4 The World Health Report 2005 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(73).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 WHO Archives:WHO12,SEARO 211 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
4 The World Health Report 2005 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 children. 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, cultural 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 unfairness 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. WHO Archives: WHO12, SEARO 211
mothers and children matter-so does their health 5 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 1948 "motherhood and childhood are entitled to special care and 1952 The General Conference of the International Labour Organi- assistance". zation adopts the Maternity Protection Convention. The Declaration of the Rights of the Child. 1959 1966 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 Elimination of All Forms of Dis-1981 crimination Against Women enjoins States parties to ensure appropriate maternal health services. 1989 The Convention on the Rights of the Child guarantees chil- At the United Nations World Summit on Children govern-1990 dren's right to health.States commit themselves to ensuring ments declare their "joint commitment...to give every child a appropriate materal health services. better future",and recognize the link between women's rights and children's well-being. The United Nations Human Rights Committee expresses 1993 concern over high rates of maternal mortality. 1994 The United Nations International Conference on Popula- 1995 tion and Development and the United Nations Fourth World The United Nations United Nations Human Rights Commit-1996 Conference on Women affirm women's right of access to tee rules that,when abortion gives rise to a criminal penalty appropriate health care services in pregnancy and childbirth. 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. 2000 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 Committee on the Rights of the Child 2003 2003 The United Nations Commission on Human Rights,states states that adolescent girls should have access to information that sexual and reproductive health are integral elements of on the impact of early marriage and early pregnancy and have the right to health. 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 2004 2004 The United Nations Sub-Commission on the Promotion and end to the extraction of confessions for prosecution purposes Protection of Human Rights adopts a resolution on"harmful from women seeking emergency medical care as a result of traditional practices affecting the health of women and the illegal abortion.The United Nations Special Rapporteur on girl child". the Right to Health reports that all forms of sexual violence are inconsistent with the right to health
mothers and children matter – so does their health 5 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 Discrimination Against Women enjoins States parties to ensure appropriate maternal health services. At the United Nations World Summit on Children governments 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 Committee 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 Organization adopts the Maternity Protection Convention. The International Covenant on Economic, Social and Cultural Rights recognizes the right to the highest attainable standard of physical and mental health. The Convention on the Rights of the Child guarantees children’s right to health. States commit themselves to ensuring appropriate maternal health services. The United Nations International Conference on Population 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 services”. 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
6 The World Health Report 2005 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. Box 1.2 Why invest public money in health care for mothers and children? Modern states quarantee health entitlements birth-weight children in turn are at greater risk maternal and child health interventions can be for mothers,newborns and children that are of dying and of suffering from infections and classified as private goods,a comprehensive grounded in human rights conventions.Ensur- growth retardation(25),have lower scores programme also includes components such as ing them access to care has become a moral on cognitive tests(26-28)and may be at information on contraception,on sexual health and political imperative,which also has a higher risk of developing chronic diseases in and rights,on breastfeeding and child care,that strong rational basis. adulthood(29.30). are obvious public goods.Moreover,the rule of From a public health point of view an Healthy children are at the core of the rescue,which gives priority to interventions important criterion for priority setting and formation of human capital.Child illnesses that save lives,applies to many maternal and public funding is that cost-effective intervention and malnutrition reduce cognitive development child health interventions. packages exist.Such packages are well and intellectual performance(31-33),school Finally,public funding for maternal and documented in the case of materal and child enrolment and attendance(34,35),which child health care is justified on grounds of health(74,15).But cost-effectiveness is only impairs final educational achievement equity.Motherhood and childhood are periods one of the criteria for public investment.Others Intrauterine growth retardation and malnutri- of particularly high vulnerability that require commonly used include:the generation of tion during early childhood have long-term "special care and assistance"(19);they are positive extemalities;the production of public effects on body size and strength(36,37)with also periods of high vulnerability because goods and the rule of rescue;and the potential implications for productivity in adulthood. women and children are more likely to be poor. to increase equity and avoid catastrophic In addition,with the death or illness of a Although systematic documentation showing expenditure(76).Any of these criteria can be woman,society loses a member whose labour that they are overrepresented among the poor a sufficient condition for public investment on and activities are essential to the life and is scarce (46).women are more likely to be its own.When more than one is present,as in cohesion of families and communities.Healthy unemployed,to have lower wages,less access maternal and child health interventions,the mothers have more time and are more available to education and resources and more restricted case for public funding is even stronger. for the social interaction and the creation of the decision-making power,all of which limit their Health care for mothers and children bonds that are the prerequisite of social capital access to care.Public investment in maternal produces obvious positive externalities through They also play an important social role in caring and child health care is justified in order to vaccination or the treatment of the infectious for those who are ill. correct these inequities. diseases of childhood,and through the im- The economic costs of poor maternal and In addition,where women and children proved child health that follows improvement child health are high(38);substantial savings represent a large proportion of the poor, of maternal health.There has been little in future expenditure are likely through family subsidizing health services for them can be systematic research on the human,social and planning programmes(39,40)and interventions an effective strategy for income redistribution economic capital generated by improving the that improve maternal and child health in the and poverty alleviation (14).Ill-health among health of mothers and children,but the negative long term.Consequent gains in human and mothers and children,and particularly the externalities of ill-health are clear. social capital translate into long-term economic occurrence of major obstetric problems, The health of mothers is a major determinant benefits (47).There is evidence of economic is largely unpredictable and can lead to of that of their children,and thus indirectly returns on investment in immunization(42) catastrophic expenditures(47)that may push affects the formation of human capital. nutrition programmes(41,43),interventions households into poverty.The risk of catastrophic Motherless children die more frequently,are to reduce low birth weight(36),and integrated expenditures is often a deterrent for the timely more at risk of becoming malnourished and health and social development programmes uptake of care-a major argument,technically ess likely to enrol at school(17,18).The babies 44.45. and politically,for public investment. of ill or undernourished pregnant women are Maternal and child health programmes are more likely to have a low birth weight(79-27) also prime candidates for public funding because and impaired development(19,22-24).Low- they produce public goods.Although many
6 The World Health Report 2005 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 became 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 costeffectively. 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 final educational achievement. Intrauterine growth retardation and malnutrition 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. Ensuring 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 improved child health that follows improvement of maternal health. There has been little 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 affects 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). Lowmaternal 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?
mothers and children matter-so does their health 7 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 Rafiqur Rahman/Reuters The health of mothers and children is now seen as an issue of rights,entitlements and day-to-day struggle to secure these entitlements
mothers and children matter – so does their health 7 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 establish 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 Rahman/Reuters
8 The World Health Report 2005 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 250 1000m 200 Africa 一Easter Mediterranean 150 World s。S0uh-East Asia 100 South-East Asia without India =■=Vestern Pacific -Western Pacific without China Americas ".·Europe 1970 1980 1990 20002003
8 The World Health Report 2005 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 deterioration” (51), set out eight specific Millennium Development Goals (MDGs), each with its numerical targets and indicators for monitoring progress. The MDGs galvanized countries 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 Development 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 Mortality rate of children under 5 years of age per 1000 live births 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