《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2005_Make every mother and child count_Overview

overview The World Health Report 2005 Make every mother and child count 徐 World Health Organization

Make every mother and child count The World Health Report 2005 World Health Organization overview

eworld Health Org 20AeA12116622t由n(e:+41271276:x+41223 ress, World Heat mmercial distribution should be addressed to WHO Press, at the above address(fax: +41 22 791 4806: e-mail: permissions @who int The designations employed and the presentation of the material in this publication do not imply the expression of any opinion oncerning the legal status of any country, territory, city or area ng the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. taken by wHo to verify the information contained in this pu terial is being distributed without warranty of any kind pretation and use of the material lies with the reader. In no event e world Health Organization be liable for dam- es arising from its use. concerning this publication can be obtained fro E-mail: whr@who int Copies of this publication and the full report can be ordered from: bookorders @who int The full report was produced under the overall direction of Joy Phumaphi(Assistant Director-General, Family and Child Health), Tim Evans(Assistant Director-General, Evidence and Information for Policy)and Wim Van Lerberghe(Editor-in-Chief). The principal authors were Wim Van Lerberghe, Annick Manuel, Zoe Matthews and Cathy Wolfheim. Thomson Prentice was the Managing Editor Valuable inputs(contributions, background papers, analytical work, reviewing, suggestions and criticism) were received from Elisabeth Aahman, Carla Abou-Zahr, Fifi es Boerma, Jo borghi, Paul Bossyns, Assia Brandrup-LukanoN, Eric Buch, Flavia Bustreo, Meena Cabral de Mello, Virginia Camacho, Guy Carrin, Andrew Cas thryn Church, Alessandro Colombo, Jane Cottingham, Bernadette Daelmans, Mario Dal Poz, Catherine dArcangues, Hugh Darrah, Luc de Bernis, Isabelle de Zoys Peggy hi ossein, Guy Hutton, Mie Inoue, Monir Islam, Christopher James, Craig Janes, Ben Johns, Rita Kabra, Betty Kirkwood, Lianne Kuppens, Joy Lawn, Jerker Liljestrand, Ornella Lincetto, Craig Lissner, Alessandro Loretti, Jane Lucas, Doris Ma Fat, Carolyn Maclennan, Ramez Mahaini, Sudhansh Malhostra, Mason, Matthews Mathai, Dileep Mavalankar, Gillian Mayers, Juliet McEachren, Abdelhai Mechbal, Mario Merialdi, Tom Merrick, Thierry Mertens, Susan Murray, Adepeju usa, Niko Speybroeck, Karin Stenberg, Will Stones, Tessa Tan-Torres Edejer, Petra Ten Hoope-Bender, Ann Tinker, Wim Van Damme, elaer. Paul Van Loo Marcel Vekemans, Cesar Victora, Eugenio Villar Montesinos, Yasmin Von Schirnding, Eva Wallstam, Steve Wiersma, Karl Wilhelmsen, Lara Wolfson, Juliana Yartey and an, Zulfiqar Bhuti nifer Bryce, Agne s, Trevor Croft, David D Vans, Charu C. Garg, Kim Gustavsen, Nasim Haque, Patricia Hernandez, Ken hill Kirkwood, Joseph Kutzin, Joy Lawn, Eduardo Levcovitz, Dilbert ason, Colin Mathers, Saul Morris, Kim Mulholland, Takondwa Mwase, Bemard Nahlen, Pamela Nal omme. Rachel Racelis olvier ronvear Alex Rowe, Hossein Salehi, lan Scott, U Than Sein, Kenji shibuya, Rick Steketee, Ruben Suarez, Tessa Tan- Torres Edej alie van de Maele. Tessa Wardlaw. Neff Walker, Hongyi Xu, Jelka Zupan, and many staff in WHO country offices, govemmental departments and agencies and Valuable comments and guidance were provided by Denis Aitken and Michel Jancloes. Additional help and advice were kindly provided by Regional Directors and members of their staff full report assisted by Barbara Campanini. Editorial, administrative and on support was provided by Shelagh Probst and Gary ated the photographs. The web site version and other electronic media were provided by gael Kemen Proofreading was by Marie Fitzsimmons. graphs(clockwise from top left): L Gubb/WHO; Pepito Frias/wHO; Armando Waak/WHO/PAHO; Carlos Gaggero/wHO/PAHO Liba Taylor/WHO; Pierre HO Back cover photographs (left to right): Pierre Virot/wHO; J. Gorstein/WHO; G. Diez/wHO; Pierre Virot/wHO. This report contains several photographs from sign: Reda Sadki hoto retouching: Reda Sadki and Denis Meissner Printing coordination: Keith Wynn

