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Programme of Action of the International Conference on Population and Development
Chapter 8 : Health, Morbidity and Mortality
A. Primary health care and the health-care sector
B. Child survival and health
C. Women's health and safe motherhood
D. Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome
(AIDS)
A. Primary health care and the health-care sector
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Basis for action
8.1. One of the main achievements of the twentieth century has been the unprecedented
increase in human longevity. In the past half century, expectation of life at birth in the
world as a whole has increased by about 20 years, and the risk of dying in the first year
of life has been reduced by nearly two thirds. Nevertheless, these achievements fall short
of the much greater improvements that had been anticipated in the World Population Plan of
Action and the Declaration of Alma Ata, adopted by the International Conference on Primary
Health Care in 1978. There remain entire national populations and sizeable population
groups within many countries that are still subject to very high rates of morbidity and
mortality. Differences linked to socio-economic status or ethnicity are often substantial.
In many countries with economies in transition, the mortality rate has considerably
increased as a result of deaths caused by accidents and violence.
8.2. The increases in life expectancy recorded in most regions of the world reflect
significant gains in public health and in access to primary health-care services. Notable
achievements include the vaccination of about 80 per cent of the children in the world and
the widespread use of low-cost treatments, such as oral rehydration therapy, to ensure
that more children survive. Yet these achievements have not been realized in all
countries, and preventable or treatable illnesses are still the leading killers of young
children. Moreover, large segments of many populations continue to lack access to clean
water and sanitation facilities, are forced to live in congested conditions and lack
adequate nutrition. Large numbers of people remain at continued risk of infectious,
parasitic and water-borne diseases, such as tuberculosis, malaria and schistosomiasis. In
addition, the health effects of environmental degradation and exposure to hazardous
substances in the workplace are increasingly a cause of concern in many countries.
Similarly, the growing consumption of tobacco, alcohol and drugs will precipitate a marked
increase in costly chronic diseases among working age and elderly people. The impact of
reductions in expenditures for health and other social services which have taken place in
many countries as a result of public-sector retrenchment, misallocation of available
health resources, structural adjustment and the transition to market economies has
pre-empted significant changes in lifestyles, livelihoods and consumption patterns and is
also a factor in increasing morbidity and mortality. Although economic reforms are
essential to sustained economic growth, it is equally essential that the design and
implementation of structural adjustment programmes incorporate the social dimension.
Objectives
8.3. The objectives are:
(a) To increase the accessibility, availability, acceptability and affordability of
health-care services and facilities to all people in accordance with national commitments
to provide access to basic health care for all;
(b) To increase the healthy life-span and improve the quality of life of all people,
and to reduce disparities in life expectancy between and within countries.
Actions
8.4. All countries should make access to basic health care and health promotion the
central strategies for reducing mortality and morbidity. Sufficient resources should be
assigned so that primary health services attain full coverage of the population.
Governments should strengthen health and nutrition information, education and
communication activities so as to enable people to increase their control over and improve
their health. Governments should provide the necessary backup facilities to meet the
demand created.
8.5. In keeping with the Declaration of Alma Ata, all countries should reduce mortality
and morbidity and seek to make primary health care, including reproductive health care,
available universally by the end of the current decade. Countries should aim to achieve by
2005 a life expectancy at birth greater than 70 years and by 2015 a life expectancy at
birth greater than 75 years. Countries with the highest levels of mortality should aim to
achieve by 2005 a life expectancy at birth greater than 65 years and by 2015 a life
expectancy at birth greater than 70 years. Efforts to ensure a longer and healthier life
for all should emphasize the reduction of morbidity and mortality differentials between
males and females as well as among geographical regions, social classes and indigenous and
ethnic groups.
8.6. The role of women as primary custodians of family health should be recognized and
supported. Access to basic health care, expanded health education, the availability of
simple cost-effective remedies, and the reappraisal of primary health-care services,
including reproductive health-care services to facilitate the proper use of women's time,
should be provided.
8.7. Governments should ensure community participation in health policy planning,
especially with respect to the long-term care of the elderly, those with disabilities and
those infected with HIV and other endemic diseases. Such participation should also be
promoted in child-survival and maternal health programmes, breast-feeding support
programmes, programmes for the early detection and treatment of cancer of the reproductive
system, and programmes for the prevention of HIV infection and other sexually transmitted
diseases.
