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Confidential: For Review O
nly
Addressing progress and change in Maternal and Child
Health: How has South Asia fared?
Journal: BMJ
Manuscript ID BMJ.2016.037097
Article Type: Analysis
BMJ Journal: BMJ
Date Submitted by the Author: 15-Dec-2016
Complete List of Authors: Akseer, Nadia; Hospital for Sick Children, Centre for Global Child Health Kamali, Mahdis; Hospital for Sick Children, Centre for Global Child Health Arifeen, Shams; International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh, Malik, Ashar; Aga Khan University, Division of Women and Child Health
Bhatti, Zaid; Aga Khan University, Division of Women and Child Health Thacker, Naveen; Deep Children Hospital & Research Centre, Department of Pediatrics of Sahyadri Ramkrishna Speciality Hospital Maksey, Mahesh; Nepal Public Health Foundation D'Silva, Harendra; University of Colombo Faculty of Medicine Bhutta, Zulfiqar; Aga Khan University, Division of Women and Child Health
Keywords: South Asia, Maternal, Child, Health, Determinants
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Confidential: For Review O
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Author list
Nadia Akseer1,2, Mahdis Kamali1, Shams E Arifeen3, Ashar Malik4, Zaid Bhatti4, Naveen
Thacker5, Mahesh Maksey6, Harendra D’Silva7, Zulfiqar A Bhutta1,2,4
Affiliations:
1 Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
2 Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
3Maternal and Child Health Division (MCHD)
International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)
4 Center of Excellence in Women and Child Health, the Aga Khan University, Karachi,
Pakistan
5Deep Children Hospital and Research Centre, Gandhidham, Gujrat, India
6Nepal Public Health Foundation, Kathmandu, Nepal
7Faculty of Medicine, University of Colombo, Sri Lanka
*Corresponding author
Professor Zulfiqar A Bhutta, FRCPCH, PhD Robert Harding Chair in Global Child Health & Policy Centre for Global Child Health The Hospital for Sick Children Toronto, ON M5G 0A4 Canada zulfiqar.bhutta@sickkids.ca
Email addresses: NA: nadia.akseer@sickkids.ca MK: mahdis.kamali@sickkids.ca ZB : zaid.bhatti@aku.edu ZAB: zulfiqar.bhutta@sickkids.ca SEA: shams@icddrb.org MKM: maskeymk8@gmail.com AM: ashar.malik@aku.edu NT: drnaveenthacker@gmail.com HD: harendra51@gmail.com
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Keywords:
South Asia, Maternal, Child, Health, Determinants
Abstract:
South Asia comprises eight culturally and socioeconomically diverse nations; the region collectively
account for a significant share of the global burden of maternal and child mortality. We explored
progress in reproductive, maternal, newborn, and child health (RMNCH) in the region since the
signing of the MDG declaration. We obtained trend data from national household health and
nutrition surveys, and global data repositories including the UN sources, Institute for Health
Metrics and Evaluation, and World Bank. We also conducted a review of peer-reviewed and grey
literature. South Asia reduced maternal mortality ratio (MMR) by 68% and under-5 mortality
(U5MR) by 60% from 1990 to 2015, with differential progress across countries. Current mortality
rates are exceptionally high in many countries including Afghanistan, Pakistan and Nepal.
Bangladesh made impressive reductions over this time period despite poverty. About 57% of all
under-5 deaths occur are among newborns, and stillbirth rates are also high in the region. South
Asia performs well in delivering antenatal care, skilled birth attendance, and vaccination
interventions on average to its populations, though wide disparities exist across wealth groups and
rural vs urban in many countries. As a whole, interventions on contraceptive use, breastfeeding,
and caring for sick children are lacking in many countries. Social determinants and health
systems/policies are key contributors to observed improvement and differentials in the region.
Despite progress in many countries, key challenges must be addressed for further gains. These
include resolutions and innovative initiatives for the ongoing conflict/insecurity, reduction of
inequities and improving health access to marginalized groups, addressing malnutrition,
encouraging empowerment of girls and women, and supporting better and timely data collection.
As a resilient populous region, South Asia is well posed to make further gains in the SDG era if key
challenges can be addressed.
Introduction:
Over twelve years ago, we explored the status of maternal and child health in South Asia in this very
journal (1). Our review evaluated the status and determinants of the poor performance of the
region in the context of the Millennium Development Goals (MDGs). We highlighted rampant
poverty, malnutrition, and lack of female empowerment as key barriers to change, and placed our
hope in countries making the right choices in terms of policies and implementation. Have things
changed over the last decade? This paper explores the current status and progress in reproductive,
maternal, newborn and child health (RMNCH) related MDGs throughout South Asia, and presents a
snap shot of the regions’ preparedness for the sustainable development goals (SDGs) (2).
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Methods & Data Sources:
We analyzed countries that are active members of the South Asian Association for Regional
Cooperation (SAARC)- a regional geopolitical and economic organization. Member states include
Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka.
Global data sources from the UN and Institute for Health Metrics (IHME) were reviewed for best
estimates of maternal mortality (3), child mortality (newborn, post-neonate and under-5) (4), and
still births (5). We obtained time series data from 1990 to 2015 when available. Cause-specific
death rates by country were retrieved from IHME for mothers (6) and the Child Health
Epidemiology Reference Group (CHERG) for newborns and post-neonates (7).
We constructed the coverage rates for interventions across the continuum of care for mothers,
infants and children in the South Asian Association for Regional Cooperation (SAARC) countries
comprising of India, Pakistan, Bangladesh, Nepal, Sri Lanka, Maldives and Afghanistan. We used
current coverage estimates from various sources including United Nations Population Fund
(UNFPA) (8), World Bank Development Database (9), the UNICEF Global Database (10), the UNICEF
Infant and Young Child Feeding Report(11), the WHO/UNICEF Coverage Estimates for
immunization (12), and the WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and
Sanitation (13). Child nutrition indicators including stunting (<-2 height for age median z-scores)
and wasting (<-2 weight for age median z-scores) measures were retrieved from the WHO/World
Bank/UNICEF Joint Malnutrition estimates (14). Full variable definitions are provided in the
appendix.
We reviewed national household surveys including the multiple indicator cluster surveys (MICS),
the demographic and health surveys (DHS), national nutrition surveys and others (Box 1) to cross-
reference data and to obtain coverage estimates by wealth quintile and for rural vs urban residence.
The surveys and other sources from the United Nations Development Programme (UNDP), World
Bank and WHO (see appendix for full source list) were used to attain additional demographic and
contextual information. Health care financing details were obtained from the most recent national
health accounts (NHA) report (15-22) and other analyses of out of pocket expenditures (23, 24). A
desk review of peer-reviewed and unpublished literature was also undertaken to identify key
health policies, strategies and other initiatives that have impacted RMNCH in the SAARC region (25-
43).
Box 1: National Survey Sources
Country Source
Afghanistan MICS 2010 (44), Afghanistan Mortality Survey 2010 (45), Afghanistan Household Survey 2012 (46), Afghanistan National Nutrition Survey 2013 (47)
Bangladesh DHS 2004 (48), DHS 2007 (49), DHS 2014 (50)
Bhutan MICS 2010 (51)
India National Family Health Survey 2005/2006 (52), Rapid Survey on Children 2013/2014 (53)
Maldives DHS 2009 (54)
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Nepal DHS 2006 (55), DHS 2011 (56), MICS 2014 (57)
Pakistan DHS 2006/2007 (58), DHS 2012/2013 (59)
Sri Lanka DHS 2006/2007 (60), National Nutrition and Micronutrient Survey 2012 (61)
Note: Final national estimates from India’s National Family Health Survey 2015/2016 were not yet
available.
