weeks old: 98% of these deaths occur in developing countries. Newborn deaths now contribute to about 40% of all deaths in children under five years of age globally, and more than half of infant mortality (54, 55). Rates are highest in sub-Saharan Africa and Asia. Two thirds of newborn deaths occur in the WHO Regions of Africa (28%) and South-East Asia (36%) (56). The gap between rich and poor countries is widening: neonatal mortal- ity is now 6.5 times lower in the high-income countries than in other countries. The lifetime risk for a woman to lose a newborn baby is now 1 in 5 in Africa, compared with 1 in 125 in more developed countries (57). The above figures do not include the 3.3 million stillbirths per year. Data on stillbirths are even more scarce than those on newborn deaths. This is not surprising, as only 14% of births in the world are registered. Both live births and deaths of newborns go underreported; fetal deaths are even more likely to go unreported, particularly early fetal deaths. The World Health Report 200510 While the burden of neonatal deaths and stillbirths is very substantial, it is in many ways only part of the problem, as the same conditions that contribute to it also cause severe and often lifelong disability. For example, over a million children who survive birth asphyxia each year develop problems such as cerebral palsy, learning difficulties and other disabilities (58). For every newborn baby who dies, at least another 20 suf- fer birth injury, infection, complications of preterm birth and other neonatal conditions. Their families are usually unprepared for such tragedies and are profoundly affected. The health and survival of newborn children is closely linked to that of their moth- ers. First, because healthier mothers have healthier babies; second, because where a mother gets no or inadequate care during pregnancy, childbirth and the postpartum period, this is usually also the case for her newborn baby. Figure 1.2 shows that both mothers and newborns have a better chance of survival if they have skilled help at birth. FEW SIGNS OF IMPROVEMENT IN MATERNAL HEALTH Pregnancy and childbirth and their consequences are still the leading causes of death, disease and disability among women of reproductive age in developing countries – more than any other single health problem. Over 300 million women in the devel- oping world currently suffer from short-term or long-term illness brought about by pregnancy and childbirth; 529 000 die each year (including 68 000 as a result of an unsafe abortion), leaving behind children who are more likely to die because they are motherless (59). There have been few signs of global improvement in this situation. However, during the 1960s and 1970s, some countries did reduce their maternal mortality by half over Figure 1.2 Neonatal and maternal mortality are related to the absence of a skilled birth attendant Europe Americas Western Pacific Western Pacific without China Eastern Mediterranean South-East Asia without India South-East Asia Africa 0 25 50 75 100 % of births without skilled attendant Maternal mortality ratio per 10 000 live births Neonatal mortality rate per 1000 live births 11mothers and children matter – so does their health a period of 10 years or less. A few countries such as Bolivia and Egypt have managed this in more recent years. Other countries appear to have suffered reversals (see Box 1.3). Recent success stories in maternal health are less often heard than those for child health. This is partly because it takes longer to show results, partly because changes in maternal mortality are much more difficult to measure with the sources of information available at present. Today, predictably, most maternal deaths occur in the poorest countries. These deaths are most numerous in Africa and Asia. Less than 1% of deaths occur in high-in- come countries. Maternal mortality is highest by far in sub-Saharan Africa, where the lifetime risk of maternal death is 1 in 16, compared with 1 in 2800 in rich countries. Information on maternal mortality remains a serious problem. In the late 1970s, less than one developing country in three was able to provide data – and these were usually only partial hospital statistics. The situation has now improved but births and deaths in developing countries are often only registered for small portions of the popu- lation except in some Asian and Latin American countries. Cause of death is routinely reported for only 100 countries of the world, covering one third of the world’s popula- tion. It is even difficult to obtain reliable survey data that are nationally representative. For 62 developing countries, including most of those with very high levels of mortal- ity, the only existing estimates are based on statistical modelling. These are even more hazardous to interpret than those from surveys or partial death registration. The countries that rely on these modelled estimates represent 27% of the world’s births. Effectively, this leaves no record of the fate of 36 million – about 1 out of 4 – of the women who give birth every year. Gradual improvements in data availability, however, mean that a growing database now exists of maternal mortality by country. Since 1990, a joint working group of WHO, the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA) has been regularly assessing and synthesizing the available information (60). It has not been possible, though, to assess changes over time with any confi- dence: the uncertainty associated with maternal mortality estimates makes it difficult to say whether that mortality has gone up or down, so no global downturn in maternal mortality ratios can yet be asserted. Nevertheless, there is a sense of progress, backed by the tracking of indicators that point to significant increases in the uptake of care during pregnancy and childbirth 2001. Third, the quality of care within health facilities deteriorated. Between 1989 and 2001 the proportion of deaths associated with defi- cient health care increased from 31% to 43%. In 2001 only one mother out of four who died in the hospital had received standard care. Wrong diagnosis (11% of deaths), delays in starting treatment (19%), wrong treatment (16%), or lack of blood for transfusion (18%): deficient hospital care was the leading principal avoid- able factor in 38% of deaths. The diminishing coverage and the worsening of the quality of care are related to the deteriorating situation of the health workforce Malawi is one country that experienced a sig- nificant reversal in maternal mortality: from 752 maternal deaths per 100 000 live births in 1992 to 1120 in 2000, according to the Malawi Demographic and Health Surveys. According to confidential enquiries into maternal deaths in health facilities in 1989 and 2001, three fac- tors apparently contributed to this increase. First, there was a sharp proportional increase in deaths from AIDS. This is not surprising since Malawi’s national HIV prevalence has now reached 8.4%. Second, fewer mothers gave birth in health facilities: the proportion dropped from 55% to 43% between 2000 and ( itself not independent from the HIV/AIDS epidemic). In remote areas one midwife often has to run the entire rural health centre and is expected to be available for work day and night, seven days a week. One maternity unit out of 10 is closed for lack of staff. Hospitals also experience severe shortages of midwives, and unskilled cleaners often conduct deliveries. The shortage of staff in maternity units is catastrophic and rapidly getting worse; the chances of Malawi women giving birth in a safe environment diminish accordingly. Box 1.3 A reversal of maternal mortality in Malawi The World Health Report 200512 in all regions except sub-Saharan Africa during the 1990s. The proportion of births assisted by a skilled attendant rose by 24% during the 1990s, caesarean sections tripled and antenatal care use rose by 21%. Since professional care is known to be crucial in averting maternal deaths as well as in improving maternal health, maternal mortality ratios are likely to be declining everywhere except for those countries which started the 1990s at high levels. For these, which are mainly in sub-Saharan Africa, there has been no sign of progress. A PATCHWORK OF PROGRESS, STAGNATION AND REVERSAL The slowing down of improvement of global indicators that so worries policy-mak- ers (67) hides a patchwork of countries that are on track, show slow progress, are stagnating or are going into reverse. As most progress is being made in countries that already have relatively low levels of maternal and child deaths, while the worst-off stagnate, the gaps between countries are inevitably widening. A total of 93 countries, including most of those in the high income bracket, are “on track” to reduce their 1990 under-five mortality rates by two thirds by 2015 or sooner. The on-track countries are those that already had the lowest rates in 1990 (taken together they had a rate of 59 in 1990). ing maternal mortality. Ascertaining cause of death and relating it to pregnancy is difficult, particularly where most deaths occur at home. Misclassified or undercounting is frequent in countries with fully functioning vital registra- tion systems – between 17% and 63% (65) – let alone in those where such systems cover only part of the population. Many developing countries where births and deaths are not routinely counted conduct sample surveys asking women for their “birth histories” and how many of their children have died, when and at what age. These surveys yield estimates of child mortality. Often quite robust, they can be biased or inaccurate when the surveys are badly sampled and not repre- sentative of the population at large. Information on a deceased child whose mother has died herself will simply not be gathered. Mothers often do not know exact dates of birth or may be unwilling or unable to recall at what age a child has died. Completeness and accuracy very much depend on the skills and the cultural sensitivity of the interviewer. Unfortunately, finding out about the quality of survey data in the public domain is often not possible. Maternal mortality is even more difficult to estimate from sample surveys. Information must be gleaned from relatives. Generally, women are asked whether their sisters died during pregnancy or shortly afterwards (66). This presupposes that each woman who dies If nobody keeps track of their births and deaths, women and children simply do not count (61). Mortality rates are frequently only rough estimates, of varying reliability. This is because the ways of estimating mortality are far from perfect and, in many cases, insufficient priority is given to obtaining such vital information. It is often assumed that the quoted numbers of maternal and child deaths rely on hospital statistics. But apart from the problems of maintaining reporting systems, only a frac- tion of events takes place in facilities. Hospital information