8.8. All countries should re-examine training curricula and the delegation of
responsibilities within the health-care delivery system in order to reduce frequent,
unnecessary and costly reliance on physicians and on secondary- and tertiary-care
facilities, while maintaining effective referral services. Access to health-care services
for all people and especially for the most underserved and vulnerable groups must be
ensured. Governments should seek to make basic health-care services more sustainable
financially, while ensuring equitable access, by integrating reproductive health services,
including maternal and child health and family-planning services, and by making
appropriate use of community-based services, social marketing and cost-recovery schemes,
with a view to increasing the range and quality of services available. The involvement of
users and the community in the financial management of health-care services should be
promoted.
8.9. Through technology transfer, developing countries should be assisted in building
their capacity to produce generic drugs for the domestic market and to ensure the wide
availability and accessibility of such drugs. To meet the substantial increase in demand
for vaccines, antibiotics and other commodities over the next decade and beyond, the
international community should strengthen global, regional and local mechanisms for the
production, quality control and procurement of those items, where feasible, in developing
countries. The international community should facilitate regional cooperation in the
manufacture, quality control and distribution of vaccines.
8.10. All countries should give priority to measures that improve the quality of life
and health by ensuring a safe and sanitary living environment for all population groups
through measures aimed at avoiding crowded housing conditions, reducing air pollution,
ensuring access to clean water and sanitation, improving waste management, and increasing
the safety of the workplace. Special attention should be given to the living conditions of
the poor and disadvantaged in urban and rural areas. The impact of environmental problems
on health, particularly that of vulnerable groups, should be monitored by Governments on a
regular basis.
8.11. Reform of the health sector and health policy, including the rational allocation
of resources, should be promoted in order to achieve the stated objectives. All
Governments should examine ways to maximize the cost- effectiveness of health programmes
in order to achieve increased life expectancy, reduce morbidity and mortality and ensure
access to basic health- care services for all people.
B. Child survival and health
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Basis for action
8.12. Important progress has been made in reducing infant and child mortality rates
everywhere. Improvements in the survival of children have been the main component of the
overall increase in average life expectancy in the world over the past century, first in
the developed countries and over the past 50 years in the developing countries. The number
of infant deaths (i.e., of children under age 1) per 1,000 live births at the world level
declined from 92 in 1970-1975 to about 62 in 1990-1995. For developed regions, the decline
was from 22 to 12 infant deaths per 1,000 births, and for developing countries from 105 to
69 infant deaths per 1,000 births. Improvements have been slower in sub-Saharan Africa and
in some Asian countries where, during 1990-1995, more than one in every 10 children born
alive will die before their first birthday. The mortality of children under age 5 exhibits
significant variations between and within regions and countries. Indigenous people
generally have higher infant and child mortality rates than the national norm. Poverty,
malnutrition, a decline in breast-feeding, and inadequacy or lack of sanitation and of
health facilities are all factors associated with high infant and child mortality. In some
countries, civil unrest and wars have also had major negative impacts on child survival.
Unwanted births, child neglect and abuse are also factors contributing to the rise in
child mortality. In addition, HIV infection can be transmitted from mother to child before
or during childbirth, and young children whose mothers die are at a very high risk of
dying themselves at a young age.
8.13. The World Summit for Children, held in 1990, adopted a set of goals for children
and development up to the year 2000, including a reduction in infant and under-5 child
mortality rates by one third, or to 50 and 70 per 1,000 live births, respectively,
whichever is less. These goals are based on the accomplishments of child-survival
programmes during the 1980s, which demonstrate not only that effective low-cost
technologies are available but also that they can be delivered efficiently to large
populations. However, the morbidity and mortality reductions achieved through
extraordinary measures in the 1980s are in danger of being eroded if the broad-based
health-delivery systems established during the decade are not institutionalized and
sustained.
8.14. Child survival is closely linked to the timing, spacing and number of births and
to the reproductive health of mothers. Early, late, numerous and closely spaced
pregnancies are major contributors to high infant and child mortality and morbidity rates,
especially where health-care facilities are scarce. Where infant mortality remains high,
couples often have more children than they otherwise would to ensure that a desired number
survive.
Objectives
8.15. The objectives are:
(a) To promote child health and survival and to reduce disparities between and within
developed and developing countries as quickly as possible, with particular attention to
eliminating the pattern of excess and preventable mortality among girl infants and
children;
(b) To improve the health and nutritional status of infants and children;
(c) To promote breast-feeding as a child-survival strategy.
