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p. 6 of 27 BACK | NEXT Executive summary Introduction Regional health context Health status Major trends in the health sector Financing of health services Global commitments to the health sector The Bank’s involvementin the health sector Issues and options The Bank’s health policy

Policy for the Health Sector : Regional health context

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Health status

Changes in health status

Health conditions in the Asian and Pacific region have dramatically improved over the last 35 years. The under-five mortality rate declined 60 percent from 225 per 1,000 live births in 1960 to 88 per 1,000 in 1995. This rate of decline is unprecedented in the history of the region. Similarly, life expectancy at birth in the DMCs has increased 39 percent from 46 years in 1960 to 64 years in 1995 (see Figure 1). Improved health status, particularly the decline in under-five mortality, has been accompanied by a substantial decrease in fertility. The total fertility rate has decreased 47 percent from 5.9 children per woman in 1960 to 3.1 children in 1995. While much work remains to be done in the area of population, previous success, such as that enjoyed by Indonesia, Republic of Korea, Sri Lanka, Thailand, and Viet Nam allow for optimism that further fertility reduction is possible.

Despite the impressive progress made in the physical well-being of its population, the region still faces serious challenges in the health sector, including the following:

1. Child mortality rates in the DMCs, particularly South Asia, are higher than in any other region in the world, except Sub-Saharan Africa. Every year in the region, more than 7 million children under age five years die, and almost all of these deaths are preventable.

2. The aggregate trends hide the fact that the progress over the last 35 years has been fragmentary. There are countries, such as the People’s Republic of China (PRC), Sri Lanka, and Viet Nam that have made dramatic improvements in the

   health of their populations. There are other countries, however, where progress for a variety of reasons has been considerably slower. In Cambodia, for example, years of war destroyed its health care system and left it with a high child mortality rate. Census data from Papua New Guinea indicates that the infant mortality rate (IMR) has actually increased since 1981.

3. Even within countries that on average enjoy good overall health status, there are large pockets of ill health. For example, the PRC has achieved remarkable gains over the last 35 years; however, in the poorest 9 percent of counties of the PRC, comprising a population of about 100 million, the IMR is three times higher than the national average.³

4. Malnutrition, particularly in South Asia, remains rampant. The subcontinent contains 75 percent of all the malnourished children in the world, and the proportion of its children who are moderately or severely underweight, at 51 percent, is 70 percent higher than in Sub-Saharan Africa.⁴

5. The ongoing economic crisis in many DMCs is endangering the health of the poor, because of reduced incomes, loss of health insurance coverage (for laid-off workers), and the rising prices of essential supplies. For example, in Indonesia, the cost of X-ray films increased by 400 percent in the last year. At the same time, governments’ ability to address these challenges is being hampered by the tightening fiscal situation.

6. Life expectancy in the Central Asian republics has declined since 1987.⁵

7. There are still countries, such as the Marshall Islands and Pakistan, that have fertility rates so high as to interfere with sustainable economic growth. With huge cohorts of children born each year, the ability of these countries to provide minimal health and education services to their children is being overwhelmed. Sick and uneducated children imply a mortgaged future.

Much of the reason for the dramatic improvements in health that have been observed in the region is increased access to health services. Other factors have played a role in improving health but the effect of each one, individually, is uncertain. For example, investments in water and sanitation may have contributed to improved health but there remains considerable controversy about the size of the effect, if any. An analysis of changes in life expectancy in 94 developing countries ascribed half of the improvement to socio-economic development. The other half of the improvement was attributed to the provision of preventive and curative health services.⁶ This conclusion is strengthened by the fact that all the newly industrialized economies of East Asia had very low IMRs before their economies took off. In the latter part of this century, rapid economic growth has followed, rather than preceded improvements in health (see Box 1).

Box 1: Improvements in health and economic take-off All of the newly industrialized economies of East Asia had very low infant mortality rates prior to their economic take-off. For example,in Singapore declines in the infant mortality rate (IMR) to the level of developed countries occurred before its spectacular growth in gross domestic product (GDP)(see Figure B1.1). The same pattern is observed in the other newly industrialized economies of East Asia (see Table B1.1).The temporal relationship between economic growt hand the improvements in health observed in the newly industrialized economies has an important logical implication. In the latter part of the 20th century, economic take-off is NOT responsible for dramatic improvements in health status because it occurred after the large declines had taken place. Waiting for economic growth to improve health status ignores the observed temporal relationship.

Regardless of the importance of other factors, there is no disagreement about the striking improvements that have been achieved in the provision of health services. While reliable data from the 1960s are not available, even figures from 1980 indicate the large improvements that have occurred in access to health care. For example, in Indonesia between 1980 and 1995, measles immunization rates for children increased from 5 to 70 percent. During the same period access to health services (defined as being able to reach appropriate health services within one hour using the usual local means of transportation) improved from 75 to 93 percent. For all of Asia and the Pacific, the ratio of doctors to population decreased from 1:11,000 in 1970 to 1:4,500 in 1990.⁷

The health of the poor

The poor in the region, as elsewhere, suffer from much worse health than their wealthier compatriots. For example, the lowest income quintile in the Lao People’s Democratic Republic (Lao PDR) experiences an IMR that is 2.8 times that of the wealthiest income quintile (see Figure 2). Similarly in the PRC, the poorest income quartile has an IMR that is 2.4 times that of the wealthiest quartile. Much of the observed difference is due to higher rates of infectious diseases among the poor and their limited access to basic health services. In the PRC the poorest-income quartile suffers from an incidence of infectious diseases that is 2.9 times that found among the wealthy. The distance the poor have to travel to obtain modern health services is also greater. In Pakistan, the poorest-income quintile have to travel 39 percent further to get to a health facility than the average citizen, and coverage of prenatal care for poor women is less than one third of that for wealthy women.

