The World Health Report 2005 Make every mother and child count World Health Organization
Make every mother and child count The World Health Report 2005 World Health Organization
销 WHO Library Cataloguing-in-Publication Data World Health Organization. The World health report:2005:make every mother and child count. 1.World health-trends 2.Maternal welfare 3.Child welfare.4.Maternal health services-organization and administration 5.Child health services -organization and administration 6.World Health Organization I.Title IL.Title:Make every mother and child count. 1SBN9241562900 (NLM Classification:WA 540.1) ISSW1020-3311 World Health Organization 2005 All rights reserved.Publications of the World Health Organization can be obtained from WHO Press,World Health Organization,20 Avenue Appia,1211 Geneva 27,Switzerland (tel:+41 22 791 2476;fax:+41 22 791 4857;e-mail:bookorders@who.int).Requests for permission to reproduce or translate WHO publications-whether for sale or for noncommercial distribution-should be addressed to WHO Press. at the above address(fax:+41 22 791 4806;e-mail:permissions@who.int). 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 mate- rial 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 can be ordered from:bookorders@who.int This report was produced under the overall direction of Joy Phumaphi(Assistant Director-General,Family and Child Health),Tim Evans(Assistant Director-General, Evidence and Information for Policy)and Wim Van Lerberghe(Editor-in-Chief).The principal authors were Wim Van Lerberghe,Annick Manuel,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, 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 Hemandez,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,Jose 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,lqbal Shah,Della Sherratt,Kenji Shibuya,Kristjana Sigurbjomnsdottir,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,Jufiana Yartey and Jelka Zupan. Contributers to statistical tables were:Elisabeth Aahman,Dorjsuren Bayarsaikhan,Ana Betran,Zulfigar 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 Hernandez. Ken Hill,Chandika Indikadahena,Mie Inoue,Gareth Jones,Betty Kirkwood,Joseph Kutzin,Joy Lawn,Eduardo Levcovitz,Edilberto Loaiza,Doris Ma Fat,Jose Martines, Elizabeth Mason,Colin Mathers,Saul Morris,Kim Mulholland,Takondwa Mwase,Bernard Nahlen,Pamela Nakamba-Kabaso,Agnes Prudhomme,Rachel Racelis,Olivier Ronveaux,Alex Rowe,Hossein Salehi.lan Scott,U Than Sein,Kenji Shibuya,Rick Steketee,Ruben 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 intemational institutions. Valuable comments and guidance were provided by Denis Aitken and Michel Jancloes.Additional help and advice were kindly provided by Regional Directors and members of their staff. The report was edited by Leo Vita-Finzi,assisted by Barbara Campanini.Editorial,administrative and production support was provided by Shelagh Probst and Gary Walker,who also coordinated the photographs.The web site version and other electronic media were provided by Gael Kemen.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. Design:Reda Sadki Layout:Steve Ewart and Reda Sadk Floures:Chnstophe Granoier Photo retouching:Reda Sadki and Denis Meissner Printing coordination:Keith Wynn Printed in France
ii Design: Reda Sadki Layout: Steve Ewart and Reda Sadki Figures: Christophe Grangier Photo retouching: Reda Sadki and Denis Meissner Printing coordination: Keith Wynn Printed in France This report was produced under the overall direction of Joy Phumaphi (Assistant Director-General, Family and Child Health), Tim Evans (Assistant Director-General, Evidence and Information for Policy) and Wim Van Lerberghe (Editor-in-Chief). The principal authors were Wim Van Lerberghe, Annick Manuel, Zoë Matthews and Cathy Wolfheim. Thomson Prentice was the Managing Editor. Valuable inputs (contributions, background papers, analytical work, reviewing, suggestions and criticism) were received from Elisabeth Aahman, Carla Abou-Zahr, Fiifi Amoako Johnson, Fred Arnold, Alberta Bacci, Rajiv Bahl, Rebecca Bailey, Robert Beaglehole, Rafael Bengoa, Janie Benson, Yves Bergevin, Stan Bernstein, Julian Bilous, Ties Boerma, Jo Borghi, Paul Bossyns, Assia Brandrup-Lukanov, Eric Buch, Flavia Bustreo, Meena Cabral de Mello, Virginia Camacho, Guy Carrin, Andrew Cassels, Kathryn Church, Alessandro Colombo, Jane