There are multiple approaches to understanding the magnitude of health inequities and what contributes to them. This report will primarily focus on analysing available quantitative data and applying new statistical methods to determine the magnitude of health inequities in South-East Asia, as well as unpacking the contribution of factors to such inequities. The latter will, in principle, assist policy-makers in identifying priority areas for action with respect to reducing health inequities.
World Health House Indraprastha Estate Mahatma Gandhi Marg New Delhi-110002, India 789290 223429 Health inequities in the South-East Asia Region: Selected country case studies Poor people encounter high rates of illness and premature deaths from preventable causes and are thus more vulnerable to disease In the WHO South-East Asia Region, many Member countries carry a significant proportion of the total burden of disease in the Region Available evidence indicates that inequalities in social and economic determinants of health exist both within and across countries in the Region The less educated, marginalized, women, children and the elderly living in rural areas and urban slums carry a conspicuous burden of disease The report is a compilation of data analysis from seven countries of the SEA Region; namely, Bangladesh, India, Indonesia, Maldives, Nepal, Sri Lanka and Thailand The analysis has been conducted concurrently with the work of the Commission on Social Determinants of Health (CSDH) The analysis reveals a strong association between a wide gamut of social and economic inequalities and health inequities It shows how health inequities relate not only to immediate material or psychosocial circumstances of the individual but also to structural factors, including government social welfare policies, quality of governance and other issues such as the power and clout that an individual wields in society Ultimately, addressing inequities in health requires a social justice approach to improve the circumstances of the poor The work of the WHO Commission on Social Determinants of Health (CSDH) including the Knowledge Networks complements publication Health inequities in the SouthEast Asia Region: selected country case studies Health inequities in the South-East Asia Region: selected country case studies Health inequities in the South-East Asia Region: selected country case studies WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia Health inequities in the South-East Asia Region: selected country case studies Delivery of health care Health status indicators Thailand Health services accessibility Socioeconomic factors Bangladesh India Nepal Sri Lanka ISBN 978-92-9022-342-9 (NLM classification: WA 30) © World Health Organization 2009 All rights reserved Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from Publishing and Sales, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publications@searo.who.int) The designations employed and the presentation of the material in this publication not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries Dotted lines on maps represent approximate border lines for which there may not yet be full agreement The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication However, the published material is being distributed without warranty of any kind, either expressed or implied The responsibility for the interpretation and use of the material lies with the reader In no event shall the World Health Organization be liable for damages arising from its use This publication does not necessarily represent the decisions or policies of the World Health Organization Printed in India Ackowledgements This publication was prepared for the World Health Organization’s Regional Office for SouthEast Asia (WHO/SEARO) as a joint collaboration between WHO/SEARO [Department of Noncommunicable Diseases (NMH), Health Promotion and Education Unit (HPE)], and WHO headquarters (HQ) [Department of Ethics, Equity, Trade and Human Rights (ETH)] The International Health Policy Programme (IHPP), Thailand; the Institute of Health Policy (IHP), Sri Lanka and Health Research Associates (HRA), Sri Lanka conducted health equity analyses in Bangladesh, India, Indonesia, Nepal and Sri Lanka using the Demographic Household Survey data The first report on regional health inequities was compiled by the Institute of Health Policy (IHP), Sri Lanka Technical support for the final report was provided by ETH, WHO/HQ Several WHO staff at both WHO/SEARO and WHO/HQ were involved in the review of the draft of this publication—their inputs are greatly appreciated The draft was thoroughly discussed at the Regional Consultation on Social Determinants of Health, held in Colombo, Sri Lanka, from 2-4 October 2007 iii Contents Acknowledgements .iii Executive summary ix Introduction 1.1 Objectives 1.1.1 Describing the magnitude of health inequities 1.1.2 Identifying the determinants of health inequities 1.2 Country context 1.3 Health situation in countries Health inequities: concepts and measurement 2.1 Health inequities, inequalities and social justice 2.2 Measurement of health inequities 10 2.2.1 Health measures 10 2.2.2 Equity stratifiers 11 2.2.3 Measures of inequity / inequality 11 Methods 3.1 Conceptual framework 13 3.2 Data 14 3.3 Indicators 16 3.4 Analytical Approach 16 3.4.1 Descriptive 16 3.4.2 Time trends 17 3.4.3 Decomposition of socioeconomic inequality 17 3.5 Interpretation approach 17 Contents v Health inequities: magnitude and trends 4.1 Inequities in health outcomes within and across countries 19 4.1.1 Infant mortality 19 4.1.2 Under-five mortality 21 4.1.3 Prevalence of stunting in children under five 22 4.1.4 Prevalence of underweight women 23 4.1.5 Prevalence of overweight women 24 4.2 Inequities in health systems variables within and across countries 25 4.2.1 Coverage of DPT3 vaccination 25 4.2.2 Coverage of skilled birth attendance 27 4.2.3 Use of modern contraception 28 4.3 Inequities in key health determinants within and across countries 29 4.3.1 Exposure to safe water 30 4.3.2 Exposure to safe sanitation 31 Identifying determinants of health inequities 5.1 Main contributors to inequities in skilled birth attendance 34 5.2 Main contributors to inequities in childhood stunting 36 Discussion 6.1 Overall magnitude and trends in health inequities 39 6.2 Key discussion points from the skilled birth attendance analysis 40 6.3 Key discussion points from the child malnutrition analysis 40 6.4 Limitations of the analysis 40 6.5 Key implications for policy and actions 41 6.5.1 The role of the health sector 41 6.5.2 Intersectoral action for health 41 6.5.3 Improving food security and reducing poverty 42 6.5.4 Knowledge exchange and sharing between countries 42 vi Health inequities in the South-East Asia Region Annexures Technical notes and definitions (A) Household wealth index 43 (B) Measures of inequality in health 44 Country reports Bangladesh 49 India 57 Indonesia 63 Nepal 71 Sri Lanka 81 Thailand 87 Reference 92 Appendix 93 Statistical Annex Inequities in health determinants and outcomes by equity stratifiers 113 Contents vii Executive summary People who are economically or socially disadvantaged suffer from worse health, on average, than their better-off counterparts There is no great mystery as to why this happens Poor people, especially in low-income countries, encounter high rates of illness, particularly infectious disease and malnutrition, because of lack of food, unclean water, low levels of sanitation and shelter, failure to deal with the environments that lead to high exposure to infectious agents and lack of appropriate medical care An increasing share of the burden of noncommunicable diseases among the poor is an emerging concern The South-East Asia (SEA) Region consists of a number of countries who are not only poor but also shoulder a significant proportion of the global disease burden For instance, countries in this Region account for two-thirds of the global burden of child malnutrition, and next to subSaharan Africa account for the highest number of maternal deaths Additionally, it is the poor, the less educated and people living in rural areas within these countries who mostly suffer the brunt of this burden Not only is this an issue of social justice, but countries in which high health inequities exist lose the opportunity to benefit from the skills, ideas and productive capacity of large sections of their populations This raises the question of what action can be taken at different levels –individual, community, government – to tackle these inequities Operationally, the important question would be how and through what mechanisms can government, as a whole, and civil society work together to reduce health inequities The Commission on Social Determinants of Health (CSDH) was established with a mandate to provide recommendations on strategies to tackle these inequities Its final report is due in 2008 The report will focus on the available evidence on inequities in health and inequalities in socioeconomic determinants that exist both within and across countries in the Region Data from seven countries have been analysed – Bangladesh, India, Indonesia, Maldives, Nepal, Sri Lanka and Thailand The analysis reveals a strong association between a variety of social and economic inequalities and health inequities It also shows how health inequities relate not only to immediate material or psychosocial circumstances of the individual, but also to structural factors, including a government’s social welfare policies, quality of governance, and other issues like the power and prestige an individual possesses within society Executive summary ix Table 16: Disparity ratios of women’s health between the highest and lowest socioeconomic status Teenage pregnancy Ante natal care by skilled health provider Skilled health personnel Health care facility 37.3% 97.8% 97.3% 96.8% 72.6% Higher: No education 0.09 1.10 1.23 1.28 1.10 Q 5: Q income per capita 0.55 1.03 1.05 1.05 0.86 Q 5: Q wealth index 0.51 1.04 1.08 1.08 0.89 Municipal: Non-municipal 0.76 1.00 1.03 1.04 0.92 Prevalence or coverage Delivery Modern contraception Disparity ratios Annex Country reports 111 Inequities in health Statistical Annex determinants and outcomes by equity stratifiers Fig SA Inequities in DPT3 vaccination by mother’s education by country Percentage [DPT vaccination] No Education 100 86 79 80 40 87 96 91 Average 97 84 87 89 76 60 40 +Secondary 64 63 66 NEP-01 BAN-97 BAN-00 85 86 SRL-93 SRL-00 69 48 47 20 21 IND-98 INO-97 INO-03 NEP-96 BAN-04 Fig SA Inequities in DPT3 vaccination by urban/rural residence by country Percentag e [DPT vaccination] Urban Rural Average 100 80 73 77 75 78 82 86 75 89 82 87 89 80 65 72 60 69 70 BAN-97 BAN-00 59 40 50 IND-98 INO-97 53 52 INO-03 NEP-96 NEP-01 BAN-04 SRL-93 SRL-00 113 Percentage [skilled birth attendance] Fig SA Inequities in skilled birth attendance by mother’s education by country No Education Secondary Average 100 94 83 80 60 79 73 68 64 98 98 83 55 40 29 30 32 25 20 15 NEP-96 NEP-01 BAN-97 BAN-00 BAN-04 IND-98 INO-97 INO-03 SRL-93 SRL-00 Percentage [skilled birth attendance] Fig SA Inequities in skilled birth attendance by urban/rural residence by country Urban Rural Average 100 99 73 80 60 47 55 33 30 20 NEP-96 84 70 35 10 NEP-01 98 79 51 40 76 BAN-97 31 IND-98 INO-97 BAN-00 33 BAN-04 INO-03 SRL-93 SRL-00 Percentage [use of modern contraception] Fig SA Inequities in use of modern contraception by mother’s education by country 114 No Education Secondary Average 80 60 42 46 47 45 47 39 40 42 34 IND-98 BAN-97 BAN-00 65 57 58 39 43 45 SRL-00 INO-97 INO-03 48 48 40 20 49 35 25 NEP-96 NEP-01 Health inequities in the South-East Asia Region BAN-04 SRL-93 Percentage [use of modern contraception] Fig SA Inequities in use of modern contraception by urban/rural residence by country Urban Rural Average 100 80 60 56 45 51 49 40 42 46 BAN-97 BAN-00 BAN-04 40 20 33 52 53 40 56 48 55 57 57 INO-97 INO-03 55 42 37 24 NEP-96 NEP-01 IND-98 SRL-93 SRL-00 Infant mortality rate per 1000 live births Fig SA Inequities in infant mortality rates by mother’s education by country No education 100 98 85 Secondary 98 87 92 81 Average 78 80 67 60 40 45 65 53 57 55 26 33 20 28 23 11 NEP-96 NEP-01 IND-98 BAN-97 BAN-00 BAN-04 INO-97 INO-03 18 14 SRL-93 SRL-00 Infant mortality rate per 1000 live births Fig SA Inequities in infant mortality rates by urban/rural residence by country Urban 100 95 79 80 Rural 91 81 80 73 60 Average 75 72 58 52 61 48 61 40 50 49 36 20 32 21 15 SRL-93 SRL-00 NEP-96 Statistical Annex NEP-01 IND-98 BAN-97 BAN-00 BAN-04 INO-97 INO-03 Inequities in health determinants and outcomes by equity stratifiers 115 Under mortality rate per 1000 live births Fig SA Inequities in under-five mortality rates by