Results:
Demographic Profile of SAARC Countries
The SAARC region (thereafter called South Asia for clarity) comprises a diverse set of countries
ranging from small nations with less than 1 million population, such as Maldives and Bhutan, to one
of the most populated nations globally- India with more than 1.3 billion people (Table 1). Since
2004, each country therein has experienced population growth ranging from 9% in Sri Lanka to
38% in Afghanistan. As the most rapidly growing state in the region, Afghanistan’s 2.8% annual
population growth rate is primarily attributed to repatriation of Afghan refugees from
neighbouring Pakistan and Iran. All other countries in the region have had moderate growth
ranging from about 1-2% per year. Nepal and Sri Lanka have the least urbanization with about 20%
of the populations live in urban settings. Approximately one-third of the civilians in other SAARC
countries live in urban areas, with the exception of Maldives where this number is almost 46%.
Mortality Trends and Causes of Death
Globally, maternal mortality ratio (MMR) dropped from 385 to 216 deaths per 100,000 live births-
a 44% reduction from 1990 to 2015 (3). Still, an estimated 303,000 mothers die every year, and
about 22% of them are in South Asia alone with India accounting for the bulk of these deaths. All
South Asian countries experienced significant MMR reductions across the MDG period (ranging
from -59% for Pakistan and Sri Lanka, to -90% for Maldives), while the region as a whole reduced
MMR by 68% (Figure 1). Afghanistan had the highest MMR in the region in 1990 (1340/100,000
births) and managed to drop this by 70% by 2015. Despite the gains, however, Afghanistan still has
the highest MMR in South Asia, followed by Nepal with 258 maternal deaths per 100,000 live births
in 2015. The major causes of maternal death vary across South Asia (appendix) though maternal
hemorrhage, hypertensive disorders, obstructed labour and uterine rupture, and
abortion/miscarriage/ectopic pregnancy are leading causes in many countries.
Globally under-five mortality rate (U5MR) reduced by about half from 1990 to 2015 (91 to 43
deaths per 1000 live births) (4). Of the 5.9 million U5 children that died in 2015, almost 1.9 million
(31%) were in South Asia. According to UN estimates, four countries in the region attained the
MDG4 goal of reducing U5MR by two-thirds from 1990 to 2015 (Bangladesh [-74%], Nepal [-75%],
Bhutan [-76%] and Maldives [-91%]) (Figure 1). Pakistan (-42%) and Afghanistan (-50%) reduced
the least over this period, and continue to have the highest U5MR in the region (81 and 91 deaths
per 1000 live births, respectively). The overall U5MR for the region dropped by 60% over this
period i.e. from 129 to 53 deaths per 1000 live births. Despite South Asia making gains in reducing
pneumonia and diarrhea-related deaths over the MDG period (notably, Bangladesh) (7), these two
preventable conditions persist as leading causes of child mortality in South Asia (appendix). About
50% of all deaths are attributed to these preventable conditions across most countries. Accidents
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and injuries are responsible for at least a further 10% of child deaths across all countries.
Congenital anomalies are leading killers of one-third of children in Sri Lanka and the Maldives.
In South Asia, 57% of all U5 deaths in 2015 occurred in the first 28 days of life; this amounts to
more than 1 million newborns dying every year in the region (4). Moreover, of the 2.6 million
stillbirths that occur globally every year, about 37% (almost 1 million) are in South Asia (5).
Newborn mortality rates (NMR) have declined by 49% in South Asia from 1990 to 2015, ranging
between 29% (Pakistan) and 89% (Maldives) (appendix). Stillbirth rates (SBR) have declined much
slower than NMR and across South Asia dropped by 30% from 41 to 29 deaths per 1000 total births
from 2000 to 2015 (appendix). NMR continues to be highest in Pakistan (45.5 deaths per 1000 live
births) and Afghanistan (35.5). The major causes of newborn death are fairly consistent across the
region with preterm birth taking the lead (about one-third), followed by intrapartum related
events, infections including sepsis and meningitis, and congenital anomalies (each contributing to
about one-fifth of newborn deaths) (appendix). Some variation exists across countries. Robust data
on causes of stillbirths were not available for comparison.
Coverage of Essential Interventions
Figure 4 presents the coverage rates for essential interventions across the continuum of MNCH and
indicates wide differentials across the region. . Contraceptive use is about 55% on average and is
lowest in Afghanistan (31%) and highest in Sri Lanka and Bhutan (about 70%). Though the median
demand for family planning is comparatively higher (75%), the distribution by country is similar.
One or more antenatal care visits (ANC1) is about 70% in most countries and reaches almost 100%
in Sri Lanka and Bhutan. ANC 4+ visits and skilled birth attendance are amongst the lesser accessed
interventions (~50% median) and have the widest variation across countries. Gaps of 70% are
noted between Afghanistan (23%) and Sri Lanka (93%) for ANC4+, and similarly for SBA. Post-
natal care within 2 days for both the newborn and mother are low in the region (30-40% median)
with some variation across countries. Data for Sri Lanka was not available.
Breastfeeding interventions (including early initiation and exclusive breastfeeding for 6 months)
exhibit parallel trends with about 50% regional coverage, and 40% gap between the highest (Sri
Lanka, Bhutan for early initiation; Afghanistan for exclusive breastfeeding) and lowest (Pakistan)
countries. The region performs well in the provision of child vaccinations, with about 90% coverage
on average for protection against newborn tetanus, Hib3, measles and DPT3. Country coverage
ranges from about 70% to 100%, with Afghanistan and Pakistan amongst the lowest and Sri Lanka
consistently the highest.
Interventions for treatment of sick children for diarrhea and pneumonia are moderately accessed in
the region on average (about 50-60%). Oral rehydration solutions (ORS) and ORS with continued
feeding are least utilized in India and Pakistan, and coverage rates are highest in Bangladesh.
Conversely, care seeking for pneumonia is most utilized in India and Maldives (almost 80%
coverage), and least accessed in Bangladesh (41%).
Coverage Inequalities within countries
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We analyzed socioeconomic and residence inequalities for two key interventions (skilled birth
attendance and measles vaccination) as they represent opposite ends of the continuum of care and
diverse delivery strategies (Figure 3). SBA coverage gaps between the richest and poorest quintiles
are pervasively present in most countries of South Asia, with upwards of 70% gaps noted in India,
Nepal and Bhutan. Sri Lanka and Maldives have minimal to no gaps. Similar country trends are
observed by residence where urban populations always had higher SBA coverage; Afghanistan had
the widest noted disparities. Inequities in measles vaccination were greatest for Pakistan, India and
Afghanistan with lowest coverage rates among the poorest populations and those living in rural
areas. Upwards of 50% coverage gap is noted between the richest and poorest in Pakistan and
Afghanistan; pro- urban gaps were at most 20% percentage points in the same countries. Sri Lanka,
Nepal, Maldives and Bangladesh had minimal to no gaps in measles vacation. Data for Bhutan was
not available.
Social Determinants of Health
Development and Poverty
In 2004, Sri Lanka and Maldives were the most developed nations in the region, with human
development indices (HDI) greater than 0.7 (Table 1). Afghanistan was the least developed
(HDI=0.40). Though this still holds true, Afghanistan has managed to increase its HDI by about 17%
up to 0.47. Nepal (+4% gain in HDI), Bangladesh (+8%), and Bhutan (+13%) have also improved
overall development. HDI has gone down slightly in Pakistan, India and Maldives. Per capita earning
is highest in the Maldives (GDP per capita 7681 USD), followed by Sri Lanka (3926 USD).