Cottingham, Bernadette Daelmans, Mario Dal Poz, Catherine d’Arcangues, Hugh Darrah, Luc de Bernis, Isabelle de Zoysa, Maria Del Carmen, Carmen Dolea, Gilles Dussault, Steve Ebener, Dominique Egger, Gerry Eijkemans, Bjorn Ekman, Zine Elmorjani, Tim Ensor, Marthe Sylvie Essengue, David Evans, Vincent Fauveau, Paulo Ferrinho, Helga Fogstad, Marta Gacic Dobo, Ulf Gerdham, Adrienne Germain, Peter Ghys, Elizabeth Goodburn, Veloshnee Govender, Metin Gulmezoglu, Jean-Pierre Habicht, Sarah Hall, Laurence Haller, Steve Harvey, Peggy Henderson, Patricia Hernández, Peter Hill, Dale Huntington, Julia Hussein, Guy Hutton, Mie Inoue, Monir Islam, Christopher James, Craig Janes, Ben Johns, Rita Kabra, Betty Kirkwood, Lianne Kuppens, Joy Lawn, Jerker Liljestrand, Ornella Lincetto, Craig Lissner, Alessandro Loretti, Jane Lucas, Doris Ma Fat, Carolyn Maclennan, Ramez Mahaini, Sudhansh Malhostra, Adriane Martin Hilber, José Martines, Elizabeth Mason, Matthews Mathai, Dileep Mavalankar, Gillian Mayers, Juliet McEachren, Abdelhai Mechbal, Mario Merialdi, Tom Merrick, Thierry Mertens, Susan Murray, Adepeju Olukoya, Guillermo Paraje, Justin Parkhurst, Amit Patel, Vikram Patel, Steve Pearson, Gretel Pelto, Jean Perrot, Annie Portela, Dheepa Rajan, K.V. Ramani, Esther Ratsma, Linda Richter, David Sanders, Parvathy Sankar, Robert Scherpbier, Peelam Sekhri, Gita Sen, Iqbal Shah, Della Sherratt, Kenji Shibuya, Kristjana Sigurbjornsdottir, Angelica Sousa, Niko Speybroeck, Karin Stenberg, Will Stones, Tessa Tan-Torres Edejer, Petra Ten Hoope-Bender, Ann Tinker, Wim Van Damme, Jos Vandelaer, Paul Van Look, Marcel Vekemans, Cesar Victora, Eugenio Villar Montesinos, Yasmin Von Schirnding, Eva Wallstam, Steve Wiersma, Karl Wilhelmson, Lara Wolfson, Juliana Yartey and Jelka Zupan. Contributers to statistical tables were: Elisabeth Aahman, Dorjsuren Bayarsaikhan, Ana Betran, Zulfiqar Bhutta, Maureen Birmingham, Robert Black, Ties Boerma, Cynthia Boschi-Pinto, Jennifer Bryce, Agnes Couffinhal, Simon Cousens, Trevor Croft, David D. Vans, Charu C. Garg, Kim Gustavsen, Nasim Haque, Patricia Hernández, Ken Hill, Chandika Indikadahena, Mie Inoue, Gareth Jones, Betty Kirkwood, Joseph Kutzin, Joy Lawn, Eduardo Levcovitz, Edilberto Loaiza, Doris Ma Fat, José Martines, Elizabeth Mason, Colin Mathers, Saul Morris, Kim Mulholland, Takondwa Mwase, Bernard Nahlen, Pamela Nakamba-Kabaso, Agnès Prudhomme, Rachel Racelis, Olivier Ronveaux, Alex Rowe, Hossein Salehi, Ian Scott, U Than Sein, Kenji Shibuya, Rick Steketee, Rubén Suarez, Tessa Tan-Torres Edejer, Nathalie van de Maele, Tessa Wardlaw, Neff Walker, Hongyi Xu, Jelka Zupan, and many staff in WHO country offices, governmental departments and agencies, and international institutions. Valuable comments and guidance were provided by Denis Aitken and Michel Jancloes. Additional help and advice were kindly provided by Regional Directors and members of their staff. The report was edited by Leo Vita-Finzi, assisted by Barbara Campanini. Editorial, administrative and production support was provided by Shelagh Probst and Gary Walker, who also coordinated the photographs. The web site version and other electronic media were provided by Gael Kernen. Proofreading was by Marie Fitzsimmons. The index was prepared by Kathleen Lyle. Front cover photographs (clockwise from top left): L. Gubb/WHO; Pepito Frias/WHO; Armando Waak/WHO/PAHO; Carlos Gaggero/WHO/PAHO; Liba Taylor/WHO; Pierre Virot/WHO. Back cover photographs (left to right): Pierre Virot/WHO; J. Gorstein/WHO; G. Diez/WHO; Pierre Virot/WHO. This report contains several photographs from “River of Life 2004” – a WHO photo competition on the theme of sexual and reproductive health. WHO Library Cataloguing-in-Publication Data World Health Organization. The World health report : 2005 : make every mother and child count. 1.World health - trends 2.Maternal welfare 3.Child welfare. 4.Maternal health services - organization and administration. 5.Child health services - organization and administration 6.World Health Organization I.Title II.Title: Make every mother and child count. ISBN 92 4 156290 0 (NLM Classification: WA 540.1) ISSN 1020-3311 © World Health Organization 2005 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). 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 can be ordered from: bookorders@who.int The World Health Report 2005
