chapter two obstacles to progress: context or policy? This chapter seeks to explain why progress in maternal and child health has apparently stumbled so badly in many countries. It shows in detail how stagnations, reversals and slow progress in some countries are clearly to poverty, HIV/AIDS, and humanitarian crises, leading to exclusion from to health care. In many countries, the strategies put in place to provide health services have not produced the hoped for results. While many countries have based their health care systems on health districts, with a backbone of health centres and a referral district hospital, there has often been a failure to implement this model successfully in an exceedingly resource-constrained context. The chapter argues that the health district model still stands as a rational way for governments to organize decentralized health care delivery. Although there has been, for decades now, a global consensus that than for children. Whatever the context, lack of progress the health of mothers and children is a public priority, much still needs is also due to failures of health systems to provide good- to be done. Most progress is being made by countries that were al- quality care and services to all mothers and children ready in a relatively good position in the early 1990s, whereas those Moving towards universal access to health care must less favourably placed, particularly in sub-Saharan Africa, have been take account of the contextual barriers to progress, the left behind. Much of this large and growing gap can be explained by reasons for exclusion from care, and the various pat the context in which health systems have developed. The stagnations, terns of exclusion. Many countries, and particularly reversals and slow progress seen in some countries are clearly related those that face the biggest challenges, have based their to contexts of poverty, humanitarian crisis and the direct and indirect health care systems on the health district model, with a effects of HIV/AIDS (see Table 2. 1). These lead to an increasingly vis- backbone of health centres and a referral district hospi- ible gap between people who have access to health care and others tal. This chapter argues that the disappointing situation ho are excluded from such benefits. Exclusion from health benefits in many countries often has more to do with the condi- leads to even greater inequalities in survival for mothers and newborns tions under which this strategy has been implemented21 chapter two obstacles to progress: context or policy? Although there has been, for decades now, a global consensus that the health of mothers and children is a public priority, much still needs to be done. Most progress is being made by countries that were al￾ready in a relatively good position in the early 1990s, whereas those less favourably placed, particularly in sub-Saharan Africa, have been left behind. Much of this large and growing gap can be explained by the context in which health systems have developed. The stagnations, reversals and slow progress seen in some countries are clearly related to contexts of poverty, humanitarian crisis and the direct and indirect effects of HIV/AIDS (see Table 2.1). These lead to an increasingly vis￾ible gap between people who have access to health care and others who are excluded from such benefits. Exclusion from health benefits leads to even greater inequalities in survival for mothers and newborns than for children. Whatever the context, lack of progress is also due to failures of health systems to provide good￾quality care and services to all mothers and children. Moving towards universal access to health care must take account of the contextual barriers to progress, the reasons for exclusion from care, and the various pat￾terns of exclusion. Many countries, and particularly those that face the biggest challenges, have based their health care systems on the health district model, with a backbone of health centres and a referral district hospi￾tal. This chapter argues that the disappointing situation in many countries often has more to do with the condi￾tions under which this strategy has been implemented This chapter seeks to explain why progress in maternal and child health has apparently stumbled so badly in many countries. It shows in detail how stagnations, reversals and slow progress in some countries are clearly related to poverty, HIV/AIDS, and humanitarian crises, leading to exclusion from access to health care. In many countries, the strategies put in place to provide health services have not produced the hoped for results. While many countries have based their health care systems on health districts, with a backbone of health centres and a referral district hospital, there has often been a failure to implement this model successfully in an exceedingly resource-constrained context. The chapter argues that the health district model still stands as a rational way for governments to organize decentralized health care delivery