overview The World Health Report 2005 Make every mother and child count 徐 World Health Organization
Make every mother and child count The World Health Report 2005 World Health Organization overview
eworld Health Org 20AeA12116622t由n(e:+41271276:x+41223 ress, World Heat mmercial distribution should be addressed to WHO Press, at the above address(fax: +41 22 791 4806: e-mail: permissions @who int The designations employed and the presentation of the material in this publication do not imply the expression of any opinion oncerning the legal status of any country, territory, city or area ng the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. taken by wHo to verify the information contained in this pu terial is being distributed without warranty of any kind pretation and use of the material lies with the reader. In no event e world Health Organization be liable for dam- es arising from its use. concerning this publication can be obtained fro E-mail: whr@who int Copies of this publication and the full report can be ordered from: bookorders @who int The full report was produced under the overall direction of Joy Phumaphi(Assistant Director-General, Family and Child Health), Tim Evans(Assistant Director-General, Evidence and Information for Policy)and Wim Van Lerberghe(Editor-in-Chief). The principal authors were Wim Van Lerberghe, Annick Manuel, Zoe Matthews and Cathy Wolfheim. Thomson Prentice was the Managing Editor Valuable inputs(contributions, background papers, analytical work, reviewing, suggestions and criticism) were received from Elisabeth Aahman, Carla Abou-Zahr, Fifi es Boerma, Jo borghi, Paul Bossyns, Assia Brandrup-LukanoN, Eric Buch, Flavia Bustreo, Meena Cabral de Mello, Virginia Camacho, Guy Carrin, Andrew Cas thryn Church, Alessandro Colombo, Jane Cottingham, Bernadette Daelmans, Mario Dal Poz, Catherine dArcangues, Hugh Darrah, Luc de Bernis, Isabelle de Zoys Peggy hi ossein, Guy Hutton, Mie Inoue, Monir Islam, Christopher James, Craig Janes, Ben Johns, Rita Kabra, Betty Kirkwood, Lianne Kuppens, Joy Lawn, Jerker Liljestrand, Ornella Lincetto, Craig Lissner, Alessandro Loretti, Jane Lucas, Doris Ma Fat, Carolyn Maclennan, Ramez Mahaini, Sudhansh Malhostra, Mason, Matthews Mathai, Dileep Mavalankar, Gillian Mayers, Juliet McEachren, Abdelhai Mechbal, Mario Merialdi, Tom Merrick, Thierry Mertens, Susan Murray, Adepeju usa, Niko Speybroeck, Karin Stenberg, Will Stones, Tessa Tan-Torres Edejer, Petra Ten Hoope-Bender, Ann Tinker, Wim Van Damme, elaer. Paul Van Loo Marcel Vekemans, Cesar Victora, Eugenio Villar Montesinos, Yasmin Von Schirnding, Eva Wallstam, Steve Wiersma, Karl Wilhelmsen, Lara Wolfson, Juliana Yartey and an, Zulfiqar Bhuti nifer Bryce, Agne s, Trevor Croft, David D Vans, Charu C. Garg, Kim Gustavsen, Nasim Haque, Patricia Hernandez, Ken hill Kirkwood, Joseph Kutzin, Joy Lawn, Eduardo Levcovitz, Dilbert ason, Colin Mathers, Saul Morris, Kim Mulholland, Takondwa Mwase, Bemard Nahlen, Pamela Nal omme. Rachel Racelis olvier ronvear Alex Rowe, Hossein Salehi, lan Scott, U Than Sein, Kenji shibuya, Rick Steketee, Ruben Suarez, Tessa Tan- Torres Edej alie van de Maele. Tessa Wardlaw. Neff Walker, Hongyi Xu, Jelka Zupan, and many staff in WHO country offices, govemmental departments and agencies and Valuable comments and guidance were provided by Denis Aitken and Michel Jancloes. Additional help and advice were kindly provided by Regional Directors and members of their staff full report assisted by Barbara Campanini. Editorial, administrative and on support was provided by Shelagh Probst and Gary ated the photographs. The web site version and other electronic media were provided by gael Kemen Proofreading was by Marie Fitzsimmons. graphs(clockwise from top left): L Gubb/WHO; Pepito Frias/wHO; Armando Waak/WHO/PAHO; Carlos Gaggero/wHO/PAHO Liba Taylor/WHO; Pierre HO Back cover photographs (left to right): Pierre Virot/wHO; J. Gorstein/WHO; G. Diez/wHO; Pierre Virot/wHO. This report contains several photographs from sign: Reda Sadki hoto retouching: Reda Sadki and Denis Meissner Printing coordination: Keith Wynn
ii The World Health Report 2005 Design: Reda Sadki Layout: Steve Ewart and Reda Sadki Figures: Christophe Grangier Photo retouching: Reda Sadki and Denis Meissner Printing coordination: Keith Wynn Printed in France © World Health Organization 2005 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; e-mail: bookorders@who. int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland E-mail: whr@who.int Copies of this publication and the full report can be ordered from: bookorders@who.int The full report was produced under the overall direction of Joy Phumaphi (Assistant Director-General, Family and Child Health), Tim Evans (Assistant Director-General, Evidence and Information for Policy) and Wim Van Lerberghe (Editor-in-Chief). The principal authors were Wim Van Lerberghe, Annick Manuel, Zoë Matthews and Cathy Wolfheim. Thomson Prentice was the Managing Editor. Valuable inputs (contributions, background papers, analytical work, reviewing, suggestions and criticism) were received from Elisabeth Aahman, Carla Abou-Zahr, Fiifi Amoako Johnson, Fred Arnold, Alberta Bacci, Rajiv Bahl, Rebecca Bailey, Robert Beaglehole, Rafael Bengoa, Janie Benson, Yves Bergevin, Stan Bernstein, Julian Bilous, Ties Boerma, Jo Borghi, Paul Bossyns, Assia Brandrup-Lukanov, Eric Buch, Flavia Bustreo, Meena Cabral de Mello, Virginia Camacho, Guy Carrin, Andrew Cassels, Kathryn Church, Alessandro Colombo, Jane Cottingham, Bernadette Daelmans, Mario Dal Poz, Catherine d’Arcangues, Hugh Darrah, Luc de Bernis, Isabelle de Zoysa, Maria Del Carmen, Carmen Dolea, Gilles Dussault, Steve Ebener, Dominique Egger, Gerry Eijkemans, Bjorn Ekman, Zine Elmorjani, Tim Ensor, Marthe Sylvie Essengue, David Evans, Vincent Fauveau, Paulo Ferrinho, Helga Fogstad, Marta Gacic Dobo, Ulf Gerdham, Adrienne Germain, Peter Ghys, Elizabeth Goodburn, Veloshnee Govender, Metin Gulmezoglu, Jean-Pierre Habicht, Sarah Hall, Laurence Haller, Steve Harvey, Peggy Henderson, Patricia Hernández, Peter Hill, Dale Huntington, Julia Hussein, Guy Hutton, Mie Inoue, Monir Islam, Christopher James, Craig Janes, Ben Johns, Rita Kabra, Betty Kirkwood, Lianne Kuppens, Joy Lawn, Jerker Liljestrand, Ornella Lincetto, Craig Lissner, Alessandro Loretti, Jane Lucas, Doris Ma Fat, Carolyn Maclennan, Ramez Mahaini, Sudhansh Malhostra, Adriane Martin Hilber, José Martines, Elizabeth Mason, Matthews Mathai, Dileep Mavalankar, Gillian Mayers, Juliet McEachren, Abdelhai Mechbal, Mario Merialdi, Tom Merrick, Thierry Mertens, Susan Murray, Adepeju Olukoya, Guillermo Paraje, Justin Parkhurst, Amit Patel, Vikram Patel, Steve Pearson, Gretel Pelto, Jean Perrot, Annie Portela, Dheepa Rajan, K.V. Ramani, Esther Ratsma, Linda Richter, David Sanders, Parvathy Sankar, Robert Scherpbier, Peelam Sekhri, Gita Sen, Iqbal Shah, Della Sherratt, Kenji Shibuya, Kristjana Sigurbjornsdottir, Angelica Sousa, Niko Speybroeck, Karin Stenberg, Will Stones, Tessa Tan-Torres Edejer, Petra Ten Hoope-Bender, Ann Tinker, Wim Van Damme, Jos Vandelaer, Paul Van Look, Marcel Vekemans, Cesar Victora, Eugenio Villar Montesinos, Yasmin Von Schirnding, Eva Wallstam, Steve Wiersma, Karl Wilhelmson, Lara Wolfson, Juliana Yartey and Jelka Zupan. Contributers to statistical tables were: Elisabeth Aahman, Dorjsuren Bayarsaikhan, Ana Betran, Zulfiqar Bhutta, Maureen Birmingham, Robert Black, Ties Boerma, Cynthia Boschi-Pinto, Jennifer Bryce, Agnes Couffinhal, Simon Cousens, Trevor Croft, David D. Vans, Charu C. Garg, Kim Gustavsen, Nasim Haque, Patricia Hernández, Ken Hill, Chandika Indikadahena, Mie Inoue, Gareth Jones, Betty Kirkwood, Joseph Kutzin, Joy Lawn, Eduardo Levcovitz, Edilberto Loaiza, Doris Ma Fat, José Martines, Elizabeth Mason, Colin Mathers, Saul Morris, Kim Mulholland, Takondwa Mwase, Bernard Nahlen, Pamela Nakamba-Kabaso, Agnès Prudhomme, Rachel Racelis, Olivier Ronveaux, Alex Rowe, Hossein Salehi, Ian Scott, U Than Sein, Kenji Shibuya, Rick Steketee, Rubén Suarez, Tessa Tan-Torres Edejer, Nathalie van de Maele, Tessa Wardlaw, Neff Walker, Hongyi Xu, Jelka Zupan, and many staff in WHO country offices, governmental departments and agencies and international institutions. Valuable comments and guidance were provided by Denis Aitken and Michel Jancloes. Additional help and advice were kindly provided by Regional Directors and members of their staff. The full report was edited by Leo Vita-Finzi, assisted by Barbara Campanini. Editorial, administrative and production support was provided by Shelagh Probst and Gary Walker, who also coordinated the photographs. The web site version and other electronic media were provided by Gael Kernen. Proofreading was by Marie Fitzsimmons. The index was prepared by Kathleen Lyle. Front cover photographs (clockwise from top left): L. Gubb/WHO; Pepito Frias/WHO; Armando Waak/WHO/PAHO; Carlos Gaggero/WHO/PAHO; Liba Taylor/WHO; Pierre Virot/WHO. Back cover photographs (left to right): Pierre Virot/WHO; J. Gorstein/WHO; G. Diez/WHO; Pierre Virot/WHO. This report contains several photographs from “River of Life 2004” – a WHO photo competition on the theme of sexual and reproductive health
message from the director-general Parenthood brings with it the strong desire to see our children grow up happily and in good health. This is one of the few constants in life in all parts of the world. Yet, even in the 21st century, we still allow well over 10 million children and half a million moth ers to die each year, although most of these deaths can be avoided. Seventy million mothers and their newbon babies as well as countless children are excluded from the health care to which they are entitled. Even more numerous are those who remain without protection against the poverty that ill-health can cause Leaders readily agree that we cannot allow this to continue, but in many countries the situation is either improving too slowly or not improving at all, and in some it is getting worse. Mothers, the newborn and children represent the well-being of a society and its potential for the future. Their health needs cannot be left unmet without harming the whole of society Families and communities themselves can do a great deal to change this situation. They can improve, for example, the position of women in society, parenting, disease prevention, care for the sick, and uptake of services. But this area of health is also a public responsibility Public health programmes need to work together so that all families have access to a continuum of care that extends from pregnancy(and even before), through childbirth and on into childhood, instead of the often fragmented services available at present. It makes no sense to provide care for a child while ignoring the mother's health, or to assist a mother giving birth but not the newbom child To ensure that all families have access to care, governments must accelerate