Actions
8.16. Over the next 20 years, through international cooperation and national
programmes, the gap between average infant and child mortality rates in the developed and
the developing regions of the world should be substantially narrowed, and disparities
within countries, those between geographical regions, ethnic or cultural groups, and
socio-economic groups should be eliminated. Countries with indigenous people should
achieve infant and under-5 mortality levels among their indigenous people that are the
same as those of the general population. Countries should strive to reduce their infant
and under-5 mortality rates by one third, or to 50 and 70 per 1,000 live births,
respectively, whichever is less, by the year 2000, with appropriate adaptation to the
particular situation of each country. By 2005, countries with intermediate mortality
levels should aim to achieve an infant mortality rate below 50 deaths per 1,000 and an
under-5 mortality rate below 60 deaths per 1,000 births. By 2015, all countries should aim
to achieve an infant mortality rate below 35 per 1,000 live births and an under-5
mortality rate below 45 per 1,000. Countries that achieve these levels earlier should
strive to lower them further.
8.17. All Governments should assess the underlying causes of high child mortality and
should, within the framework of primary health care, extend integrated reproductive
health-care and child-health services, [including safe motherhood, 21/ child-survival
programmes and family-planning services, to all the population and particularly to the
most vulnerable and underserved groups. Such services should include prenatal care and
counselling, with special emphasis on high-risk pregnancies and the prevention of sexually
transmitted diseases and HIV infection; adequate delivery assistance; and neonatal care,
including exclusive breast-feeding, information on optimal breast-feeding and on proper
weaning practices, and the provision of micronutrient supplementation and tetanus toxoid,
where appropriate. Interventions to reduce the incidence of low birth weight and other
nutritional deficiencies, such as anaemia, should include the promotion of maternal
nutrition through information, education and counselling and the promotion of longer
intervals between births. All countries should give priority to efforts to reduce the
major childhood diseases, particularly infectious and parasitic diseases, and to prevent
malnutrition among children, especially the girl child, through measures aimed at
eradicating poverty and ensuring that all children live in a sanitary environment and by
disseminating information on hygiene and nutrition. It is also important to provide
parents with information and education about child care, including the use of mental and
physical stimulation.
8.18. For infants and children to receive the best nutrition and for specific
protection against a range of diseases, breast-feeding should be protected, promoted and
supported. By means of legal, economic, practical and emotional support, mothers should be
enabled to breast-feed their infants exclusively for four to six months without food or
drink supplementation and to continue breast- feeding infants with appropriate and
adequate complementary food up to the age of two years or beyond. To achieve these goals,
Governments should promote public information on the benefits of breast-feeding; health
personnel should receive training on the management of breast-feeding; and countries
should examine ways and means to implement fully the WHO International Code of Marketing
of Breast Milk Substitutes.
C. Women's health and safe motherhood
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Basis for action
8.19. Complications related to pregnancy and childbirth are among the leading causes of
mortality for women of reproductive age in many parts of the developing world. At the
global level, it has been estimated that about half a million women die each year of
pregnancy-related causes, 99 per cent of them in developing countries. The gap in maternal
mortality between developed and developing regions is wide: in 1988, it ranged from more
than 700 per 100,000 live births in the least developed countries to about 26 per 100,000
live births in the developed regions. Rates of 1,000 or more maternal deaths per 100,000
live births have been reported in several rural areas of Africa, giving women with many
pregnancies a high lifetime risk of death during their reproductive years. According to
the World Health Organization, the lifetime risk of dying from pregnancy or
childbirth-related causes is 1 in 20 in some developing countries, compared to 1 in 10,000
in some developed countries. The age at which women begin or stop child-bearing, the
interval between each birth, the total number of lifetime pregnancies and the
socio-cultural and economic circumstances in which women live all influence maternal
morbidity and mortality. At present, approximately 90 per cent of the countries of the
world, representing 96 per cent of the world population, have policies that permit
abortion under varying legal conditions to save the life of a woman. However, a
significant proportion of the abortions carried out are self-induced or otherwise unsafe,
leading to a large fraction of maternal deaths or to permanent injury to the women
involved. Maternal deaths have very serious consequences within the family, given the
crucial role of the mother for her children's health and welfare. The death of the mother
increases the risk to the survival of her young children, especially if the family is not
able to provide a substitute for the maternal role. Greater attention to the reproductive
health needs of female adolescents and young women could prevent the major share of
maternal morbidity and mortality through prevention of unwanted pregnancies and any
subsequent poorly managed abortion. Safe motherhood has been accepted in many countries as
a strategy to reduce maternal morbidity and mortality.
