mothers and children matter - so does their health 5 Box 1.1 Milestones in the establishment of the rights of women and children In the 20th century several international treaties came into being, holding signatory countries accountable for the human rights of their citizens. Over the past two decades United Nations bodies, as well as international, regional and national courts, have increasingly focused on the human ights of mothers and children The Universal Declaration of Human Rights states that 1948- motherhood and childhood are entitled to special care and 1952 The General Conference of the International Labour Organi- assistance zation adopts the Maternity Protection Convention The Declaration of the Rights of the Child 1966 The International Covenant on Economic, Social and Cul tural Rights recognizes the right to the highest attainable stan dard of physical and mental health on on the Elimination of All Forms of Dis- 1981 Against Women enjoins States parties to ensure opropriate maternal health services. 1989 The Convention on the Rights of the child guarantees chil At the United Nations World Summit on Children govern- 1990 dren s right to health States commit themselves to ensuring ments declare their "joint commitment. to give every child a appropriate matemal health services. better future", and recognize the link between womens rights and children s well-being The United Nations Human Rights Committee expresses 1993 concern over high rates of maternal mortality 1994 The United Nations International Conference on Popula- 1995 tion and Development and the United Nations Fourth World The United Nations United Nations Human Rights Commit- 1996 Conference on Women affirm women's right of access to tee rules that, when abortion gives rise to a criminal penal appropriate health care services in pregnancy and childbirth even if a woman is pregnant as a result of rape, a womans ight to be free from inhuman and degrading treatment might 2000 The United Nations Committee on Economic Cultural Rights states that measures are required child and maternal health, sexual and reproductive = vIces The United Nations Committee on the Rights of the Child 2003-2003 The United Nations Commission on Human Rights, states states that adolescent girls should have access to informatio that sexual and reproductive health are integral elements of on the impact of early marriage and early pregnancy and have the right to health. The United Nations Committee on the Rights of the Child dopts its General Comment on HIV/AIDS and that on the Rights of the Child The United Nations Committee Against Torture calls for an 2004-2004 The United Nations Sub-Commission on the Promotion and traction of confessions for prosecution Protection of Human Rights adopts a resolution on"harmful from women seeking emergency medical care as a result of traditional practices affecting the health of women and the illegal abortion. The United Nations Special Rapporteur on the Right to Health reports that all forms of sexual violence are inconsistent with the right to heal
mothers and children matter – so does their health 5 Box 1.1 Milestones in the establishment of the rights of women and children In the 20th century several international treaties came into being, holding signatory countries accountable for the human rights of their citizens. Over the past two decades United Nations bodies, as well as international, regional and national courts, have increasingly focused on the human rights of mothers and children. The Universal Declaration of Human Rights states that “motherhood and childhood are entitled to special care and assistance”. The Declaration of the Rights of the Child. The Convention on the Elimination of All Forms of Discrimination Against Women enjoins States parties to ensure appropriate maternal health services. At the United Nations World Summit on Children governments declare their “joint commitment ... to give every child a better future”, and recognize the link between women’s rights and children’s well-being. The United Nations Human Rights Committee expresses concern over high rates of maternal mortality. The United Nations United Nations Human Rights Committee rules that, when abortion gives rise to a criminal penalty even if a woman is pregnant as a result of rape, a woman’s right to be free from inhuman and degrading treatment might be violated. The United Nations Committee on the Rights of the Child states that adolescent girls should have access to information on the impact of early marriage and early pregnancy and have access to health services sensitive to their needs and rights. The United Nations Committee on the Rights of the Child adopts its General Comment on HIV/AIDS and that on the Rights of the Child. The United Nations Committee Against Torture calls for an end to the extraction of confessions for prosecution purposes from women seeking emergency medical care as a result of illegal abortion. The United Nations Special Rapporteur on the Right to Health reports that all forms of sexual violence are inconsistent with the right to health. The General Conference of the International Labour Organization adopts the Maternity Protection Convention. The International Covenant on Economic, Social and Cultural Rights recognizes the right to the highest attainable standard of physical and mental health. The Convention on the Rights of the Child guarantees children’s right to health. States commit themselves to ensuring appropriate maternal health services. The United Nations International Conference on Population and Development and the United Nations Fourth World Conference on Women affirm women’s right of access to appropriate health care services in pregnancy and childbirth. The United Nations Committee on Economic, Social and Cultural Rights states that measures are required to “improve child and maternal health, sexual and reproductive health services”. The United Nations Commission on Human Rights, states that sexual and reproductive health are integral elements of the right to health. The United Nations Sub-Commission on the Promotion and Protection of Human Rights adopts a resolution on “harmful traditional practices affecting the health of women and the girl child”. 1948 1952 1959 1966 1981 1990 1993 1996 1994 2000 1995 2003 2003 2004 2004 1989
