Sri Lanka: gender and health

Sri Lanka: gender and health 2017 20192018 12584.10 13620.1213168.17 20162015 2017 490.5 503.6 GDP1 Current health expenditure2 465.9 20121995 2016 5.33 5.424.91 Unit: PPP per capita current $ INT Unit: $ INT 20152014 2016 48.9 50.1 2017 49.848.7 Unit: % Catastrophic health expenditure3 Proportion of out-of-pocket expenditure4 Unit: % Gender is a major determinant of health for women and men in Sri Lanka. Gender norms, roles and relations interact with biological factors, in turn influencing people’s exposure to disease and risks for ill health. Therefore, it is important for health policy-makers to consider the different gender needs of all men and women. Tailoring health policies and programmes to take account of these differences and trends can improve their impact, reduce health inequities and advance the right to health for all. Unit: index from 0 to 1 Unit: index from 0 to 1 HDI-IHDI8 GDI9 Poverty level5 2016 0.9% 2009 2016 GINI6 Unit: scale of 0-100, with 0 being better Unit: % 36.4 39.8 2012 39.2 Sex ratio at birth7 104 males per 100 females 2016 20162017 20172018 2018 0.74 0.79 0.69 0.74 0.79 0.67 0.75 0.936 0.937 0.9380.80 0.69 HDI female HDI male IHDI Why does gender matter for health in Sri Lanka? Unit: index from 0 to 1 GII10 2016 2017 2018 0.384 0.381 0.380 Women comprise about six in every 10 doctors and over nine in every 10 nurses.23 Only 3.5 % of households in Sri Lanka are now located more than half an hour from a water source.25 Health is significantly determined by social, economic, and environmental factors that lie beyond the health sector, such as poverty, education, employment and physical security. Gender inequality, an important determinant of health, remains a challenge in Sri Lanka, as elsewhere. Women lag behind men in many indicators of social well-being, like tertiary education, share in agricultural holdings and wages. Women’s lower labour force participation rate and their higher average hours per day spent in unpaid care work also reflect gender inequality. Do men and women in Sri Lanka have equal access to determinants of health? 1.4%0.5% 46.7 56.2 The literacy rate between men and women in Sri Lanka is comparable.15 Unit: % Only about three in every twenty agricultural holders are women.11 $ $ $ $ $ $ $ $ $ $ $ $ $ $Men Women 2018 2020Male Female 2016 2017 20182016 2017 2018 Female Male Secondary Primary Tertiary Unit: ratio Unit: %Informal employment 2018 2016 1.35 1.34 1.32 1.03 1.05 1.05 0.98 0.99 0.99 Girls have achieved parity with boys in school enrolment.16 Only two in every five science, technology, engineering & mathematics graduates is a woman.17 In 2020, women earned an estimated US$ 3.9 for every US$ 10 earned by men, a slight increase over the estimated US$ 3.5 in 2018.22 About one in four managers in Sri Lanka is a woman.24 Most women in Sri Lanka have access to at least one form of mass media.12 Fewer than one in five women has access to the internet.13 While seven in every 10 men participate in the labour force, only three in every 10 women do so and this gap has persisted over time.18 Unit: %2017 2018 2019 Male Female36.6 33.6 34.574.5 73.0 73.0 About three in every four married women in Sri Lanka say that they, alone or jointly, make major household decisions.14 Nearly three in every four women in Sri Lanka hold a bank account, either by themselves or jointly with someone else.21 Almost six in every 10 men and five in every 10 women in the labour force work in the informal sector.19 Boys’ share in child labour is thrice that of girls.20 91.49 90.97 90.8 93.46 92.98 92.77 $ $ $ $ $ $ $ $ $ $ $ $ $ $Men Women NEWS Life expectancy and healthy life expectancy at birth by sex27 Unit: Years Male 2015 Female 2015 Male 2019 Female 2019 Healthy life expectancy at birth Life expectancy at birth Women have better life expectancy and healthy life expectancy at birth than men in Sri Lanka. Do men and women in Sri Lanka have similar life expectancies?On average, women spend more than twice as many hours per day as men in doing unpaid house work and care work.26 The health status of all women and men in Sri Lanka, as elsewhere, is determined by the interaction between social (gender) and biological (sex) differences. The differences in health status between men and women go beyond sexual and reproductive health. Besides gender, factors such as location of residence (urban/rural), education and income also affect health status. The survival and nutritional status of children under five years of age have improved over time. However, children of mothers with lower education levels and children