Health Status of South Asian Region

By:Bikal Dhungel

South Asia is the poorest region of the world. The largest number of poor people with less than $1.25 a day live in South Asia. It is also the most populous place where over a quarter of world population live. Stretching from Afghanistan to Myanmar, South Asia is politically unstable with dozens of ethnic and regional conflicts. THe region still has hangover of Colonialism with many places either under authoritarian regime or at least a government which care less about its citizens. Geography remains complex. The himalayan mountain range from Myanmar to Afghanistan complicates development process and the lowlands in India and Bangladesh are vulnerable to rising sea level which is currently under threat. Ethnically it is a diverse region with three big religions, Hinduism, Islam and Buddhism and lots of other groups within it. Poverty is rampant and all countries face the same challenges. This article focuses on health sector and gives a basic introduction in a comparable form in five countries, Nepal, India, Bangladesh, Pakistan and Sri Lanka. 

1 -Nepal

Total population (2012)                                                                            27,474,000                                   

Gross National Income per capita (PPP international $, 2012)               1,470

Life expectancy at birth m/f (years, 2011)                                                  67/69

Probability of dying under five (per 1000 live births, 2012)                       42

Probability of dying between 15-60 years m/f (per 1000 population, 2011 183/157

Total expenditure on health per capita (Intl $, 2011)                                    68

Total expenditure on health as % of GDP (2011)                                           5.4

(Source: World Bank, 2013)

Nepalese health expenditure per capita in 2011 was a meager 68$ which is much less than sufficient. However, in terms of total expenditure on health as % of GDP was 5.4% which does not deviate from the expenditure of most developed countries. A 10 year long Civil War destroyed many infra-structures and that drove the country back to many years and impeded further developments.  

Other challenges like the lack of finances, scarcity of skilled health workers and disease burden exists. As a consequence of 10 year long civil war that caused 14,000 deaths and 200,000 internally displaced people, and other difficulties, Nepalese government needs international support. However, Nepal achieved a milestone in health sector since 1990. The absolute poverty which is one of the most important factors for poor health, has decreased from 42% in 1996 to 25.4% in 2009 (Source: FAO). Nepal has emerged as one of the few countries on track to meet MDGs related to reducing maternal and child mortality and making progress on hunger, eradication of HIV/AIDS, malaria and other diseases (USAID). Life expectancy has increased from 48 years in 1980 to 68 in 2012 (World Bank). The following figures show improvement in other health indicators. 

( Source: WHO Health Profile, Nepal, 2012 )

Out of a GDP of 18.7 billion(2010/2011), remittances comprise of 25-30% and foreign aid represents 26% of national budget (Source: Development Gateway website).  The following figures show that out of total aid disbursement of $ 1.08 billion, 129.6 million are for Health or roughly 13% of total amount. UK, Japan, India, US and Norway are the top bilateral partners.

2 – India

Total population (2012)                                                                      1,237,000,000                                                                                                                       

Gross National Income per capita (PPP international $)                  $4307 

Life expectancy at birth (years, 2012)                                                 66 

Total expenditure on health per capita (Intl $, 2012)                         61 

Total expenditure on health as % of GDP (2012)                                4%                                                                      

(Source: World Bank, IMF, WHO data)

India has the 10^th largest GDP of the world (World Bank). With 4.7% growth as per 2012, India is second most populous country in the world with 1.23 billion people ( World Bank, 2012 ) India is culturally similar to Nepal. Hence, the life-style and traditions do not vary tremendously. However, India lies more down to tropical region which makes it more vulnerable to diseases in comparison to Nepal. Additionally, India’s population density was 416 in 2012 (World Bank) and this tendency is increasing rapidly. It is expected that with this growth rate, India will become the most populous country of the world. This also means that demand for healthcare will increase. In the absence of current growth rate of 4.7%, the current level of health infra-structures and workforce including additional budget for Healthcare might not be sufficient to support the system. The following figures concludes some of the recent health developments. 