ii The World Health Report 2005 Design: Reda Sadki Layout: Steve Ewart and Reda Sadki Figures: Christophe Grangier Photo retouching: Reda Sadki and Denis Meissner Printing coordination: Keith Wynn Printed in France © World Health Organization 2005 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; e-mail: bookorders@who. int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for dam￾ages arising from its use. Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland E-mail: whr@who.int Copies of this publication and the full report can be ordered from: bookorders@who.int The full report was produced under the overall direction of Joy Phumaphi (Assistant Director-General, Family and Child Health), Tim Evans (Assistant Director-General, Evidence and Information for Policy) and Wim Van Lerberghe (Editor-in-Chief). The principal authors were Wim Van Lerberghe, Annick Manuel, Zoë Matthews and Cathy Wolfheim. Thomson Prentice was the Managing Editor. Valuable inputs (contributions, background papers, analytical work, reviewing, suggestions and criticism) were received from Elisabeth Aahman, Carla Abou-Zahr, Fiifi Amoako Johnson, Fred Arnold, Alberta Bacci, Rajiv Bahl, Rebecca Bailey, Robert Beaglehole, Rafael Bengoa, Janie Benson, Yves Bergevin, Stan Bernstein, Julian Bilous, Ties Boerma, Jo Borghi, Paul Bossyns, Assia Brandrup-Lukanov, Eric Buch, Flavia Bustreo, Meena Cabral de Mello, Virginia Camacho, Guy Carrin, Andrew Cassels, Kathryn Church, Alessandro Colombo, Jane Cottingham, Bernadette Daelmans, Mario Dal Poz, Catherine d’Arcangues, Hugh Darrah, Luc de Bernis, Isabelle de Zoysa, Maria Del Carmen, Carmen Dolea, Gilles Dussault, Steve Ebener, Dominique Egger, Gerry Eijkemans, Bjorn Ekman, Zine Elmorjani, Tim Ensor, Marthe Sylvie Essengue, David Evans, Vincent Fauveau, Paulo Ferrinho, Helga Fogstad, Marta Gacic Dobo, Ulf Gerdham, Adrienne Germain, Peter Ghys, Elizabeth Goodburn, Veloshnee Govender, Metin Gulmezoglu, Jean-Pierre Habicht, Sarah Hall, Laurence Haller, Steve Harvey, Peggy Henderson, Patricia Hernández, Peter Hill, Dale Huntington, Julia Hussein, Guy Hutton, Mie Inoue, Monir Islam, Christopher James, Craig Janes, Ben Johns, Rita Kabra, Betty Kirkwood, Lianne Kuppens, Joy Lawn, Jerker Liljestrand, Ornella Lincetto, Craig Lissner, Alessandro Loretti, Jane Lucas, Doris Ma Fat, Carolyn Maclennan, Ramez Mahaini, Sudhansh Malhostra, Adriane Martin Hilber, José Martines, Elizabeth Mason, Matthews Mathai, Dileep Mavalankar, Gillian Mayers, Juliet McEachren, Abdelhai Mechbal, Mario Merialdi, Tom Merrick, Thierry Mertens, Susan Murray, Adepeju Olukoya, Guillermo Paraje, Justin Parkhurst, Amit Patel, Vikram Patel, Steve Pearson, Gretel Pelto, Jean Perrot, Annie Portela, Dheepa Rajan, K.V. Ramani, Esther Ratsma, Linda Richter, David Sanders, Parvathy Sankar, Robert Scherpbier, Peelam Sekhri, Gita Sen, Iqbal Shah, Della Sherratt, Kenji Shibuya, Kristjana Sigurbjornsdottir, Angelica Sousa, Niko Speybroeck, Karin Stenberg, Will Stones, Tessa Tan-Torres Edejer, Petra Ten Hoope-Bender, Ann Tinker, Wim Van Damme, Jos Vandelaer, Paul Van Look, Marcel Vekemans, Cesar Victora, Eugenio Villar Montesinos, Yasmin Von Schirnding, Eva Wallstam, Steve Wiersma, Karl Wilhelmson, Lara Wolfson, Juliana Yartey and Jelka Zupan. Contributers to statistical tables were: Elisabeth Aahman, Dorjsuren Bayarsaikhan, Ana Betran, Zulfiqar Bhutta, Maureen Birmingham, Robert Black, Ties Boerma, Cynthia Boschi-Pinto, Jennifer Bryce, Agnes Couffinhal, Simon Cousens, Trevor Croft, David D. Vans, Charu C. Garg, Kim Gustavsen, Nasim Haque, Patricia Hernández, Ken Hill, Chandika Indikadahena, Mie Inoue, Gareth Jones, Betty Kirkwood, Joseph Kutzin, Joy Lawn, Eduardo Levcovitz, Edilberto Loaiza, Doris Ma Fat, José Martines, Elizabeth Mason, Colin Mathers, Saul Morris, Kim Mulholland, Takondwa Mwase, Bernard Nahlen, Pamela Nakamba-Kabaso, Agnès Prudhomme, Rachel Racelis, Olivier Ronveaux, Alex Rowe, Hossein Salehi, Ian Scott, U Than Sein, Kenji Shibuya, Rick Steketee, Rubén Suarez, Tessa Tan-Torres Edejer, Nathalie van de Maele, Tessa Wardlaw, Neff Walker, Hongyi Xu, Jelka Zupan, and many staff in WHO country offices, governmental departments and agencies and international institutions. Valuable comments and guidance were provided by Denis Aitken and Michel Jancloes. Additional help and advice were kindly provided by Regional Directors and members of their staff. The full report was edited by Leo Vita-Finzi, assisted by Barbara Campanini. Editorial, administrative and production support was provided by Shelagh Probst and Gary Walker, who also coordinated the photographs. The web site version and other electronic media were provided by Gael Kernen. Proofreading was by Marie Fitzsimmons. The index was prepared by Kathleen Lyle. Front cover photographs (clockwise from top left): L. Gubb/WHO; Pepito Frias/WHO; Armando Waak/WHO/PAHO; Carlos Gaggero/WHO/PAHO; Liba Taylor/WHO; Pierre Virot/WHO. Back cover photographs (left to right): Pierre Virot/WHO; J. Gorstein/WHO; G. Diez/WHO; Pierre Virot/WHO. This report contains several photographs from “River of Life 2004” – a WHO photo competition on the theme of sexual and reproductive health

message from the director-general Parenthood brings with it the strong desire to see our children grow up happily and in good health. This is one of the few constants in life in all parts of the world. Yet, even in the 21st century, we still allow well over 10 million children and half a million moth ers to die each year, although most of these deaths can be avoided. Seventy million mothers and their newbon babies as well as countless children are excluded from the health care to which they are entitled. Even more numerous are those who remain without protection against the poverty that ill-health can cause Leaders readily agree that we cannot allow this to continue, but in many countries the situation is either improving too slowly or not improving at all, and in some it is getting worse. Mothers, the newborn and children represent the well-being of a society and its potential for the future. Their health needs cannot be left unmet without harming the whole of society Families and communities themselves can do a great deal to change this situation. They can improve, for example, the position of women in society, parenting, disease prevention, care for the sick, and uptake of services. But this area of health is also a public responsibility Public health programmes need to work together so that all families have access to a continuum of care that extends from pregnancy(and even before), through childbirth and on into childhood, instead of the often fragmented services available at present. It makes no sense to provide care for a child while ignoring the mother's health, or to assist a mother giving birth but not the newbom child To ensure that all families have access to care, governments must accelerate the building up of coherent, integrated and effective health systems. This means tackling the health workforce crisis, which in turn calls for a much higher level of funding and better organization of it for these aspects of health. the objective must be health sys- tems that can respond to these needs, eliminate financial barriers to care, and protect people from the poverty that is both a cause and an effect of ill-health he world needs to support countries striving to achieve universal access and finan- cial protection for all mothers and children. Only by doing so can we make sure that every mother, newborn baby and child in need of care can obtain it, and no one is driven into poverty by the cost of that care. In this way we can move not only towards the Millennium Development Goals but beyond them Director-General World Health Organization Geneva, April 2005

overview 1 Parenthood brings with it the strong desire to see our children grow up happily and in good health. This is one of the few constants in life in all parts of the world. Yet, even in the 21st century, we still allow well over 10 million children and half a million moth￾ers to die each year, although most of these deaths can be avoided. Seventy million mothers and their newborn babies, as well as countless children, are excluded from the health care to which they are entitled. Even more numerous are those who remain without protection against the poverty that ill-health can cause. Leaders readily agree that we cannot allow this to continue, but in many countries the situation is either improving too slowly or not improving at all, and in some it is getting worse. Mothers, the newborn and children represent the well-being of a society and its potential for the future. Their health needs cannot be left unmet without harming the whole of society. Families and communities themselves can do a great deal to change this situation. They can improve, for example, the position of women in society, parenting, disease prevention, care for the sick, and uptake of services. But this area of health is also a public responsibility. Public health programmes need to work together so that all families have access to a continuum of care that extends from pregnancy (and even before), through childbirth and on into childhood, instead of the often fragmented services available at present. It makes no sense to provide care for a child while ignoring the mother’s health, or to assist a mother giving birth but not the newborn