mother’s education by country No Education 180 149 150 Secondary 145 121 Average 130 123 113 120 108 90 90 62 60 78 15 70 67 61 30 37 32 35 28 20 INO-97 INO-03 SRL-93 NEP-96 NEP-01 IND-98 BAN-97 BAN-00 BAN-04 15 SRL-00 Under mortality rate per 000 live births Fig SA 10 Inequities in under-five mortality rates by urban/rural residence by country Urban Rural Average 180 150 143 131 112 120 113 112 98 90 60 84 79 96 97 65 92 82 52 66 65 48 30 42 26 NEP-96 NEP-01 IND-98 BAN-97 BAN-00 BAN-04 INO-97 INO-03 SRL-93 17 SRL-00 Fig SA 11 Inequities in prevalence of childhood stunting by mother’s education by country Percentage [prevalence of stunting] No Education + Secondary Average 80 60 55 54 61 52 52 51 46 36 40 31 20 28 17 15 NEP-96 116 29 25 NEP-01 IND-98 BAN-97 Health inequities in the South-East Asia Region BAN-00 BAN-04 13 10 SRL-93 SRL-00 Fig SA 12 Inequities in prevalence of childhood stunting by urban/rural residence by country Percentage [prevalence of stunting] Urban Rural Average 80 60 49 54 56 52 47 49 44 34 40 37 35 39 36 38 35 20 17 NEP-96 NEP-01 IND-98 BAN-97 BAN-00 BAN-04 SRL-93 SRL-00 Fig SA 13 Inequities in prevalence of maternal underweight by mother’s education by country Percentage [women underweight] No Education + Secondary Average 80 60 58 52 43 40 40 29 38 30 38 30 20 17 20 BAN-04 NEP-96 13 18 17 IND-98 SRL-00 BAN-97 BAN-00 NEP-01 Fig SA 14 Inequities in prevalence of maternal underweight by urban/rural residence by country Percentage [women underweight] Urban Rural Average 80 60 54 50 49 39 37 40 29 28 36 36 30 20 25 23 17 15 BAN-97 Statistical Annex BAN-00 BAN-04 NEP-96 NEP-01 IND-98 SRL-00 Inequities in health determinants and outcomes by equity stratifiers 117 Fig SA 15 Inequities in prevalence of maternal overweight by mother’s education by country Percentage [women overweight] No Education + Secondary Average 40 35 27 26 30 19 20 10 5 IND-98 BAN-04 NEP-01 SRL-00 Fig SA 16 Inequities in prevalence of maternal overweight by urban/rural residence by country Percentage [women overweight] Urban Rural Average 40 36 30 24 20 20 11 10 10 5 IND-98 BAN-04 NEP-01 SRL-00 Fig SA 17 Inequities in access to safe water by urban/rural residence by country P ercentage [A ccess to safe w ater] 2Urban 118 100 Rural 96 91 72 40 99 97 93 89 80 60 Average 99 99 95 96 97 BAN-97 BAN-00 BAN-04 76 65 75 75 68 48 20 INO-03 INO-97 SRL-00 NEP-96 Health inequities in the South-East Asia Region NEP-01 IND-98 P ercen tage [A ccess to safe san itation ] Fig SA 18 Inequities in access to safe sanitation by urban/rural residence by country Urban 100 Rural 83 80 80 71 49 55 41 38 25 22 NEP-01 IND-98 91 74 79 28 20 71 56 60 40 75 Average 37 14 NEP-96 Statistical Annex BAN-97 BAN-00 BAN-04 INO-97 INO-03 SRL-00 Inequities in health determinants and outcomes by equity stratifiers 119 120 Health inequities in the South-East Asia Region 97 61 India (2) Indonesia (3) 35 Sri Lanka (6) Thailand (7) 86 Nepal (5) Maldives (4) 90 Bangladesh (1) 27 88 50 81 66 30 77 44 76 75 19 73 36 55 59 Q4 14 53 17 38 65 Q5 31 42 130 77 141 121 34 125 64 118 98 Q2 32 104 56 101 97 Q3 25 97 45 70 81 Q4 14 68 22 46 72 Q5 Q1 Q3 Q1 Q2 Under-five mortality rate (per 1,000 live births) Infant mortality rate (per 1,000 live births) 16 30 61 53 55 Q1 13 26 50 49 46 Q2 13 19 50 45 41 Q3 12 47 39 37 Q4 33 28 26 Q5 Prevalence of stunting in children under five years (%) Health Outcome Indicators 27 50 46 Q1 30 47 39 Q2 33 41 34 Q3 29 30 30 Q4 15 15 17 Q5 Prevalence of underweight women (%) Q1 Q2 Q3 12 10 Q4 22 21 25 Q5 Prevalence of overweight women (%) Statistical Annex Inequities in health determinants and outcomes by equity stratifiers 121 36 39 India (2) Indonesia (3) 62 91 93 Nepal (5) Sri Lanka (6) Thailand (7) Maldives (4) 71 Bangladesh (1) Q1 95 97 69 49 43 82 Q2 92 96 72 67 59 82 Q3 94 95 80 63 72 85 Q4 Coverage of DPT3 vaccination (%) 91 98 85 71 85 91 Q5 93 91 36 16 Q1 98 97 52 26 Q2 98 96 10 65 42 10 Q3 99 98 14 78 61 17 Q4 100 99 45 93 84 39 Q5 Coverage of skilled birth attendance (%) Health systems indicators 76 63 24 49 29 45 Q1 77 57 29 58 35 48 Q2 73 49 32 60 45 47 Q3 70 42 39 59 50 47 Q4 68 38 55 58 55 50 Q5 Current use of modern contraception (%) 65 27 74 96 Q1 62 45 77 97 Q2 93 60 79 97 Q3 74 72 84 97 Q4 94 77 88 99 Q5 Exposure to safe