Afghanistan is one of the poorest and ranks far below all countries in the region with only 590 USD
per head on average. The proportion of the population living below national poverty lines or $1.08
per day is highest in Afghanistan (36%), with similar levels in Bangladesh, Nepal and Bhutan. Only
7% of Sri Lankans live below this threshold.
Malnutrition
Malnutrition of children and women remains a pervasive issue in South Asia (Figure 3). Since the
early 2000s, the prevalence of under-5 stunting dropped by about one-third in Afghanistan,
Bangladesh, India, Nepal, and Maldives. Pakistan, however, experienced an increase over this
period (from 42% to 45%). Despite progress, current levels of stunting are more than 30% in most
countries in the region, except Sri Lanka (15%) and Maldives (20%). Similar reduction patterns are
noted for childhood underweight, and currently approximately one-third of all children are
underweight in most countries except Bhutan (13%) and Maldives (18%) (appendix). Prevalence of
wasting has varied marginally over the decade, and currently ranges from negligible in Bhutan
(6%) to alarming levels in Sri Lanka (21%) (appendix).
Both over- and under-nutrition are concerns among women age 15-49 years in South Asia (Figure
3). Maternal underweight (defined as body mass index (BMI) < 18.5) is prevalent in about 36% of
women in India- about double that of the next highest countries (Nepal 18% and Bangladesh 19%).
Obesity (BMI>=30) is highest in Pakistan (15%) and Maldives (13%). Afghanistan has comparable
levels of underweight (9%) and obesity (8%) among women. Data for Bhutan was not available.
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Empowerment of Girls and Women
All countries in the region have experienced an overall reduction in fertility rates since 2004,
ranging between 9%-36% (Table 2). Current fertility rates are highest in Afghanistan and Pakistan,
where women are having on average 4.8 and 3.6 children, respectively. Similar patterns are noted
for births among adolescent girls (age 15-19 years) which have declined more than 50% in Bhutan,
Maldives, and India. Pakistan has made the least progress in reducing fertility among adolescent
girls (11% reduction). Current adolescent fertility levels are highest in Bangladesh, Afghanistan and
Nepal as more than 7% of adolescent girls experience their first pregnancy. Average age at first
marriage is lowest in Bangladesh (19.2 years), and highest in Sri Lanka (23.6 years). While most
countries have increased this average age of marriage by 2%-7%, Afghanistan had the fastest rate
of change over the last decade (from 15.0 years in 2006 to 21.2 years in 2011).
Literacy of women (age 15+ years) is greater than 90% in Sri Lanka (92%) and the Maldives (99%),
and about half in other SAARC nations except Afghanistan where only 24% of women are literate.
Literacy of female youth (age 15-24 years) is >85% in all countries, excluding Pakistan (67%) and
Afghanistan (46%).
Access to Improved Water and Sanitation
The availability of improved water is almost universal throughout the region except in Afghanistan
where only 55% of the population has access (Table 1, Figure 4). The country, however, has made
the most dramatic gains in the region, having increased access by 48% from the 2004 coverage
levels (37%). Other countries in the region have increased coverage by 2%-14% from 2004 to
2015. Improved sanitation facilities are less available in the region (about 55% regional median),
and wide variation is noted between the lowest coverage nation (Afghanistan at 32%) and better
off nations (Sri Lanka and Maldives at >90% coverage). Given lower baseline levels in 2004,
countries in the region have made greater gains in improving coverage of this indicator (by 11%-
62%) than improved water.
Investments in Health Systems and RMNCH
The density of health care personnel including physicians, nurses and midwives varies dramatically
across the region (Table 1). Collectively, there approximately 64.5 such health workers per 10,000
population in Maldives, and only 5.7 per 10,000 in Bangladesh, 6.5 in Afghanistan, and 6.7 in Nepal.
These three countries, plus Bhutan (12.4 per 10,000) and Pakistan (14.0 per 10,000) do not meet
the WHO recommended threshold of minimum 23 health workers per 10,000 population. India and
Sri Lanka are at the cusp of the recommended cut-off.
A timeline of key high impact health initiatives implemented in SAARC countries across the MDG
period is presented in Table 3. Cross-national commonalities include: the adaptation of a basic
package of health care services and strategies to expand universally, contracting out delivery of
health care services to NGOs for rapid scale-up, health care financial incentive
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programmes/abolishing user fees, and community-based health care initiatives and training of
midwives.
We evaluated national health care financing in the region and summarize it in Table 4. Health
expenditure as a % of GDP is highest in the Maldives (9.2%) and Afghanistan (8.0%), and lowest in
Pakistan (3.0%). Per capita expenditure on health is highest in the Maldives (561 USD), and lowest
in Nepal (25 USD) and Bangladesh (27 USD). Government health expenditure as a proportion of
total health expenditure (THE) is a high of 71.0% in Bhutan and strikingly low in Afghanistan
(5.6%). Out of pocket (OOP) payments comprise the majority of total health expenditure in
Afghanistan (73.3%), India (64.2%), Bangladesh (63.0%) and Pakistan (60.4%). High OOP health
expenditures annually drag about 4% of the population into poverty in the three most populous
countries of the region i.e. India, Bangladesh and Pakistan. Data for Afghanistan was not available
for comparison. Of the four countries with available data, RMNCH spending constitutes between
9.8% (Sri-Lanka) and 21.0% (Pakistan) of THE. Catastrophic impact (OOP health payments
exceeding 25% of the total expenditure) is highest in Bangladesh (5.0%) and Pakistan (4.5%).
Across the region, Afghanistan, Nepal and Bhutan have the greatest share of official development
assistance in their total health expenditure (about one-fifth of THE).
Discussion:
Despite wide variations, South Asia as a region has made impressive progress in RMNCH over the
last decade. In many countries with widespread conflict and grinding poverty, notably Nepal and
Afghanistan, these gains are quite remarkable. However, the reductions were related to differing
approaches and investments.
Nepal invested heavily in community-based approaches to address community-based detection of
serious childhood illnesses and management of pneumonia (62). A range of innovative approaches
for addressing maternal health and nutrition through women’s groups provided some of the first
bodies of evidence on the role of community empowerment in rural Makwanpur (63). Bangladesh
also saw a range of interventions and changes among which community empowerment,
investments in education and young women and large national roll out of community health
workers including through non-governmental organizations such as BRAC, and was able to rapidly
roll out interventions through a range of community outreach programs (64, 65). However, the
gains in maternal mortality reduction in Bangladesh far outstripped the gains in skilled birth
attendance coverage and facility births (66). Similarly, reductions in child mortality (and especially
diarrheal diseases mortality) have been remarkable, and while there have been major gains in oral
rehydration therapy, care seeking for childhood pneumonia is low and rates of childhood
undernutrition still high (67). It is therefore likely that the role of investments in social
determinants and non-health sectors such as education, especially girls’ education, female
empowerment, reduction in early marriages and high fertility rates, as well as effective
communication strategies are especially important for gains in RMNCH outcomes and must be
sustained moving forwards.
These findings are different elsewhere. In war ravaged Afghanistan, where given the shortage of
skilled public sector workers, the government adopted the model of rolling out services through
contracting NGOs to provide a basic package of primary care services (68). While the transaction
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costs were high, the model allowed for rapid population coverage in difficult to reach rural
populations.
