PHM-Exch> [PHMNEWS] New data show shocking disease burden in maternal and child health and extreme inequalities in the distribution of that burden

[Claudio Schuftan]

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From: David <dlegge at phmovement.org>
Date: Sat, Jan 20, 2024 at 9:34 AM

And extreme inequalities in the distribution of that burden

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New data show shocking disease burden in maternal and child health and
extreme inequalities in the distribution of that burden

A new report (EB154/12
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=7edab7442d&e=ade41a541f>)
to be considered by WHO’s Executive Board meeting in Geneva next week
paints a very distressing picture of maternal and child health; the
absolute disease burden and the wide inequalities in the distribution of
this disease burden. The analysis of current trends (paras 2 - 12) is very
clear and should be circulated widely.

The report approaches causation in two ways: first, a review of the reach
of key service interventions (clinical and preventive) necessary for
maternal and child health; and second, a more general exploration of
obstacles to achieving the maternal and child mortality targets.

The report documents large shortfalls in the delivery of key interventions
for maternal and child health as well as wide inequalities within and
between countries. While equity comparisons are presented for the coverage
of interventions, similar data are not shown for outcomes. These would show
wide disparities between top and bottom income quintiles for morbidity and
mortality. Among the shortfalls, sexual and reproductive health services
stand out (including free safe abortion for girls and adolescents). Breast
feeding (early initiation and exclusive for six months) is also cited as
one of the largest gaps.

In its exploration of obstacles to maternal and child health (paras 18-23)
the report lists health system weaknesses as well as wider socio-economic
barriers.

In terms of health system weaknesses the report cites: community awareness,
out of pocket payment as a barrier to access, distance and travel barriers,
access to quality medicines, equipment and commodities, and the shortage of
a competent health and care workforce.

The report’s discussion of workforce shortages is particularly useful,
citing in particular the under-use and under-supply of community health
workers and midwives. The report falls short in not calling for full
recognition of community health workers as regular workers to be properly
remunerated and provided with social security accordingly.

The report also highlights shortfalls with respect to quality of care. This
should explicitly include disrespectful care which is a major issue.
Quality of care is not just a technical issue involving skills, resources
and governance. It is also a question of patients’ rights which need to be
respected, promoted and protected throughout the care process.

The report acknowledges growing evidence that persistent inequities in
socioeconomic development contribute significantly to poor maternal health.
This underlines the need for disaggregated data and the use of such data in
program development. The report also notes ‘a growing body of knowledge’
linking climate change to adverse maternal and child health outcomes; not
just heat and air pollution but others such as floods and landslides and
other extreme weather events leading to food insecurity, displacement and
migration..
Secondary health system capacity The report emphasises comprehensive
primary health care and the need for more community health workers and
midwives. However, it is also necessary to highlight the importance of
referral support and outreach from the secondary level of the health
system. This secondary capacity, eg comprehensive obstetric and newborn
care facilities in district hospitals) is necessary to ensure that primary
care practitioners can fulfill their potential.

Secondary support capacity includes emergency care, surgery, blood,
anaesthesia and continuing technical support. This demands integrated
comprehensive capacity; not the narrow range of skills and facilities
defined by vertical intervention programs. It also requires inter-facility
transport as well as transport from home to care.

Improved health system leadership and governance at regional, district and
facility levels are critical. This includes understanding the health needs
of the populations being served and service availability within its
catchment area. Community awareness The report makes a vague reference to
“limited awareness of the needs and available care” but with no
elaboration. The context suggests that in some settings, families and
communities are unaware of the risks of pregnancy and early childhood or of
the efficacy of available clinical and preventive interventions. Perhaps
‘awareness’ does not wholly capture the range of constraints on the full
utilisation of such services. In many cases communities are aware of risks
and needs but face steep access barriers. The same may apply, in some
settings, to food distribution in the household and community.

The emphasis on the need for community health workers and midwives
elsewhere in the paper is a necessary part of any response to the problems
of ‘limited awareness’. However, it would also be appropriate to look
towards strengthening the understanding and sensitivity of health system
managers and policy makers regarding knowledge of, and demand for, services
and resources. Privatisation and marketisation In its discussion of health
system obstacles, the report makes no mention of the pressures to privatise
health care delivery and marketise health insurance (common consequences of
‘universal health coverage’ policies).