Objectives
8.20. The objectives are:
(a) To promote women's health and safe motherhood; to achieve a rapid and substantial
reduction in maternal morbidity and mortality and reduce the differences observed between
developing and developed countries and within countries. On the basis of a commitment to
women's health and well-being, to reduce greatly the number of deaths and morbidity from
unsafe abortion; 20/
(b) To improve the health and nutritional status of women, especially of pregnant and
nursing women.
Actions
8.21. Countries should strive to effect significant reductions in maternal mortality by
the year 2015: a reduction in maternal mortality by one half of the 1990 levels by the
year 2000 and a further one half by 2015. The realization of these goals will have
different implications for countries with different 1990 levels of maternal mortality.
Countries with intermediate levels of mortality should aim to achieve by the year 2005 a
maternal mortality rate below 100 per 100,000 live births and by the year 2015 a maternal
mortality rate below 60 per 100,000 live births. Countries with the highest levels of
mortality should aim to achieve by 2005 a maternal mortality rate below 125 per 100,000
live births and by 2015 a maternal mortality rate below 75 per 100,000 live births.]
However, all countries should reduce maternal morbidity and mortality to levels where they
no longer constitute a public health problem. Disparities in maternal mortality within
countries and between geographical regions, socio-economic and ethnic groups should be
narrowed.
8.22. All countries, with the support of all sections of the international community,
must expand the provision of maternal health services in the context of primary health
care. These services, based on the concept of informed choice, should include education on
safe motherhood, prenatal care that is focused and effective, maternal nutrition
programmes, adequate delivery assistance that avoids excessive recourse to caesarean
sections and provides for obstetric emergencies; referral services for pregnancy,
childbirth and abortion complications; post-natal care and family planning. All births
should be assisted by trained persons, preferably nurses and midwives, but at least by
trained birth attendants. The underlying causes of maternal morbidity and mortality should
be identified, and attention should be given to the development of strategies to overcome
them and for adequate evaluation and monitoring mechanisms to assess the progress being
made in reducing maternal mortality and morbidity and to enhance the effectiveness of
ongoing programmes. Programmes and education to engage men's support for maternal health
and safe motherhood should be developed.
8.23. All countries, especially developing countries, with the support of the
international community, should aim at further reductions in maternal mortality through
measures to prevent, detect and manage high-risk pregnancies and births, particularly
those to adolescents and late-parity women.
8.24. All countries should design and implement special programmes to address the
nutritional needs of women of child-bearing age, especially those who are pregnant or
breast-feeding, and should give particular attention to the prevention and management of
nutritional anaemia and iodine-deficiency disorders. Priority should be accorded to
improving the nutritional and health status of young women through education and training
as part of maternal health and safe motherhood programmes. Adolescent females and males
should be provided with information, education and counselling to help them delay early
family formation, premature sexual activity and first pregnancy.
8.25. In no case should abortion be promoted as a method of family planning. All
Governments and relevant intergovernmental and non-governmental organizations are urged to
strengthen their commitment to women's health, to deal with the health impact of unsafe
abortion 20/ as a major public health concern and to reduce the recourse to abortion
through expanded and improved family-planning services. Prevention of unwanted pregnancies
must always be given the highest priority and every attempt should be made to eliminate
the need for abortion. Women who have unwanted pregnancies should have ready access to
reliable information and compassionate counselling. Any measures or changes related to
abortion within the health system can only be determined at the national or local level
according to the national legislative process. In circumstances where abortion is not
against the law, such abortion should be safe. In all cases, women should have access to
quality services for the management of complications arising from abortion. Post-abortion
counselling, education and family-planning services should be offered promptly, which will
also help to avoid repeat abortions.
8.26. Programmes to reduce maternal morbidity and mortality should include information
and reproductive health services, including family-planning services. In order to reduce
high-risk pregnancies, maternal health and safe motherhood programmes should include
counselling and family-planning information.
8.27. All countries, as a matter of some urgency, need to seek changes in high- risk
sexual behaviour and devise strategies to ensure that men share responsibility for sexual
and reproductive health, including family planning, and for preventing and controlling
sexually transmitted diseases, HIV infection and AIDS.
D. Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome
(AIDS)
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Basis for action
8.28. The AIDS pandemic is a major concern in both developed and developing countries.
WHO estimates that the cumulative number of AIDS cases in the world amounted to 2.5
million persons by mid-1993 and that more than 14 million people had been infected with
HIV since the pandemic began, a number that is projected to rise to between 30 million and
40 million by the end of the decade if effective prevention strategies are not pursued. As
of mid-1993, about four fifths of all persons ever infected with HIV lived in developing
countries where the infection was being transmitted mainly through heterosexual
intercourse and the number of new cases was rising most rapidly among women. As a
consequence, a growing number of children are becoming orphans, themselves at high risk of
illness and death. In many countries, the pandemic is now spreading from urban to rural
areas and between rural areas and is affecting economic and agricultural production.
Objectives
8.29. The objectives are:
(a) To prevent, reduce the spread of and minimize the impact of HIV infection; to
increase awareness of the disastrous consequences of HIV infection and AIDS and associated
fatal diseases, at the individual, community and national levels, and of the ways of
preventing it; to address the social, economic, gender and racial inequities that increase
vulnerability to the disease;
(b) To ensure that HIV-infected individuals have adequate medical care and are not
discriminated against; to provide counselling and other support for people infected with
HIV and to alleviate the suffering of people living with AIDS and that of their family
members, especially orphans; to ensure that the individual rights and the confidentiality
of persons infected with HIV are respected; to ensure that sexual and reproductive health
programmes address HIV infection and AIDS;
(c) To intensify research on methods to control the HIV/AIDS pandemic and to find an
effective treatment for the disease.
Actions
8.30. Governments should assess the demographic and development impact of HIV infection
and AIDS. The AIDS pandemic should be controlled through a multisectoral approach that
pays sufficient attention to its socio-economic ramifications, including the heavy burden
on health infrastructure and household income, its negative impact on the labour force and
productivity, and the increasing number of orphaned children. Multisectoral national plans
and strategies to deal with AIDS should be integrated into population and development
strategies. The socio-economic factors underlying the spread of HIV infection should be
investigated, and programmes to address the problems faced by those left orphaned by the
AIDS pandemic should be developed.
8.31. Programmes to reduce the spread of HIV infection should give high priority to
information, education and communication campaigns to raise awareness and emphasize
behavioural change. Sex education and information should be provided to both those
infected and those not infected, and especially to adolescents. Health providers,
including family-planning providers, need training in counselling on sexually transmitted
diseases and HIV infection, including the assessment and identification of high-risk
behaviours needing special attention and services; training in the promotion of safe and
responsible sexual behaviour, including voluntary abstinence, and condom use; training in
the avoidance of contaminated equipment and blood products; and in the avoidance of
sharing needles among injecting drug users. Governments should develop guidelines and
counselling services on AIDS and sexually transmitted diseases within the primary
health-care services. Wherever possible, reproductive health programmes, including
family-planning programmes, should include facilities for the diagnosis and treatment of
common sexually transmitted diseases, including reproductive tract infection, recognizing
that many sexually transmitted diseases increase the risk of HIV transmission. The links
between the prevention of HIV infection and the prevention and treatment of tuberculosis
should be assured.
8.32. Governments should mobilize all segments of society to control the AIDS pandemic,
including non-governmental organizations, community organizations, religious leaders, the
private sector, the media, schools and health facilities. Mobilization at the family and
community levels should be given priority. Communities need to develop strategies that
respond to local perceptions of the priority accorded to health issues associated with the
spread of HIV and sexually transmitted diseases.
8.33. The international community should mobilize the human and financial resources
required to reduce the rate of transmission of HIV infection. To that end, research on a
broad range of approaches to prevent HIV transmission and to seek a cure for the disease
should be promoted and supported by all countries. In particular, donor and research
communities should support and strengthen current efforts to find a vaccine and to develop
women-controlled methods, such as vaginal microbicides, to prevent HIV infection.
Increased support is also needed for the treatment and care of HIV-infected persons and
AIDS patients. The coordination of activities to combat the AIDS pandemic must be
enhanced. Particular attention should be given to activities of the United Nations system
at the national level, where measures such as joint programmes can improve coordination
and ensure a more efficient use of scarce resources. The international community should
also mobilize its efforts in monitoring and evaluating the results of various efforts to
search for new strategies.
8.34. Governments should develop policies and guidelines to protect the individual
rights of and eliminate discrimination against persons infected with HIV and their
families. Services to detect HIV infection should be strengthened, making sure that they
ensure confidentiality. Special programmes should be devised to provide care and the
necessary emotional support to men and women affected by AIDS and to counsel their
families and near relations.
8.35. Responsible sexual behaviour, including voluntary sexual abstinence, for the
prevention of HIV infection should be promoted and included in education and information
programmes. Condoms and drugs for the prevention and treatment of sexually transmitted
diseases should be made widely available and affordable and should be included in all
essential drug lists. Effective action should be taken to further control the quality of
blood products and equipment decontamination.
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