Notwithstanding the above, high rates of newborn mortality (and intrapartum stillbirths) are a
major challenge across the region, and are associated with poor quality of care in both community
and facility settings (69). Further gains in reducing U5MR will need to address the dual challenge of
improving care during pregnancy and child birth in community settings and facilitation of facility
births, as well as improving care of newborns in referral facilities. Pakistan invested in a major
national program of primary care “Lady Health Workers” which now number over a 100,000 and
cover almost two thirds of the rural population (70), and India has also introduced a major public
sector program of community-based ASHA workers. Evidence has shown that there is considerable
opportunity for innovations in facilitating the work of front-line workers in addressing these
challenges (71-74). In other regions of South Asia where there have been relatively rapid gains, we
need to invest in strategies to improve the quality of care in referral facilities, especially those
responsible for secondary care.
Notwithstanding important strides in the region, major challenges remain. The rapid growth of
urban slums, frequently accounting for over a third of the population of mega cities, poses huge
challenges to effective care and governance. These and other marginalized populations, including
indigenous groups and those relegated on the basis of ethnicity, religion or caste systems, will
require innovative targeting to reduce inequities. Further, reaching the poorest and remote
populations in countries with substantial pro-rich and pro-urban RMNCH interventions
inequalities, such as Afghanistan and Pakistan, is critical to achieving universal coverage. Recent
reviews have underscored innovative strategies for reducing such inequities to improve maternal
and child health (75). Conflict and insecurity are an ongoing challenge facing many South Asian
countries (such as Afghanistan and border areas of Pakistan). A focus on identifying sources of
conflict and peace building in the region is critical to sustaining and scaling up RMNCH gains. Post-
conflict settings, such as Northern and Eastern Sri Lanka, especially the Jaffna area, need attention
and dire support to rebuild health systems.
Finally the state and international partners must support and protect women and children who
suffer from risk of gender-based violence, lack of economic security and physical immobility. High
rates of maternal and adolescent malnutrition remain tenacious underlying risk factors for ill health
and mortality in the region. Direct policies and initiatives to improve nutrition of all populations are
critical for health gains in South Asia. Low rates of breastfeeding and complementary feeding are
specifically a concern, and should be prioritized for scale-up. Quality and timely data is
indispensable for effective monitoring, evaluation and rapid feedback. Countries should focus on
efforts to enhance administrative databases, HMIS systems, vital registries and national surveys on
various health and well-being areas to track progress towards the SDGs.
South Asia comprises a substantial chunk of the global population and contains some of the highest
maternal and child mortality rates worldwide. Gains over the last decade provide evidence that
progress is possible, but much more can be done with targeted focus on scaling up evidence-based
interventions and addressing barriers as key investments in reaching the sustainable development
goals.
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16. Government of the People's Republic of Bangladesh, Ministry of Health and Family Welfare. Bangladesh National Health Accounts 1997-2012 2015 [Available from: http://www.heu.gov.bd/pdf/bnha%201997-2012.pdf.
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30. Meier BM, Chakrabarti A. The paradox of happiness: health and human rights in the Kingdom of Bhutan. Health and Human Rights. 2016;18(193-207).
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32. Paul VK, Sachdev HS, Mavalankar D, Ramachandran P, Sankar MJ, Bhandari N, et al. Reproductive health, and child health and nutrition in India: meeting the challenge. Lancet. 2011;377(9762):332-49.
33. Kumar AKS, Chen LC, Choudhury M, Ganju S, Mahajan V, Sinha A, et al. Financing health care for all: challenges and opportunities. The Lancet. 2011;377(9766):668-79.
34. La Forgia G, Nagpal S. Government-sponsored health insurance in India: Are you covered? 2012 [Available from: http://www.worldbank.org/en/news/feature/2012/10/11/government-sponsored-health-insurance-in-india-are-you-covered.
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36. Sulaiman AI, Abu Bakar SH, Wahab HA. Primary Health Care: Hope and Challenges for Public Health in Maldives. Journal of Community Health. 2014;39(3):627-31.
37. Sato M, Gilson L. Exploring health facilities' experiences in implementing the free health-care policy (FHCP) in Nepal: how did organizational factors influence the implementation of the user-fee abolition policy? Health Policy and Planning. 2015;30(10):1272-88.
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40. Loevinsohn B, Haq Iu, Couffinhal A, Pande A. Contracting-in management to strengthen publicly financed primary health services—The experience of Punjab, Pakistan. Health Policy. 2009;91(1):17-23.
41. WHO. Country Cooperation Strategy at a Glance: United Arab Emirates. WHO: 2007.
42. Mumtaz Z, Levay A, Bhatti A, Salway S. Good on paper: the gap between programme theory and real-world context in Pakistan's Community Midwife programme. Bjog. 2015;122(2):249-58.
43. World Bank. Sri Lanka- Second Health Sector Development Project: P118806- Project Appraisal Document 2013 [Available from: http://documents.worldbank.org/curated/en/381321468106472542/pdf/PID-Appraisal-Print-P118806-02-11-2013-1360575747265.pdf.
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44. Central Statistics Organization, UNICEF. Afghanistan Multiple Indicator Cluster Survey, 2010–2011 2013 [11/25/2016
]. Available from: http://cso.gov.af/Content/files/AMICS.pdf.
45. USAID. Afghanistan Mortality Survey 2010 2011 [Available from: http://dhsprogram.com/pubs/pdf/FR248/FR248.pdf.
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47. UNICEF, Ministry of Public Health, Afghanistan. National Nutrition Survey Afghanistan, 2013. 2014 [Available from: http://reliefweb.int/sites/reliefweb.int/files/resources/Report%20NNS%20Afghanistan%202013%20%28July%2026-14%29.pdf.
48. National Institute of Population Research and Training Bangladesh. Demographic and Health Survey, 2004. 2005 [Available from: http://dhsprogram.com/pubs/pdf/FR165/FR-BD04[FR165].pdf.
49. National Institute of Population Research and Training Bangladesh. Demographic and Health Survey, 2007. 2009 [Available from: http://dhsprogram.com/pubs/pdf/FR207/FR207[April-10-2009].pdf.
50. USAID. Bangladesh Demographic and Health Survey, 2014. 2016 [Available from: https://dhsprogram.com/pubs/pdf/FR311/FR311.pdf.
51. UNICEF. Multiple Indicator Cluster Survey, 2010. 2011 [Available from: https://mics-surveys-prod.s3.amazonaws.com/MICS4/South%20Asia/Bhutan/2010/Final/Bhutan%202010%20MICS_English.pdf.
52. International Institute for Population Sciences. India. National Family Health Survey, 2005-2006. 2007 [Available from: http://dhsprogram.com/pubs/pdf/FRIND3/FRIND3-Vol1andVol2.pdf.
53. UNICEF, Government of India. Rapid Survey on Children India, 2013-2014. 2015 [Available from: http://wcd.nic.in/sites/default/files/RSOC%20National%20Report%202013-14%20Final.pdf.
54. Ministry of Health and Family Maldives. Demographic and Health Survey, 2009. 2010 [Available from: http:// www.health.gov.mv/publications/MDHS%202009%20Prelimina ry%20Report_LATEST.pdf. .
55. Ministry of Health and Population Nepal. Demographic and Health Survey, 2006. 2007 [Available from: http://dhsprogram.com/pubs/pdf/fr191/fr191.pdf.
56. USAID. Nepal Demographic and Health Survey, 2011. 2012 [Available from: http://dhsprogram.com/pubs/pdf/FR257/ FR257%5B13April2012%5D.pdf 2011.