child. To ensure that all families have access to care, governments must accelerate the building up of coherent, integrated and effective health systems. This means tackling the health workforce crisis, which in turn calls for a much higher level of funding and better organization of it for these aspects of health. The objective must be health sys￾tems that can respond to these needs, eliminate financial barriers to care, and protect people from the poverty that is both a cause and an effect of ill-health. The world needs to support countries striving to achieve universal access and finan￾cial protection for all mothers and children. Only by doing so can we make sure that every mother, newborn baby and child in need of care can obtain it, and no one is driven into poverty by the cost of that care. In this way we can move not only towards the Millennium Development Goals but beyond them. message from the director-general LEE Jong-wook Director-General World Health Organization Geneva, April 2005

Were This year's World Health Report comes at a time when only a decade is left to achieve the Millennium Development Goals(MDGs), which set internationally agreed devel- opment aspirations for the world's population to be met by 2015. These goals have underlined the importance of improving health, and particularly the health of mothers and children, as an integral part of poverty reduction The health of mothers and children is a priority that emerged long before the 1990s it builds on a century of programmes, activities and experience. What is new in the last decade, however, is the global focus of the MDGs and their insistence on tracking progress in every part of the world. Moreover, the nature of the priority status of ma- ternal and child health(MCH)has changed over time. Whereas mothers and children were previously thought of as targets for well-intentioned programmes, they now increasingly claim the right to access quality care as an entitlement guaranteed by the state. In doing so, they have transformed maternal and child health from a technical concern into a moral and political imperative. This report identifies exclusion as a key feature of inequity as well as a key constraint to progress. In many countries, universal access to the care all women and children are entitled to is still far from realization. Taking stock of the erratic progress to date the report sets out the strategies required for the accelerated improvements that are known to be possible. It is necessary to refocus the technical strategies developed within maternal and child health programmes, and also to put more emphasis on the importance of the often overlooked health problems of newborns. In this regard, the report advocates the repositioning of MCH as MNCH(maternal, newbom and child proper technical strategies to improve MNCH can be put in place effectively they are implemented, across programmes and service providers, throughout pregnancy and childbirth through to childhood. It makes no sense to provide care for a child and ignore the mother, or to worry about a mother giving birth and fail to pay attention to the health of the baby. To provide families universal access to such a continuum of care requires programmes to work together, but is ultimately dependent on extending and strengthening health systems. At the same time, placing MNCH at the core of the drive for universal access provides a platform for building sustainable health systems where existing structures are weak or fragile. Even where the MDGs will not be fully achieved by 2015, moving towards universal access has the potential to transform the lives of millions for decades to come

overview 3 overview This year’s World Health Report comes at a time when only a decade is left to achieve the Millennium Development Goals (MDGs), which set internationally agreed devel￾opment aspirations for the world’s population to be met by 2015. These goals have underlined the importance of improving health, and particularly the health of mothers and children, as an integral part of poverty reduction. The health of mothers and children is a priority that emerged long before the 1990s – it builds on a century of programmes, activities and experience. What is new in the last decade, however, is the global focus of the MDGs and their insistence on tracking progress in every part of the world. Moreover, the nature of the priority status of ma￾ternal and child health (MCH) has changed over time. Whereas mothers and children were previously thought of as