指 contents Message from the Director-General Overview xiⅷ Patchy progress and widening gaps-what went wrong? w Making the right technical and strategic choices xiv Moving towards universal coverage:access for all, with financial protection xvi Chapter summaries xix Chapter 1 Mothers and children matter-so does their health The early years of maternal and child health 3 Where we are now:a moral and political imperative Mothers,children and the Millennium Development Goals 7 Uneven gains in child health 8 The newborn deaths that went unnoticed 9 Few signs of improvement in maternal health 10 A patchwork of progress,stagnation and reversal 12 The numbers remain high 13 Chapter 2 Obstacles to progress:context or policy? 21 Context matters 2 Poverty undermines progress The direct and indirect effects of HIV/AIDS 23 Conflicts and emergencies set systems back 24 The many faces of exclusion from care 25 Sources of exclusion 6 Patterns of exclusion 29 Different exclusion patterns,different challenges Are districts the right strategy for moving towards universal coverage? 32 A strategy without resources Have districts failed the test? 33
iii contents Message from the Director-General xi Overview xiii Patchy progress and widening gaps – what went wrong? xiv Making the right technical and strategic choices xiv Moving towards universal coverage: access for all, with financial protection xvi Chapter summaries xix Chapter 1 Mothers and children matter – so does their health 1 The early years of maternal and child health 2 Where we are now: a moral and political imperative 3 Mothers, children and the Millennium Development Goals 7 Uneven gains in child health 8 The newborn deaths that went unnoticed 9 Few signs of improvement in maternal health 10 A patchwork of progress, stagnation and reversal 12 The numbers remain high 13 Chapter 2 Obstacles to progress: context or policy? 21 Context matters 22 Poverty undermines progress 22 The direct and indirect effects of HIV/AIDS 23 Conflicts and emergencies set systems back 24 The many faces of exclusion from care 25 Sources of exclusion 26 Patterns of exclusion 29 Different exclusion patterns, different challenges 30 Are districts the right strategy for moving towards universal coverage? 32 A strategy without resources 32 Have districts failed the test? 33 overview
iv Chapter 3 Great expectations:making pregnancy safer 41 Realizing the potential of antenatal care Meeting expectations in pregnancy 42 Pregnancy-a time with its own dangers 44 Seizing the opportunities 46 Critical directions for the future 47 Not every pregnancy is welcome 48 Planning pregnancies before they even happen 48 Unsafe abortion:a major public health problem 50 Dealing with the complications of abortion 51 Valuing pregnancy:a matter of legal protection 52 Chapter 4 Attending to 136 million births,every year 61 Risking death to give life 61 Skilled professional care:at birth and afterwards 65 Successes and reversals:a matter of building health systems 65 Skilled care:rethinking the division of labour 68 Care that is close to women-and safe 69 A back-up in case of complications 72 Rolling out services simultaneously 73 Postpartum care is just as important 73 Chapter 5 Newborns:no longer going unnoticed 79 The greatest risks to life are in its beginning 79 Progress and some reversals 82 No longer falling between the cracks 85 Care during pregnancy 86 Professional care at birth 86 Caring for the baby at home 88 Ensuring continuity of care 89 Planning for universal access 90 Benchmarks for supply-side needs 90 Room for optimism,reasons for caution 91 Closing the human resource and infrastructure gap 93 Scenarios for scaling up 93 Costing the scale up 98 Chapter 6 Redesigning child care: survival,growth and development 103 Improving the chances of survival 103 The ambitions of the primary health care movement 103 The successes of vertical programmes 103 Time for a change of strategy 105 Combining a wider range of interventions 105 Dealing with children,not just with diseases 107 Organizing integrated child care 108