57. UNICEF. Nepal Multiple Indicator Cluster Survey, 2014. 2015 [Available from: http://unicef.org.np/uploads/files/597341286609672028-final-report-nmics-2014-english.pdf.
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58. National Institute of Population Studies. Pakistan Demographic and Health Survey, 2006–2007. 2008 [Available from: http://dhsprogram.com/pubs/pdf/FR200/FR200.pdf.
59. USAID. Pakistan Demographic and Health Survey, 2012–2013. 2013 [Available from: https://dhsprogram.com/pubs/pdf/ FR290/FR290.pdf.
60. Census and Statistics/ Ministry of Health Care and Nutrition. Sri Lanka Demographic and Health Survey, 2006/7 2008 [Available from: http://www.statistics.gov.lk/social/DHS%20Sri%20Lanka%20Preliminary%20Report.pdf.
61. UNICEF, Ministry of Health. Sri Lanka National Nutrition and Micronutrient Survey, 2012. 2013 [Available from: https://www.unicef.org/srilanka/MNS_Report-28.02.2013.pdf.
62. Dawson P, Pradhan YV, Houston R, Karki S, Poudel D, Hodgins S. From research to national expansion: 20 years’ experience of community-based management of childhood pneumonia in Nepal. Bulletin of the World Health Organization. 2008;86(5):339-43.
63. Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. The Lancet.364(9438):970-9.
64. Chowdhury AMR, Bhuiya A, Chowdhury ME, Rasheed S, Hussain Z, Chen LC. The Bangladesh paradox: exceptional health achievement despite economic poverty. The Lancet.382(9906):1734-45.
65. El Arifeen S, Christou A, Reichenbach L, Osman FA, Azad K, Islam KS, et al. Community-based approaches and partnerships: innovations in health-service delivery in Bangladesh. The Lancet.382(9909):2012-26.
66. El Arifeen S, Hill K, Ahsan KZ, Jamil K, Nahar Q, Streatfield PK. Maternal mortality in Bangladesh: a Countdown to 2015 country case study. The Lancet.384(9951):1366-74.
67. Rahman AE, Moinuddin M, Molla M, Worku A, Hurt L, Kirkwood B, et al. Childhood diarrhoeal deaths in seven low- and middle-income countries. Bull World Health Organ. 2014;92(9):664-71.
68. Akseer N, Salehi AS, Hossain SMM, Mashal MT, Rasooly MH, Bhatti Z, et al. Achieving maternal and child health gains in Afghanistan: a Countdown to 2015 country case study. The Lancet Global Health.4(6):e395-e413.
69. Das JK, Rizvi A, Bhatti Z, Paul V, Bahl R, Shahidullah M, et al. State of neonatal health care in eight countries of the SAARC region, South Asia: how can we make a difference? Paediatrics and international child health. 2015;35(3):174-86.
70. Hafeez A, Mohamud BK, Shiekh MR, Shah SA, Jooma R. Lady health workers programme in Pakistan: challenges, achievements and the way forward. JPMA The Journal of the Pakistan Medical Association. 2011;61(3):210-5.
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71. Bhutta ZA, Soofi S, Cousens S, Mohammad S, Memon ZA, Ali I, et al. Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial. The Lancet.377(9763):403-12.
72. Bhandari N, Mazumder S, Taneja S, Sommerfelt H, Strand TA. Effect of implementation of Integrated Management of Neonatal and Childhood Illness (IMNCI) programme on neonatal and infant mortality: cluster randomised controlled trial. BMJ. 2012;344.
73. Baqui AH, Saha SK, Ahmed ASMNU, Shahidullah M, Quasem I, Roth DE, et al. Safety and efficacy of alternative antibiotic regimens compared with 7 day injectable procaine benzylpenicillin and gentamicin for outpatient treatment of neonates and young infants with clinical signs of severe infection when referral is not possible: a randomised, open-label, equivalence trial. The Lancet Global Health.3(5):e279-e87.
74. Soofi S, Cousens S, Imdad A, Bhutto N, Ali N, Bhutta ZA. Topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of Pakistan: a community-based, cluster-randomised trial. The Lancet.379(9820):1029-36.
75. Yuan B. What interventions are effective on reducing inequalities in maternal and child health in low- and middle-income settings? A systematic review. BMC Public Health. 2014;14.
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Tables and Figures: MNCH in South Asia Page 1 Table 1: Demographics of South Asian Countries
Country Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka
Total population (current, 2015) 32526562 160995642 774830 1311050527 409163 28513700 188924874 20966000
Total population (baseline, 2004) 23499850 23499850 23499850 23499850 23499850 23499850 23499850 23499850
Population change (%) +38.4 +14.3 +22.2 +16.4 +31.1 +13.2 +25.7 +9.0
Population growth (annual %) (2015) 2.8 1.2 1.3 1.2 2.0 1.2 2.1 0.9
Urban population (% of total) (2015) 26.7 34.3 38.6 32.7 45.5 18.6 38.8 18.4
Human development index (current, 2014) 0.465 0.570 0.605 0.609 0.706 0.548 0.538 0.757
Human development index (baseline, 2004) 0.399 (2005) 0.530 0.538 0.611 0.739 0.527 0.539 0.755
Human development change (%) +16.5 +7.6 +12.5 -0.3 -4.5 +4.0 -0.2 +0.3
GDP per capita (US$) (2015) 590.3 1211.7 2532.5 1581.6 7681.1 732.3 1429.0 3926.2
Population living below national poverty line/$ 1.08 a day (% total)
35.8 (2011)
32.0 (2010)
31.5 (2012)
21.9 (2011)
15.7 (2009)
33.0 (2010)
22.5 (2013)
6.7 (2012)
Density of physicians, nurses and midwives (per 10,000 population)
6.5 (2012)
5.74 (2011)
12.4 (2012)
24.54 (2011)
64.5 (2010)
6.69 (2004)
14.0 (2010)
23.21 (2010)
Improved drinking water sources (current, 2015) 55.3 86.9 100 94.1 98.6 91.6 91.4 95.6 Improved drinking water sources (baseline, 2004) 37.3 79.1 89.1 84.5 96.6 81.2 89.3 84.2
Improved drinking water sources change (%) +48.3 +9.9 +12.2 +11.3 +2.1 +12.8 +2.3 +13.5
Improved sanitation facilities (current, 2015) 31.9 60.6 50.4 39.6 97.9 45.8 63.5 95.1
Improved sanitation facilities (baseline, 2004) 25.7 49.7 37.4 29.6 87.3 28.3 44.1 85.4
Improved sanitation facilities change (%) +24.2 +22.0 +34.9 +33.8 +12.1 +62.1 +44.0 +11.4
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Tables and Figures: MNCH in South Asia Page 2 Figure 1: Mortality Trends in South Asian Countries, 1990-2015 A) Maternal
B) Under-5
*Sri Lanka’s 2004 U5MR estimate was smoothed using linear interpolation
0
200
400
600
800
1000
1200
1400
1600
19901991 19921993 1994 19951996 19971998 19992000 20012002 20032004 20052006 2007 20082009 20102011 20122013 20142015
Ma
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ea
ths
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r 1
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,00
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e b
irth
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Year
Afghanistan
Bangladesh
Bhutan
India
Maldives
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Pakistan
Sri Lanka
Global
South Asia
0
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40
60
80
100
120
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19901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015
Un
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Afghanistan
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South Asia
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Tables and Figures: MNCH in South Asia Page 3 Figure 2: Coverage of Essential Interventions in South Asian Countries (best recent estimates)
*Bar height denotes median coverage
0
10
20
30
40
50
60
70
80
90
100
Co
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Use
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%