is currently the most flawed source of data on births and deaths. The best approach to estimating maternal and child mortality is to count births and deaths through vital registration systems. In many developing countries, however, such systems are still incomplete. The births and deaths that are registered under-represent the rural popula- tion and the socioeconomically disadvantaged. In 47 countries of the world, less than 50% of the population registers their deaths. A reliable neonatal mortality rate, for example, can there- fore be calculated for only 72 countries – less than 14% of births in the world. Internationally recommended definitions of what constitutes a neonatal death are not always used (62, 63). The calculated rates, especially in central Asia, are therefore not always comparable across countries (64). Vital registration systems are currently even less satisfactory for estimat- in childbirth had a sister, that her sister is alive to tell the tale, that she knows of her sister’s death, and knows her sister’s age and preg- nancy status at death. As maternal deaths are statistically rare, it is difficult to obtain reports on enough deaths to estimate the maternal mortality ratio with sufficient precision and reliability without undertaking more expensive studies such as a reproductive age mortality survey (60). The result is that levels and trends are often very difficult to interpret. In countries where registration is incomplete and where no survey has been conducted, the only remaining option for assessing mortality is to construct a modelled estimate. This is effectively an educated guess based on infor- mation from similar or neighbouring countries. A total of 28 countries rely only on such esti- mates for neonatal mortality, 62 for maternal mortality. These modelled estimates should be treated with great caution, but may be the only information available. For the first time, this World Health Report presents, separately, tables with country esti- mates of mortality derived from surveys or vital registration, where these are available, and tables for all countries with country estimates that have been modelled and adjusted. These estimates can be found in Annex Tables 2a, 2b and 8. Box 1.4 Counting births and deaths 13mothers and children matter – so does their health A total of 51 other countries are showing slower progress: the number of deaths among children under five years of age is going down and the mortality rates are drop- ping, but not fast enough to reach one third of their 1990 level by 2015 unless they significantly accelerate progress during the coming 10 years. These countries started from a somewhat higher level than those that are on track: an average under-five mortality rate of 92 per 1000. More problematic are the 29 countries where mortality rates are “stagnating” – where the number of deaths continues to grow, because modest reductions of mortal- ity rates are too small to keep up with the increasing numbers of births. These are the countries that had the highest levels (207 on average) in 1990. Finally, there are 14 “reversal” countries, where under-five mortality rates went down to an average of 111 in 1990 but have increased since. During the 1990s there were more such countries than during the two previous decades combined. These reversals were also more pronounced than before. Countries that show reversal or stagnation are overwhelm- ingly in the African Region. This grouping of countries,1 categorized according to progress in under-five mortality during the 1990s, roughly corresponds to what happened in terms of neonatal and maternal health in these same countries. Although trend data are not available, neo- natal and maternal mortality is highest in the countries with reversal and stagnation in under-five mortality (see Table 1.1 and Figures 1.3–1.6). THE NUMBERS REMAIN HIGH As the situation improves at a slower pace than expected – and hoped for – the gains in avoided deaths are partially offset by the demographic momentum. The numbers of untimely deaths of mothers and children could well be on the increase, because while rates are dropping, the numbers of mothers, births and children continue to grow. Worldwide, the number of live births will peak at 137 million per year towards 2015 (68) : 3.5 million more than at present. Most of the increase will be in sub-Saharan Africa and in parts of Asia – Pakistan and northern India – where the number of births will continue to grow well into the 2020s, even if fertility continues to drop. These are areas where the protection of adolescents and young women against early or unwant- ed pregnancy is most inadequate, mortality from unsafe abortion most pronounced, giving birth most hazardous and childhood most difficult to survive. Why is it still necessary for this report to emphasize the importance of focusing on the health of mothers and children, after decades of priority status, and more than 10 years after the United Nations International Conference on Population and Develop- ment? Progress has slowed down and is increasingly uneven, with a widening gap be- tween rich and poor countries as well as, often, between the poor and the rich within countries. The reasons for this patchy progress are examined in the next chapter. ing maternal mortality. Ascertaining cause of death and relating it to pregnancy is difficult, particularly where most deaths occur at home. Misclassified or undercounting is frequent in countries with fully functioning vital registra- tion systems – between 17% and 63% (65) – let alone in those where such systems cover only part of the population. Many developing countries where births and deaths are not routinely counted conduct sample surveys asking women for their “birth histories” and how many of their children have died, when and at what age. These surveys yield estimates of child mortality. Often quite robust, they can be biased or inaccurate when the surveys are badly sampled and not repre- sentative of the population at large. Information on a deceased child whose mother has died herself will simply not be gathered. Mothers often do not know exact dates of birth or may be unwilling or unable to recall at what age a child has died. Completeness and accuracy very much depend on the skills and the cultural sensitivity of the interviewer. Unfortunately, finding out about the quality of survey data in the public domain is often not possible. Maternal mortality is even more difficult to estimate from sample surveys. Information must be gleaned from relatives. Generally, women are asked whether their sisters died during pregnancy or shortly afterwards (66). This presupposes that each woman who dies If nobody keeps track of their births and deaths, women and children simply do not count (61). Mortality rates are frequently only rough estimates, of varying reliability. This is because the ways of estimating mortality are far from perfect and, in many cases, insufficient priority is given to obtaining such vital information. It is often assumed that the quoted numbers of maternal and child deaths rely on hospital statistics. But apart from the problems of maintaining reporting systems, only a frac- tion of events takes place in facilities. Hospital information is currently the most flawed source of data on births and deaths. The best approach to estimating maternal and child mortality is to count births and deaths through vital registration systems. In many developing countries, however, such systems are still incomplete. The births and deaths that are registered under-represent the rural popula- tion and the socioeconomically disadvantaged. In 47 countries of the world, less than 50% of the population registers their deaths. A reliable neonatal mortality rate, for example, can there- fore be calculated for only 72 countries – less than 14% of births in the world. Internationally recommended definitions of what constitutes a neonatal death are not always used (62, 63). The calculated rates, especially in central Asia, are therefore not always comparable across countries (64). Vital registration systems are currently even less satisfactory for estimat- in childbirth had a sister, that her sister is alive to tell the tale, that she knows of her sister’s death, and knows her sister’s age and preg- nancy status at death. As maternal deaths are statistically rare, it is difficult to obtain reports on enough deaths to estimate the maternal mortality ratio with sufficient precision and reliability without undertaking more expensive studies such as a reproductive age mortality survey (60). The result is that levels and trends are often very difficult to interpret. In countries where registration is incomplete and where no survey has been conducted, the only remaining option for assessing mortality is to construct a modelled estimate. This is effectively an educated guess based on infor- mation from similar or neighbouring countries. A total of 28 countries rely only on such esti- mates for neonatal mortality, 62 for maternal mortality. These modelled estimates should be treated with great caution, but may be the only information available. For the first time, this World Health Report presents, separately, tables with country esti- mates of mortality derived from surveys or vital registration, where these are available, and tables for all countries with country estimates that have been modelled and adjusted. These estimates can be found in Annex Tables 2a, 2b and 8. Box 1.4 Counting births and deaths 1 No data available for five countries. The World Health Report 200514 Figure 1.4 Patterns of reduction of under-5 mortality rates, 1990–2003 On track Slow progress Reversal Stagnation No data More than 2 years of humanitarian crisis between 1992 and 2004 Figure 1.3 Changes in under-5 mortality rates, 1990–2003: countries showing progress, stagnation or reversal % in cr ea se in un de r-5 m or ta lit y On track for MDG goal Reversal Slow progress Stagnation % d ec re as e in un de r-5 m or ta lit y 150 100 50 0 50 100 50 100 150 200 250 300 350 Under-5 mortality rate in 1990 15mothers and children matter – so does their health Figure 1.5 Maternal mortality ratio per 100 000 live births in 2000 < 50 50–299 300–549 ≥ 550 No data Figure 1.6 Neonatal mortality rate per 1000 live births in 2000a < 12.5 12.5–24.9 25–37.4 ≥ 37.5 No data aThese data are estimates from various international sources and may not be the same as Member States’ own estimates. They have not been submitted to Member States for consideration. 