iv Chapter 3 Great expectations: making pregnancy safer 41 Realizing the potential of antenatal care 42 Meeting expectations in pregnancy 42 Pregnancy – a time with its own dangers 44 Seizing the opportunities 46 Critical directions for the future 47 Not every pregnancy is welcome 48 Planning pregnancies before they even happen 48 Unsafe abortion: a major public health problem 50 Dealing with the complications of abortion 51 Valuing pregnancy: a matter of legal protection 52 Chapter 4 Attending to 136 million births, every year 61 Risking death to give life 61 Skilled professional care: at birth and afterwards 65 Successes and reversals: a matter of building health systems 65 Skilled care: rethinking the division of labour 68 Care that is close to women – and safe 69 A back-up in case of complications 72 Rolling out services simultaneously 73 Postpartum care is just as important 73 Chapter 5 Newborns: no longer going unnoticed 79 The greatest risks to life are in its beginning 79 Progress and some reversals 82 No longer falling between the cracks 85 Care during pregnancy 86 Professional care at birth 86 Caring for the baby at home 88 Ensuring continuity of care 89 Planning for universal access 90 Benchmarks for supply-side needs 90 Room for optimism, reasons for caution 91 Closing the human resource and infrastructure gap 93 Scenarios for scaling up 93 Costing the scale up 98 Chapter 6 Redesigning child care: survival, growth and development 103 Improving the chances of survival 103 The ambitions of the primary health care movement 103 The successes of vertical programmes 103 Time for a change of strategy 105 Combining a wider range of interventions 105 Dealing with children, not just with diseases 107 Organizing integrated child care 108 The World Health Report 2005
Households and health workers 109 Referring sick children 111 Bringing care closer to children 112 Rolling out child health interventions 112 The cost of scaling up coverage 115 From cost projections to scaling up 117 Chapter 7 Reconciling maternal,newborn and child health with health system development 125 Repositioning MNCH 125 Different constituencies,different languages 128 Sustaining political momentum 130 Rehabilitating the workforce 132 Not just a question of numbers 132 Recovering from the legacy of past neglect 134 Destabilization with the best of intentions 136 Tackling the salary problem 136 Financial protection to ensure universal access 137 Replacing user fees by prepayment,pooling and a refinancing of the sector 138 Making the most of transitory financial protection mechanisms 139 Generalizing financial protection 140 Channelling funds effectively 140 Statistical annex 149 Explanatory notes 149 Annex Table 1 Basic indicators for all WHO Member States 174 Annex Table 2a Under-five mortality rates:estimates for 2003,annual average percent change 1990-2003,and availability of data 1980-2003 182 Annex Table 2b Under-five mortality rates(per 1000)directly obtained from surveys and vital registration,by age and latest available period or year 186 Annex Table 3 Annual number of deaths by cause for children under five years of age in WHO regions,estimates for 2000-2003 190 Annex Table 4 Annual number of deaths by cause for neonates in WHO regions, estimates for 2000-2003 190 Annex Table 5 Selected national health accounts indicators:measured levels of expenditure on health,1998-2002 192 Annex Table 6 Selected national health accounts indicators:measured levels of per capita expenditure on health.1998-2002 200 Annex Table 7 Selected immunization indicators in all WHO Member States 204 Annex Table 8 Selected indicators related to reproductive,maternal and newborn health 212
v Households and health workers 109 Referring sick children 111 Bringing care closer to children 112 Rolling out child health interventions 112 The cost of scaling up coverage 115 From cost projections to scaling up 117 Chapter 7 Reconciling maternal, newborn and child health with health system development 125 Repositioning MNCH 125 Different constituencies, different languages 128 Sustaining political momentum 130 Rehabilitating the workforce 132 Not just a question of numbers 132 Recovering from the legacy of past neglect 134 Destabilization with the best of intentions 136 Tackling the salary problem 136 Financial protection to ensure universal access 137 Replacing user fees by prepayment, pooling and a refinancing of the sector 138 Making the most of transitory financial protection mechanisms 139 Generalizing financial protection 140 Channelling funds effectively 140 Statistical annex 149 Explanatory notes 149 Annex Table 1 Basic indicators for all