EDITORIALS

Exclusion, inequity and health system development: the critical emphases for maternal, neonatal and child health

Andrew Green^I,1; Nancy Gerein^II

^IProfessor and Head, Nuffield International Centre for Health and Development, University of Leeds, 71–75 Clarendon Road, Leeds LS2 9PL, England
^IIHead of Reproductive Health Programme, Nuffield International Centre for Health and Development, University of Leeds, Leeds, England

The World health report 2005 provides a powerful analysis of the global scandal of mothers' and children's ill-health (1). Every year, over half a million women die from pregnancy-related causes and over 10 million children die under five years of age. These deaths are largely preventable. The report correctly identifies the causes as lying primarily in failures within health systems to provide appropriate frameworks and resources to deliver the technical interventions, and in broader social and cultural factors.

Evidence on technical interventions is well covered. Midwifery-led care at the first level of services, with accessible back-up in hospitals, is essential for reducing maternal and neonatal mortality. The report is crystal clear on this, acknowledging past failures of training traditional birth attendants and problems of over-medicalization of childbirth. Universal access, both financial and geographical, to care by skilled attendants is emphasized, although a description of the requirements of referral systems to ensure timely access to obstetric care would have been helpful. Issues too often ignored are included: violence, discrimination and marginalization during pregnancy, sex selection, and the need for evidence to develop policy on postpartum care.

Making pregnancy safer requires high-quality antenatal care, improving society's care of pregnant women, and dealing with unwanted pregnancies. Building on WHO-sponsored research (2), the report describes how antenatal care could deal more opportunely with issues such as malnutrition, malaria, tuberculosis, family planning, and sexually transmitted infections and HIV/AIDS. The health burden from unsafe abortion is graphically described, but the report misses the opportunity to note the responsibility of health ministries to advocate on this issue, and to consider the underexploited technology of emergency contraception (3). Neonatal mortality receives a welcome analysis, but kangaroo care (strapping the newborn baby next to the mother's skin for warmth and breastfeeding) is unfortunately omitted, though it echoes the statement that progress in neonatal health does not require sophisticated technology. Child health is well summarized, building on experiences with developing a continuum of care from community to referral level throughout the health system.

The report focuses on health system aspects critical for maternal, neonatal and child health (MNCH) but which also provide a wider foundation to strengthen health systems. Firstly, it endorses the district health system as the appropriate structure to deliver the integrated care essential in MNCH, but recognizes earlier failings to support this. It also suggests that emphasis on primary care may have had the unintended consequence of neglecting hospitals, a critical part of the referral chain. Such an integrated approach challenges the vertical approaches of donors and public–private partnerships.

Secondly, the report focuses on the need for an extra 334 000 midwives, 100 000 multipurpose professionals and 4.6 million community workers by 2015. Structural adjustment and low economic levels have resulted in public salaries so low that they lead to migration to the private sector or abroad, or coping strategies which weaken the system (the effect of these on public sector values is particularly well described). The call for increased salaries is laudable, but carries implications for other health workers and professional groups that raise stark political and economic questions. Increasing globalization is also likely to lead to greater migratory movement as richer health systems plug their gaps with overseas professionals (4).

The report estimates the resources needed for scaling up MNCH activities as an additional US$ 91 billion over the next decade. While the accuracy of these figures may be debated, their implication is indisputable. A massive increase is required, particularly in those countries most ill-equipped to provide them. The report rightly rejects user fees as a response and points to the need for social insurance or tax-based responses. For the short and medium term, filling this gap requires significant external support.

It is pleasing to see WHO focus so strongly on the critical issues of exclusion and equity which underpin the need for a rights-based approach to MNCH. The report reminds us of the importance of wider determinants of health, such as nutrition, and the social and economic position of groups. This includes the disempowerment that many women experience, many determinants of which lie outside the control of the health system. The health system has a responsibility, however, to ensure that it does not reinforce this disempowerment and to point out its health implications and advocate for social change.

"The weakest link in the care chain is skilled attendance at birth"; "workforce shortages are staggering"; "user fees institutionalize the exclusion of the poor"; "finances are the killer assumption" (5). These challenging statements declare WHO's determination to reduce the unacceptable toll of maternal, newborn and child deaths in the poorest societies in the world.

References

1. The world health report 2005 – Make every mother and child count. Geneva: World Health Organization; 2005.

2. Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gulmezoglu M, Mugford M, et al., WHO Antenatal Care Trial Research Group. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet 2001;357:1565-70.

3. Ellertson C, Winikoff B, Armstrong E, Camp S, Senanayake P. Expanding access to emergency contraception in developing countries. Studies in Family Planning 1995;26:251-63.

4. Joint Learning Initiative strategy report. Human resources for health: overcoming the crisis. Boston (MA): Global Health Initiative, Harvard University; 2005. Available from: http://www.globalhealthtrust.org/Report.html

5. The world health report 2005 – Make every mother and child count. Geneva: World Health Organization; 2005:xiii-xxiii.

1 Correspondence should be sent to this author (email: a.t.green@leeds.ac.uk).