from lower-income and rural households tend to fare worse. Compared to their urban counterparts, children from rural areas have a 9% higher risk of dying, a 15% higher risk of stunting, a 26% higher risk of being underweight and a 20% higher risk of wasting.35 Cirrhosis of the liver and road injuries feature in the 10 leading causes of deaths among men, but not among women. Alzheimer’s disease and other circulatory diseases feature in the 10 leading causes of deaths among women, but not among men. Similarly, cirrhosis of the liver, road injuries and self-harm figure in the 10 leading causes of DALYs lost among men, but not among women. Alzheimer’s disease, back and neck pain and kidney diseases feature in the 10 leading causes of DALYs lost among women, but not among men. Do gender, location of residence, education and income affect the health status of people in Sri Lanka? Under-five mortality rate by sex30 Male Total Female Unit: per thousand live births 31.29 12.73 10.65 9.01 8.41 6.07 5.87 5.48 5.25 5.24 Ischemic heart disease Stroke Diabetes mellitus Cirrhosis of the liver Other malignant neoplasms Chronic obstructive pulmonary disease Asthma Lower respiratory infections Road injury Kidney diseases 27.88 15.18 13.23 11.54 7.41 7.09 5.62 4.72 4.49 2.82 Ischemic heart disease Diabetes mellitus Stroke Alzheimer's diseases & other dementias Other malignant neoplasms Asthma Kidney diseases Chronic obstructive pulmonary disease Lower respiratory infections Other circulatory diseases Female Male Unit: Cause-specific death rates as % of 10 leading causes Unit: Cause-specific death rates as % of 10 leading causes 26.08 12.03 10.93 10.24 8.06 7.81 6.94 6.75 5.63 5.51 Ischaemic heart disease Diabetes mellitus Cirrhosis of the liver Stroke Road injury Other malignant neoplasms Self-harm Chronic obstructive pulmonary disease Other hearing loss Asthma 21.96 18.17 11.09 8.50 7.72 7.53 7.35 6.06 5.88 5.74 Ischaemic heart disease Diabetes mellitus Stroke Other malignant neoplasms Other hearing loss Asthma Alzheimer's disease and other dementias Back and neck pain Kidney diseases Chronic obstructive pulmonary disease Male Unit: Disease-specific DALYs lost as % of 10 leading diseases Unit: Disease-specific DALYs lost as % of 10 leading diseases Female 10 leading causes of death among men and women28 10 leading causes of DALYs lost among men and women29 2016 Nutritional status of children by sex34 Urban Rural Unit: % 2016 Male Total Female Estate Unit: % 2016 11 14 10 Disease burdens are different between men and women. Under-five mortality rate by mother’s education31 Under-five mortality rate by household income quintile32 Passed Grade 1-5 Passed Grade 6-10 Passed G.C.E.(O/L) Passed G.C.E.(A/L) Degree and above 14 12 12 11 6 Unit: per thousand live births 2016 14 9 Unit: per thousand live births 1010 2016 Poorest Second Middle Fourth Richest Under-five mortality rate by location of residence33 Urban Rural Estate Unit: per thousand live births 11 12 2016 15 17 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 17.3 17.9 Stunting 16.6 20.5 20.5 20.5 Underweight 15.415.1 14.7 Wasting Wasting 15.612.9 13.4 Stunting 14.7 17.0 31.7 Underweight 16.4 20.8 29.7 73.064.4 79.468.6 73.865.1 79.869.0 Urban Rural Unit: per thousand women aged 15-191987 Total45 3856 36 36 36 2000 2005 2010 2015 Unit: per 100,000 live births Urban Rural Unit: average number of births per woman Total Passed G.C.E.(O/L) No education Passed Grade 1-5 Passed Grade 6-10 Degree and above Passed G.C.E.(A/L) 2016 2017 Unit: % Poorest Second Middle Fourth Richest 11.714.015.918.925.2 10.014.115.018.317.3 Mothers’ chances of dying during and after childbirth in Sri Lanka have reduced to about two-thirds of the level in 2000.38 Fertility rates have declined more rapidly among adolescent women, compared to adult women.39 Biological and gender-related factors interact to result in differences between men and women in Sri Lanka in their exposure to health risks and vulnerabilities. Besides gender, location of residence (urban/rural), education and income also affect exposure to health risks and vulnerabilities. Do gender, location of residence, education and income affect exposure to health risks and vulnerabilities in Sri Lanka? 