24 The World Health Report 2005 In humanitarian crises, basic maternal and child health services are often disrupted (New Jalozai refugee camp, Peshawar, Pakistan) differences among countries. HIV prevalence rates are much higher in the countries in stagnation or reversal than in the others(17/); in 9 of the 10 African countries in reversal, HIV/AIDS was responsible for more than 10% of child deaths in 1999, a much higher proportion than in 1990 (18). But HIV/AIDS as a direct cause of death cannot explain all of the slowing or reversal of trends in child mortality HIV/AIDS also affects the health of mothers and children in a more indirect way Appropriate diagnosis and treatment of HIV/AIDS in women and children are rarely provided and pose particular challenges in resource-limited settings. HIV/AIDS puts an additional strain on fragile health systems. It generates demand for new services such as prevention of HIv transmission from mothers to infants, HIV testing and counselling and complex diagnostic and investigative procedures(19, 20). This calls for increased spending on infrastructure, equipment, drugs and human resources. Where increases in funding do not follow, maternal and child health services have to share their scarce resources and personnel. As health workers themselves fall ill, the workforce becomes overstretched(21). Work performance is further reduced by fear, lack of knowledge about HIV/AIDS and protective practices, and the stress of caring for patients whose condition appears hopeless. As a result it is increasingly difficult to recruit young people into medical and nursing professions, particularly obstetrics Conflicts and emergencies set systems back Of the 43 countries showing stagnation or reversal in child mortality, 19 have been the subject of a Consolidated Appeal Process for a humanitarian crisis with a duration of24 The World Health Report 2005 differences among countries. HIV prevalence rates are much higher in the countries in stagnation or reversal than in the others (17); in 9 of the 10 African countries in reversal, HIV/AIDS was responsible for more than 10% of child deaths in 1999, a much higher proportion than in 1990 (18). But HIV/AIDS as a direct cause of death cannot explain all of the slowing or reversal of trends in child mortality. HIV/AIDS also affects the health of mothers and children in a more indirect way. Appropriate diagnosis and treatment of HIV/AIDS in women and children are rarely provided and pose particular challenges in resource-limited settings. HIV/AIDS puts an additional strain on fragile health systems. It generates demand for new services such as prevention of HIV transmission from mothers to infants, HIV testing and counselling, and complex diagnostic and investigative procedures (19, 20). This calls for increased spending on infrastructure, equipment, drugs and human resources. Where increases in funding do not follow, maternal and child health services have to share their scarce resources and personnel. As health workers themselves fall ill, the workforce becomes overstretched (21). Work performance is further reduced by fear, lack of knowledge about HIV/AIDS and protective practices, and the stress of caring for patients whose condition appears hopeless. As a result it is increasingly difficult to recruit young people into medical and nursing professions, particularly obstetrics. Conflicts and emergencies set systems back Of the 43 countries showing stagnation or reversal in child mortality, 19 have been the subject of a Consolidated Appeal Process for a humanitarian crisis with a duration of US$ 1.5 and US$ 3 per inhabitant per year), especially when compared with those available in refugee camps in the same area through relief agencies. Utilization of curative services and preventive coverage rates has actually increased: vaccination coverage has tripled. Maternal health activities have been intensified both quantitatively and qualitatively, with 52% of deliveries taking place in health centres and the hospital, and a population-based caesarean section rate of 1.4%; case-fatality of caesar￾ean sections dropped from 7.2% to 2.9%. The Since the 1980s, in North Kivu Province of the Democratic Republic of the Congo (formerly Zaire), the socioeconomic environment has been deteriorating. The province also faced an influx of Rwandan refugees in July 1994. In these difficult circumstances the Rutsh￾uru Health District was nevertheless able to adjust and maintain its medical activities. For 11 years the health care network remained accessible and functional, although human and financial resources were extremely lim￾ited (external assistance fluctuated between district was able to cope with a workload of 65 000 cases of various pathological condi￾tions in Rwandan refugees settled outside the camps, a 400% increase in the curative workload. The district was under severe pres￾sure but its services managed to respond effi- ciently to the repeated crisis situations, mainly by maintaining a solid district management structure rooted in ongoing communication and participation of the population (23). Box 2.3 Health districts can make progress, even in adverse circumstances In humanitarian crises, basic maternal and child health services are often disrupted (New Jalozai refugee camp, Peshawar, Pakistan). J.M. Giboux/WHO