water (%) 14 24 Q1 22 19 46 Q2 45 26 63 Q3 63 77 41 79 Q4 93 97 67 90 Q5 Exposure to safe sanitation (%) Health determinants 122 Health inequities in the South-East Asia Region 49 32 India (2) Indonesia (3) 21* Sri Lanka (6) Thailand** (7) 50 Nepal (5) Maldives (4) 72 Bangladesh (1) Urban 24 79 52 80 72 Rural Infant mortality rate (per 1,000 live births) 26* 66 42 65 92 Urban 30 112 65 112 98 Rural Under five mortality rate (per 1,000 live births) 17 37 36 38 Urban 13 23 52 49 44 Rural Prevalence of stunting in children under five years (%) Health Outcome Indicators 17 36 25 Urban 28 39 37 Rural Prevalence of underweight women (%) 24 11 20 Urban 10 Rural Prevalence of overweight women (%) Statistical Annex Inequities in health determinants and outcomes by equity stratifiers 123 73 65 India (2) Indonesia (3) 78 82 91 Nepal (5) Sri Lanka (6) Thailand (7) Maldives (4) 86 Bangladesh (1) 94 87 72 53 50 80 99 99 51 79 73 30 97 95 10 55 33 Rural Urban Urban Rural Coverage of skilled birth attendance (%) Coverage of DPT3 vaccination (%) Health Systems Indicators 68 37 56 57 51 52 Urban 74 46 33 57 40 46 Rural 97 72 76 99 Urban 75 48 89 97 Rural Current use of modern Exposure to safe water contraception (%) (%) 80 74 22 71 Urban 25 37 56 55 Rural Exposure to safe sanitation (%) Health Determinants 124 Health inequities in the South-East Asia Region 71 40 India (2) Indonesia (3) 20 Sri Lanka (6) Thailand (7) 75 Nepal (5) Maldives (4) 64 Bangladesh (1) 31 79 46 75 80 27 112 51 105 91 38 105 58 98 102 Male Female Female Male Under-five mortality rate (per 000 live births) Infant mortality rate (per 1,000 live births) 12 25 52 47 44 Female 12 23 49 44 43 Male Prevalence of stunting in children under five years (%) Health Outcome Indicators Female Male Prevalence of underweight women (%) Female Male Prevalence of overweight women (%) World Health House Indraprastha Estate Mahatma Gandhi Marg New Delhi-110002, India 789290 223429 Health inequities in the South-East Asia Region: Selected country case studies Poor people encounter high rates of illness and premature deaths from preventable causes and are thus more vulnerable to disease In the WHO South-East Asia Region, many Member countries carry a significant proportion of the total burden of disease in the Region Available evidence indicates that inequalities in social and economic determinants of health exist both within and across countries in the Region The less educated, marginalized, women, children and the elderly living in rural areas and urban slums carry a conspicuous burden of disease The report is a compilation of data analysis from seven countries of the SEA Region; namely, Bangladesh, India, Indonesia, Maldives, Nepal, Sri Lanka and Thailand The analysis has been conducted concurrently with the work of the Commission on Social Determinants of Health (CSDH) The analysis reveals a strong association between a wide gamut of social and economic inequalities and health inequities It shows how health inequities relate not only to immediate material or psychosocial circumstances of the individual but also to structural factors, including government social welfare policies, quality of governance and other issues such as the power and clout that an individual wields in society Ultimately, addressing inequities in health requires a social justice approach to improve the circumstances of the poor The work of the WHO Commission on Social Determinants of Health (CSDH) including the Knowledge Networks complements publication Health inequities in the SouthEast Asia Region: selected country case studies Health inequities in the South-East Asia Region: selected country case studies ... 4.3 Inequities in key health determinants within and across countries Inequities in key health determinants mirror the inequities in health outcomes that are found within countries of the South-East. . .Health inequities in the South-East Asia Region: selected country case studies WHO Library Cataloguing -in- Publication data World Health Organization, Regional Office for South-East Asia Health. .. a successful example in the Region for reducing stunting as well as inequities in stunting 22 Health inequities in the South-East Asia Region Fig 13 Prevalence of stunting in SEAR countries (most