the building up of coherent, integrated and effective health systems. This means tackling the health workforce crisis, which in turn calls for a much higher level of funding and better organization of it for these aspects of health. the objective must be health sys- tems that can respond to these needs, eliminate financial barriers to care, and protect people from the poverty that is both a cause and an effect of ill-health he world needs to support countries striving to achieve universal access and finan- cial protection for all mothers and children. Only by doing so can we make sure that every mother, newborn baby and child in need of care can obtain it, and no one is driven into poverty by the cost of that care. In this way we can move not only towards the Millennium Development Goals but beyond them Director-General World Health Organization Geneva, April 2005
overview 1 Parenthood brings with it the strong desire to see our children grow up happily and in good health. This is one of the few constants in life in all parts of the world. Yet, even in the 21st century, we still allow well over 10 million children and half a million mothers to die each year, although most of these deaths can be avoided. Seventy million mothers and their newborn babies, as well as countless children, are excluded from the health care to which they are entitled. Even more numerous are those who remain without protection against the poverty that ill-health can cause. Leaders readily agree that we cannot allow this to continue, but in many countries the situation is either improving too slowly or not improving at all, and in some it is getting worse. Mothers, the newborn and children represent the well-being of a society and its potential for the future. Their health needs cannot be left unmet without harming the whole of society. Families and communities themselves can do a great deal to change this situation. They can improve, for example, the position of women in society, parenting, disease prevention, care for the sick, and uptake of services. But this area of health is also a public responsibility. Public health programmes need to work together so that all families have access to a continuum of care that extends from pregnancy (and even before), through childbirth and on into childhood, instead of the often fragmented services available at present. It makes no sense to provide care for a child while ignoring the mother’s health, or to assist a mother giving birth but not the newborn child. To ensure that all families have access to care, governments must accelerate the building up of coherent, integrated and effective health systems. This means tackling the health workforce crisis, which in turn calls for a much higher level of funding and better organization of it for these aspects of health. The objective must be health systems that can respond to these needs, eliminate financial barriers to care, and protect people from the poverty that is both a cause and an effect of ill-health. The world needs to support countries striving to achieve universal access and financial protection for all mothers and children. Only by doing so can we make sure that every mother, newborn baby and child in need of care can obtain it, and no one is driven into poverty by the cost of that care. In this way we can move not only towards the Millennium Development Goals but beyond them. message from the director-general LEE Jong-wook Director-General World Health Organization Geneva, April 2005
Were This year's World Health Report comes at a time when only a decade is left to achieve the Millennium Development Goals(MDGs), which set internationally agreed devel- opment aspirations for the world's population to be met by 2015. These goals have underlined the importance of improving health, and particularly the health of mothers and children, as an integral part of poverty reduction The health of mothers and children is a priority that emerged long before the 1990s it builds on a century of programmes, activities and experience. What is new in the last decade, however, is the global focus of the MDGs and their insistence on tracking progress in every part of the world. Moreover, the nature of the priority status of ma- ternal and child health(MCH)has changed over time. Whereas mothers and children were previously thought of as targets for well-intentioned programmes, they now increasingly claim the right to access quality care as an entitlement guaranteed by the state. In doing so, they have transformed maternal and child health from a technical concern into a moral and political imperative. This report identifies exclusion as a key feature of inequity as well as a key constraint to progress. In many countries, universal access to the care all women and children are entitled to is still far from realization. Taking stock of the erratic progress to date the report sets out the strategies required for the accelerated improvements that are known to be possible. It is necessary to refocus the technical strategies developed within maternal and child health programmes, and also to put more emphasis on the importance of the often overlooked health problems of newborns. In this regard, the report advocates the repositioning of MCH as MNCH(maternal, newbom and child proper technical strategies to improve MNCH can be put in place effectively 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 3 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
