Policy brief Integrating maternal, newborn and child health programmes by packaging a set of simple, affordable and effective interventions for Make skilled care the centrepiece of the MNCH strategy b Where there the combined management of the childhood illnesses and malnutrition is a large human resource base of health professionals, any remaining under the label of "Integrated Management of Childhood lIness"(IMCi). shortages should be corrected and skill mixes adapted to the needs. In IMCI combines interventions not only for preventing deaths, taking into some countries however, the shortages are such that the task ahead may account the changing profile of mortality causes, but also for improving seem overwhelming. The shortcut of relying on non-professionals may children healthy growth and development. More than just adding more then seem attractive, particularly for child care where some of the tasks programmes to a single delivery channel it has sought to transform the can be delegated to less skilled workers or trained non-professionals way the health system looks at child care by shifting its focus from health Such shortcuts are faster in bringing care closer to the people, but may centres alone to a continuum of care that implicates families and com- not lead to the expected results in mortality reduction. In any case it is munities, health centres, and referral-level hospitals IMCI has now been important to focus on long term strategies built around skilled, profes adopted by more than 100 countries, but its implementation is often still sional care, and to make sure that investment in intermediate short term quite limited. The reality is that today many children do not benefit from solutions will not be at the expense of investment in the future such comprehensive and integrated care. As child health programmes continue to move towards integration, they also need to move from small- Roll out the whole MNCH continuum, district per district p To maxim- scale projects to universal access ise the synergies of empowerment, good home care, first-level services such as those provided by midwives for pregnant women, or by multi- purpose health workers for children-and hospital care, all these layers of SCALING UP TO FULL COVERAGE OF EFFECTIVE care must be rolled out in parallel. To concentrate on one of these layers CARE WILL REQUIRE EXTRA FUNDS at the expense of the others is no longer acceptable. This often means The World Health Report 2005 estimates that within 10 years it is building-and financing - integrated district health systems on a district feasible, in the 75 worst affected countries of the world, to reach per district basis all children and three quarters of all mothers and babies with the priority child health interventions and with the full range of the in- Reconcile MNCH programmes with health system development P All terventions that are effective during pregnancy, childbirth and the too often the world of MNCH programmes is far removed from that of postpartum. In most of these countries, this would achieve or ge health systems. Governments have to establish concrete and functional beyond the MDG set for child health and reach or come close to the links between the programmes and the core health system development MDG set for maternal health. According to the latest available data, processes. To do this, the planning of MNCH scale up efforts has to be public expenditure on health in these countries is currently around integrated in comprehensive health sector investment plans and budgets USS 97 Billion per year, i.e. approximately USS 22 per inhabitant To First, to ensure that MNCH care and its specific requirements remain at achieve the increase in coverage would require an extra expenditure the core of the health system's agenda. Second, to ensure that efforts to of USs 0.69 per inhabitant in 2006, increasing, as coverage expands, scale up MNCH are not limited to increase the supply of services, but that to USS 2.66 in 2015-a total of, on the average, USS 9 billion per financial and other barriers to access are eliminated and that mothers year over the coming 10 years. These sums are however a low-er children are protected from catastrophic expenditure Third, to make su estimate of what is needed and the efforts would need to continue to that synergies are developed with the wider agenda of the fight again grow afterwards the initial 10-year period until universal coverage is gender discrimination, poverty and exclusion reached for all women newborns and children the additional efforts required vary considerably from country to country, but on the whole Take legal and regulatory measures to protect the rights of women and will require substantial additional efforts from both countries and the children b Human rights treaties place legal obligations on countries to international community take measures to ensure that the rights of children and women are pro tected. For governments this means not only guaranteeing entitlements to care, but also introducing and implementing laws and policies to, for ex- POLICY RECOMMENDATIONS ample, establish a minimum age for marriage, criminalise violence against Upgrade skills, delegate tasks and redefine responsibilities b The short- women, prohibit female genital mutilation or enforce birth registration. It age of human resources calls for pragmatic solutions. For example, a also means protecting pregnant women in the workplace and putting sys- lack of obstetricians or anaesthesiologists for obstetric surgery can be tems into place that protect women, their babies and their children against corrected for by relying on purposefully trained general practitioners or over-medicalisation and financial exploitation by unscrupulous providers mid-level technicians; or where nurses are in short supply, many of the priority interventions to treat children can be delegated to non-profes sional workers or volunteers- again after specific training and with the in a rosary back-up. But these providers also need to be able to practice in a regulated environment. All too often health professionals are or are For further information conceming The World Health Report nottrainedtotheirfullpotentialorwhentheyarenotallowedtoputthepleasevisitourwebsiteathttp://www.who.int/whr/en/ full range of their skills into action: allowing midwives or nurses to treat or contact: women with oxytocin, for example, which they are perfectly able to do, Joy Phumaphi, ADG FCH (phumaphij @who. int) can save many lives. Governments need to put the legal and regulatory Tim Evans, ADG ElP (evanst@who int arrangements into place that can accelerate the scaling up of MNCH care. Wim Van Lerberghe, Editor-in-Chief WHRO5 (vanlerberghew @who. int) They have to do this in collaboration with professional organizations to keep all the professional constituencies on board. Cover photo credits: left, H. Faird/wHO-right, WHO/PhotoPolicy brief Integrating