2.82.7 2.1 1987 3232 34 Compared to children under five of highly educated mothers, children of uneducated mothers have a 133% higher risk of dying, a 210% higher risk of stunting, a 239% higher risk of being underweight and a 105% higher risk of wasting.36 Compared to children from the richest households, those from the poorest households have an 88% higher risk of dying, a 115% higher risk of stunting, a 73% higher risk of wasting and a 120% higher risk of being underweight.37 Unit: % 33.9 30.2 24.6 18.6 15.4 10.0 2016 Underweight 17.9 17.6 17.5 14.9 12.2 8.7 2016 Wasting 37.6 27.2 20.3 15.9 12.2 12.1 2016 Stunting 2016 Wasting 2016 Stunting $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 12.516.120.924.527.6 2016 Underweight $ $ $ $ $ $ $ $ $ $ $ $ $ $ 2.2 2016 2016 21 The higher prevalence of overweight and obesity among women and the lower prevalence of vigorous physical activity among women and girls than among men and boys represent higher exposure to risk of noncommunicable diseases. Overweight prevalence among adults by sex42 Female Total Male Unit: % population Obesity prevalence among adults by sex43 Adolescent fertility rate by location of residence41Total fertility rate by location of residence40 Female Total Male Unit: % population Physical activity among adults by sex44 Female Total Male Unit: % population 2006 20.3 15.9 24.6 2015 23.4 21.0 26.0 5.9 3.5 8.4 20152006 4.7 3.6 5.9 Low physical activity Moderate physical activity Vigorous physical activity 2015 36.0 28.1 44.2 2006 25.0 17.9 31.9 2015 20.9 18.2 23.6 2006 21.5 17.4 25.6 2015 43.1 53.7 32.2 2006 53.5 64.7 42.5 Alcohol consumption among adults by sex45 Unit: % population Female Male Total Unit: % population Prevalence rate of current tobacco use among adults by sex46 Female Total Male 34.817.9 0.5 2015 2016 23.3 3.143.6 2018 22.9 2.743.226.013.5 1.2 2006 Nearly one in four women in Sri Lanka experiences intimate partner violence in their lifetime, with uneducated men and those from the poorest households facing significantly higher risk.54 Women and girls are exposed to household smoke from unclean fuels while performing their assigned gender role of cooking. In Sri Lanka, about 70% of the population relies primarily on unclean fuels for cooking.58 Geographical, financial, socio-cultural or other barriers may compound gender-related barriers to access to services. Women in Sri Lanka report facing gender-related barriers such as lack of availability of a woman health provider, problems in going alone to seek care, lower mobility, lack of access to household and / or public transportation or household resources such as money, and weak decision-making power. Do gender, location of residence, education and income affect access to health services in Sri Lanka? Antenatal care coverage by location of residence60 Antenatal care coverage by level of education61 Skilled birth attendance by location of residence62 Female Estate Total Male Unit: % population 2016 96.0 96.5 95.4 Unit: % population2008 0.60.40.5 Female Total Male Obesity among adolescents by sex48 Unit: % population2016 11.719.3 Female Total Male Female Total Male Physical activity among adolescents by sex49 Overweight among adolescents by sex47 Unit: % population2008 4.5 4.8 4.2 Female Total Male Prevalence rate of current tobacco use among adolescents by sex50 Unit: % population2016 3.015.69.2 15.5 Ever use of marijuana among adolescents by sex51 Unit: % population2016 0.84.62.8 Female Total Male Alcohol consumption among adolescents by sex52 Unit: % population2016 1.05.53.2 Female Total Male Only one in every six adolescent girls in Sri Lanka has comprehensive knowledge about HIV/AIDS.53 DTP vaccination rates in Sri Lanka have improved over time and inequities based on location of residence, mother’s education level and household income quintiles have also reduced significantly.59 Unit: % population Urban 2016 91.9 96.9 93.6 Rural Unit: % population 2016 99.4 97.0 94.896.1 93.1 Unit: % population 2016 Poorest Second Middle Fourth Richest 96.0 97.5 97.0 97.6 91.7 Urban Rural Unit: %2016 99.5 99.6 99.5 98.9 Total Estate Urban Rural Unit: %2016 98.8 98.5 98.9 97.6 Total Estate Passed Grade 1-5 Passed Grade 6-10 Unit: % 2016 Passed G.C.E.(O/L) Passed G.C.E.(A/L) Degree and above No education98.9 98.997.796.3 97.999.0 Unit: % population 2016 19.816.6 16.0 17.0 Rural Urban Passed G.C.E.(O/L) or equivalent Passed G.C.E.(A/L) or equivalent Degree and above Total Estate Unit: % population 2016 24.8 29.8 18.1 14.6 11.5 12.5 Passed Grade 1-5 No education Passed G.C.E.(O/L) Passed G.C.E.(A/L) Degree and above Passed Grade 6-10 Passed Grade 1-5 2016 17.828.1 13.7 12.8 Middle Fourth Richest Unit:% population Second Poorest11.9 Proportion of ever-partnered women who ever experienced IPV and/or sexual violence by location of residence55 Proportion of ever-partnered women who ever experienced IPV and/or sexual violence by level of education56 Proportion of ever-partnered women who ever experienced IPV and/or sexual violence by household income quintile57 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7.7 8.5 Unit: % 7.38.0 6.2 2016 Poorest Second Middle Fourth Richest Unmet need for family planning by location of residence63 Urban Rural Unit: %2016 7.5 10.9 6.8 9.3 Total Estate Unmet need for family planning by level of education64 Unmet need for family planning by household income quintile65 Passed Grade 1-5 Passed Grade 6-10 Unit: % 2016 Passed G.C.E.(O/L) Passed G.C.E.(A/L) Degree and above No education6.8 8.26.82.3 7.38.9 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Are gender, equity and human rights perspectives reflected in the legal and institutional arrangements and capacity in Sri Lanka? Ratification of treaties that include the right to health69 • “All persons are equal before the law and are entitled to the equal protection of the law.” • “No citizen shall be discriminated against on grounds of race, religion, language, caste, sex, political opinion, place of birth or anyone of such grounds.” • “No person shall, on the grounds of race, religion, language, caste, sex or any one of such grounds, be subject to any disability, liability, restriction or condition with regard to access to shops, public restaurants, hotels, places of public entertainment and places of public worship of his own religion.” • “Nothing in this Article shall prevent special provision being made, by law, subordinate legislation or executive action, for the advancement of women, children or disabled persons (Article 12).” Constitutional provisions on equality and non-discrimination70 Ratified Ratified Ratified Ratified Ratified International Covenant on Economic, Social, and Cultural Rights International Covenant on Civil and Political Rights International Convention on the Elimination of all forms of Racial Discrimination Convention on the Elimination of All Forms of Discrimination against Women Convention on the Rights of the Child International Convention on the Protection of the Rights of all Migrant Workers and Members of their Families Convention on the Rights of Persons with Disabilities Ratified Legal arrangements related to inheritance, land ownership, divorce, marriage, sexual orientation, gender identity and intimate partner violence71 Widows and daughters enjoy the same rights as widowers and sons to inherit land and non-land assets. This applies to all groups of women. However, there are some customary, religious or traditional laws that discriminate against women's inheritance rights. Women and men have the same legal rights and secure access to land assets, without legal exceptions regarding some groups of women. Customary, religious and traditional laws or practices do not discriminate against women’s legal rights. Women and men have the same legal rights and secure access to land assets, without legal exceptions regarding some groups of women. However, some customary, religious or traditional practices or laws discriminate against women’s legal right. Women have both the same rights to initiate divorce and the same requirements to finalise divorce or annulment as men, without negative repercussions on their parental authority. This applies to all groups of women. Customary, religious and traditional laws or practices do not discriminate against women's rights regarding divorce or parental authority after divorce. Women have both the same rights to initiate divorce and the same requirements to finalise divorce or annulment as men, without negative repercussions on their parental authority. This applies to all groups of women. However, there are some customary, religious or traditional laws or practices that discriminate against women's rights regarding divorce and/or parental authority after divorce. Intimate partner violence 72 The legal framework protects women from violence including intimate partner violence, rape and sexual harassment, without any legal exceptions and in a comprehensive approach. The legal framework protects women from violence including intimate partner violence, rape and sexual harassment, without any legal exceptions. However, the approach is not comprehensive. 0.25 0 0 0 0.25 Inheritance Land ownership Divorce Widows and daughters enjoy the same rights as widowers and sons to inherit land and non-land assets. This applies to all groups of women. Customary, religious and traditional laws or practices do not discriminate against women's inheritance rights. 