4 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 ie 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 ost, of the critical health problems and hazards that affect the health and survival o 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
4 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 5 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 ives 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. he 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 ecome clear that the MDG for child mortality will not be reached without substantial advances for the newbom. 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 5 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
6 The World Health Report 2005 Progress in newborn health does not require expensive technology. It does however require health systems that provide continuity of care starting from the beginning of pregnancy (and even before)and continuing through professional skilled care at birth into the postnatal period. Most crucially, there is a need to ensure that the delicate and often overlooked handover between maternal and child services actually takes place Newborns who are breastfed, loved and kept warm will mostly be fine, but problems can and do occur. It is essential to empower households- mothers and fathers in particular- so that they can take good care of their babies, recognize dangers early, and get professional help immediately when difficulties arise. The greatest risks to life are in its beginning, but they do not disappear as the newborn grows into an infant and a young child. Programmes to tackle vaccine preventable diseases, malnutrition, diarrhoea, or respiratory infections still have a large unfinished agenda. Immunization, for example, has made satisfactory progress in some regions, but in others coverage is stagnating at levels between 50% and 70% and has to find a new momentum. These programmes have, however, made such inroads on the burden of ill-health that in many countries its profile has changed There is now a need for more integrated approaches: first, to deal efficiently with the changing spectrum of problems that need attention; second, to broaden the focus of care from the child's survival to its growth and development. This is what is needed from a public health point of view; it is also what families expect The Integrated Management of Childhood lIness(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 IMCl available to all families with children, and create the conditions for them to avail themselves of such care whenever needed MOVING TOWARDS UNIVERSAL COVERAGE ACCESS FOR ALL. WITH FINANCIAL PROTECTION There is a strong consensus that, even if all the right technical choices are made, maternal, newborn and child health programmes will only be effective if together, and with households and communities, they establish a continuum of care, from pregnancy through childbirth into childhood. This continuity requires greatly strengthened health systems with maternal, newborn and child health care at the core of their develop ment strategies. It is forcing programmes and stakeholders with different histories. interests and constituencies to join forces. The common project that can pull together the different agendas is universal access to care. This is not just a question of fine tuning advocacy language: it frames the health of mothers, babies and children within a broader, straightforward political project, responding to society's claim for the pro tection of the health of its citizens and for access to care-a claim that is increasingly seen as legitimate. The magnitude of the challenge of scaling up services towards universal access. however should not be underestimated
6 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
overview 7 Reaching all children with a package of essential child health interventions neces ary to comply with and even go beyond the MDGs is technically feasible within the next decade. In the 75 countries that account for most of child mortality this will require USS 52. 4 billion, in addition to current expenditure of which USS 25 billion represents additional costs for human resources. This US$ 52. 4 billion corresponds to an increase as of now of 6% of current median public expenditure on health in these countries, rising to 18% by 2015. In the 21 countries facing the greatest constraints and where a long lead time is likely, current public expenditure on health would have to grow by 27% as of 2006, rising to around 76% in 2015 For maternal and newbom care, universal access is further away. It is possible to envisage various scenarios for scaling up services, taking into account the specific cir- cumstances in each of the same 75 countries. At present, some 43%of mothers and newborns receive some care, but by no means the full range of what they need even just to avoid maternal deaths. Adding up the optimistic -but also realistic -scenarios for each of the 75 countries gives access to a full package of first-level and back-up care to 101 million mothers(some 73% of the expected births)in 2015, and to their abies. If these scenarios were implemented, the MDG for maternal health would not be reached in every country, but the reduction of maternal and perinatal mortality globally would be well on the way. The costs of implementing these 75 country sce narios would be in the region of USs 39 billion