(Figures taken from WHO website) 

Public Health challenges are likely to increase because of India’s increasing urbanization which potentially put pressure on environmental, as well as nutritional requirement resulting in nutritional deficiency, poor sanitation, increasing communicable and non-communicable diseases etc  (Source: Indian Institute of Public Health )

The Table shows the challenges of health sector in India

-          - Accounts for 21% of global burden of disease -          - High selective gender abortion -          - One of the five countries with lowest public health expenditure in the world -     - The unfinished agenda of health system modernization, including high out of pocket expenditure, insufficiency and uneven distribution of staff, service provision and its quality. -  - Changes in the epidemiological profile, with emergence of cardiovascular and cerebrovascular diseases, metabolic diseases, cancer and mental diseases as first order problems while tuberculosis, AIDS, water-borne diseases and sexually transmitted diseases remain frequent.

Source: WHO ( Country Cooperation Strategy, India 2013 )

Partners of India and main focus area (Source: WHO):

Partners -          DFID, UK -          USAID -          European Commission -          JICA -          UNCT -          UNDAF -          World Bank -          UNICEF -       Global Health Partnerships (eg: Global Fund to fight AIDS, TB and Malaria -          GAVI -          Bill and Melinda Gates Foundation -          Norway India Partnership Foundation -          Oxfam, World Vision, Action Aid, Red Cross

Main Focus Area    Implementing International Health Regulation                           Strengthening Pharmaceutical sector                      Improving stewardship of Health System        Promoting universal health system coverage              Properly accrediting health delivery institutions                      Scaling up reproductive, maternal, newborn, child and adolescent health services

3- Bangladesh:

Total Population (2012):                                               155,000,000                                                                                                    

GNI per capita (2012):                                                   2030

Life expectancy at birth: m/f (2012):                              69/71

Total expenditure on health per capita (2012):                68

Total Expenditure on health as % of GDP (2012):          3.6                                                                      

   (Source: WHO Country Info, Bangladesh, 2012) 

Following figures summarizes the basic health indicators of Bangladesh. 

Under-5 mortality was brought below 50 in 2010 from 180 in 1990, stunted children was almost halved and per capita expenditure increased from below 20 to 70 in only 15 years. These basic indicators show a huge improvement in Bangladeshi health sector.

Bangladesh has made considerable progress in recent decades in improving the health of its people. The population growth rate has declined, life expectancy at birth has increased, infant and under-five mortality rates and maternal mortality ratio have decreased, and a demographic transition is beginning to emerge (WHO)

One of the major causes of death, Malaria is also decreasing in number however, challenges remain. However, Bangladesh is prone to natural disasters such as floods and cyclones that lead to outbreaks of communicable diseases. During the floods of 2004, more than 400000 people suffered from different diseases in the aftermath and required treatment (WHO). The health system must be strengthened, both in terms of its preparedness and response capability, to cope with this scale of emergency. 

Bangladesh is especially vulnerable to cyclones because of its location at the triangular shaped head of the Bay of Bengal (Source: Nat Hazards), the sea-level geography of its coastal area, its high population density and the lack of coastal protection system. About 40% of the total global storm surges are recorded in Bangladesh (Source: WHO Bulletin)

Major challenges of Bangladesh’s Healthcare (Source: WHO)

-          Combating major communicable diseases

-          Containing the increasing the trend of major NCDs and reversing the trend

-          Ensuring equitable and sustainable access to safe water and sanitation, and promoting environmental and occupational health.

-          Strengthening epidemic alert, emergency preparedness and response

-          Strengthening human resources for health development

Major partners in Healthcare (source: OECD)

-          World Bank

-          Asian Development Bank

-          Germany

-          Netherlands

-          Canada

-          Japan

-          Sweden

-          Switzerland

-          IFAD

-          USA

-          Denmark

-          Norway

-          Australia

4- Pakistan:

Total Population(2012):                                                                                       179,000,000

GNI per capita ($PPP, 2012):                                                                              2880

Life Expectancy at birth m/f(2012):                                                                       64/66

Probability of dying under five (per 1000 live births, 2012):                                    86

Total expenditure on health per capita($, 2012):                                                     91

Total expenditure on health as % of GDP (2012):                                                   3.2

                                                                                                

(Source: WHO Country Statistics, 2012)

Following figures summarize basic health indicators. 

