Make every mother and child count: key findings of The World Health Report 2005.

Children are the future of society and mothers are guardians of that future. However, each year 3.3 million babies are stillborn, about 4 million die within 28 days of coming into the world and about 6.6 million children die before their fifth birthday. Maternal deaths also continue unabated--the annual total stands at 529,000 deaths--often sudden and unpredicted, which occur during pregnancy, at birth or shortly after. The irony is that these deaths are largely avoidable.

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The World Health Report 2005-Make every mother and child count examines why these deaths continue to occur on such a scale and how the annual toll can be reduced. It states that interventions already exist to save the lives of millions of mothers and children. It also argues that maternal, newborn and child health (MNCH) should constitute the core of the health entitlements, protected and funded through public funds and social health insurance systems.

Humanitarian crises, pervasive poverty and the HIV/AIDS pandemic have all compounded the effects of economic downturns and the health workforce crisis. With widespread exclusion from care and growing inequalities, progress calls for massively strengthened health systems. Unless efforts are stepped up radically, there is little hope of eliminating avoidable maternal and child mortality in all countries.

With the advancement of technology, antenatal care is a major success story. However, more can be made of the considerable potential of such care by emphasizing other effective health programmes and interventions, such as the treatment or prevention of HIV/AIDS, other sexually transmitted infections, tuberculosis and malaria, and also family planning initiatives. 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 safe and responsive services during and after abortions.

Attending to all 136 million births every year is one of the major challenges that face the world's health systems. For optimum safety, every woman needs professional, skilled care when giving birth. A woman should also be able to give birth in an appropriate environment that is close to where she lives and that respects her birthing culture. Such care can best be provided by a registered midwife or a health worker with midwifery skills in first-level facilities. This can avert many life-threatening problems that may arise during childbirth and can reduce maternal mortality to surprisingly low levels. The need for care does not stop when the birth is over; the hours, days and weeks that follow can be dangerous for both mothers and 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 and many diseases occur.

The health problems of newborns have been unduly neglected and underestimated. As the newborns make up a sizeable proportion of the mortality of children under five, it has become clear that the Millennium Development Goal (MDG) to reduce child mortality by two thirds will not be reached by 2015 without substantial advances for the newborn. Progress in the health of newborns does not require expensive technology; it needs health systems that provide continuity of professional skilled care from the beginning of, and even before, pregnancy into the post-natal period. It is also essential to empower households so that they can take good care of the baby and get professional help immediately when difficulties arise.

The greatest risks to life are at its beginning, but they do not disappear as the newborn grows into infancy and early childhood. Programmes to tackle preventable diseases, malnutrition, diarrhoea and respiratory infections still have a large unfinished agenda. These programmes have, however, made such inroads on the burden of ill-health that its profile in many countries has changed. From a public health viewpoint and the expectation of families, there is a need for more integrated approaches, including dealing efficiently with the changing spectrum of problems that require attention and broadening the focus of care from the child's survival to his/her growth and development.

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 to childbirth and into childhood. Such continuity requires strengthened health systems, with MNCH care at the core of their development strategies. This means putting the health of mothers and children within a broader, straightforward political project, responding to society's claim that is increasingly seen as legitimate, for the protection of citizens' health and their access to care.

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Reaching all children with a package of essential health interventions necessary to comply with and even go beyond the MDGs is technically feasible within the next decade. But for maternal and newborn care, universal access is further away. The World Health Report states that it is possible to envisage various scenarios for scaling up services, taking into account the specific circumstances in each of the 75 worst-affected countries. Currently, some 43 per cent of mothers and newborns receive some care, but it is by no means the full range of what they need just to avoid maternal deaths. Adding up the optimistic but also realistic scenarios for each country gives access to a full package of first-level and backup care to 101 million mothers (some 73 per cent of expected births) and their babies in 2015. If these scenarios were implemented, the MDG for maternal health would not be reached in every country, but globally the reduction of maternal and perinatal mortality would be well on the way. In the worst-affected countries, scaling-up coverage of MNCH programmes will require at least $91 billion over the coming ten years, in addition to current expenditure, compared with around $97 billion per year, which is the total public health expenditure in these countries, according to the latest available data.

Putting in place the health workforce needed for increasing maternal, newborn and child health services towards universal access is the 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. After years of neglect, there are problems that require immediate attention: first and foremost is the nagging question of workforce remuneration. In many countries, salary levels are rightfully considered unfair and insufficient. This situation is one of the root causes of demotivation, lack of productivity and various forms of brain drain and migration, from rural to urban, public to private and from poorer to richer countries. It also seriously hampers the proper functioning of services, as health workers set up dual practices to improve their living conditions, leading to competition for time, a loss of resources for the public sector, and conflicts of interest in dealing with clients. There are even more serious consequences when workers resort to predatory behaviour; financial exploitation may have catastrophic effects on patients who use the services and may create barriers to access for others. It also contributes to a crisis of trust in the services to which mothers and children are entitled.

There is an urgent need to establish and deploy a whole range of measures to break the vicious circle and bring productivity and dedication back to what the population expects and to which most health workers aspire. One of the most challenging is the rehabilitation of workforce remuneration-a measure that would have political and economic implications and one that cannot be done without a major effort not only by Governments but also through international assistance. On the eve of a decade that will be focused on human health resources, this will require a worldwide fundamental debate on the volume of funds to be allocated and on channeling them.

At the same time, ensuring universal access is not merely a question of increasing the supply of MNCH services and paying health-care providers. Financial barriers to access have to be eliminated and users given predictable financial protection against the costs of seeking care, particularly against catastrophic payments that can push households into poverty. Such payments occur wherever charges are significant and households have limited ability to pay. 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 services towards universal access; second, financial protection systems have to be established at the same time as access improves; and 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. Although it requires major capacity-building efforts, channelling increased funding flows through national health insurance schemes offers the best avenue to meet these three challenges simultaneously.

The move towards universal coverage, with financial protection and access for all, can be accelerated during this decade. This will ensure that no mother, no newborn and no child in need will remain unattended. Every mother and every child counts.

The authors constitute the core writing team of The World Health Report 2005. Wim Van Lerberghe (left) is Editor-in-Chief of the Report and team coordinator in the Health System Policies and Operations Department at the World Health Organization in Geneva. Annick Manuel (centre) works in the same Department. Zoe Matthews (right) is a demographer with the University of Southampton.

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