additional to current expenditure. This corresponds to a growth of 3%, in 2006, rising to 14%over the years, of current me dian public expenditure on health in these countries. In the 20 countries with currently the lowest coverage and facing the greatest constraints, current public expenditure on health would have to grow by 7% in 2006, rising to 43% in 2015. Putting in place the health workforce needed for scaling up maternal, newborn and child health services towards universal access is the first and most pressing task. Making up for the staggering shortages and imbalances in the distribution of health workers in many countries will remain a major challenge for years to come The extra work required for scaling up child care activities requires the equivalent of 100 000 full-time multipurpose professionals, supplemented, according to the sce- narios that have been costed, by 4.6 million community health workers. Projected staffing requirements for extending coverage of maternal and newborn care assumes the production in the coming 10 years of at least 334 000 additional midwives-or their equivalents-as well as the upgrading of 140 000 health professionals who are currently providing first-level maternal care and of 27 000 doctors who currently do not have the competencies to provide back-up care Without planning and capacity- building at national level and within health districts, it will not be possible to correct the shortages and to improve the skills mix and the working environment. Planning is not enough, however, to put right disruptive histories that have eroded workforce development. After years of neglect there are problems that require immediate attention: first and foremost is the nagging question of the remuneration of the workforce In many countries, salary levels are rightfully considered unfair and insufficient to provide for daily living costs, let alone to live up to the expectations of health profes ionals. This situation is one of the root causes of demotivation, lack of productivity and the various forms of brain-drain and migration: rural to urban, public to private and from poorer to richer countries. It also seriously hampers the correct functioning of services as health workers set up in dual practice to improve their living conditions or merely to make ends meet- leading to competition for time, a loss of resources for
overview 7 Reaching all children with a package of essential child health interventions necessary to comply with and even go beyond the MDGs is technically feasible within the next decade. In the 75 countries that account for most of child mortality this will require US$ 52.4 billion, in addition to current expenditure, of which US$ 25 billion represents additional costs for human resources. This US$ 52.4 billion corresponds to an increase as of now of 6% of current median public expenditure on health in these countries, rising to 18% by 2015. In the 21 countries facing the greatest constraints and where a long lead time is likely, current public expenditure on health would have to grow by 27% as of 2006, rising to around 76% in 2015. For maternal and newborn care, universal access is further away. It is possible to envisage various scenarios for scaling up services, taking into account the specific circumstances in each of the same 75 countries. At present, some 43% of mothers and newborns receive some care, but by no means the full range of what they need even just to avoid maternal deaths. Adding up the optimistic – but also realistic – scenarios for each of the 75 countries gives access to a full package of first-level and back-up care to 101 million mothers (some 73% of the expected births) in 2015, and to their babies. If these scenarios were implemented, the MDG for maternal health would not be reached in every country, but the reduction of maternal and perinatal mortality globally would be well on the way. The costs of implementing these 75 country scenarios would be in the region of US$ 39 billion additional to current expenditure. This corresponds to a growth of 3%, in 2006, rising to 14% over the years, of current median public expenditure on health in these countries. In the 20 countries with currently the lowest coverage and facing the greatest constraints, current public expenditure on health would have to grow by 7% in 2006, rising to 43% in 2015. Putting in place the health workforce needed for scaling up maternal, newborn and child health services towards universal access is the first and most pressing task. Making up for the staggering shortages and imbalances in the distribution of health workers in many countries will remain a major challenge for years to come. The extra work required for scaling up child care activities requires the equivalent of 100 000 full-time multipurpose professionals, supplemented, according to the scenarios that have been costed, by 4.6 million community health workers. Projected staffing requirements for extending coverage of maternal and newborn care assumes the production in the coming 10 years of at least 334 000 additional midwives – or their equivalents – as well as the upgrading of 140 000 health professionals who are currently providing first-level maternal care and of 27 000 doctors who currently do not have the competencies to provide back-up care. Without planning and capacity-building, at national level and within health districts, it will not be possible to correct the