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Bangladesh
Bhutan
India
Maldives
Nepal
Pakistan
Sri Lanka
Pregnancy Birth Post-natal
CareInfancy Childhood Water and
SanitationPre-
Pregnancy
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Tables and Figures: MNCH in South Asia Page 4 Figure 3: Inequalities in Skilled Birth Attendance and Measles Vaccination by Country
A) Skilled Birth Attendance
B) Measles Vaccination
0
10
20
30
40
50
60
70
80
90
100
Ind
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20
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)
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%
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0
10
20
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50
60
70
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100
Afg
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(2
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)
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La
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%
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0
10
20
30
40
50
60
70
80
90
100
Pa
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Poorest Quintile Quintile 2 Quintile 3 Quintile 4 Richest Quintile
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%
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Tables and Figures: MNCH in South Asia Page 5 Figure 4: Malnutrition Trends in South Asian Countries Note: Baseline is the earliest estimate between 1999-2004; current is the most recent estimate between 2009-2015
A) Child Stunting B) Maternal Malnutrition
*Maternal malnutrition graphs: India’s Rapid Survey on Children (RSOC) 2013-2014 National Report only included child malnutrition estimates; therefore DHS 2005-2006 was used for maternal malnutrition estimates; Nepal’s MICS 2014 does not include maternal BMI therefore DHS 2011 was used; Examined Sri Lanka’s DHS 2006-07, Nutrition and food security survey 2009 by WFP and the National nutrition and micronutrient survey 2012 and estimates were comparable across all, the definition for women used is women of 18-59 years of age
59.3
50.854.2
31.9
57.1
41.5
18.4
40.9
36.133.6
38.7
20.3
37.4
[VALUE].0
14.7
0
10
20
30
40
50
60
70
%
Baseline Current
9.2
18.6
35.6
7.5
18.2
13.9 14.9
8.3
4.42.8
13.1
2.2
15
6.9
0
5
10
15
20
25
30
35
40
45
50
%
Low BMI (<18.5) Obesity (>= 30)
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Fertility rate (average births per woman) (current, 2014)
4.8 2.2 2.0 2.4 2.1 2.2 3.6 2.1
Fertility rate (average births per woman) (baseline, 2004)
7.0 2.8 3.0 3.0 2.4 3.4 4.1 2.3
Fertility rate change (%) -30.7 -21.7 -31.6 -20.1 -12.2 -35.2 -12.4 -8.6
Adolescent fertility rate (average births per woman aged 15-19) (current, 2014)
76.7 83.5 22.7 25.7 7.3 72.5 39.2 15.4
Adolescent fertility rate (average births per woman aged 15-19) (2004)
134.7 101.1 61.7 54.0 20.1 104.1 44.2 25.7
Adolescent fertility rate change (%) -43.0 -17.5 -63.2 -52.4 -63.7 -30.4 -11.4 -40.1
Age at first marriage (mean, current) 21.2 (2011) 19.2 (2013) 21.4 (2010) 20.7 (2011) 22.4 (2009) 20.7 (2014) 23.1 (2013) 23.6 (2007)
Age at first marriage (mean, baseline) 15.0 (2006) 18.7 (2004) 21.8 (2005) 20.2 (2006) 22.9 (2006) 19.4 (2006) 22.3 (2003) Data not available
Age at first marriage change (%) +41.3 +2.7 -1.8 +2.5 -2.2 +6.7 +3.6 --
Female adult literacy rate (% of females ages 15 and above) (current, 2015)
23.9 58.3 55.1 63.0 98.9 54.8 42.7 91.7
Female adult literacy rate (% of females ages 15 and above) (baseline)
Data not available
Data not available
38.7 (2005) 50.8 (2006) 98.4 (2006) Data not available
35.4 (2005) 89.1 (2006)
Female adult literacy rate change (%) -- -- +42.4 +23.9 +0.5 -- +20.7 +2.9
Youth Female Literacy Rate (% of female ages 15-24) (current, 2015)
46.1 85.9 90.4 87.3 99.5 87.4 66.8 99.2
Youth Female Literacy Rate (% of female ages 15-24) (baseline)
Data not available
Data not available
68.0 (2005) 74.4 (2006) 99.4 (2006) Data not available
53.1 (2005) 97.9 (2006)
Youth Female Literacy Rate change (%) +33.0 +17.3 +0.1 +25.8 +1.3
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Table 3. Key Health Policies and Reforms in South Asian Countries
Country Reform Year started
Focus
Afghanistan Midwifery training program 2002 Provided pre services training to midwife for community care and hospital based care.
Basic package of health services
2004 Basic primary care services including maternal health and family planning.
Contracting of primary health services to NGO
2004 Capitation based (USD 3.8 to USD 5.1 per capita) contracts with providers through a bidding process.
Bangladesh
BRAC Shasthya Shebikas Community health workers
1970* Scaled up to all 64 districts: from 1080 CHWs to 91000 CHW by 2010
SWAp 1998* A shift from project-based planning to sector-wide planning, management and financing.
Bangladesh national strategy for maternal health
2001 Adopted community based skilled birth attendant to supplement institution based care.
Demand side financing 2007 Maternal health voucher scheme Current converge in 53 upazilas.
Bhutan
Universal access to health services
2008 In the constitution of 2008 health is recognized as human right and as one of the nine domains of gross national happiness.
Health policy 2012 Pledges universal health access to modern and traditional care, 90% population living within three hours walking distance to a health facility.
India National rural health mission 2004 Integration of vertical reproductive and maternal health programs and health system strengthening in 18 states.
Janani Suraksha Yojana 2005 Conditional cash transfer to pregnant women Accredited Social Health Activist (ASHA)
2006 820000 community health workers (ASHA) as of 2012
Rashtriya Swasthya Bima Yojna
2008 In patient (including maternity) coverage for the poor. 41.3 million People covered by 2016.
Maldives Madhana 2008 Publically funded health insurance scheme initially covering public employees and the elderly.
Aasandha 2012 Universal health coverage (up to Rf 100,000) including treatment in neighboring countries.
Nepal National safe motherhood plan 2002 Increase the access of poor and marginalized people on the reproductive health services.
Free healthcare policy 2006 Abolishing user’s fee at public facilities. By 2009 free essential health services including maternity services.
National safe motherhood/ neonatal health plan
2006 Birth preparedness package.
Community based neonatal care package
2007 Piloted in 10 districts and planned to scale up to 35 more districts by 2013
Pakistan Social Action Program I & II National Program for family planning and primary healthcare
1992/1998 1994
Sector wide approach for primary and secondary healthcare Currently over 100000 lady health workers covering more than 80% of rural population
People’s primary healthcare initiative
2004 Contracting of primary healthcare facilitates to NGOs. Implemented in 75 districts (out of 113).
Community midwife program 2005 New cadre of community midwife is introduced.
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18th constitutional amendment 2010 Devolution of health sector to the provinces National health insurance scheme
2014 Financial protection from health shocks to the population living below poverty line for inpatient care including maternity services.