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Decline No. of Population Average Under-5 Under-5 No. of Neonatal No. of Maternal No. of of child countries (2003)a live births mortality mortality under-5 mortality newborn mortality maternal mortality per year rate rate deaths rate deaths ratio deaths (1990–2003) (2000–2005)a (1990)b (2003)b (2003)a (2000)b (2000)a (2000)c (2000)a On track 30 1 155 219 14 980 22 13 190.5 7 110.5 29 4.3 (OECD) (18%) (11%) (2%) (3%) (1%) 63 1 386 579 30 782 78 39 1200.5 19 591.6 216 65 (non-OECD) (22%) (23%) (12%) (15%) (12%) Slow progress 51 3 011 922 58 858 92 72 4 185.5 35 2 069.5 364 212.9 (48%) (44%) (40%) (52%) (40%) In reversal 14 241 209 7 643 111 139 1 046.9 41 305.4 789 59.9 (4%) (6%) (10%) (8%) (11%) Stagnating 29 487 507 20 678 207 188 3 773.9 47 921.3 959 185.8 (8%) (16%) (36%) (23%) (35%) aNumbers in thousands. bPer 1000 live births. cPer 100 000 live births. 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Goldenberg R, Hack M, Grantham-McGregor SM, Schürch B. Report of the IDECG/IUNS Working Group on IUGR: effects on neurological, sensory, cognitive, and behavioural function. Lausanne, IDECG Secretariat, c/o Nestlé Foundation, 1999. 29. Barker DJP. Mothers, babies and health in later life, 2nd ed. Sydney, Churchill Livingstone, 1998. 30. Grivetti L, Leon D, Rasmussen K, Shetty PS, Steckel R, Villar J. Report of the IDECG Working Group on Variation in Fetal Growth and Adult Disease. European Journal of Clinical Nutrition, 1998, 52(Suppl. 1):S102–S103. 31. Bhargava A. Nutrition, health and economic development: some policy priorities. Geneva, World Health Organization, 2001 (Commission on Macroeconomics and Health, CMH Working Paper Series, Paper No. WG1:14). 32. Scrimshaw NS. Malnutrition, brain development, learning, and behavior. Nutrition Research, 1998, 18:351–379. 33. Grantham-McGregor SM, Ani CC. Undernutrition and mental development. 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Investing in our children, what we know and don’t know about the costs and benefits of early childhood interventions. Santa Monica, CA, RAND Corporation, 1998. 43. Behrman JR. The economic rationale for investing in nutrition in developing countries. World Development, 1993, 21:1749–1771. 44. Behrman JR, Hoddinott J. Evaluacion del impacto de progresa en la talla del nino en edad preescolar [An evaluation of the impact of PROGRESA on pre-school child height]. Washington, DC, International Food Policy Research Institute, 2000. 45. Van der Gaag J, Tan JP. The benefits of early child development programs: an economic analysis. Washington, DC, World Bank, 1996. 46. Quisumbing AR, Haddad L, Pena C. Are women overrepresented among the poor? An analysis of poverty in 10 developing countries. Journal of Developing Economics, 2001, 66:225–269. 47. Borghi J, Hanson K, Acquah CA, Ekanmian G, Filippi V, Ronsmans C et al. 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Bulletin of the World Health Organization, 2003, 81:717–725. 60. Maternal mortality in 2000. Estimates developed by WHO, UNICEF and UNFPA . Geneva, World Health Organization, 2004. 61. Graham W, Hussein J. The right to count, Lancet, 363:67-68. 62. Elkoff VA, Miller JE. Trends and differentials in infant mortality in the Soviet Union, 1970–90: how much is due to misreporting? Population Studies, 1995, 49:241–258. 63. Mugford M. A comparison of reported differences in definitions of vital events and statistics. World Health Statistics Quarterly, 1983, 36:201–212. 64. Social Monitor, 2003. Special feature: infant mortality. New York, NY, United Nations Children’s Fund, 2003. 65. Bouvier Colle MH, Varnoux N, Costes P, Hatton F. Reasons for the under-reporting of maternal mortality in France, as indicated by a survey of all deaths among women of childbearing age. International Journal of Epidemiology, 1991, 20:717–721. 66. The sisterhood method for estimating maternal mortality: guidance for potential users. Geneva, World Health Organization, 1997 (WHO/RHT/97.28). 67. Human development report 2003 – Millennium Development Goals: a compact among nations to end human poverty. New York, NY, Oxford University Press for the United Nations Development Programme, 2003. 68. United Nations Population Division. World population prospects: the 2002 revision population database (http://esa.un.org/unpp/, accessed 28 December 2004). 21 chapter two obstacles to progress: context or policy? Although there has been, for decades now, a global consensus that the health of mothers and children is a public priority, much still needs to be done. Most progress is being made by countries that were al- ready in a relatively good position in the early 1990s, whereas those less favourably placed, particularly in sub-Saharan Africa, have been left behind. Much of this large and growing gap can be explained by the context in which health systems have developed. The stagnations, reversals and slow progress seen in some countries are clearly related to contexts of poverty, humanitarian crisis and the direct and indirect effects of HIV/AIDS (see Table 2.1). These lead to an increasingly vis- ible gap between people who have access to health care and others who are excluded from such benefits. Exclusion from health benefits leads to even greater inequalities in survival for mothers and newborns than for children. Whatever the context, lack of progress is also due to failures of health systems to provide good- quality care and services to all mothers and children. Moving towards universal access to health care must take account of the contextual barriers to progress, the reasons for exclusion from care, and the various pat- terns of exclusion. Many countries, and particularly those that face the biggest challenges, have based their health care systems on the health district model, with a backbone of health centres and a referral district hospi- tal. This chapter argues that the disappointing situation in many countries often has more to do with the condi- tions under which this strategy has been implemented This chapter seeks to explain why progress in maternal and child health has apparently stumbled so badly in many countries. It shows in detail how stagnations, reversals and slow progress in some countries are clearly related to poverty, HIV/AIDS, and humanitarian crises, leading to exclusion from access to health care. In many countries, the strategies put in place to provide health services have not produced the hoped for results. While many countries have based their health care systems on health districts, with a backbone of health centres and a referral district hospital, there has often been a failure to implement this model successfully in an exceedingly resource-constrained context. The chapter argues that the health district model still stands as a rational way for governments to organize decentralized health care delivery. The World Health Report 200522 than with the failure of the strategy itself. A new commitment is needed to create the conditions for moving towards effec- tive implementation. CONTEXT MATTERS Poverty undermines progress Many of the countries whose child mor- tality rates are stagnating or reversing are poor in terms of gross domestic product; others are facing economic downturn. Conventional wisdom has it that income poverty is on its way out because the proportion and the total number of peo- ple around the world living on less than US$ 1 per day is decreasing (1). However, almost all of this progress has been made in Asia. Sub-Saharan Africa, where most of the countries whose child mortality rates have stagnated or reversed are to be found, has emerged as the region with the highest incidence of extreme poverty, and the greatest depth of poverty (2). Furthermore, the average income of poor people in Africa has been falling over time, in contrast with that of poor people in the rest of the developing world (3). But poverty also influences maternal health. When women die in childbirth it is usu- ally the result of a cascade of breakdowns in their interactions with the health system: delays in seeking care, inability to act on medical advice, and failure of the health system to provide adequate or timely care. These breakdowns are more likely to occur and to come together into a fateful combination when the macroeconomic and social contexts deteriorate. In Mongolia, for example, widespread social chaos and economic collapse followed the introduction of economic “shock therapy” in the early 1990s (4, 5), with a rapid increase in unemployment and widespread poverty. Government ex- she did not follow their advice and was soon pregnant again. She did not seek prenatal care, but the family doctor discovered her pregnancy during an antenatal examination of her 18-year- old daughter. Because of Dashnyam’s history and age, and because she said that she did not want the child, the family doctor urged her to go to the provincial hospital for an abortion. How- ever, by the time she had collected sufficient funds, her pregnancy was too far advanced and abortion was no longer an option. She returned home and received antenatal care from the family doctor. As she came closer to term, she manifested symptoms of pre-eclampsia – high blood pressure and oedema. Because of her age, history of complications, and the presence Dashnyam, a 41-year-old housewife, was a very poor migrant from the countryside to a provin- cial capital of Mongolia. She and her husband were unemployed and often homeless, with six children. During her last pregnancy Dashnyam had oedema and pre-eclampsia and required manual extraction of the placenta. Afterwards, she said she wanted no more children and was given an intrauterine device ( IUD). She had problems with the IUD and finally, in 2002 after six years of use, she asked to have it removed because of pelvic inflammatory disease and associated pain. The obstetrician who removed the IUD urged her to use another form of birth control, and her primary care physician gave her the same advice. For reasons that are unclear, of these serious symptoms, the doctor urged her to go to the provincial hospital’s maternity waiting home. However, her admission was delayed for over a week to solve bureaucratic issues, initially because she had no proof of having health insurance, and then because there were no beds available. Eventually, Dashnyam delivered via caesarean section, but suffered severe haemorrhage. After delay in finding the anaesthetist, the bleeding was eventually stopped by emergency surgery, but the hospital had no blood for transfusion. She died from haemorrhagic shock. (Names and places have been changed.) Source: (7). Table 2.1 Factors hindering progress Decline of More than two years Adult HIV GDP per capita child mortality of humanitarian prevalence rate (weighted average crisis since 1992 (weighted average) 1990–2002 in 1995 international dollars) 93 countries are 3/93 countries 0.3 20 049 (OECD) on tracka 4179 (non-OECD) 51 countries are making 10/51 countries 0.7 2657 slower progressa 14 countries are 8/14 countries 10.2 1627 in reversal (excluding South Africa) 29 countries have 11/29 countries 4.1 896 stagnating mortality a Towards Millennium Development Goal 4. Box 2.1 Economic crisis and health system meltdown: a fatal cascade of events 23obstacles to progress: context or policy? Ch an ge in g ro ss d om es tic pr od uc t p er c ap ita M