shortages and to improve the skills mix and the working environment. Planning is not enough, however, to put right disruptive histories that have eroded workforce development. After years of neglect there are problems that require immediate attention: first and foremost is the nagging question of the remuneration of the workforce. In many countries, salary levels are rightfully considered unfair and insufficient to provide for daily living costs, let alone to live up to the expectations of health professionals. This situation is one of the root causes of demotivation, lack of productivity and the various forms of brain-drain and migration: rural to urban, public to private and from poorer to richer countries. It also seriously hampers the correct functioning of services as health workers set up in dual practice to improve their living conditions or merely to make ends meet – leading to competition for time, a loss of resources for
8 The World Health Report 2005 the public sector, and conflicts of interest in dealing with their clients. There are even more serious consequences when health workers resort to predatory behaviour: finan cial exploitation may have catastrophic effects on patients who use the services, and create barriers to access for others it contributes to a crisis of trust in the services to which mothers and children are entitled There is an urgent need to invent and deploy a whole range of measures to break the vicious circle, and bring productivity and dedication back to the level the popula ion expects and to which most health workers aspire. Among these, one of the most challenging is rehabilitating the workforce's remuneration. Even a modest attempt to do so, such as doubling or even tripling the total workforce's salary mass and benefits in the 75 countries for which scenarios were developed, might still be insufficient to attract, retain and redeploy quality staff. But it would correspond to an increase of 2% rising, over 10 years, to 17%of current public expenditure on health, merely for payment of the MNCH workforce. Such a measure would have political and macro economic implications and is something that cannot be done without a major effort, not only by governments but by international solidarity as well. On the eve of a decade that will be focused on human resources for health this will require a fundamental debate, in countries as well as internationally, on the volume of the funds that can be allocated and on the channelling of these funds. This is all the more important becaus rehabilitating the remuneration of the workforce is only one part of the answer: estab lishing an atmosphere of stability and hope is also needed to give health professionals the confidence they need to work effectively and with dedication At the same time, ensuring universal access is not merely a question of increasing the supply of services and paying health care providers for services to be taken up, financial barriers to access have to be eliminated and users given predictable financial protection against the costs of seeking care, and particularly against the catastrophic payments that can push households into poverty. Such catastrophic payments occur wherever user charges are significant, households have limited ability to pay, and pooling and prepayment is not generalized To attain the financial protection that has to go with universal access, countries throughout the world have to move away from user charges, be they official or under-the-counter, and generalize prepayment and pooling schemes. Whether they choose to organize financial protection on the basis of tax-generated funds, through social health insurance or through a mix of schemes, two things are important: first, that ultimately no population groups are excluded; second that maternal and child health services are at the core of the health entitlements of the population, and that they be financed in a coherent way through the selected system While it can take many years to move from a situation of a limited supply of services, high out-of-pocket payments and exclusion of the poorest to a situation of universal access and financial protection, the extension of health care supply networks has to proceed in parallel with the construction of such insurance mechanisms Financing is the killer assumption underlying the planning of matemal, newborn and child health care. First, increased funding is required to pay for building up the supply of services towards universal access. Second, financial protection systems have to be built at the same time as access improves. third, the channelling of increased funds, both domestic and international, has to guarantee the flexibility and predictability that make it possible to cope with the principal health system constraints- particularly the problems facing the workforce. Channelling increased funding flows through national health insurance schemes-be they organized as tax-based, social health insurance, or mixed systems -offers the best avenue to meet these three challenges simultaneously. It requires major capacity-
8 The World Health Report 2005 the public sector, and conflicts of interest in dealing with their clients. There are even more serious consequences when health workers resort to predatory behaviour: financial exploitation may have catastrophic effects on patients who use the services, and create barriers to access for others; it contributes to a crisis of trust in the services to which mothers and children are entitled. There is an urgent need to invent and deploy a whole range of measures to break the vicious circle, and bring productivity and dedication back to the level the population expects and to which most health workers aspire. Among these, one of the most challenging is rehabilitating the workforce’s remuneration. Even a modest attempt to do so, such as doubling or even tripling the total workforce’s salary mass and benefits in the 75 countries for which scenarios were developed, might still be insufficient to attract, retain and redeploy quality staff. But it would correspond to an increase of 2% rising, over 10 years, to 17% of current public expenditure on health, merely for payment of the MNCH workforce. Such a measure would have political and macroeconomic implications and is something that cannot be done without a major effort, not only by governments but by international solidarity as well. On the eve of a decade that will be focused on human resources for health, this will require a fundamental debate, in countries as well as internationally, on the volume of the funds that can be allocated and on the channelling of these funds. This is all the more important because rehabilitating the remuneration of the workforce is only one part of the answer: establishing an atmosphere of stability and hope is also needed to give health professionals the confidence they need to work effectively and with dedication. At the same time, ensuring universal access is not merely a question of increasing the supply of services and paying health care providers. For services to be taken up, financial barriers to access have to be eliminated and users given predictable financial protection against the costs of seeking care, and particularly against the catastrophic payments that can push households into poverty. Such catastrophic payments occur wherever user charges are significant, households have limited ability to pay, and pooling and prepayment is not generalized. To attain the financial protection that has to go with universal access, countries throughout the world have to move away from user charges, be they official or under-the-counter, and generalize prepayment and pooling schemes. Whether they choose to organize financial protection on the basis of tax-generated funds, through social health insurance or through a mix of schemes, two things are important: first, that ultimately no population groups are excluded; second, that maternal and child health services are at the core of the health entitlements of the population, and that they be financed in a coherent way through the selected system. While it can take many years to move from a situation of a limited supply of services, high out-of-pocket payments and exclusion of the poorest to a situation of universal access and financial protection, the extension of health care supply networks has to proceed in parallel with the construction of such insurance mechanisms. Financing is the killer assumption underlying the planning of maternal, newborn and child health care. First, increased funding is required to pay for building up the supply of services towards universal access. Second, financial protection systems have to be built at the same time as access improves. Third, the channelling of increased funds, both domestic and international, has to guarantee the flexibility and predictability that make it possible to cope with the principal health system constraints – particularly the problems facing the workforce. Channelling increased funding flows through national health insurance schemes – be they organized as tax-based, social health insurance, or mixed systems – offers the best avenue to meet these three challenges simultaneously. It requires major capacity-
overview 9 building efforts, but it offers the possibility of protecting the funding of the workforce in public sector and health sector reform policies and in the forums where macroeco- nomic and poverty-reduction policies are decided. It offers the possibility of tackling the problem of the remuneration and the working conditions of health workers in way that gives them long-term, credible prospects, which traditional budgeting or the stopgap solutions of project funding do not offer While the financing effort seems to be within reasonable reach in some countries in many it will go beyond what can be borne by governments alone. Both countries and the international community will need to show a sustained political commitment to mobilize and redirect the considerable resources that are required, to build the in- stitutional capacity to manage them, and to ensure that maternal, newborn and child health remains at the core of these efforts. This decade can be one of accelerating the move towards universal coverage, with access for all and financial protection That will ensure that no mother no newborn and no child in need remains unattended because every mother and every child counts CHAPTER SUMMARIES Chapter 1. Mothers and children matter-so does their health his chapter recalls how the health of mothers and children became a public health priority during the 20th century. For centuries, care for mothers and young children was regarded as a domestic affair, the realm of mothers and midwives. In the 20th century this purely domestic concern was transformed into a public health priority. In the opening years of the 21st century, the MDGs place it at the core of the struggle against poverty and inequality, as a matter of human rights. This shift in emphasis has far-reaching consequences for the way the world responds to the very uneven progress in different countries The chapter summarizes the current situation regarding the health of mothers, new borns and children. Most progress has been made by countries that were already in a relatively good position in the early 1990s, while countries that started with the highest mortality rates are also those where improvements have been most disap- Globally, mortality rates in children under five years of age fell throughout the latter part of the 20th century: from 146 per 1000 live births in 1970 to 79 in 2003. Towards the turn of the millennium however the overall downward trend started to falter in some parts of the world. Improvements continued or accelerated in the WHO Regions of the Americas, South-East Asia and Europe, while the African, Eastern Mediter- anean and Western Pacific Regions experienced a slowing down of progress In 93 countries, totalling 40% of the world population, under-five mortality is decreasing fast. A further 51 countries, with 48% of the world population, are making slower progress: they will only reach the MDGs if improvements are accelerated significantly Even more worrying are the 43 countries that contain the remaining 12% of the world population, where under-five mortality was high or very high to start with and is now Reliable data on newborns are only recently becoming available and are more dif- ficult to interpret. The most recent estimates show that newborn mortality is consid erably higher than usually thought and accounts for 40% of under-five deaths; less than 2% of newborn deaths currently occur in high income countries. The difference etween rich and poor countries seems to be widening
overview 9 building efforts, but it offers the possibility of protecting the funding of the workforce in public sector and health sector reform policies and in the forums where macroeconomic and poverty-reduction policies are decided. It offers the possibility of tackling the problem of the remuneration and the working conditions of health workers in a way that gives them long-term, credible prospects, which traditional budgeting or the stopgap solutions of project funding do not offer. While the financing effort seems to be within reasonable reach in some countries, in many it will go beyond what can be borne by governments alone. Both countries and the international community will need to show a sustained political commitment to mobilize and redirect the considerable resources that are required, to build the institutional capacity to manage them, and to ensure that maternal, newborn and child health remains at the core of these efforts. This decade can be one of accelerating the move towards universal coverage, with access for all and financial protection. That will ensure that no mother, no newborn, and no child in need remains unattended – because every mother and every child counts. CHAPTER SUMMARIES Chapter 1. Mothers and children matter – so does their health This chapter recalls how the health of mothers and children became a public health priority during the 20th century. For centuries, care for mothers and young children was regarded as a domestic affair, the realm of mothers and midwives. In the 20th century this purely domestic concern was transformed into a public health priority. In the opening years of the 21st century, the MDGs place it at the core of the struggle against poverty and inequality, as a matter of human rights. This shift in emphasis has far-reaching consequences for the way the world responds to the very uneven progress in different countries. The chapter summarizes the current situation regarding the health of mothers, newborns and children. Most progress has been made by countries that were already in a relatively good position in the early 1990s, while countries that started with the highest mortality rates are also those where improvements have been most disappointing. Globally, mortality rates in children under five years of age fell throughout the latter part of the 20th century: from 146 per 1000 live births in 1970 to 79 in 2003. Towards the turn of the millennium, however, the overall downward trend started to falter in some parts of the world. Improvements continued or accelerated in the WHO Regions of the Americas, South-East Asia and Europe, while the African, Eastern Mediterranean and Western Pacific Regions experienced a slowing down of progress. In 93 countries, totalling 40% of the world population, under-five mortality is decreasing fast. A further 51 countries, with 48% of the world population, are making slower progress: they will only reach the MDGs if improvements are accelerated significantly. Even more worrying are the 43 countries that contain the remaining 12% of the world population, where under-five mortality was high or very high to start with and is now stagnating or reversing. Reliable data on newborns are only recently becoming available and are more dif- ficult to interpret. The most recent estimates show that newborn mortality is considerably higher than usually thought and accounts for 40% of under-five deaths; less than 2% of newborn deaths currently occur in high income countries. The difference between rich and poor countries seems to be widening