6 The World Health Report 2005 1994. The conference produced a 20-year plan of action that focused on universal access to reproductive health services(of which maternal and child health care be came a subset), which was grounded in individual choices and rights. This change in perspective is important, because it alters the rationale for investing in the health of mothers and children Today, more is known than ever before about what determines the health of women and children and about which interventions bring about improvements most cost effectively. This knowledge makes investment more successful, and withholding care even less acceptable. The health of mothers and children satisfies the classical criteria for setting public health priorities(see Box 1.2). Compelling as these arguments may be, however, they miss two vital points Box 1.2 Why invest public money in health care for mothers and children? Modern states guarantee health birth-weight children in turn are at greater risk maternal and child health interventions can be or mothers, newborns and children of dying and of suffering from infections and classified as private goods, a comprehensive grounded in human rights convention growth retardation(25), have lower scores programme also includes components such as ing them access to care has become on cognitive tests(26-28)and may be at information on contraception, on sexual health and political imperative, which also has a higher risk of developing chronic diseases in and rights, on breastfeeding and child care, that rong rational basis. are obvious public goods. Moreover, the rule of From a public health point of view a Healthy children are at the core of the rescue, which gives priority to interventions important criterion for priority setting and formation of human capital. Child illnesses that save lives, applies to many maternal and public funding is that cost-effective intervention and malnutrition reduce cognitive development child health interventions ckages exist Such packages are well and intellectual performance (31-33), school Finally, public funding for maternal and documented in the case of matemal and child enrolment and attendance (34, 35), which child health stified on grounds health(14, 15). But cost-effectiveness is only impairs final educational achievement. equity Motherhood and childhood are periods one of the criteria for public investment. Others Intrauterine growth retardation and malnutri- of particularly high vulnerability that require commonly used include: the generation of tion during early childhood have long-term special care and assistance"(19); they are sitive extemalities; the production of public effects on body size and strength(36, 37) with also periods of high vulnerability because oods and the rule of rescue; and the potential for productivity in adul women and children are more likely to be poor expenditure (16). Any of these criteria can be woman, society loses a member whose labour that they are overrepresented among the poor a sufficient condition for public investment on and activities are essential to the life and is scarce (46). women are more likely to be ten. l nen chore heant ie is westin she montershat a more me cnomaremors Heathly toemuplatyen to as owes ad es, r Ss acts. case for public funding is even stronger. for the social interaction and the creation of the decision-making power, all of which limit their Health care for mothers and children bonds that are the prerequisite of social capital. access to care. Public investment in maternal produces obvious positive externalities through They also play an important social role in caring and child health care is justified in order t accination or the treatment of the infectious for those who are ill diseases of childhood, and through the im- The economic costs of poor maternal and e women proved child health that follows improveme ild health are high (38), substantial savings represent a large proportion of the poor, of maternal health. There has been little in future expenditure are likely through family subsidizing health services for them can be systematic research on the human, social and planning programmes (39, 40) and interventions an effective strategy for income redistribution conomic capital generated by improving the that improve maternal and child health in the and poverty alleviation(14 ) Ill-health among health of mothers and children, but the negative long term. Consequent gains in human and mothers and children, and particularly the externalities of ill-health are clear ocial capital translate into long-term economic occurrence of major obstetric problems The health of mothers is a major determinant benefits (41). There is evidence of economic is largely unpredictable and can lead to of that of their children, and thus indirectly returns on investment in immunization (42), catastrophic expenditures(47)that may push affects the formation of human capital. nutrition programmes (41, 43), interventions households into poverty. The risk of catastrophic Motherless children die more frequently, are to reduce low birth weight ( 36), and integrated expenditures is often a deterrent for the timel more at risk of becoming malnourished and health and social development programmes uptake of care-a major argument, technically less likely to enrol at school(17, 18). The babies (44, 45) and politically, for public investmen f ill or undernourished pregnant women are Maternal and child health programmes ar more likely to have a low birth weight(19-21) also prime candidates for public funding because and impaired development(19, 22-24). Low- they produce public goods. Although many