aternal m ortality per 100 000 live births 0.05 0 -0.05 -0.1 250 200 150 1991 1992 1993 1994 1995 1996 1997 1998 1999 Figure 2.1 A temporary reversal in maternal mortality: Mongolia in the early 1990s (miscarriage, anaemia, postpartum haemor- rhage, puerperal sepsis and post-surgical com- plications). AIDS is also a major indirect cause of maternal mortality through increased rates of malaria and opportunistic infections such as tuberculosis (12). The combined effect of these different mechanisms may overshadow prog- ress made in reducing maternal mortality from other causes. In Rakai, Uganda, for example, maternal mortality was 1687 per 100 000 live births among HIV-infected women and 310 among non-infected women (13). The maternal mortality ratio in the University Teaching Hospi- tal in Lusaka, Zambia, has increased eightfold over the past two decades, mainly because of the increase in non-obstetric causes of death. While such causes were almost negligible in 1975, HIV-related tuberculosis and unspeci- fied chronic respiratory illnesses accounted for 27% of all causes of maternal deaths in 1997 (14). The HIV/AIDS pandemic takes an increas- ing toll of women and children, especially in sub-Saharan Africa. Some 39 million people are now living with HIV, of whom 2.2 mil- lion are children under 15 years of age and 18 million are women. In 2004, there were 4.9 million new cases of infection, including 640 000 children under 15 (8). Almost 90% of paediatric infections occur in sub-Saharan Africa, where there are both high fertility rates and high HIV prevalence rates among women (9). In 2004, 3.1 million people died of AIDS, 510 000 of whom were children (8). HIV/AIDS has thus led to significant increases in mortal- ity in many countries: it is a leading cause of death among women and children in the most severely affected countries in sub-Saharan Africa (10). Across the world, around 2.2 million women with HIV infection give birth each year (11). HIV infection in pregnancy increases the risk of complications of pregnancy and childbirth Children of an HIV-positive mother have a higher mortality risk than children of HIV-nega- tive mothers (13). As parents die of AIDS, the number of orphans increases: 9% of children under 15 years of age in 40 countries in sub- Saharan Africa have lost one parent, and 1% have lost both (15). Orphans are especially vul- nerable to social and health risks: they are less likely to attend school and may live in house- holds where conditions are less favourable for health and development than the average. HIV infection in children, almost always acquired through mother-to-child transmission, causes high mortality rates and some 60% die before their fifth birthday (16). In Malawi, HIV/AIDS accounts for up to 10% of child deaths, and in one of the most affected countries, Botswana, child mortality doubled in the 1990s, and HIV/ AIDS was responsible for more than 60% of child mortality in 2000 (16). Box 2.2 How HIV/AIDS directly affects the health of women and children penditure halved, reflecting a widespread drop in investment in social services, health care and education. Hospitals, clinics and maternity homes closed or curtailed operations (6). The health sec- tor recovered eventually with the support of sizeable development loans, but not before the meltdown of services had led to a temporary reversal in maternal mor- tality (see Figure 2.1). The ways in which the dynamics of increasing poverty can create a fatal series of events are illus- trated in Box 2.1. The direct and indirect effects of HIV/AIDS In a number of countries, particularly in sub-Saharan Africa, the effects of pov- erty and economic downturns on the environment in which people live, on their health and on the functioning of health systems are compounded by HIV/AIDS epidemics. HIV/AIDS has direct and indirect effects. It directly affects the health of infected women and children (see Box 2.2). Globally, the direct contribution of HIV/AIDS to the number of children dying is limited, but it has been increasing steadily in sub-Saharan Africa. In 1990 HIV/AIDS accounted for around 2% of under-five mortality in that part of the world; 10 years later this had risen to 6.5%, although there are significant The World Health Report 200524 differences among countries. HIV prevalence rates are much higher in the countries in stagnation or reversal than in the others (17) ; in 9 of the 10 African countries in reversal, HIV/AIDS was responsible for more than 10% of child deaths in 1999, a much higher proportion than in 1990 (18). But HIV/AIDS as a direct cause of death cannot explain all of the slowing or reversal of trends in child mortality. HIV/AIDS also affects the health of mothers and children in a more indirect way. Appropriate diagnosis and treatment of HIV/AIDS in women and children are rarely provided and pose particular challenges in resource-limited settings. HIV/AIDS puts an additional strain on fragile health systems. It generates demand for new services such as prevention of HIV transmission from mothers to infants, HIV testing and counselling, and complex diagnostic and investigative procedures (19, 20). This calls for increased spending on infrastructure, equipment, drugs and human resources. Where increases in funding do not follow, maternal and child health services have to share their scarce resources and personnel. As health workers themselves fall ill, the workforce becomes overstretched (21). Work performance is further reduced by fear, lack of knowledge about HIV/AIDS and protective practices, and the stress of caring for patients whose condition appears hopeless. As a result it is increasingly difficult to recruit young people into medical and nursing professions, particularly obstetrics. Conflicts and emergencies set systems back Of the 43 countries showing stagnation or reversal in child mortality, 19 have been the subject of a Consolidated Appeal Process for a humanitarian crisis with a duration of US$ 1.5 and US$ 3 per inhabitant per year), especially when compared with those available in refugee camps in the same area through relief agencies. Utilization of curative services and preventive coverage rates has actually increased: vaccination coverage has tripled. Maternal health activities have been intensified both quantitatively and qualitatively, with 52% of deliveries taking place in health centres and the hospital, and a population-based caesarean section rate of 1.4%; case-fatality of caesar- ean sections dropped from 7.2% to 2.9%. The Since the 1980s, in North Kivu Province of the Democratic Republic of the Congo (formerly Zaire), the socioeconomic environment has been deteriorating. The province also faced an influx of Rwandan refugees in July 1994. In these difficult circumstances the Rutsh- uru Health District was nevertheless able to adjust and maintain its medical activities. For 11 years the health care network remained accessible and functional, although human and financial resources were extremely lim- ited (external assistance fluctuated between district was able to cope with a workload of 65 000 cases of various pathological condi- tions in Rwandan refugees settled outside the camps, a 400% increase in the curative workload. The district was under severe pres- sure but its services managed to respond effi- ciently to the repeated crisis situations, mainly by maintaining a solid district management structure rooted in ongoing communication and participation of the population (23). Box 2.3 Health districts can make progress, even in adverse circumstances In humanitarian crises, basic maternal and child health services are often disrupted (New Jalozai refugee camp, Peshawar, Pakistan). J.M . Giboux/W HO 25obstacles to progress: context or policy? more than two years on their territory. Such situations, where local or national systems are disrupted or overwhelmed to the extent of being unable to meet the people’s most basic needs, and that require an international response going beyond the mandate or capacity of any single agency, often involve a considerable breakdown of authority and a large amount of violence – against human beings, against the environment, infra- structure and property. In such situations women and children pay the heaviest price: they are the most vulnerable and also the most exposed (adult men tend to leave such areas, to fight or to look for work) (22). Armed attacks often target key infrastructures and systems, such as roads, water supplies, communications and health facilities. The collapse of immunization and disease control programmes, referral systems and hospitals primarily affect women and children. Insecurity and military operations deny access to large areas of territory and constrain the delivery of and access to health services. Much, however, depends on the way health systems are organized to cope with such difficult situations, and well-structured health districts have proved to be remarkably resilient (see Box 2.3). THE MANY FACES OF EXCLUSION FROM CARE Many more mothers and children have access to reproductive, maternal and child care entitlements than ever before in history. In many countries, however, universal access to the goods, services and opportunities that improve or preserve health is still a distant goal. A varying but large proportion of mothers and children remain excluded from the health benefits that others in the same country enjoy. Exclusion is related to socioeconomic inequalities. In many countries it is a sign of increasing dualism in so- ciety: as growing middle classes in urban areas gain disproportionate access to public services, including education and health care, they effectively enter into competition with the poor for scarce resources, and easily come out on top (24). The result is that exclusion from access to health care is commonplace in poor countries. In the 42 countries that in 2000 accounted for 90% of all deaths of children under five years of age, 60% of children with pneumonia failed to get the antibiotic they needed, and 70% of children with malaria failed to receive treatment (25). One third of children did not receive the vitamin A available to others in the same countries, and half had no safe water or sanitation. From 1999 to 2001, less than 2% of children from endemic malaria areas slept under insecticide-treated nets every night. Stagna- tion of progress in coverage for a number of interventions has meant that large parts US$ 1.5 and US$ 3 per inhabitant per year), especially when compared with those available in refugee camps in the same area through relief agencies. Utilization of curative services and preventive coverage rates has actually increased: vaccination coverage has tripled. Maternal health activities have been intensified both quantitatively and qualitatively, with 52% of deliveries taking place in health centres and the hospital, and a population-based caesarean section rate of 1.4%; case-fatality of caesar- ean sections dropped from 7.2% to 2.9%. The Since the 1980s, in North Kivu Province of the Democratic Republic of the Congo (formerly Zaire), the socioeconomic environment has been deteriorating. The province also faced an influx of Rwandan refugees in July 1994. In these difficult circumstances the Rutsh- uru Health District was nevertheless able to adjust and maintain its medical activities. For 11 years the health care network remained accessible and functional, although human and financial resources were extremely lim- ited (external assistance fluctuated between district was able to cope with a workload of 65 000 cases of various pathological condi- tions in Rwandan refugees settled outside the camps, a 400% increase in the curative workload. The district was under severe pres- sure but its services managed to respond effi- ciently to the repeated crisis situations, mainly by maintaining a solid district management structure rooted in ongoing communication and participation of the population (23). Box 2.3 Health districts can make progress, even in adverse circumstances The World Health Report 200526 of the population have continued to be excluded (26). Immunization coverage, for example, maintained its upward trend during the 1990s in the WHO European Region, the Region of the Americas and the Western Pacific Region, but in the other regions it has levelled off at a mere 50% to 70% (see Figure 2.2). Sources of exclusion In many of the countries experiencing stagnation and reversal (particularly in sub- Saharan Africa), barriers to the uptake of health benefits, and specifically the lack of an accessible supply of services, are a critical source of exclusion. For many people, services simply do not exist, or cannot be reached. For example, lack of access to hospitals where major obstetric interventions can be performed is the prime reason why large numbers of mothers in rural areas are excluded from life-saving care at childbirth (see Box 2.4). But there are many other barriers to the uptake of health benefits: service use is often constrained because of women’s lack of decision-making power, the low value placed on women’s health and the negative or judgemental attitudes of family mem- bers (28, 29). Gender is thus a frequent source of exclusion: in India, for example, a girl is 1.5 times less likely to be hospitalized than a boy (30) – and up to 50% more likely to die between her first and fifth birthdays (31). People excluded from health care benefits by such barriers to the uptake of ser- vices are also usually excluded from other services such as access to electricity, water supply, basic sanitation, educa- tion or information. Their exclusion from care is also reflected in inferior health indicators. In Kazakhstan, for example, children born to ethnic Kazakh parents have a 1.5 times higher risk of death than those born to parents of Russian ethnic- ity; in Nigeria, children of uneducated mothers have about a 2.5 times higher risk of death than those of mothers with secondary school or higher education. As part of its work on extension of social protection in health, the Pan American Health Organization has started map- ping exclusion from health benefits in a number of Latin American countries (32). Nearly half of the population is excluded from some, and usually from most health care benefits. The relative importance of underlying reasons for exclusion varies from country to country. “External” sources of exclusion, such as the ones described above, include geographical isolation, as well as barri- ers generated by poverty, race, language and culture – often in association with unemployment or informal employment. For many people the critical factor is the a Third dose of diphtheria, tetanus and pertussis vaccine. Figure 2.2 Levelling off after remarkable progress: DTP3a vaccine coverage since 1980 Co ve ra ge (% ) 1980 1985 1990 1995 2000 0 25 50 75 100 Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific 27obstacles to progress: context or policy? Box 2.4 Mapping exclusion from life-saving obstetric care The extent of exclusion from major life-saving obstetric interventions has been quantified in Burkina Faso, Mali and Niger, and in parts of Benin, Haiti, Pakistan and the United Republic of Tanzania, in a study of 2.7 million deliver- ies. The Unmet Obstetric Needs Network, a collaboration of ministries of health, clinicians and researchers, analysed this population over a one-year period. The network established a benchmark of 1.4% as a conservative estimate of the proportion of deliveries where a major obstetric intervention (caesarean section, hys- terectomy, craniotomy, laparotomy, or version extraction) was required to prevent the mother from dying from a specified set of life-threaten- ing complications. Interventions performed for other indications, including fetal conditions, were not included. The figure illustrates the results. Only 1.1% of urban mothers and 0.3% of rural mothers benefited from these interven- tions. Between 80% (in Niger) and 98% (in Pakistan) of the interventions were caesar- ean sections. Among the 12 242 mothers who benefited from the interventions, 93.8–99.5% survived (in Burkina Faso and Pakistan, respec- tively), as did 7779 of the babies. None of these interventions was for a reason other than the identified life-threatening maternal indications. As such indications are present in at least 1.4% of births, the implication is that no less than 25% of urban and 79% of rural mothers in the study were excluded from access to the major obstetric intervention they needed. Although there is, on average, at least one hospital for every 500 000 inhabitants in the areas of the study (except Niger), the extent of exclusion is clearly related to the availability and accessibility of the health care infrastruc- ture. Indeed, the average distance women have to travel to reach a hospital varies from 9 km in Haiti to 43 km in Burkina Faso and 103 km in Niger. The survey made it possible to map the num- ber of mothers in need of a major life-saving intervention who failed to get it. Similar maps of unmet needs exist in a few other countries. They can be used as a planning tool and as a baseline against which to measure progress in coverage. 5683 got the intervention and survived At least 37 733 mothers out of 2 695 000 needed a major life-saving intervention 2007 did not get the intervention, most died 5901 got the intervention and survived Urban 23 484 did not get the intervention, most died Rural 211 got the intervention, but died 447 got the intervention, but died Many women remain excluded from obstetric interventions, even for the most stringent life-saving indications Proportion of mothers excluded from life-saving interventions when complications arise during childbirth. Benin, Burkina Faso, Mali, Niger, rural and urban areas. < 20% 20–39.9% 40–59.9% 60–79.9% ≥ 80% No survey/no data Mali Benin Niger Burkina Faso Source: (27). The World Health Report 200528 deterrent effect of uncertainty about the cost of care, or of the awareness that care will be unaffordable or catastrophically expensive. Such external factors affecting uptake of services are the most important source of exclusion in, for example, Peru and Paraguay (32). Other, “internal”, sources of exclusion lie within the way the health system actually operates. Even for people who do use services, what is offered may be untimely, inef- fective, unresponsive or discriminatory. Being poor or being a woman is often a reason for being discriminated against, and may result in abuse, neglect and poor treatment, poorly explained reasons for procedures, compounded by the view sometimes held by health workers that women are ignorant. When, for example, in a busy urban maternity hospital in India, the nurses in the labour ward do not complete patient case notes for low-caste women, that deprives them of the quality safeguards given to other women (33). Poor and anonymous patients often have to wait longer, are examined more superficially, or are treated with disdain; they may get inferior treatment, especially when scarce resources are reserved for richer patients. In rural areas of the United Republic of Tanzania, for example, children from the poorest part of the population who sought care for probable pneumonia were less than half as likely to be given antibiotics as richer children (34). Such factors internal to health services can be important sources of exclusion; throughout the world, many mothers and children are excluded from what they are entitled to because of the failure of the health system to deliver the right services at the right time, to the right people, and in the right manner. In Ecuador and Honduras, for example, what happens within the health system, rather than failed uptake, is the dominant source of exclusion (32). Joyce Ching/W HO Waiting for treatment that does not come. 29obstacles to progress: context or policy? Exclusion from “normal” treatment – what a patient can expect, based on what other people are given – does not go unnoticed by those concerned. In India, for example, 55% of poorer mothers said they had been made to wait too long (only half as many of the richer mothers had that impression), and only 50% were given clear information about their treatment, as against 89% of the richer patients. Other patients are also aware of such practices: 67% of the patients in Conakry, Guinea, are convinced that rich and well-dressed patients get better treatment (34). The – often justified – expectation of ill-treatment or discrimination in turn discour- ages uptake of services, completing a vicious circle of exclusion, compounded by the absence of adequate systems to protect mothers and children against catastrophic expenditure or financial exploitation. Poverty, humanitarian crises, and the HIV/AIDS epidemics all directly affect the health and survival of mothers and children. But they also affect their health by creat- ing barriers to the uptake of services. Furthermore, they influence the way services are provided to mothers and children who do use them, and thus add to sources of exclusion within the health system. Patterns of exclusion The extent and depth of exclusion vary from region to region within countries, but also between countries. At one extreme are the poorest countries where large parts of the population are deprived of care, even among the better off: only a small minority enjoys reasonable access to a reasonable range of health benefits, cre- ating a pattern of massive deprivation. At the other extreme are countries where a large part of the population enjoys a wide range of benefits but a minority is excluded: a pattern of marginalization. Looking at health care coverage by wealth group provides a crude illustration of these different patterns (see Figure 2.3). Between the extremes of massive deprivation (typical for countries with major problems of supply of services and low-density health care networks) and