WHO Member States 174 Annex Table 2a Under-five mortality rates: estimates for 2003, annual average percent change 1990–2003, and availability of data 1980–2003 182 Annex Table 2b Under-five mortality rates (per 1000) directly obtained from surveys and vital registration, by age and latest available period or year 186 Annex Table 3 Annual number of deaths by cause for children under five years of age in WHO regions, estimates for 2000–2003 190 Annex Table 4 Annual number of deaths by cause for neonates in WHO regions, estimates for 2000–2003 190 Annex Table 5 Selected national health accounts indicators: measured levels of expenditure on health, 1998–2002 192 Annex Table 6 Selected national health accounts indicators: measured levels of per capita expenditure on health, 1998–2002 200 Annex Table 7 Selected immunization indicators in all WHO Member States 204 Annex Table 8 Selected indicators related to reproductive, maternal and newborn health 212 overview
i Index 221 Figures Figure 1.1 Slowing progress in child mortality:how Africa is faring worst 8 Figure 1.2 Neonatal and maternal mortality are related to the absence of a skilled birth attendant 10 Figure 1.3 Changes in under-5 mortality rates,1990-2003: countries showing progress,stagnation or reversal 14 Figure 1.4 Patterns of reduction of under-5 mortality rates,1990-2003 14 Figure 1.5 Maternal mortality ratio per 100 000 live births in 2000 15 Figure 1.6 Neonatal mortality rate per 1000 live births in 2000 15 Figure 2.1 A temporary reversal in maternal mortality: Mongolia in the early 1990s 23 Fiqure 2.2 Levelling off after remarkable progress: DTP3 vaccine coverage since 1980 26 Figure 2.3 Different patterns of exclusion:massive deprivation at low levels of coverage and marginalization of the poorest at high levels 29 Figure 2.4 From massive deprivation to marginal exclusion: moving up the coverage ladder 30 Figure 2.5 Survival gap between rich and poor:widening in some countries narrowing in others Figure 3.1 Coverage of antenatal care is rising 42 Figure 3.2 The outcomes of a year's pregnancies 49 Figure 3.3 Grounds on which abortion is permitted around the world 52 Figure 4.1 Causes of maternal death 62 Figure 4.2 Maternal mortality since the 1960s in Malaysia,Sri Lanka and Thailand 66 Figure 4.3 Number of years to halve materal mortality,selected countries 68 Figure 5.1 Deaths before five years of age,2000 80 Figure 5.2 Number of neonatal deaths by cause,2000-2003 80
vi Index 221 Figures Figure 1.1 Slowing progress in child mortality: how Africa is faring worst 8 Figure 1.2 Neonatal and maternal mortality are related to the absence of a skilled birth attendant 10 Figure 1.3 Changes in under-5 mortality rates, 1990–2003: countries showing progress, stagnation or reversal 14 Figure 1.4 Patterns of reduction of under-5 mortality rates, 1990–2003 14 Figure 1.5 Maternal mortality ratio per 100 000 live births in 2000 15 Figure 1.6 Neonatal mortality rate per 1000 live births in 2000 15 Figure 2.1 A temporary reversal in maternal mortality: Mongolia in the early 1990s 23 Figure 2.2 Levelling off after remarkable progress: DTP3 vaccine coverage since 1980 26 Figure 2.3 Different patterns of exclusion: massive deprivation at low levels of coverage and marginalization of the poorest at high levels 29 Figure 2.4 From massive deprivation to marginal exclusion: moving up the coverage ladder 30 Figure 2.5 Survival gap between rich and poor: widening in some countries, narrowing in others 31 Figure 3.1 Coverage of antenatal care is rising 42 Figure 3.2 The outcomes of a year’s pregnancies 49 Figure 3.3 Grounds on which abortion is permitted around the world 52 Figure 4.1 Causes of maternal death 62 Figure 4.2 Maternal mortality since the 1960s in Malaysia, Sri Lanka and Thailand 66 Figure 4.3 Number of years to halve maternal mortality, selected countries 68 Figure 5.1 Deaths before five years of age, 2000 80 Figure 5.2 Number of neonatal deaths by cause, 2000–2003 80 The World Health Report 2005