maternal, newborn and child health programmes by packaging a set of simple, affordable and effective interventions for the combined management of the childhood illnesses and malnutrition under the label of “Integrated Management of Childhood Illness” (IMCI). IMCI combines interventions not only for preventing deaths, taking into account the changing profile of mortality causes, but also for improving children healthy growth and development. More than just adding more programmes to a single delivery channel it has sought to transform the way the health system looks at child care by shifting its focus from health centres alone to a continuum of care that implicates families and com￾munities, health centres, and referral-level hospitals. IMCI has now been adopted by more than 100 countries, but its implementation is often still quite limited. The reality is that today many children do not benefit from such comprehensive and integrated care. As child health programmes continue to move towards integration, they also need to move from small￾scale projects to universal access. POLICY RECOMMENDATIONS Upgrade skills, delegate tasks and redefine responsibilities ► The short￾age of human resources calls for pragmatic solutions. For example, a lack of obstetricians or anaesthesiologists for obstetric surgery can be corrected for by relying on purposefully trained general practitioners or mid-level technicians; or where nurses are in short supply, many of the priority interventions to treat children can be delegated to non-profes￾sional workers or volunteers – again after specific training and with the necessary back-up. But these providers also need to be able to practice in a regulated environment. All too often health professionals are or are not trained to their full potential, or when they are, not allowed to put the full range of their skills into action: allowing midwives or nurses to treat women with oxytocin, for example, which they are perfectly able to do, can save many lives. Governments need to put the legal and regulatory arrangements into place that can accelerate the scaling up of MNCH care. They have to do this in collaboration with professional organizations to keep all the professional constituencies on board. Make skilled care the centrepiece of the MNCH strategy ► Where there is a large human resource base of health professionals, any remaining shortages should be corrected and skill mixes adapted to the needs. In some countries however, the shortages are such that the task ahead may seem overwhelming. The shortcut of relying on non-professionals may then seem attractive, particularly for child care where some of the tasks can be delegated to less skilled workers or trained non-professionals. Such shortcuts are faster in bringing care closer to the people, but may not lead to the expected results in mortality reduction. In any case it is important to focus on long term strategies built around skilled, profes￾sional care, and to make sure that investment in intermediate short term solutions will not be at the expense of investment in the future. Roll out the whole MNCH continuum, district per district ► To maxim￾ise the synergies of empowerment, good home care, first-level services – such as those provided by midwives for pregnant women, or by multi￾purpose health workers for children – and hospital care, all these layers of care must be rolled out in parallel. To concentrate on one of these layers at the expense of the others is no longer acceptable. This often means building – and financing - integrated district health systems on a district per district basis. Reconcile MNCH programmes with health system development ► All too often the world of MNCH programmes is far removed from that of health systems. Governments have to establish concrete and functional links between the programmes and the core health system development processes. To do this, the planning of MNCH scale up efforts has to be integrated in comprehensive health sector investment plans and budgets. First, to ensure that MNCH care and its specific requirements remain at the core of the health system’s agenda. Second, to ensure that efforts to scale up MNCH are not limited to increase the supply of services, but that financial and other barriers to access are eliminated and that mothers and children are protected from catastrophic expenditure. Third, to make sure that synergies are developed with the wider agenda of the fight against gender discrimination, poverty and exclusion. Take legal and regulatory measures to protect the rights of women and children ► Human rights treaties place legal obligations on countries to take measures to ensure that the rights of children and women are pro￾tected. For governments this means not only guaranteeing entitlements to care, but also introducing and implementing laws and policies to, for ex￾ample, establish a minimum age for marriage, criminalise violence against women, prohibit female genital mutilation or enforce birth registration. It also means protecting pregnant women in the workplace and putting sys￾tems into place that protect women, their babies and their children against over-medicalisation and financial exploitation by unscrupulous providers. For further information concerning The World Health Report please visit our website at: http://www.who.int/whr/en/ or contact: Joy Phumaphi, ADG FCH (phumaphij@who.int) Tim Evans, ADG EIP (evanst@who.int) Wim Van Lerberghe, Editor-in-Chief WHR05 (vanlerberghew@who.int) Cover photo credits: left, H. Faird/WHO - right, WHO/Photo SCALING UP TO FULL COVERAGE OF EFFECTIVE CARE WILL REQUIRE EXTRA FUNDS The World Health Report 2005 estimates that within 10 years it is feasible, in the 75 worst affected countries of the world, to reach all children and three quarters of all mothers and babies with the priority child health interventions and with the full range of the in￾terventions that are effective during pregnancy, childbirth and the postpartum. In most of these countries, this would achieve or go beyond the MDG set for child health and reach or come close to the MDG set for maternal health. According to the latest available data, public expenditure on health in these countries is currently around US$ 97 Billion per year, i.e. approximately US$ 22 per inhabitant. To achieve the increase in coverage would require an extra expenditure of US$ 0.69 per inhabitant in 2006, increasing, as coverage expands, to US$ 2.66 in 2015 – a total of, on the average, US$ 9 billion per year over the coming 10 years. These sums are however a low-end estimate of what is needed and the efforts would need to continue to grow afterwards the initial 10-year period until universal coverage is reached for all women, newborns and children. The additional efforts required vary considerably from country to country, but on the whole will require substantial additional efforts from both countries and the international community