Even though child mortality rate decreased from 1990 to 2010, number of children stunted didn’t change from 2000 to 2010. It has slightly increased at that time.

Lying on the laps of Himalaya, Pakistan also consists mostly of mountains and hills like most of Nepal and northern India. 32% of the population live below the poverty line. Geopolitical changes, such as the Afghan war and the situation after 11 September 2001, have affected the country significantly. Globally Pakistan has the third highest burden of maternal, fetal, and child mortality according to WHO.  It has made slow progress in achieving the Millennium Development Goals ( MDGs ) 4 and 5 and in addressing common social determinants of health. The country has huge challenges of political fragility, complex security issues, and natural disasters. Currently, 50% of the population is below 20, which will mean, there will be 235 million people in the working age group. This increase in population is likely to bring more challenges and put pressure on already overwhelmed healthcare system. Looking back to the history of natural disasters, Pakistan is prone to almost all natural disasters. 

Challenges of Pakistan

-          Efforts in improving MDG related health indicators will not be sufficient to achieve the set target -          The devolution of the EPI program is having an adverse impact on Polio Eradication and routine immunization. -          Pakistani women continue to face the risk of limited access to reproductive health services and pregnancy related morbidity and mortality

                                                                           Source: Brief WHO Country Cooperation Strategy

5 - Sri Lanka

Total Population(2012):                                                                                         21,098,000

GNI per capita ($PPP, 2012):                                                                                6030

Life Expectancy at birth m/f(2012):                                                                      71/78

Probability of dying under five (per 1000 live births, 2012):                             10

Total expenditure on health per capita($, 2012):                                                   189

Total expenditure on health as % of GDP (2012):                                                    3.2

                                                                                

(Source: WHO country statistics, Srilanka, 2012)

Following figures gives basic introduction of health indicators. 

( Source: WHO, Brief Country Information, Sri lanka )

Srilanka is an island nation below India which lies on the indian ocean and is prone to natural disasters like cyclones and tsunami. The Tsunami of 2004 caused 31,000 deaths and 4000 missing and more than half million became homeless (Source: WHO). Srilanka achieved great success in areas of health, education, nutrition, despite their low per capita income (The Lancet). However, due to a long conflict between two major groups Tamils and Singhalese, Srilanka faces a difficult challenge for a sustainable development in health sector.

5 years ago, government forces in Sri lanka overwhelmed the liberation tigers of Tamil Eelam, bringing an end to a 26 year long brutal civil war that brought a death toll estimated by the UN at 80,000 – 100,000 (Source: The Lancet). Sri lanka has free education without discrimination, up to completion of university education. This contributed greatly to delaying the age at marriage, thereby reducing teenage pregnancies. Education also empowered women and gave them access to electronic and print media which have enabled them to have a greater awareness regarding health. There is also a provision of healthcare services free of charge (Source: Wiley Online Library).

Challenges and Cooperation partners

Challenges -          Strengthening the stewardship role of the ministry of Health -          Meeting the rising costs of healthcare in view of the rapid increase in NCDs -          Improving use of primary care facilities -          Strengthening of information systems, Public Health laboratory services, mental health services -          Addressing environmental and climate change factors -          Coordination of private and public healthcare providers -          Large number of health partners with varied expectations

Partners -          UN Agencies ( ILO, IOM, UNDP, UNFPA, UNICEF, WFP, WHO) -          Multi-lateral and bi-lateral organisations ( World Bank, ADB, JICA, AusAID, USAID etc )

                                                     Source: WHO Country Cooperation Strategy, Sri Lanka, 2011 

Hence, it can be concluded that all five nations have similar challenges, they are all dependent on external support and their problems lies not only in health sector but also in other sectors. The spill over of political violence, instability, conflicts, natural disasters and economic downturn  impose a burden on health sector which is currently not in a condition to cope with it. Optimism lies on the possible economic growth in the region led by China and India but till then, there is lot to be done as better health should not only be the consequence of economic growth but it can also impede economic growth.