targets for well-intentioned programmes, they now increasingly claim the right to access quality care as an entitlement guaranteed by the state. In doing so, they have transformed maternal and child health from a technical concern into a moral and political imperative. This report identifies exclusion as a key feature of inequity as well as a key constraint to progress. In many countries, universal access to the care all women and children are entitled to is still far from realization. Taking stock of the erratic progress to date, the report sets out the strategies required for the accelerated improvements that are known to be possible. It is necessary to refocus the technical strategies developed within maternal and child health programmes, and also to put more emphasis on the importance of the often overlooked health problems of newborns. In this regard, the report advocates the repositioning of MCH as MNCH (maternal, newborn and child health). The proper technical strategies to improve MNCH can be put in place effectively only if they are implemented, across programmes and service providers, throughout pregnancy and childbirth through to childhood. It makes no sense to provide care for a child and ignore the mother, or to worry about a mother giving birth and fail to pay attention to the health of the baby. To provide families universal access to such a continuum of care requires programmes to work together, but is ultimately dependent on extending and strengthening health systems. At the same time, placing MNCH at the core of the drive for universal access provides a platform for building sustainable health systems where existing structures are weak or fragile. Even where the MDGs will not be fully achieved by 2015, moving towards universal access has the potential to transform the lives of millions for decades to come

4 The World Health Report 2005 PATCHY PROGRESS AND WIDENING GAPS WHAT WENT WRONG? Each year 3.3 million babies-or maybe even more-are stillborn, more than 4 million ie within 28 days of coming into the world, and a further 6.6 million young children die before their fifth birthday. Matemal deaths also continue unabated- the annual total now stands at 529 000 often sudden, unpredicted deaths which occur during preg nancy itself (some 68 000 as a consequence of unsafe abortion), during childbirth,or after the baby has been born- leaving behind devastated families, often pushed into poverty because of the cost of health care that came too late or was ineffective How can it be that this situation continues when the causes of these deaths are largely avoidable? And why is it still necessary for this report to emphasize the impor tance of focusing on the health of mothers, newboms and children, after decades of priority status, and more than 10 years after the United Nations International Confer- ence on Population and Development put access to reproductive health care for all firmly on the agenda? Although an increasing number of countries have succeeded in improving the health and well-being of mothers, babies and children in recent years, the countries that started off with the highest burdens of mortality and ill-health made least progress during the 1990s. In some countries the situation has actually worsened, and worry- ing reversals in newborn, child and maternal mortality have taken place. Progress has slowed down and is increasingly uneven, leaving large disparities between countries as well as between the poor and the rich within countries. Unless efforts are stepped up radically, there is little hope of eliminating avoidable maternal and child mortality in all countries Countries where health indicators for mothers, newborns and children have stag nated or reversed have often been unable to invest sufficiently in health systems. The health districts have had difficulties in organizing access to effective care for women and children. Humanitarian crises, pervasive poverty, and the HIv/AIDS epidemic have all compounded the effect of economic downturns and the health workforce crisis With widespread exclusion from care and growing inequalities, progress calls for mas- sively strengthened health systems Technical choices are still important, though, as in the past programmes have not always pursued the best approaches to make good care accessible to all. Too often, programmes have been allowed to fragment, thus hampering the continuity of care, or have failed to give due attention to professionalizing services. Technical experi- ence and the