Sri Lanka National maternal and child healthcare program
1965* Family Planning and reproductive health were integrated
Strategic framework for health development 2004-2015
2003 Health master plans and health development plan were implemented
National health development plan
2012 World Bank assisted project for out-sourcing non-clinical services and other financing reforms
*Key initiatives that were further accelerated post-2000
Table 4: Health Care Financing Overview in South Asian Countries (best recent estimate)
India Bangladesh Pakistan Afghanistan Sri-Lanka Nepal Bhutan Maldives
Health expenditure as % of GDP 4.0% 3.5% 3.0% 8.0% 3.2% 5.3% 3.7% 9.2%
Per capita health expenditure in USD 59 27 40 56 97 25 107 561
Share of government health expenditure in total health expenditure 28.6% 23.0% 32.1% 5.6% 55.0% 21.0% 71.0% 44.0%
Share of out-of-pocket health payments in total health expenditure 64.2% 63.0% 60.4% 73.3% 37.9% 54.8% 11.0% 49.0%
Share of RMNCH expenditure in total health expenditure - 12.0% 21.0% 16.0% 9.8% - - -
Share of official development assistance in total health expenditure 0.3% 8.3% 7.0% 20.8% 1.5% 18.9% 18.0% 3.0% Percentage points of population impoverished due to OOP health payments 3.7% 3.8% 3.8% - 0.3% 3.0% - - Percentage of population with OOP health expenditure greater than 25% of total expenditure 1.8% 4.5% 5.0% - 0.5% 1.2% - - Source: National health accounts for India (2013-14), Bangladesh (2012), Pakistan (2013-14), Sri Lanka (2013), Afghanistan (2011-12), Maldives (2011), Nepal (2008-09), Bhutan (2009-10). Dooslear et al (2006) for Impoverishment impact of OOP health payments (except Pakistan Malik, 2016) and Doorslaer (2007) for OOP health payments exceeding 25% of the household total expenditure
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Web Appendix 1Box 1: Indicators and definitions with their source
Indicator Definition Source Links
Contraceptive
use (any
method)
Prevalence of current contraceptive use among
married women 15-49 years old, any method
(%).
World Bank http://data.worldbank.org/indicator/SP.D
YN.CONU.ZS
Demand for
family
planning
satisfied
Demand for Family Planning Satisfied:
Percentage of total demand for family planning
among married or in-union women aged 15 to
49 that is satisfied (contraceptive prevalence
divided by total demand for family planning).
United Nations
Population Fund
(UNFPA)
http://www.unfpa.org/sites/default/files/sowp/dow
nloads/The_State_of_World_Population_2016_-
_English.pdf
Antenatal care
1+ visit
Percentage of women attended at least once
during pregnancy by skilled health personnel.
UNICEF Global
Database
https://data.unicef.org/topic/maternal-
health/antenatal-care/
Antenatal care
4+ visits
Percentage of women attended four or more
times during pregnancy by any provider.
UNICEF Global
Database
https://data.unicef.org/topic/maternal-
health/antenatal-care/
Protection
against
newborn
tetanus
Percentage of mothers who’s last live birth in the
five-year period before the survey was protected
from neonatal tetanus.
World Bank http://data.worldbank.org/indicator/SH.V
AC.TTNS.ZS
Skilled birth
attendance
Percentage of live births attended by skilled
health personnel.
UNICEF Global
Database
https://data.unicef.org/topic/maternal-
health/delivery-care/
Post-natal care
for newborns
within 2 days
Percentage of newborns who received postnatal
care within two days of birth.
UNICEF Global
Database
https://data.unicef.org/topic/maternal-
health/newborn-care/
Post-natal care
for mothers
within 2 days
Percentage of mothers who received postnatal
care within two days of childbirth.
UNICEF Global
Database
https://data.unicef.org/topic/maternal-
health/newborn-care/
Initiation of
breastfeeding
within 1
hour of birth
Percentage of newborns put to the breast within
one hour of birth.
UNICEF Global
Database
https://data.unicef.org/topic/nutrition/inf
ant-and-young-child-feeding/
Exclusive
breastfeeding
for 0-5 months
Exclusive breastfeeding refers to the percentage
of children less than six months old who are fed
breast milk alone (no other liquids) in the past
24 hours.
World Bank http://data.worldbank.org/indicator/SH.S
TA.BFED.ZS
Introduction of
solid and semi-
solid food soft
food
Percentage of infants ages 6–8 months who
receive solid, semi-solid or soft foods.
UNICEF Global
Database
https://data.unicef.org/topic/nutrition/inf
ant-and-young-child-feeding/
Children who
received three
doses of
Haemophilus
influenzae type
B vaccine
The percentage of 1 year olds who have received
three doses of Haemophilus influenzae type B
vaccine in a given year.
World Health
Organization and
United Nations
Children’s Fund
estimates of
national
immunization
coverage
https://data.unicef.org/topic/child-
health/immunization/
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Web Appendix 2Children who
are immunized
against
measles
The percentage of children aged 12-23 months
who have received at least one dose of measles-
containing vaccine in a given year.
World Health
Organization and
United Nations
Children’s Fund
estimates of
national
immunization
coverage
https://data.unicef.org/topic/child-
health/immunization/
Children who
received 3
doses of
diphtheria,
pertussis,
tetanus
vaccine
The percentage of one-year-olds who have
received three doses of the combined diphtheria,
tetanus toxoid and pertussis (DTP3) vaccine in a
given year.
World Health
Organization and
United Nations
Children’s Fund
estimates of
national
immunization
coverage
https://data.unicef.org/topic/child-
health/immunization/
Oral
rehydration
with continued
feeding for
diarrhea
treatment
Percentage of children under age five ill with
diarrhea during the two-week period before the
survey and, among children ill with diarrhea, the
percentage who received ORT and continued
breastfeeding.
UNICEF Global
Database
https://data.unicef.org/topic/child-
health/diarrhoeal-disease/
Oral
rehydration
salts for
diarrhea
treatment
Percentage of children under age five ill with
diarrhea during the two-week period before the
survey and, among children ill with diarrhea, the
percentage who received ORS (ORS packet or
pre-packaged ORS fluid).
UNICEF Global
Database
https://data.unicef.org/topic/child-
health/diarrhoeal-disease/
Care seeking
for suspected
pneumonia
Percentage of children under age five with
symptoms of acute respiratory illness (ARI)
during the two-week period before the survey
and, among children with symptoms of ARI, the
percentage who were taken to an appropriate
health provider.
World Bank https://data.unicef.org/topic/child-
health/pneumonia/
Use of
improved
drinking water
sources
Percentage of the population using improved
drinking water sources (piped on premises or
other improved drinking water sources).
Joint Monitoring
Programme for
Water and
Sanitation
http://www.wssinfo.org/data-estimates/
Use of
improved
sanitation
facilities
Percentage of the population using improved
sanitation facilities.
Joint Monitoring
Programme for
Water and
Sanitation
http://www.wssinfo.org/data-estimates/
Total
Population
Total population of a country counting all
residents, regardless of legal status of
citizenship.
World Bank http://data.worldbank.org/indicator/SP.P
OP.TOTL
Population
Growth
Annual population growth rate, expressed as a
percentage.
World Bank http://data.worldbank.org/indicator/SP.P
OP.GROW
Urban
Population
Percentage of people living in urban areas as
defined by national statistical offices.
World Bank http://data.worldbank.org/indicator/SP.U
RB.TOTL.IN.ZS
Human A summary measure of average achievement in United Nations http://hdr.undp.org/sites/default/files/20
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Web Appendix 3Development
Index
key dimensions of human development: life
expectancy at birth, education (mean years of
schooling and expected years of schooling) and
gross natural income per capita. The HDI ranges
between 0 and 1 and higher HDI values indicate
higher levels of human development.
