obstacles to progress: context or policy? 25 more than two years on their territory. Such situations, where local or national systems are disrupted or overwhelmed to the extent of being unable to meet the peoples most basic needs, and that require an international response going beyond the mandate or capacity of any single agency, often involve a considerable breakdown of authority and a large amount of violence- against human beings, against the environment, infra- structure and property. In such situations women and children pay the heaviest price they are the most vulnerable and also the most exposed (adult men tend to leave such areas, to fight or to look for work( 22). Armed attacks often target key infrastructures and systems, such as roads, water supplies, communications and health facilities The collapse of immunization and disease control programmes, referral systems and hospitals primarily affect women and children. Insecurity and military operations deny access to large areas of territory and constrain the delivery of and access to health services. Much, however, depends on the way health systems are organized to cope with such difficult situations, and well-structured health districts have proved to be remarkably resilient (see Box 2.3) THE MANY FACES OF EXCLUSION FROM CARE Many more mothers and children have access to reproductive, maternal and child care entitlements than ever before in history. In many countries, however, universal access to the goods, services and opportunities that improve or preserve health is still a distant goal. A varying but large proportion of mothers and children remain excluded from the health benefits that others in the same country enjoy. Exclusion is related to socioeconomic inequalities In many countries it is a sign of increasing dualism in so- ciety: as growing middle classes in urban areas gain disproportionate access to public services, including education and health care, they effectively enter into competition with the poor for scarce resources, and easily come out on top (24) The result is that exclusion from access to health care is commonplace in poor countries In the 42 countries that in 2000 accounted for 90% of all deaths of children under five years of age, 60% of children with pneumonia failed to get the antibiotic they needed, and 70% of children with malaria failed to receive treatment(25). One third of children did not receive the vitamin a available to others in the same countries and half had no safe water or sanitation from 1999 to 2001. less than 2% of children from endemic malaria areas slept under insecticide-treated nets every night. Stagna- tion of progress in coverage for a number of interventions has meant that large parts Box 2.3 Health districts can make progress, even in adverse circumstances Since the 1980s, in North Kivu Province of the US$ 1.5 and Uss 3 per inhabitant per year), district was able to cope with a workload of Democratic Republic of the Congo (formerly especially when compared with those available 65 000 cases of various pathological condi been deteriorating. The province also faced relief agencies. Utilization of curative services the camps, a 400% increase in the curative an influx of Rwandan refugees in July 1994. and preventive coverage rates has actually workload. The district was under severe pres- In these difficult circumstances the Rutsh- increased: vaccination coverage has tripled. but its services managed to respond effi uru Health District was nevertheless able to Maternal health activities have been intensified ciently to the repeated crisis situations, mainly djust and maintain its medical activities. For both quantitatively and qualitatively, with 52% by maintaining a solid district management 11 years the health care network remained of deliveries taking place in health centres and structure rooted in ongoing communication and essible and functional, although human the hospital, and a population-based caesarean participation of the population (23)
obstacles to progress: context or policy? 25 more than two years on their territory. Such situations, where local or national systems are disrupted or overwhelmed to the extent of being unable to meet the people’s most basic needs, and that require an international response going beyond the mandate or capacity of any single agency, often involve a considerable breakdown of authority and a large amount of violence – against human beings, against the environment, infrastructure and property. In such situations women and children pay the heaviest price: they are the most vulnerable and also the most exposed (adult men tend to leave such areas, to fight or to look for work) (22). Armed attacks often target key infrastructures and systems, such as roads, water supplies, communications and health facilities. The collapse of immunization and disease control programmes, referral systems and hospitals primarily affect women and children. Insecurity and military operations deny access to large areas of territory and constrain the delivery of and access to health services. Much, however, depends on the way health systems are organized to cope with such difficult situations, and well-structured health districts have proved to be remarkably resilient (see Box 2.3). THE MANY FACES OF EXCLUSION FROM CARE Many more mothers and children have access to reproductive, maternal and child care entitlements than ever before in history. In many countries, however, universal access to the goods, services and opportunities that improve or preserve health is still a distant goal. A varying but large proportion of mothers and children remain excluded from the health benefits that others in the same country enjoy. Exclusion is related to socioeconomic inequalities. In many countries it is a sign of increasing dualism in society: as growing middle classes in urban areas gain disproportionate access to public services, including education and health care, they effectively enter into competition with the poor for scarce resources, and easily come out on top (24). The result is that exclusion from access to health care is commonplace in poor countries. In the 42 countries that in 2000 accounted for 90% of all deaths of children under five years of age, 60% of children with pneumonia failed to get the antibiotic they needed, and 70% of children with malaria failed to receive treatment (25). One third of children did not receive the vitamin A available to others in the same countries, and half had no safe water or sanitation. From 1999 to 2001, less than 2% of children from endemic malaria areas slept under insecticide-treated nets every night. Stagnation of progress in coverage for a number of interventions has meant that large parts 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 caesarean 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 Rutshuru 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 limited (external assistance fluctuated between district was able to cope with a workload of 65 000 cases of various pathological conditions in Rwandan refugees settled outside the camps, a 400% increase in the curative workload. The district was under severe pressure 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