marginalization (typical for rich or mid- dle-income countries with dense health care networks) are the countries where poor populations have to queue behind the better off, waiting to get access to health services and hoping that benefits will eventually trickle down. As countries move from a pattern of massive deprivation towards one of mar- ginalization, the poor-rich gap in cover- age and uptake of services grows in size, to diminish only as the curves flatten out when universal access is within reach Figure 2.3 Different patterns of exclusion: massive deprivation at low levels of coverage and marginalization of the poorest at high levels a Asset quintiles provide an index of socioeconomic status at the household level. They divide populations into five groups (in ascending order of wealth from 1 to 5), using a methodology that combines information on household head characteristics as well as household ownership of certain assets, availability of services, and housing characteristics (35). Data source: (36). Le ve l o f c ov er ag e (% ) Brazil 1996 Ethiopia 2000 Asset quintilesa 1 2 3 4 5 100 75 50 25 0 ≥ 4 Antenatal care visits Birth in a health facility Skilled attendance at birth The World Health Report 200530 (see Figure 2.4). Unless specific measures are taken to extend coverage and promote uptake in all population groups simultaneously, improvement of aggregate population coverage will go through a phase of increasing inequality. These complex dynamics also affect the distribution of health outcomes. For a long time policy-makers used aggregate health indicators – particularly the under-five mor- tality rate – to monitor health policies. As more sophisticated analyses of health out- comes by asset quintile have become possible (37), attention has been drawn to the occurrence of increasing survival gaps between the poorest and the better off (38). The gaps in mortality rates between the children of rich and poor families have in- creased in the majority of 21 developing countries that had reduced their overall rate of mortality among children under five years of age (see Figure 2.5). Health and survival among the poorest actually deteriorated in eight of these countries, while the richest children in the same countries improved their chances of survival. As a result, national averages that show progress may conceal persisting or widening inequalities. Similar divergence appears to be occurring for maternal mortality in some countries (39). DIFFERENT EXCLUSION PATTERNS, DIFFERENT CHALLENGES The policy challenges differ between countries that are close to universal access (where exclusion is limited) and those where exclusion is pervasive. The countries where exclusion is limited to a small and marginalized part of the population are usu- ally on track, or at least show slow progress in terms of reduction of child mortality. These are countries with well-extended health systems, although not always with an Figure 2.4 From massive deprivation to marginal exclusion: moving up the coverage ladder 0 25 50 75 100 1 2 3 4 5 Asset quintilesa % o f b irt hs in fa ci lit ie s Dominican Republic 1996 Colombia 1995 Côte d'Ivoire 1998 Côte d'Ivoire 1994 Guatemala 1998 Chad 1997 Bangladesh 1993 aAsset quintiles provide an index of socioeconomic status at the household level. They divide populations into five groups (in ascending order of wealth from 1 to 5), using a methodology that combines information on household head characteristics as well as household ownership of certain assets, availability of services, and housing characteristics (35). Data source: (36). 31obstacles to progress: context or policy? optimal range of technical interventions. Examples of countries in this group include Brazil, Colombia and the Dominican Republic. Here, the challenge is one of targeting to give the mothers and children currently excluded the possibility of claiming their entitlements: tackling the roots of social exclusion, removing the barriers to the uptake of health benefits, responding appropriately to their needs, and offering them financial protection from the consequences of illness and obtaining care. Most of the countries that stagnated or went into reversal, and many of those that showed slow progress in terms of child mortality reduction, show patterns of massive exclusion or queuing. Such countries include Bangladesh, Chad and Ethiopia. They typically have weak, low-density and fragile health systems; they also suffer from poverty, and sometimes HIV/AIDS and complex emergencies, additional constraints to health systems development. In this group the main challenge is to build and roll out primary health care as the vehicle for maternal, newborn and child health care. The momentum created by the primary health care movement of the early 1980s focused attention on issues of equity and access, and resulted in the extension of basic health services to the rural poor. Maternal and child health programmes were integral to this extended coverage: antenatal clinics were intended to provide the first contact that would continue through childbirth and postnatal care for the mother and with clinics for children. In the early 1990s, the view gained ground that primary health care had to be de- centralized and organized in “integrated health districts”. Countries that had been Do m in ic an R ep ub lic 1 98 6– 19 96 Ca m er oo n 19 91 –1 99 8 In do ne sia 1 99 1– 19 97 Ni ge r 1 99 2– 19 98 Ba ng la de sh 1 99 3– 19 97 M ad ag as ca r 1 99 2– 19 97 Gh an a 19 88 –1 99 8 Se ne ga l 1 99 3– 19 97 M al aw i 1 99 2– 20 00 Be ni n 19 91 –2 00 1 Bo liv ia 1 99 4– 19 98 M al i 1 98 7– 19 96 Pe ru 1 98 6– 20 00 Co lo m bi a 19 86 –2 00 0 Br az il 19 86 –1 99 6 In di a 19 93 –1 99 8 Eg yp t 1 99 2– 20 00 Ph ilip pi ne s 19 93 –1 99 8 Gu at em al a 19 87 –1 99 8 M or oc co 1 98 7– 19 92 Tu rk ey 1 99 3– 19 98 Ka za kh st an 1 99 5– 19 99 Cô te d ’Iv oi re 1 99 4– 19 98 Bu rk in a Fa so 1 99 3– 19 98 Un ite d Re pu bl ic o f T an za ni a 19 92 –1 99 9 Ke ny a 19 93 –1 99 8 Zi m ba bw e 19 88 –1 99 9 Za m bi a 19 92 –1 99 6 15 10 5 0 -5 -10 -15 -20 -25 % d ec re as e in th e ric h- po or g ap in u nd er -5 m or ta lit y ra te % in cr ea se in th e ric h- po or g ap in u nd er -5 m or ta lit y ra te Note: The rich-poor gap is the difference between the under-5 mortality rates of the poorest and richest wealth quintiles. Data source: (36). Countries with diminishing under-5 mortality rate between two Demographic and Health Surveys Countries with increasing under-5 mortality rate between two Demographic and Health Surveys Figure 2.5 Survival gap between rich and poor: widening in some countries, narrowing in others The World Health Report 200532 doing so for quite some time saw their earlier choices reinforced, and others, such as Cambodia and Niger, moved to adopt district policies. Many development agencies put districts at the core of their health development strategies, particularly for the coun- tries that combined the poorest health status with the weakest health systems. Are districts the right strategy for moving towards universal coverage? Organizing the delivery of primary health care through health districts promised a fast-track response to the rising demand for health care. Apart from the frustration caused by the diminishing returns of the vertical approaches of the 1970s and 1980s, there were three good reasons for this. The first was that the “health centre” – the heir of the dispensaries, but now the centrepiece of the whole system, and the equivalent of the family doctor or general practitioner – was the most viable alternative to village health workers, vertical pro- grammes and commercial health care. It was also the only one that responded to the demand for care by the population. National decision-makers were alert to this argu- ment, which was based on the experiences of a number of small and medium-scale field projects: Pahou in Benin, Danfa in Ghana, Machakos in Kenya, Pikine in Senegal, and Kasongo and Kinshasa in Zaire. These projects had shown that health centres were a feasible (40, 41), affordable (42–44) and efficient (45–47) option for delivering care, and a realistic alternative to vertical disease control programmes. Second, hospitals providing referral-level care were part and parcel of the district model. Although the referral system remained the weak point, it became possible to take on the maternal health agenda because of the hospital’s ability to deal with obstetric complications. Moreover, the inclusion of hospitals brought a vital part of the public health infrastructure and personnel back on the scene. This was a relief for the administrative elite and the middle class, who had never considered the grassroots primary health care of the 1980s as something to aspire to for themselves. Third, the health district fitted well with the movement towards decentralization, to which most countries were at least theoretically committed. Health districts seemed both manageable and sufficiently decentralized to be flexible and affordable (40,48). A strategy without resources By the mid-1990s many countries were creating district systems, setting up drug procurement agencies and defining a minimum package of services. However, as in the years after Alma-Ata, money did not follow, particularly in sub-Saharan Africa, and results were slow to come. In the bleak economic environment, financing remained a real barrier to progress. With a decrease in gross domestic product per capita in real terms between 1990 and 2002, total health expenditure in many African countries stagnated or decreased, and public health expenditure remained below US$ 10 per person. External assistance did not make up for this, as per capita flows also stag- nated up to 1999 (49). The real extent of the failure to increase financing of the health sector during the 1980s and 1990s appears in the detailed breakdown of what financing there was: in Cameroon, for example, recurrent public expenditure declined from US$ 5 per inhabitant in 1990 to US$ 3.5 in 1996. Of this, US$ 2.1 went on salaries and US$ 1.12 on other recurrent expenditures. The districts were left with a mere US$ 0.28 per person per year for non-salary recurrent expenditures. 