Not only do the poor suffer from adverse health conditions, they also face more serious consequences as a result of ill health. As they are more dependent on their physical labor and have fewer savings, the economic effects of illnesses on the poor are more severe and frequent. For example, in Bangladesh, 27 percent of poor urban households indicated that they had faced a financial crisis during the previous year, and in 47 percent of the cases, the crisis arose from the illness of a family member and the expenses that were incurred. Similarly, the Grameen Bank has found that ill health is the single most important cause of default among its borrowers. The economic consequences of illness on the poor are, to a large extent, preventable because the diseases that they suffer from disproportionately are amenable to prevention or cure at low cost.

In spite of the benefits to be derived from concentrating public health expenditures on the poor, most public subsidies in the Bank’s DMCs are being captured by the upper-income groups. For example in Indonesia, the wealthiest and the poorest quintiles capture 28 and 10 percent of all public subsidies for health and 41 and 5 percent of subsidies for public hospitals (see Figure 3). The Asian economic crisis may exacerbate this problem as the nonpoor switch from private to public hospital care. Since hospital care accounts for the majority of the public health budget across Asia, increasing the proportion of subsidies for hospitals that are captured by the poor poses an important challenge.

Women’s health

Throughout their lives, women face serious health problems, and specific efforts to improve their health are of recent origin and limited success. The lack of progress in improving the health of women is exemplified by the absence of a significant downward trend in maternal mortality ratios (MMRs) in the DMCs. While under-five mortality rates and life expectancy have improved considerably, there has been little change in the MMRs. For example, in Bangladesh from 1972 to 1992, under-five mortality was cut in half, the total fertility rate declined by one third, but the MMR remained virtually unchanged. It is also in the area of maternal mortality where developing Asia is lagging furthest behind industrialized countries. With an average of 410 deaths per 100,000 live births, the DMCs have an MMR that is 32 times higher than the average for developed countries. By comparison, the average under-five mortality rate is 11 times higher than in the industrialized economies.

Women’s health status is affected by complex biological, social, and cultural factors; however, there are some common issues that cut across most of Asia.First,womensuffer from widespread discrimination as witnessed by the deficits in the female population arising from excessive female mortality. It is estimated that there are 29 million and 23 million such “missing” women in the PRC and India, respectively.⁸ The problem is pronounced among children in South Asia (see Box 2). Second, women have less access to family resources and generally are financially constrained when they become seriously ill. Third, women often find that the public health care system is insensitive to their needs in

Box 2: Hidden mortality among young girls Household surveys in Bangladesh, India, and Pakistan indicate that child mortality rates for girls are higher than for boys. They should not be. Girls should have a lower rate due to their biological advantage. Using comparisons with developed countries when they had similar mortality rates, it is possible to estimate what the size of that advantage ought to be (Figure B2.1). The data indicate that girls in the three countries suffer a substantial disadvantage, particularly from ages one to four. Part of the reason for the hidden mortality includes small but consistent differences in use of health services and in nutritional status (Table B2.1). However, as the example of Sri Lanka suggests, high female literacy rates and greater gender equality can restore the natural advantage of young girls.

The consequences of ill health among women are felt not just by the individuals directly affected but also by their families. To a large ex-tent, the well-being and proper development of children depends on the health of their mother. In Bangladesh, children (especially girls) are much more likely to die if their mother dies than if their father dies or neither parent dies.⁹ Similarly, women in the region are often responsible for looking after the elderly, and the health and well-being of the latter is thus dependent on women remaining healthy themselves. Women’s contribution to the economic well-being of the family is substantial but only partly reflected in official statistics. Besides household work, women are often responsible for producing food. Loss of income resulting from illness may be particularly deleterious because women tend to spend a much greater proportion of their earnings on consumption by dependent family members.

The health of indigenous peoples

Though often discussed, there is little reliable information on the health status of indigenous ethnic minorities in the region. What information exists suggests that there is a significant problem. In Viet Nam, indigenous peoples suffer an IMR that is between 1.75 and 2.75 times higher than ethnic Kinh (Vietnamese). In Lao PDR, the IMR among the Lao Theung and Lao Sung is 30 percent higher than among lowland Lao (Lao Loum) and chronic malnutrition (stunting) is 31 percent more prevalent among the former. Part of the explanation for the poorer health status among the ethnic groups is that they tend to live in very remote rural areas where they have little physical access to health services. In Lao PDR, the Lao Theung and Lao Sung have to spend 65 percent more time to get to a health facility than the Lao Loum. While physical access is important, there are other impediments that limit access to services, such as the shortage of indigenous health workers. Ethnic minorities also tend to rely more heavily on traditional practitioners and have had less exposure to information about modern medicine. For example, 91 percent of lowland Lao women knew about modern methods of contraception, compared with only one third of indigenous women.

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