26 The World Health Report 2005 of the population have continued to be excluded(26). Immunization coverage, for example, maintained its upward trend during the 1990s in the WHO European Region he Region of the Americas and the Western Pacific Region, but in the other regions it has levelled off at a mere 50% to 70%(see Figure 2.2) Sources of exclusion In many of the countries experiencing stagnation and reversal (particularly in sub Saharan Africa), barriers to the uptake of health benefits, and specifically the lack of an accessible supply of services, are a critical source of exclusion. For many people, services simply do not exist, or cannot be reached. For example, lack of access to hospitals where major obstetric interventions can be performed is the prime reason why large numbers of mothers in rural areas are excluded from life-saving care at childbirth(see Box 2.4) But there are many other barriers to the uptake of health benefits: service use is often constrained because of women,s lack of decision-making power, the low value placed on women's health and the negative or judgemental attitudes of family mem- bers (28, 29). Gender is thus a frequent source of exclusion: in India, for example, a girl is 1.5 times less likely to be hospitalized than a boy (30 -and up to 50%more likely to die between her first and fifth birthdays (31) People excluded from health care benefits by such barriers to the uptake of ser vices are also usually excluded from other services such as access to electricity water supply, basic sanitation, educa- Figure 2.2 Levelling off after remarkable progress tion or information their exclusion from DTP3 vaccine coverage since 1980 care is also reflected in inferior health indicators In Kazakhstan, for example, children born to ethnic Kazakh parents have a 1.5 times higher risk of death than ama those born to parents of Russian ethnic- ity; in Nigeria, children of uneducated mothers have about a 2.5 times higher risk of death than those of mothers with secondary school or higher education As part of its work on extension of social protection in health, the Pan American Health Organization has started map- ping exclusion from health benefits in a number of Latin American countries (32) Africa Nearly half of the population is excluded om some, and usually from most health ncas care benefits. The relative importance of a South-East Asia underlying reasons for exclusion varies mm Europe om country to country Eastern Mediterranean External"sources of exclusion such Western Pacific as the ones described above include geographical isolation, as well as barri- ers generated by poverty, rac 2000 and culture often in association with unemployment or informal employment. Third dose of diphtheria, tetanus and pertussis vaccine For many people the critical factor is the
26 The World Health Report 2005 of the population have continued to be excluded (26). Immunization coverage, for example, maintained its upward trend during the 1990s in the WHO European Region, the Region of the Americas and the Western Pacific Region, but in the other regions it has levelled off at a mere 50% to 70% (see Figure 2.2). Sources of exclusion In many of the countries experiencing stagnation and reversal (particularly in subSaharan Africa), barriers to the uptake of health benefits, and specifically the lack of an accessible supply of services, are a critical source of exclusion. For many people, services simply do not exist, or cannot be reached. For example, lack of access to hospitals where major obstetric interventions can be performed is the prime reason why large numbers of mothers in rural areas are excluded from life-saving care at childbirth (see Box 2.4). But there are many other barriers to the uptake of health benefits: service use is often constrained because of women’s lack of decision-making power, the low value placed on women’s health and the negative or judgemental attitudes of family members (28, 29). Gender is thus a frequent source of exclusion: in India, for example, a girl is 1.5 times less likely to be hospitalized than a boy (30) – and up to 50% more likely to die between her first and fifth birthdays (31). People excluded from health care benefits by such barriers to the uptake of services are also usually excluded from other services such as access to electricity, water supply, basic sanitation, education or information. Their exclusion from care is also reflected in inferior health indicators. In Kazakhstan, for example, children born to ethnic Kazakh parents have a 1.5 times higher risk of death than those born to parents of Russian ethnicity; in Nigeria, children of uneducated mothers have about a 2.5 times higher risk of death than those of mothers with secondary school or higher education. As part of its work on extension of social protection in health, the Pan American Health Organization has started mapping exclusion from health benefits in a number of Latin American countries (32). Nearly half of the population is excluded from some, and usually from most health care benefits. The relative importance of underlying reasons for exclusion varies from country to country. “External” sources of exclusion, such as the ones described above, include geographical isolation, as well as barriers generated by poverty, race, language and culture – often in association with unemployment or informal employment. For many people the critical factor is the a Third dose of diphtheria, tetanus and pertussis vaccine. Figure 2.2 Levelling off after remarkable progress: DTP3a vaccine coverage since 1980 Coverage (%) 1980 1985 1990 1995 2000 0 25 50 75 100 Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific