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 USS 1 billion in 2006,increasing,as coverage expands,to US$6 billion in 2015:a total of USS 39 billion over ten years,in addition to present expenditure on maternal and newborn health.This corresponds to an extra outlay of around USS 0.22 per inhabitant per year initially,increasing to USS 1.18 in 2015.A preliminary estimate of the potential impact of this scaling up suggests a reduction of materal 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
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 numerous 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 firstlevel 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 problemsolving. 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
overview xxiii 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 USS 2.2 billion in 2006,increasing,as coverage expands,to USS 7.8 billion in 2015:a total of USS 52.4 billion over 10 years,in addition to present expenditure on child health.This corresponds to an extra outlay of around USS 0.47 per inhabitant per year initially,expanding to USS 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 quaranteed 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
overview xxiii 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 with noticeable results.However,the countries with the and well and to see it grow up in good health.Their chances of doing highest burden of mortality and ill-health to start with so are better in 2005 than ever before-not least because they are made little progress during the 1990s.In some,the situ- becoming aware of their rights.With today's knowledge and technol- ation has actually worsened in recent years.Progress ogy,the vast majority of the problems that threaten the world's moth-has therefore been patchy and unless it is accelerated ers and children can be prevented or treated.Most of the millions of significantly,there is little hope of reducing maternal untimely deaths that occur are avoidable,as is much of the suffering mortality by three quarters and child mortality by two that comes with ill-health.A mother's death is a tragedy unlike others,thirds by the target date of 2015-the targets set by the because of the deeply held feeling that no one should die in the course Millennium Declaration (2,3). of the normal process of reproduction and because of the devasta- In too many countries the health of mothers and chil- ting effects on her family (1).In all cultures,families and communities dren is not making the progress it should.The reasons acknowledge the need to care for mothers and children and try to do for this are complex and vary from one country to an- so to the best of their ability. other.They include the familiar,persistent enemies of An increasing number of countries have succeeded in improving the health-poverty,inequality,war and civil unrest,and the health and well-being of mothers,babies and children in recent years, destructive influence of HIV/AIDS-but also the failure to
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 technology, the vast majority of the problems that threaten the world’s mothers 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 devastating 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 situation 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 children is not making the progress it should. The reasons for this are complex and vary from one country to another. 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
2 The World Health Report 2005 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 Leon 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'CEuvre de la goutte de lait':Dr Variot's consultation at the Belleville Dispensary,Paris
2 The World Health Report 2005 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 responsive 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 children 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 increasingly 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 accelerated 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
mothers and children matter-so does their health 3 "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 Interational 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 matemal 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 (77). WHERE WE ARE NOW:A MORAL AND POLITICAL IMPERATIVE The early implementation of primary health care often had a narrow focus,but among Archives 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 de I'Assistance Publique-Hopitaux de Parts 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
mothers and children matter – so does their health 3 “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 Kingdom. 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 vulnerable 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 scaling up of health care coverage in rural areas boosted maternal and child health programmes 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