33obstacles to progress: context or policy? There has been little flexibility to improve working conditions in the public sector, especially in terms of salaries and incentives, because of civil service regulations and structural adjustment policies. As a result many health workers have moved to the private sector. Data from Ghana, Zambia and Zimbabwe show that losses of health workers from the public health sector continued or accelerated during the 1990s (50). The stringent budgetary measures under structural adjustment programmes also im- posed ceilings on recruitment. Even in countries with unemployed health professionals such as Zambia, governments often were not able to enrol more staff (50). Absenteeism was another major issue that affected the already scarce human resources. In Burkina Faso, for example, absenteeism of health district doctors in seven rural districts in 1997 varied between 30% and more than 80% (51). Vacancy rates for doctors in Ghana increased from 43% in 1998 to 47% in 2002. Over the same period vacancy rates for registered nurses rose from 26% to 57% (52). Much of the absenteeism was related to inadequate working conditions, insufficient salaries and declining staff morale. In a number of countries, however, the HIV/AIDS epidemics aggravated what was becoming an acute human resource crisis. Data are scarce but suggest that besides contributing to absenteeism, HIV/AIDS may cost Africa’s health systems one fifth of their employees over the next few years (53). The absence of ad- equate measures to protect health workers against HIV/AIDS and the stress of caring for HIV/AIDS patients are additional factors motivating them to migrate. The real wages of public servants continued their decline in the 1990s: in six years they dropped by 21% from their 1990 level in Togo, 34% in Burkina Faso, 35% in Guinea-Bissau, and 41% in Niger. Absenteeism continued – 35% for district doctors in 1997 in Burkina Faso – as did “seminaritis”: in 1995 in Mali, regional health staff spent 34% of their total working time in workshops and supervision missions sup- ported by international agencies; this figure rose to 48% for chief medical officers. Predatory behaviour (54–57) and moonlighting (58, 59) became the norm, contribut- ing to the shortage of health workers in the public sector (50). The shortages of health personnel are the most visible aspect of the human resourc- es crisis in sub-Saharan Africa. The figures are stark: in Zimbabwe, of the 1200 physi- cians trained during the 1990s, only 360 were still practising in the country in 2001 (60). Ghana’s loss of 328 nurses in 1999 was the equivalent of its annual output (50). More than half of the health professionals in Zimbabwe, Ghana and South Africa are thinking of migrating to other countries (61). At the same time, 35 000 South African nurses are not employed in the health sector and two thirds of the health workforce in Swaziland is working in the private sector (62, 63). Have districts failed the test? The environment in which district health systems had to be set up has been decid- edly unfavourable. Some countries, such as Mali, managed to expand health centre networks and services for mothers and children (64). Overall expansion, however, has been slow. In 2000, for example, only 13 of Niger’s hospitals had appropriate facili- ties to perform a caesarean section (65). This was also the case for only 17 of the 53 district hospitals in Burkina Faso, nearly 10 years after districts had been established; moreover, only five of those 17 hospitals had the three doctors required to ensure continuity throughout the year (66). The slowness of rolling out health districts has been disappointing: it takes time to transform an administrative district into a functional health system (see Box 2.5). Nev- ertheless, where districts have reached the critical point of becoming stable and viable The World Health Report 200534 In the mid 1990s Ouallam, one of the poorest districts in Niger with 250 000 inhabitants living at an average distance of 74 km from the hospital, had seven dysfunctional health centres and an almost empty district hospital. Emergencies could not be referred to the hospital in an area with no means of communication. Several measures were, however, put in place to change the situation. Some were general measures to solve problems in the district and others were specifically aimed at improving the referral system. Making the changes took eight years (see table below). Box 2.5 Building functional health districts: sustainable results require a long-term commitment In the mid-1990s Ouallam, one of the poor- est districts in Niger with 250 000 inhabitants living at an average distance of 74 km from the hospital, had seven dysfunctional health centres and an almost empty district hospital. Emergencies could not be referred to the hospi- tal in an area with no means of communication. Several measures were, however, put in place to change the situation. Some were general measures to solve problems in the district and others were specifically aimed at improving the referral system. Making the changes took eight years (see table below). This sustained investment of time and effort paid off: antenatal care coverage increased by 42%, coverage by clinics for children under five years of age tripled, and vaccina- tion coverage doubled. In a year the number of new acceptors for modern family planning methods increased from 568 to 1444, and hospitalizations increased from 434 to 1420; surgical interventions and blood transfusions, not possible previously, totalled 219 and 86, respectively, in 2003. The number of emer- gency evacuations to the hospital increased markedly, mainly for obstetric causes. Over distances averaging more than 50 km, these evacuations were carried out by the hospital’s vehicle, partly subsidized and partly on a cost-recovery basis at US$ 23 per emergency evacuation (see figure below). No single intervention alone explains the progress that has been made: the results came from the combined action on different aspects of the system, and investment in the capacities of the personnel (65). Initiatives aimed at increasing demand for services Established health com- mittees Discussed and negotiated health care coverage plan Negotiated fees for emer- gency evacuation Built credibility of health centre through improved quality of care Increased acceptability of referral to district hospital through discussion of referrals and emergency evacuations Initiatives aimed at increasing uptake of services Established a health care coverage plan Created seven additional health centres Initiatives aimed at improving case man- agement in the health centre Standardized diagnosis- treatment-referral procedures Introduced vitamin A distribution, stepped up vaccination coverage, in- troduced detection/treat- ment of malnutrition Introduced outreach Discussed referral results with health care nurses Standardized referral criteria and procedures Initiatives aimed at facilitating emergency transfer to the hospital Introduced solar energy radios and ambulance service Introduced cost-recovery mechanisms for ambu- lance Renegotiated emergency evacuation fees Initiatives aimed at improving case man- agement in the hospital Rehabilitated physical infrastructure Introduced surgery and blood transfusion Internal reorganization negotiated and imple- mented with staff Introduced system of patient records Introduced nutritional rehabilitation unit Improved laboratory and X-ray services Introduced quality assurance The combination of diverse initiatives undertaken to facilitate effective access to health services in Ouallam, Niger, 1996–2003 Emergency evacuation in Ouallam, Niger Ca lls fo r e m er ge nc y ev ac ua tio n 1996 7 1997 8 1998 8 1999 9 2000 12 2001 12 2002a 2003 14 Year Bypassing health centres Originating from health centres Hospital upgraded Radio- ambulance 0 50 100 150 200 250 300 350 400 450 Number of health centresa No data for 2002. 35obstacles to progress: context or policy? structures, they have shown credible and visible results, sometimes in very adverse circumstances, as in Guinea and the Democratic Republic of the Congo. On balance, the experience of the last decade suggests that health districts still stand as a rational way for governments to roll out primary health care through networks of health centres, family practices or equivalent decentralized structures, backed up by referral hospitals. There are no real alternatives to serve as a vehicle for a continuum of integrated care for mothers, newborns and children. The challenge now is to scale up implementation in an adverse environment where exclusion is further fuelled by the rampant commercialization of the health sector, including within public and not- for-profit facilities. The second challenge is to tailor health care delivery strategies to the specific situation and exclusion patterns of each country. At the same time, it is no longer possible to experiment with district projects without looking at the wider context of cross-cutting, system-wide constraints. Without a real commitment to strengthening district health services, talking about the priority status of mothers and children is likely to remain mere lip service. Part of the task ahead is political. Maternal, newborn and child health cannot be reduced to a set of programmes to be delivered to a target population. Rather, moth- ers and children must be in a position to claim a set of entitlements as their right. This implies an adjustment of macro-level health policies and resource mobilization, at country level and internationally. Three issues cry out for attention: the funding of the health sector, the human resource crisis, and the accountability of health systems and providers to their clients. But the task ahead is also one of refocusing programme content. For too long at- tention has been directed towards the development of technologies, rather than to- wards embedding these in viable organizational strategies that organize and ensure a continuum of care. Given the complexity of expanding district health care systems, the temptation is to go back to vertical programmes built around disease control technologies. In the past this has led to a considerable amount of fragmentation, at the expense of ensuring the continuity of care from pregnancy throughout childhood. Much of the challenge, in fact, is to accommodate both programmatic and systemic concerns: an organizational rather than a technical problem. The next chapters relo- cate the technical strategies available for improving the health of mothers, newborns and children within health systems that are scaling up and facing an increasingly vocal demand for care. In the mid 1990s Ouallam, one of the poorest districts in Niger with 250 000 inhabitants living at an average distance of 74 km from the hospital, had seven dysfunctional health centres and an almost empty district hospital. Emergencies could not be referred to the hospital in an area with no means of communication. 