vii Figure 5.3 Changes in neonatal mortality rates between 1995 and 2000 81 Figure 5.4 Neonatal mortality in African countries shows stagnation and some unusual reversals 82 Figure 5.5 Neonatal mortality is lower when mothers have received professional care 88 Figure 5.6 The proportion of births in health facilities and those attended by medical doctors is increasing 92 Figure 5.7 The human resource gap in Benin,Burkina Faso,Mali and Niger,2001 95 Figure 5.8 Cost of scaling up maternal and newborn care,additional to current expenditure % Figure 6.1 An integrated approach to child health 111 Figure 6.2 Proportion of districts where training and system strengthening for IMCI had been started by 2003 114 Figure 6.3 Cost of scaling up child health interventions,additional to current expenditure 116 Boxes Box 1.1 Milestones in the establishment of the rights of women and children 5 B0x1.2 Why invest public money in health care for mothers and children? B0x1.3 A reversal of maternal mortality in Malaw 11 B0x1.4 Counting births and deaths 12 B0X2.1 Economic crisis and health system meltdown:a fatal cascade of events 22 Box 2.2 How HIV/AIDS affects the health of women and children 23 B0x2.3 Health districts can make progress,even in adverse circumstances 25 B0X2.4 Mapping exclusion from life-saving obstetric care 27 B0x2.5 Building functional health districts:sustainable results require a long-term commitment 34 B0x3.1 Reducing the burden of malaria in pregnant women and their children 44 Box3.2 Anaemia-the silent killer 45
vii Figure 5.3 Changes in neonatal mortality rates between 1995 and 2000 81 Figure 5.4 Neonatal mortality in African countries shows stagnation and some unusual reversals 82 Figure 5.5 Neonatal mortality is lower when mothers have received professional care 88 Figure 5.6 The proportion of births in health facilities and those attended by medical doctors is increasing 92 Figure 5.7 The human resource gap in Benin, Burkina Faso, Mali and Niger, 2001 95 Figure 5.8 Cost of scaling up maternal and newborn care, additional to current expenditure 96 Figure 6.1 An integrated approach to child health 111 Figure 6.2 Proportion of districts where training and system strengthening for IMCI had been started by 2003 114 Figure 6.3 Cost of scaling up child health interventions, additional to current expenditure 116 Boxes Box 1.1 Milestones in the establishment of the rights of women and children 5 Box 1.2 Why invest public money in health care for mothers and children? 6 Box 1.3 A reversal of maternal mortality in Malawi 11 Box 1.4 Counting births and deaths 12 Box 2.1 Economic crisis and health system meltdown: a fatal cascade of events 22 Box 2.2 How HIV/AIDS affects the health of women and children 23 Box 2.3 Health districts can make progress, even in adverse circumstances 25 Box 2.4 Mapping exclusion from life-saving obstetric care 27 Box 2.5 Building functional health districts: sustainable results require a long-term commitment 34 Box 3.1 Reducing the burden of malaria in pregnant women and their children 44 Box 3.2 Anaemia – the silent killer 45 overview
viii B0X3.3 Violence against women 47 B0X4.1 Obstetric fistula:surviving with dignity 64 B0X4.2 Maternal depression affects both mothers and children 65 B0x4.3 Screening for high-risk childbirth:a disappointment 69 B0x4.4 Traditional birth attendants:another disappointment 70 B0x4.5 Preparing practitioners for safe and effective practice 72 B0x5.1 Explaining variations in maternal,neonatal and child mortality: care or context? 83 B0x5.2 Sex selection 85 B0x5.3 Overmedicalization 94 B0x5.4 A breakdown of the projected costs of extending the coverage of maternal and newborn care 97 Box 6.1 What do children die of today? 106 Box6.2 How households can make a difference 110 B0x6.3 A breakdown of the projected cost of scaling up 118 Box 7.1 International funds for maternal,newborn and child health 126 B0x7.2 Building pressure:the partnerships for maternal,newborn and child health 127 B0x7.3 MNCH,poverty and the need for strategic information 128 B0X7.4 Sector-wide approaches 129 B0x7.5 Rebuilding health systems in post-crisis situations 133 B0X7.6 Civil society involvement requires support 142
viii Box 3.3 Violence against women 47 Box 4.1 Obstetric fistula: surviving with dignity 64 Box 4.2 Maternal depression affects both mothers and children 65 Box 4.3 Screening for high-risk childbirth: a disappointment 69 Box 4.4 Traditional birth attendants: another disappointment 70 Box 4.5 Preparing practitioners for safe and effective practice 72 Box 5.1 Explaining variations in maternal, neonatal and child mortality: care or context? 83 Box 5.2 Sex selection 85 Box 5.3 Overmedicalization 94 Box 5.4 A breakdown of the projected costs of extending the coverage of maternal and newborn care 97 Box 6.1 What do children die of today? 106 Box 6.2 How households can make a difference 110 Box 6.3 A breakdown of the projected cost of scaling up 118 Box 7.1 International funds for maternal, newborn and child health 126 Box 7.2 Building pressure: the partnerships for maternal, newborn and child health 127 Box 7.3 MNCH, poverty and the need for strategic information 128 Box 7.4 Sector-wide approaches 129 Box 7.5 Rebuilding health systems in post-crisis situations 133 Box 7.6 Civil society involvement requires support 142 The World Health Report 2005
x Tables Table 1.1 Neonatal and maternal mortality in countries where the decline in child mortality has stagnated or reversed 16 Table 2.1 Factors hindering progress 22 Table 4.1 Incidence of major complications of childbirth,worldwide 63 Table 4.2 Key features of first-level and back-up maternal and newborn care 71 Table 5.1 Filling the supply gap to scale up first-level and back-up maternal and newborn care in 75 countries(from the current 43%to 73% coverage by 2015 and full coverage in 2030) 96 Table 6.1 Core interventions to improve child survival 115
ix Tables Table 1.1 Neonatal and maternal mortality in countries where the decline in child mortality has stagnated or reversed 16 Table 2.1 Factors hindering progress 22 Table 4.1 Incidence of major complications of childbirth, worldwide 63 Table 4.2 Key features of first-level and back-up maternal and newborn care 71 Table 5.1 Filling the supply gap to scale up first-level and back-up maternal and newborn care in 75 countries (from the current 43% to 73% coverage by 2015 and full coverage in 2030) 96 Table 6.1 Core interventions to improve child survival 115 overview
x 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 newborn babies,as well as countless children,are excluded from the health care to which they are entitled.Even more numerous are those who remain without protection against the poverty that ill-health can cause. Leaders readily agree that we cannot allow this to continue,but in many countries the situation is either improving too slowly or not improving at all,and in some it is getting worse.Mothers,the newborn and children represent the well-being of a society and its potential for the future.Their health needs cannot be left unmet without harming the whole of society. Families and communities themselves can do a great deal to change this situation. They can improve,for example,the position of women in society,parenting,disease prevention,care for the sick,and uptake of services.But this area of health is also a public responsibility. Public health programmes need to work together so that all families have access to a continuum of care that extends from pregnancy(and even before),through childbirth and on into childhood,instead of the often fragmented services available at present. It makes no sense to provide care for a child while ignoring the mother's health,or to assist a mother giving birth but not the newborn child. To ensure that all families have access to care.governments must accelerate the building up of coherent,integrated and effective health systems.This means tackling the health workforce crisis,which in turn calls for a much higher level of funding and better organization of it for these aspects of health.The objective must be health sys- tems that can respond to these needs,eliminate financial barriers to care,and protect people from the poverty that is both a cause and an effect of ill-health. The world needs to support countries striving to achieve universal access and finan- cial protection for all mothers and children.Only by doing so can we make sure that every mother,newborn baby and child in need of care can obtain it,and no one is driven into poverty by the cost of that care.In this way we can move not only towards the Millennium Development Goals but beyond them. LEE Jong-wook Director-General World Health Organization Geneva,April 2005
xi Parenthood brings with it the strong desire to see our children grow up happily and in good health. This is one of the few constants in life in all parts of the world. Yet, even in the 21st century, we still allow well over 10 million children and half a million 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 overview