Trploe WHO
xii The World Health Report 2005
xiii 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 quaranteed 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,newbom 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
overview xiii 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 development 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 maternal 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.Matemal 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,newboms 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
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 pregnancy 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 importance 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 Conference 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 worrying 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 stagnated 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 massively 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 experience 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 treatment of sexually transmitted infections, tuberculosis and malaria initiatives, and family
overview XV 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 newbor.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
overview xv 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, adolescents 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 occur 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 underestimated. 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 occurred 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 reqions,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 matemal,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
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 vaccinepreventable 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 development. 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 referral 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 development 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 finetuning advocacy language: it frames the health of mothers, babies and children within a broader, straightforward political project, responding to society’s claim for the protection 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