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Given the extent of unintended pregnancy and the unacceptably high levels of unsafe abortion around the world, continuing efforts to provide family planning services, education, information and safe abortion services – to the extent allowed by law – are essential public health interventions. Tackling the low status of women, violence against women and lack of employment rights for pregnant women is vital in helping to build societies that support pregnant women. Pregnancy is not just a matter of waiting to give birth. Often a defining phase in a woman’s life, pregnancy can be a joyful and fulfilling period, for her both as an individual and as a member of society. It can also be one of misery and suffering, when the pregnancy is unwanted or mistimed, or when complications or adverse circumstances compro- mise the pregnancy, cause ill-health or even death. Pregnancy may be natural, but that does not mean it is problem-free. Rarely is a pregnancy greeted with indifference. When a pregnancy occurs, women, their partners and families most often experience a mixture of joy, concern and hope that the outcome will be the best of all: a healthy mother and a healthy baby. All societies strive to ensure that pregnancy is indeed a happy event. They do so by providing appropriate antenatal care during pregnancy to promote health and cope with problems, by taking measures to avoid unwanted pregnancies, and by making sure that pregnancies take place in socially and environmentally favourable conditions. Women around the world face many inequities during pregnancy. At this crucial time women rely on care and help from health services, as well as on support systems in the home and community. Exclusion, marginalization and discrimination can severely affect the health of mothers and that of their babies. The World Health Report 200542 REALIZING THE POTENTIAL OF ANTENATAL CARE Meeting expectations in pregnancy A pregnancy brings with it great hope for the future, and can give women a special and highly appreciated social status. It also brings great expectations of health care that is often willingly sought at this time. This explains, at least in part, the extraordinary success of antenatal care consultations. Women want confirmation that they are preg- nant. At the same time they know that pregnancy can be dangerous, particularly in the developing world. In many countries pregnant women are likely to know of maternal deaths, stillbirths or newborn deaths among their own extended family or in their com- munity. It is natural that demand is high for health care that can provide reassurance, solve problems that may arise and confirm the status conferred by pregnancy. In high-income and middle-income countries today, use of antenatal care by pregnant women is almost universal – except among marginalized groups such as migrants, ethnic minorities, unmarried adolescents, the very poor and those living in isolated rural communities. Even in low-income settings, coverage rates for antenatal care – at least for one visit – are often quite high, certainly much higher than use of a skilled health care professional during childbirth. There were noticeable increases in the use of antenatal care in developing countries during the 1990s. The greatest progress was seen in Asia, mainly as a result of rapid changes in a few large countries such as Indonesia (see Figure 3.1). Significant increases also took place in the Caribbean and Latin America, although countries in these areas already had relatively high levels of antenatal care. In sub-Saharan Africa, by contrast, antenatal care use increased only marginally over the decade (although levels in Africa are relatively high compared with those in Asia). While antenatal care coverage has improved significantly in recent years, it is generally recognized that the antenatal care services currently provided in many parts of the world fail to meet the recommended standards. A huge potential thus Figure 3.1 Coverage of antenatal care is rising % o f p re gn an t w om en 100 90 80 70 60 50 40 30 20 10 0 Eastern Mediterranean (6; 57%)a World (56; 55%)a Western Pacific (1; 8%)a Americas (17; 46%)a Africa (25; 61%)a Europe (1; 14%)a South-East Asia (6; 96%)a 1990 2000 +11% +34% +6%+15% +4%+17% +20% a Number of countries and percentage of the regional population included in the analysis. Data source: Multiple Indicator Cluster Surveys (UNICEF) and Demographic and Health Surveys. 43great expectations: making pregnancy safer remains insufficiently exploited. Although progress has been made globally in terms of increasing access and use of one antenatal visit, the proportion of women who are obtaining the recommended minimum of four visits is too low (1) . The first consultation is often late in pregnancy, whereas maximum benefit requires an early initiation of antenatal care. Antenatal care is given by doctors, midwives and nurses and many other cadres of health workers (2). Little is known about the capacities of non-professional workers such as traditional birth attendants to deliver the known effective interventions during pregnancy. It is October 2004 and Bounlid, from the Lao People’s Democratic Republic, is seven months pregnant and feeling tired. She is finding it much harder to work and her family’s income has slipped because of this. The rice-cropping season is starting and the rice needs to be brought in soon. When she goes to the fields she has to leave her children on their own, as she does not have the energy to deal with them and work at the same time. “I’ve had no antenatal care and I don’t expect to have any for the rest of my pregnancy. I plan to give birth at home, as I did with my other four children. It is too expensive for most people in my village to give birth with a skilled attendant at the clinic, which, in any case, has very basic facilities and no telephone or ambulance if there were complications.” Bounlid has not received any professional advice about the birth or nutrition concerning the baby. J. Holm es/W HO The World Health Report 200544 Pregnancy – a time with its own dangers Antenatal care is not just a way to identify women at risk of troublesome deliveries (3, 4). While less prominent than the dangers that can occur during childbirth, those surrounding pregnancy are far from being negligible. Women expect that antenatal care will help them deal with the health problems that can occur during pregnancy itself. If left unchecked, some of these may threaten health and survival before the child is due to be born. A substantial proportion of maternal deaths – perhaps as many as one in four – occur during pregnancy. Data on mortality during pregnancy, however, are very fragmentary (5). The proportion of maternal deaths during pregnancy varies significantly from country to country according to the importance of unsafe abortion, violence, and disease conditions in the area (6, 7). In Egypt 9% of all maternal deaths occur during the first six months of pregnancy and a further 16% during the last three months (8). Apart from complications of unsafe abortion, which can be prevented or dealt with by good post-abortion care, three types of health problems exist in pregnancy. First, the complications of pregnancy itself, second, diseases that happen to affect a pregnant woman and which may or may not be aggravated by pregnancy, and third, the negative effects of unhealthy lifestyles on the outcome of pregnancy. All have to be tackled by antenatal care. Pregnancy has many complications that require care (9). In Lusaka, Zambia, nearly 40% of pregnancy-related referrals to the university teaching hospital were related to problems of the pregnancy itself, rather than to childbirth: 27% for threatened abortion or abortion complications, 13% for illness not specific to pregnancy such as malaria and infections, and 9% for hypertensive disorders of pregnancy (10). In a recent study of six west African countries, a third of all pregnant women were shown to experience some illness during pregnancy, (not including problems related to unsafe abortion) of whom 2.6% needed to be hospitalized (11). Interventions against malaria and anaemia are well known, and though not perfect, can do a lot to reduce malaria morbidity and mortality. Maternal, neonatal and child health services are a prime vehicle for such interventions. Apart from prompt treatment of malaria infections (23), maternal, neonatal and child health services can contribute by increasing the use of insecticide-treated nets and provid- ing intermittent preventive treatment. Insecticide-treated nets limit the harm done by malaria: they reduce parasitaemia, the frequency of low birth weight, and anae- mia (24–26). These nets have been shown to reduce all-cause mortality in young children by around one fifth, saving an average of six lives for every 1000 children aged 1–59 months protected each year (26) . They represent a highly cost-effective use of scarce health care resources (27). Each year, approximately 50 million women living in malaria-endemic countries throughout the world become pregnant. Around 10 000 of these women and 200 000 of their infants die as a result of malaria infection, severe malarial anaemia contributing to more than half of these deaths (14,15) . Malaria in pregnancy also increases the risk of stillbirth, spontaneous abortion, low birth weight and neonatal death. The risk of severe malaria is increased in pregnant women coinfected with HIV. More than 90% of the one million annual deaths from malaria are among young African children, as are most cases of severe malarial anaemia (16–18) . Severe anaemia probably accounts for more than half of all childhood deaths from malaria in Africa, with case fatal- ity rates of between 8% and 18% in hospitals (16–22) and probably more than that in the community. Intermittent preventive treatment in preg- nancy is the administration of a full therapeutic dose of an antimalarial drug (sulfadoxine- pyrimethamine) at specified intervals in the second and third trimesters, regardless of whether or not the woman is infected. This reduces maternal anaemia, placental malaria, and low birth weight by approximately 40% (28–30). Intermittent preventive treatment is one of the most cost-effective strategies for preventing the morbidity and mortality associ- ated with malaria (31, 32), and recent evidence suggests that it may be a useful strategy for the control of malaria and anaemia in young infants (33,34) . An Intermittent Preventive Treatment in Infants Consortium, comprising WHO, UNICEF, and research groups in Africa, Europe and the USA, is tackling the outstand- ing research issues. Box 3.1 Reducing the burden of malaria in pregnant women and their children 45great expectations: making pregnancy safer Classic complications of pregnancy include pre-eclampsia and eclampsia which affect 2.8% of pregnancies in developing countries and 0.4% in developed countries (12), leading to many life-threatening cases and over 63 000 maternal deaths worldwide every year. Haemorrhage following placental abruption or placenta praevia affects about 4% of pregnant women (13). Less common, but very serious complications include ectopic pregnancy and molar pregnancy. Diseases and other health problems can often complicate, or become more severe during, pregnancy. Malaria worsens during pregnancy, for example, and together with anaemia is responsible for 10 000 maternal deaths and 200 000 infant deaths per year (see Boxes 3.1 and 3.2). Mortality from HIV/AIDS duri

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