Development
Programme
15_human_development_report.pdf
GDP per capita
(US$)
Gross domestic product (GDP) is the sum of
gross value added by all resident producers in
the economy plus any product taxes and minus
any subsidies not included in the value of
products. Data are in current U.S. dollars.
World Bank http://data.worldbank.org/indicator/NY.G
DP.PCAP.CD
GINI Index Measures the extent to which the distribution of
income (or, in some cases, consumption
expenditure) among individuals or households
within an economy deviates from a perfectly
equal distribution. A GINI index of 0 represents
perfect equality, while an index of 100 implies
perfect inequality.
World Bank http://data.worldbank.org/indicator/SI.PO
V.GINI
Fertility rate
(average births
per woman)
Total fertility rate represents the number of
children that would be born to a woman if she
were to live to the end of her childbearing years
and bear children in accordance with age-
specific fertility rates of the specified year.
World Bank http://data.worldbank.org/indicator/SP.D
YN.TFRT.IN?
Adolescent
fertility rate
(births per
1000 women
aged 15-19)
Adolescent fertility rate is the number of births
per 1,000 women ages 15-19.
World Bank http://data.worldbank.org/indicator/SP.A
DO.TFRT
Age at first
marriage
(female, mean)
The average length of single life expressed in
years among those females who marry before
age 50.
World Bank
Gender Statistics
http://databank.worldbank.org/data/repo
rts.aspx?source=gender-
statistics&Type=TABLE&preview=on
Age at first
birth (median,
ages 25-49)
Percentage of women ages 25-49 median age at
first birth.
Demographic
Health Survey
https://dhsprogram.com/What-We-
Do/survey-
search.cfm?pgtype=main&SrvyTp=country
Female adult
literacy rate (%
of females ages
15 and above)
Percentage of the female population age 15 and
above who can, with understanding, read and
write a short, simple statement on their
everyday life.
World Bank http://data.worldbank.org/indicator/SE.A
DT.LITR.FE.ZS
Female youth
literacy rate (%
of females ages
15-24)
Percentage of females ages 15-24 who can both
read and write with understanding a short
simple statement about their everyday life.
World Bank http://data.worldbank.org/indicator/SE.A
DT.1524.LT.FE.ZS
Male youth
literacy rate (%
of males ages
15-24)
Percentage of males ages 15-24 who can both
read and write with understanding a short
simple statement about their everyday life.
World Bank http://data.worldbank.org/indicator/SE.A
DT.1524.LT.MA.ZS
Density of
physicians,
Density of physicians, nurses and midwives per
10 000 population.
Global Health
Observatory
http://apps.who.int/gho/data/node.main.
A1444?lang=en
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Web Appendix 4nurses and
midwives (per
10,000)
Figure 1: Mortality Trends in South Asian Countries, 1990-2015
A) Stillbirth
0
10
20
30
40
50
60
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Sti
llb
irth
ra
te (
pe
r 1
00
0 t
ota
l b
irth
s)
Year
Afghanistan
Bangladesh
Bhutan
India
Maldives
Nepal
Pakistan
Sri Lanka
Global
South Asia
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Web Appendix 5
B) Neonatal
0
10
20
30
40
50
60
70
80
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
Ne
on
ata
l d
ea
ths
pe
r 1
00
0 l
ive
bir
ths
Year
Afghanistan
Bangladesh
Bhutan
India
Maldives
Nepal
Pakistan
Sri Lanka
Global
South Asia
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Web Appendix 6Figure 2: Causes of Death in South Asian Countries, 2015
A) Maternal
B) Neonatal
30.2
41.7
7.4 10.3 13.78.0
38.9
24.3
10.7
6.5
3.9
2.2
6.67.2
3.9
1.6
7.2
3.5
17.1
17.6
21.3
18.5
20.4
13.4
21.6
22.2
6.8
8.5
5.7
6.1
14.6
22.8
21.1
1.312.2
1.1
11.5
11.2
16.0
13.0
14.2
5.6
15.0 10.3
51.5
11.26.1
6.7
11.5
9.2
24.4
8.86.9
4.4
2.4 1.6
3.4
2.4
1.5
3.1
0.72.9
0.4
0.8
12.2
36.8
23.0
10.9
20.512.1 14.0
21.5
11.9
0.0 0.0 0.1 0.1 0.0 0.0 0.0
0
10
20
30
40
50
60
70
80
90
100Maternal deathsaggravated by HIV/AIDS
Other maternal disorders
Late maternal deaths
Indirect maternal deaths
Maternal abortion,miscarriage, and ectopicpregnancyMaternal obstructed laborand uterine rupture
Maternal hypertensivedisorders
Maternal sepsis and othermaternal infections
Maternal hemorrhage
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C) Post-Neonatal
6.0 6.5 6.0 4.9 5.2 2.6 5.8 5.9 3.1
35.2 32.4 30.3 35.842.6
39.5 31.339.0
36.2
23.6 26.2
22.720.8
19.4
10.5 23.2
21.1
12.5
15.018.0
20.4 17.3
14.4
7.9
18.7
17.7
3.9
1.32.3
0.5 0.40.9
0.0
0.7
2.6
1.5
7.0
7.0
7.2 6.25.7
10.5
6.8
6.6
16.9
11.46.3
12.1 14.2 11.0
28.9
12.95.8
25.8
0.7 1.2 0.7 0.4 0.7 0.0 0.7 1.3
0
10
20
30
40
50
60
70
80
90
100
Global Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka
Diarrhea
Congenital
Other disorders
Tetanus
Sepsis/meningitis
Intrapartumrelated events
Preterm
Pneumonia
23.328.1 28.8 26.1 28.4
13.8
29.5 26.5
9.9
3.4
4.2 3.34.3
4.9
3.4
2.82.9
4.0
1.8
1.0 1.7 1.61.2
6.9
2.32.5
2.8
3.5
4.1 4.12.7
4.2
3.4
4.22.8
1.8
20.1
24.3 22.4 27.1 17.8
27.6
18.2 25.1
30.9
6.3
4.0 3.86.9
6.0
31.0
4.04.3
30.615.6
19.514.8
13.3 22.2
3.4
14.3
19.6
4.5
2.3
1.7
5.0 0.5
4.50.0
2.6
1.6 0.010.0
11.1 14.5 13.87.8 10.3
14.9
11.9 12.99.4
0.0 0.60.0 1.3
0.00.1 0.02.6 0.1 0.0 3.2 0.8
0.80.1 0.51.7 1.8 1.0 0.8
6.42.6 2.1
0
10
20
30
40
50
60
70
80
90
100
Global Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka
Pertussis
AIDS
Malaria
Injury
Measles
Diarrhea
Congenital
Other disorders
Meningitis
Intrapartumrelated eventsPreterm
Pneumonia
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Web Appendix 8Figure 3: Malnutrition Trends in South Asian Countries
Note: Baseline is the earliest estimate between 1999-2004; current is the most recent estimate between 2009-2015
A) Child Wasting
B) Child Underweight
8.6
12.5
17.1
13.4
11.3
14.2
15.5
9.5
14.3
5.9
15.1
10.211.3
10.5
21.4
0
5
10
15
20
25
Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka
Wa
stin
g P
rev
ale
nc
e (
%)
Baseline Current
32.9
42.3
46.3
25.7
43
31.3
22.825
32.6
12.8
29.4
17.8
30.131.6
26.3
0
5
10
15
20
25
30
35
40
45
50
Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka
Un
de
rwe
igh
t P
rev
ale
nc
e (
%)
Baseline Current
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