<div dir="ltr"><div class="gmail_default" style="font-size:large"><br></div><br><div class="gmail_quote"><div dir="ltr" class="gmail_attr">---------- Forwarded message ---------<br>From: <b class="gmail_sendername" dir="auto">David</b> <span dir="auto"><<a href="mailto:dlegge@phmovement.org">dlegge@phmovement.org</a>></span><br>Date: Sat, Jan 20, 2024 at 9:34 AM<br></div><br><div class="msg-7550827780407257269"><u></u>
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<span class="m_-7550827780407257269mcnPreviewText" style="display:none;font-size:0px;line-height:0px;max-height:0px;max-width:0px;opacity:0;overflow:hidden">And extreme inequalities in the distribution of that burden</span>
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<h1 style="text-align:center;display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:26px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal">New data show shocking disease burden in maternal and child health and extreme inequalities in the distribution of that burden </h1>
<p style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">A new report (<a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=7edab7442d&e=ade41a541f" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">EB154/12</a>) 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.<br>
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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. <br>
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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. <br>
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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.<br>
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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.<br>
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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. <br>
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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. <br>
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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.. </p>
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Secondary health system capacity</h2>
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.<br>
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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.<br>
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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.
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Community awareness</h2>
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. <br>
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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.
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Privatisation and marketisation</h2>
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). <br>
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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. <br>
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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). <br>
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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.<br>
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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.
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Climate change </h2>
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. <br>
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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.
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Inequalities and discrimination</h2>
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.<br>
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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. <br>
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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.
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Malnutrition</h2>
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.<br>
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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. <br>
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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.
<h2 style="display:block;margin:0;padding:0;color:#202020;font-family:Helvetica;font-size:22px;font-style:normal;font-weight:bold;line-height:125%;letter-spacing:normal;text-align:left">Civil society</h2>
<p style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">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. <br>
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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. </p>
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<p style="font-family:Tahoma,Verdana,Segoe,sans-serif;font-size:12px;line-height:100%;text-align:left;margin:10px 0;padding:0;color:#202020">The full <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=28e836fbdd&e=ade41a541f" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">PHM commentary on this item</a> provides more detail and references. <br>
The WHO Tracker and the PHM item commentaries are produced as part of WHO Watch which is a project of the <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=36d33f5670&e=ade41a541f" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">People's Health Movement</a> in association with <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=c7c2010881&e=ade41a541f" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Medicus Mundi International</a>, <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=51813dd9fb&e=ade41a541f" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Third World Network</a> and a number of other civil society networks. WHO Watch aims to contribute to democratising global health governance, through new alliances, new information flows and by broadening the policy discourse.<br>
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See the WHO Tracker page for this EB154 session (<a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=00e41c8a0d&e=ade41a541f" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">here</a>). See PHM’s <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=3847bc1646&e=ade41a541f" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">integrated commentary</a> on the full agenda of EB154. To ensure that you receive Update Alerts ensure you are <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=34f11f6e2f&e=ade41a541f" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">subscribed </a>to the Updater. <br>
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You can support WHO Watch by forwarding this Item Alert, publicising the <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=4d68ba9a27&e=ade41a541f" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">Tracker</a>; inviting others to <a href="https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=8cab407273&e=ade41a541f" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">subscribe to the Updater</a>; and by following us on Twitter via @PHMglobal and @WorldHealthWatch. To provide feedback on this newsletter please write to <a href="mailto:editor@phmovement.org" style="color:#007c89;font-weight:normal;text-decoration:underline" target="_blank">editor@phmovement.org</a>.</p>
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