6 The World Health Report 2005 1994. The conference produced a 20-year plan of action that focused on universal access to reproductive health services (of which maternal and child health care became a subset), which was grounded in individual choices and rights. This change in perspective is important, because it alters the rationale for investing in the health of mothers and children. Today, more is known than ever before about what determines the health of women and children and about which interventions bring about improvements most costeffectively. This knowledge makes investment more successful, and withholding care even less acceptable. The health of mothers and children satisfies the classical criteria for setting public health priorities (see Box 1.2). Compelling as these arguments may be, however, they miss two vital points. birth-weight children in turn are at greater risk of dying and of suffering from infections and growth retardation(25), have lower scores on cognitive tests (26–28) and may be at higher risk of developing chronic diseases in adulthood(29, 30 ). Healthy children are at the core of the formation of human capital. Child illnesses and malnutrition reduce cognitive development and intellectual performance(31–33), school enrolment and attendance(34, 35), which impairs final educational achievement. Intrauterine growth retardation and malnutrition during early childhood have long-term effects on body size and strength(36, 37) with implications for productivity in adulthood. In addition, with the death or illness of a woman, society loses a member whose labour and activities are essential to the life and cohesion of families and communities. Healthy mothers have more time and are more available for the social interaction and the creation of the bonds that are the prerequisite of social capital. They also play an important social role in caring for those who are ill. The economic costs of poor maternal and child health are high (38); substantial savings in future expenditure are likely through family planning programmes (39, 40) and interventions that improve maternal and child health in the long term. Consequent gains in human and social capital translate into long-term economic benefits (41). There is evidence of economic returns on investment in immunization (42), nutrition programmes (41, 43), interventions to reduce low birth weight (36), and integrated health and social development programmes (44, 45). Maternal and child health programmes are also prime candidates for public funding because they produce public goods. Although many Modern states guarantee health entitlements for mothers, newborns and children that are grounded in human rights conventions. Ensuring them access to care has become a moral and political imperative, which also has a strong rational basis. From a public health point of view an important criterion for priority setting and public funding is that cost-effective intervention packages exist. Such packages are well documented in the case of maternal and child health (14, 15). But cost-effectiveness is only one of the criteria for public investment. Others commonly used include: the generation of positive externalities; the production of public goods and the rule of rescue; and the potential to increase equity and avoid catastrophic expenditure (16). Any of these criteria can be a sufficient condition for public investment on its own. When more than one is present, as in maternal and child health interventions, the case for public funding is even stronger. Health care for mothers and children produces obvious positive externalities through vaccination or the treatment of the infectious diseases of childhood, and through the improved child health that follows improvement of maternal health. There has been little systematic research on the human, social and economic capital generated by improving the health of mothers and children, but the negative externalities of ill-health are clear. The health of mothers is a major determinant of that of their children, and thus indirectly affects the formation of human capital. Motherless children die more frequently, are more at risk of becoming malnourished and less likely to enrol at school(17, 18). The babies of ill or undernourished pregnant women are more likely to have a low birth weight(19–21) and impaired development(19, 22–24). Lowmaternal and child health interventions can be classified as private goods, a comprehensive programme also includes components such as information on contraception, on sexual health and rights, on breastfeeding and child care, that are obvious public goods. Moreover, the rule of rescue, which gives priority to interventions that save lives, applies to many maternal and child health interventions. Finally, public funding for maternal and child health care is justified on grounds of equity. Motherhood and childhood are periods of particularly high vulnerability that require “special care and assistance” (19); they are also periods of high vulnerability because women and children are more likely to be poor. Although systematic documentation showing that they are overrepresented among the poor is scarce (46), women are more likely to be unemployed, to have lower wages, less access to education and resources and more restricted decision-making power, all of which limit their access to care. Public investment in maternal and child health care is justified in order to correct these inequities. In addition, where women and children represent a large proportion of the poor, subsidizing health services for them can be an effective strategy for income redistribution and poverty alleviation (14). Ill-health among mothers and children, and particularly the occurrence of major obstetric problems, is largely unpredictable and can lead to catastrophic expenditures (47) that may push households into poverty. The risk of catastrophic expenditures is often a deterrent for the timely uptake of care – a major argument, technically and politically, for public investment. Box 1.2 Why invest public money in health care for mothers and children?