0.25 0 Ratified Ratified 0.25 Compared to men, a smaller proportion of women diagnosed with raised blood pressure receive treatment. The blood sugar and blood pressure of a greater proportion of women remain uncontrolled despite treatment.66 2016 Unit: % Diagnosis, treatment and control of blood sugar among adults by sex67 11.262.1 10.7 9.2 15.9 69.3 11.4 10.0 12.254.9 20.4 12.5 Diagnosed but untreated Undiagnosed Treated and controlled Treated but uncontrolled Unit: % Diagnosis, treatment and control of blood pressure among adults by sex68 Female Total Male 2016Diagnosed but untreated Undiagnosed Treated and controlled Treated but uncontrolled 44.5 12.2 21.8 21.1 3.941.2 32.0 22.9 8.242.9 26.7 22.0 Female Total Male Widows or daughters do not enjoy the same rights as widowers and sons to inherit land and/or non-land assets. Widows and daughters do not enjoy the same rights as widowers and sons to inherit land and/or non-land assets. Women and men have the same legal rights and secure access to land assets. However, this does not apply to all groups of women. Women and men have the same legal rights to own land assets; but not to use, make decisions and/or use land assets as collateral. Women do not have the same legal rights as men to own land assets. Women have both the same rights to initiate divorce and the same requirements to finalise divorce or annulment as men, without negative repercussions on their parental authority. However, this does not apply to all groups of women. Women do not have the same rights over divorce as men: either their rights to initiate divorce and/or the requirements to finalise divorce or annulment are unequal, or their parental authority after divorce is restricted. Women do not have the same rights over divorce as men: their rights to initiate divorce and/or the requirements to finalise divorce or annulment are unequal, and their parental authority after divorce is restricted. The legal framework protects women from violence including intimate partner violence, rape and sexual harassment. However, some legal exceptions occur. The legal framework protects women from some forms of violence including intimate partner violence, rape or sexual harassment but not all. The legal framework does not protect women from violence nor intimate partner violence nor rape and sexual harassment. Name of law: Prevention of Domestic Violence Act, 2005 0.75 1 1 1 Sri Lanka score 0.5 1 0.75 0.75 0.5 Widows and daughters enjoy the same rights as widowers and sons to inherit land and non-land assets. However, this does not apply to all groups of women. 0.5 0.5 0.75 Legal protection for all sexual orientations and gender identities.74 Same-sex relationships are criminalized. Legal protection is not available against discrimination based on sexual orientation. Gender identities are recognized. A Gender Recognition Certificate, issued by the Ministry of Health, Nutrition and Indigenous Medicine, allows for a change of sex in the birth certificate. Legal arrangements related to sexual and reproductive health and rights75 Abortion Direct support for family planning Permitted only when the life of the mother is threatened by the pregnancy. Not permitted in the case of rape or incest. Yes, direct support is provided by the legal framework. Ministry of Child Development and Women’s Affairs Relevant policies include: a chapter on Women’s Rights in the Human Rights Action Plan (2017-2021), the National Framework for Women-Headed Households (2017-2019), and the introduction of quotas and gender mainstreaming committees in public institutions. Yes. Policy framework and National Plan of Action to address Sexual and Gender-based Violence in Sri Lanka (2016-2020). Institutional arrangements and capacity76 National gender machinery Whether national development policy mentions gender mainstreaming and the most recent one? Gender policy from national women's machinery and year introduced? Conclusion Forward-looking policies, if effectively implemented through suitable institutional mechanisms and adequate capacity support the mainstreaming of gender, equity and human rights perspectives in health and enable change towards greater equity. • Given the influence of gender on health in Sri Lanka, putting a gender perspective into health interventions is important. When applying a gender lens to health interventions, it is important to remember that gender interacts with other forms of social exclusion, such as ethnicity, age and socioeconomic position. • Several tools are available for gender analysis, assessment and planning or programming, which can help to identify gender issues and inequalities in health and tailor the design, implementation and monitoring of health policies and programmes to take account of these differences, for improved