successes and failures of the recent past have shown how best to move forward MAKING THE RIGHT TECHNICAL AND STRATEGIC CHOICES There is no doubt that the technical knowledge exists to respond to many, if not ost, of the critical health problems and hazards that affect the health and survival o systems together can make sure these technical solutions are put into action for all, in the right place and at the right time, are also becoming increasingly clear. Antenatal care is a major success story: demand has increased and continues to increase in most parts of the world. However, more can be made of the considerable potential of antenatal care by emphasizing effective interventions and by using it as a platform for other health programmes such as HIV/AIDS and the prevention and treat ment of sexually transmitted infections, tuberculosis and malaria initiatives, and family

4 The World Health Report 2005 PATCHY PROGRESS AND WIDENING GAPS – WHAT WENT WRONG? Each year 3.3 million babies – or maybe even more – are stillborn, more than 4 million die within 28 days of coming into the world, and a further 6.6 million young children die before their fifth birthday. Maternal deaths also continue unabated – the annual total now stands at 529 000 often sudden, unpredicted deaths which occur during preg￾nancy itself (some 68 000 as a consequence of unsafe abortion), during childbirth, or after the baby has been born – leaving behind devastated families, often pushed into poverty because of the cost of health care that came too late or was ineffective. How can it be that this situation continues when the causes of these deaths are largely avoidable? And why is it still necessary for this report to emphasize the impor￾tance of focusing on the health of mothers, newborns and children, after decades of priority status, and more than 10 years after the United Nations International Confer￾ence on Population and Development put access to reproductive health care for all firmly on the agenda? Although an increasing number of countries have succeeded in improving the health and well-being of mothers, babies and children in recent years, the countries that started off with the highest burdens of mortality and ill-health made least progress during the 1990s. In some countries the situation has actually worsened, and worry￾ing reversals in newborn, child and maternal mortality have taken place. Progress has slowed down and is increasingly uneven, leaving large disparities between countries as well as between the poor and the rich within countries. Unless efforts are stepped up radically, there is little hope of eliminating avoidable maternal and child mortality in all countries. Countries where health indicators for mothers, newborns and children have stag￾nated or reversed have often been unable to invest sufficiently in health systems. The health districts have had difficulties in organizing access to effective care for women and children. Humanitarian crises, pervasive poverty, and the HIV/AIDS epidemic have all compounded the effect of economic downturns and the health workforce crisis. With widespread exclusion from care and growing inequalities, progress calls for mas￾sively strengthened health systems. Technical choices are still important, though, as in the past programmes have not always pursued the best approaches to make good care accessible to all. Too often, programmes have been allowed to fragment, thus hampering the continuity of care, or have failed to give due attention to professionalizing services. Technical experi￾ence and the successes and failures of the recent past have shown how best to move forward. MAKING THE RIGHT TECHNICAL AND STRATEGIC CHOICES There is no doubt that the technical knowledge exists to respond to many, if not most, of the critical health problems and hazards that affect the health and survival of mothers, newborns and children. The strategies through which households and health systems together can make sure these technical solutions are put into action for all, in the right place and at the right time, are also becoming increasingly clear. Antenatal care is a major success story: demand has increased and continues to increase in most parts of the world. However, more can be made of the considerable potential of antenatal care by emphasizing effective interventions and by using it as a platform for other health programmes such as HIV/AIDS and the prevention and treat￾ment of sexually transmitted infections, tuberculosis and malaria initiatives, and family