Promoting quality of care, efficiency of resource use, more equitable
distribution of resources and the development of comprehensive primary
health care requires a strong regulatory framework and publicly accountable
single payer financing.

Privatisation reduces the reach of clinical governance and the promotion of
quality of care. Privatisation and marketisation weakens the policy
leverage available to ministries of health for efficient resource use and
equitable distribution of resources.  Competitive marketised health
insurance is too often associated with stratified levels of health cover
ranging from generous to minimal (with heavy out of pocket costs for those
on very basic plans).

WHO has been too cautious in terms of critiquing the campaign for the
privatisation of health care, driven in particular by the World Bank and
the Rockefeller Foundation. Privatisation of health care and health care
financing is also driven by the IMF and international finance markets
through their demands for fiscal austerity. Fiscal austerity is also a
consequence of tax avoidance and the conditionalities of foreign investment.

PHM urges WHO to rework EB154/12, before it is presented to the Health
Assembly May, in order to give proper attention to the development of
strong publicly funded and administered health systems and to the wider
macroeconomic context to be addressed as a condition for health system
strengthening. Climate change  EB154/12 mentions climate change as an
obstacle to achieving maternal and child health targets. However, it is
perplexing that the report only mentions heat stress, infectious disease
and air pollution as mediators, overlooking issues such as the nexus with
food security and displacement and migration.

PHM urges EB members to also highlight floods, drought, displacement, and
conflict in the next iteration of this paper. In view of the continuing
resistance to curbing fossil fuel use, evident in particular at COP28, WHO
must continue to contribute to building the case for effective action for
mitigation and adaptation. Inequalities and discrimination The report
acknowledges persistent inequities in socioeconomic development which
contribute to poor maternal and child health. However, there is no
elaboration on the underlying obstacles to development. There is no mention
of unsustainable debt, the imposition of austerity, and the role of trade
liberalisation in driving unemployment, underemployment, and precarious
employment. Gender-based violence and discrimination need to be recognised
as a paramount priority.

Migration, conflict and war are major obstacles to achieving the SDGs
generally, including better health outcomes of mothers, newborns and
children. Such disruptions have got worse since 2020 and remain an
ever-increasing public health disaster. The ongoing conflict in Gaza is
having a huge impact on everyone, including pregnant women and children.

Obstetric violence should be highlighted because this is a factor linked to
maternal morbidity and mortality, not only because of inadequate care, but
also because it prevents women from searching for appropriate and timely
care because of fear of being mistreated. This of course is subject to
variation by race and social class.  Malnutrition It is unfortunate that
maternal anaemia is not mentioned in the report. This is both a reflection
of health system weaknesses and of inequality and discrimination. Anaemia
is a major factor in determining maternal and infant health outcomes.
Anaemia among adolescent girls, including failure to address adolescent
health needs such as heavy menstrual bleeding, is commonly followed by
anaemia in pregnancy.

The report mentions the continuing prevalence of stunting in under-fives,
particularly in South Asia and Africa. Stunting is an indirect indicator of
levels of poverty and reflects food insecurity which in turn is shaped by
the intersections of economic inequality, inequitable trade agreements and
the corporate control of agricultural value chains, as well as climate
change.

Malnutrition is an underlying condition for up to 50% of all child
mortality. If WHO is serious about the social (including commercial)
determinants of health or the ‘economics of health for all’ these
underlying obstacles must be explicitly identified and addressed. Civil
society

Completely missing from this report is any recognition of the agency of
civil society in promoting maternal and child health, including through
challenging community assumptions, demanding health policy changes and
holding institutions to account. Measures such as social audits of services
illustrate the potential contribution of community participation.

As a member state organisation WHO has been too cautious about recognising
the potential contribution of civil society, including social movements, in
the struggle for Health for All. PHM calls upon the Secretariat to provide
more leadership researching and documenting the potential roles of civil
society and building relationships with civil society at the country and
community levels.

The full PHM commentary on this item
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=28e836fbdd&e=ade41a541f>
provides
more detail and references.
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