outcomes. These tools include the WHO gender analysis matrix (GAM) and gender analysis questions (GAQ), the WHO gender responsive assessment scale (GRAS) and gender analysis tool (GAT), the WHO gender and health planning and programming checklist and the WHO gender responsive log-frame.82 • The Innov8 approach83 and Human Rights and Gender Equality in Health Sector Strategies: how to assess policy coherence84 are tools that support the development of equity-enhanc- ing, gender-responsive and human rights-based national health policies, programmes and strategies. Additionally, using a human rights framework in health planning and policy making can help in identifying and adequately addressing the biological and sociocultural factors that differentially influence the health of men and women. Recommendations Endnotes Gender-responsive budgeting77 No. No. Mention of gender-responsive budgeting in plans, year introduced Legislation for gender-responsive budgeting National plan/strategy for gender-responsive budgeting Gender focal points in government78 Gender policy/strategy in the Ministry of Health79 Yes. Line ministries have gender focal points. No. Gender training for Ministry of Health staff 80 Gender analysis by the Ministry of Health81 Yes. The Family Health Bureau extensively trains staff of Gender-Based Violence Care Centres (Mithuru Piyasa) in hospitals before the centres are set up. Curative and preventive health staff and primary health care teams also receive basic, in-service and post graduate training on gender and gender-based violence. Information not available. Marriage73 The legal age of marriage is 18; however, this is not applicable to all religious / cultural groups. Marital rape is not a criminal offense. No. 1. 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In: Gender, Institutions and Development Database (GID-DB) 2019, OECD. Stat [database]. Paris: Organisation for Economic Co-operation and Development; 2020 (https://stats.oecd.org/index.aspx?que- ryid=54757, [See: Data by themes Social protection and well-being Gender Gender, Institutions and Development Database (GID-DB) 2019 Restricted access to productive and financial services Secure access to land assets Practice], accessed 12 October 2020). 12. Sri Lanka Demographic and Health Survey 2016. Colombo, Sri Lanka: Department of Census and Statistics and Ministry of Health, Nutrition and Indigenous Medicine; 2017 (http://www.statistics.gov.lk/Health/StaticalInformation/De- mographicAndHealthSurvey-2016FullReport, accessed 12 October 2020). 13. Ibid. 14. Ibid. 15. Adult literacy rate, by sex. In: World Bank Development Research Group [database]. Washington D.C., World Bank; 2020 (https://data.worldbank.org/indicator/SE.ADT.LITR.FE.ZS?locations=TH, accessed 12 October 2020). 16. Gender parity index of the gross enrolment ratios in primary, secondary and tertiary education. In: World Bank Development Research Group [database]. Washington D.C., World Bank; 2020 (https://data.worldbank.org/indica- tor/SE.ENR.PRIM.FM.ZS, accessed 12 October 2020). 53. Sri Lanka Demographic and Health Survey 2016. Colombo, Sri Lanka: Department of Census and Statistics and Ministry of Health, Nutrition and Indigenous Medicine; 2017 (http://www.statistics.gov.lk/Health/StaticalInformation/De- mographicAndHealthSurvey-2016FullReport, accessed 12 October 2020). 54. Violence against women prevalence estimates, 2018. Global, regional and national prevalence estimates for intimate partner violence against women and global and regional prevalence estimates for non-partner sexual violence against women. Geneva: World Health Organization, on behalf of the United Nations Inter-Agency Working Group on Violence Against Women Estimation and Data (UNICEF, UNFPA, UNODC, UNSD, UN Women); 2021 (https://cdn.who.int/me- dia/docs/default-source/documents/violence-prevention/vaw_report_web_09032021_oleksandr.pdf?sfvrsn=a82ef89c _5&download=true, accessed 12 March 2021). 55. Sri Lanka Demographic and Health Survey 2016. Colombo, Sri Lanka: Department of Census and Statistics and Ministry of Health, Nutrition and Indigenous Medicine; 2017 (http://www.statistics.gov.lk/Health/StaticalInformation/De- mographicAndHealthSurvey-2016FullReport, accessed 12 October 2020). 56. Ibid. 57. Ibid. 58. Proportion of population with primary reliance on clean fuels and technologies (%). In: Global Health Observatory Data Repository [database]. Geneva: World Health Organization; 2020 (https://www.who.int/data/gho/indicator-metadata-reg- istry/imr-details/4673, accessed 12 October 2020). 59. 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