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A framework for implementing the reproductive health strategy in the South-East Asia Region

31 декабря 2008 г. Всемирная организация здравоохранения

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Полный текст



 in the South-East Asia Region

The Regional Context



 in the South-East Asia Region

2008

WHO Library Cataloguing-in-Publication data World Health Organization, Regional Ofﬁce for South-East Asia. A framework for implementing the reproductive health strategy in the South-East Asia Region. 1. Reproductive Health Services. 2. Family Planning Services. 3. Maternal Mortality. 4. Perinatal Mortality. 5. Adolescent Health Services. 6. Pregnancy Complications – prevention and control. 7. Sexually Transmitted Diseases – prevention and control.

ISBN

978-92-9022-329-0

(NLM classiﬁcation: WP 630)

© World Health Organization 2008 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 do 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. Printed in India, August 2008

 Abbreviations and acronyms Foreword 4 5 7

1 Introduction 2 The Regional Context 2. 1. Situational analysis 2. 2. Barriers to progress Pregnancy, childbirth, post-partum and health of newborns Family Planning Unsafe abortion Sexually transmitted infections, including HIV and reproductive tract infections Inequalities related to access to skilled health care Adolescents’ exposure to risks Expenditure on reproductive health Human resource for reproductive health Inequalities related to gender Organization of health service delivery

8 8 12 8 10 11 11 12 12 12 13 13 13 14 15

3 Goal and Objectives 4 Areas of Action and Partnership 4.1. Strengthening health systems capacity 4.2. Improving information for priority-setting 4.3. Mobilizing political will 4.4. Creating supportive legislative and regulatory frameworks 4.5. Strengthening monitoring, evaluation and accountability

15 16 16 17 17 19 19 20 20 20 21 22 23 25

5 Indicators for Evaluating Progress 5.1. Improving antenatal, delivery, postpartum and newborn care 5.2. High-quality services for family planning 5.3. Eliminating unsafe abortion 5.4. Combating sexually transmitted infections, cervical cancer and other gynecological morbidities 5.5. Promoting sexual health

6. Conclusion References Annexes Country Reproductive Health Data Sheets: South-East Asia

A Framework for Implementing the RHS in the South-East Asia Region

 AIDS ANC CPR FP GDP HIV ICPD IEC MCH MDGs MOH NGO RTI RH SBA SRH STI SEA UNAIDS UNDP UNFPA UNICEF WHA WHO Acquired Immune Deﬁciency Syndrome Antenatal care Contraceptive Prevalence Rate Family planning Gross Domestic Product Human Immunodeﬁciency Virus International Conference on Population and Development Information-education-communication Maternal and child health Millennium Development Goals Ministry of Health Nongovernmental organization Reproductive tract infection Reproductive health Skilled birth attendant Sexual and reproductive health Sexually Transmitted Infection South-East Asia Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Population Fund United Nations Children’s Fund World Health Assembly World Health Organization

4 A Framework for Implementing the RHS in the South-East Asia Region

 Reproductive and sexual health is fundamental for individuals, couples and families, as well as for social and economic development of communities and nations. Everyone has the right to enjoy reproductive health, which is the basis for having healthy children, a healthy reproductive life and happy families. Women living in developing countries suffer disproportionately from unintended pregnancies, maternal death and disability, sexually transmitted infections, including HIV, genderbased violence and other problems related to their reproductive system and their partner’s sexual behaviour. Young people often face barriers in trying to get the information and care they need, which places adolescent reproductive health as another issue that needs attention. The critical importance of reproductive health to development has been acknowledged at the highest level with the commitment to achieve universal access to reproductive health by 2015. This is the culmination of more than a decade of advocacy since the consensus at the International Conference on Population and Development held in Cairo in 1994. At the 2005 World Summit, 189 Member States agreed to integrate access to reproductive health into national strategies to attain universal access to reproductive health as a part of the achievement of the relevant Millennium Development Goals. The global reproductive health community is fully committed to mobilize support and scale up efforts to make reproductive health for all a reality by 2015. The Fifty seventh World Health Assembly adopted the ﬁrst Global Reproductive Health Strategy in May 2004 with the aim to accelerate progress towards reproductive health by 2015. For the successful implementation of the Global Strategy, it is necessary to foster wide-range collaboration and commitment towards attaining reproductive health targets. This can be done by translating global strategies into concrete actions in the countries based on their national and sub-national priorities and situation. This framework provides guidance to countries in implementing the Global Reproductive Health Strategy considering the regional context, country situations and needs. It is intended to guide policy makers, reproductive health programme managers and development partners in accelerating the achievement of reproductive health targets. The document provides country reproductive health data sheets, which would be useful in understanding the reproductive health challenges in each country of the Region. The document is a result of extensive consultations in the South-East Asia Region with representatives from the ministries of health, United Nations partner agencies, and other key stakeholders. We thank all Member Countries and development partners for their involvement in ﬁnalizing this framework, as well as their commitment to use it as a basis for future collaboration in accelerating the achievement of reproductive health targets in the Region.

Dr Samlee Plianbangchang, M.D., Dr. P.H. Regional Director

 health, particularly those set by the International Conference on Population and Development (ICPD) in 1994, and its ﬁve-year follow-up (ICPD+5). A new MDG Monitoring Framework adopted by the Sixty-second United Nations General Assembly in October 2007 includes a new target, "Achieve, by 2015, universal access to reproductive health" and related indicators under the MDG 5, which recognizes the centrality of reproductive health and reproductive rights in improving maternal and infant health and in reducing poverty (Table 1). To attain the MDGs and the global reproductive health targets, the strategy calls for actions in ﬁve key areas:  strengthening health systems capacity;  improving information for priority-setting;  mobilizing political will;  creating supportive legislative and regulatory frameworks; and  strengthening monitoring, evaluation and accountability. The strategy is targeted at a wide range of policy-makers in governments, international agencies, professional associations, nongovernmental organizations and other institutions.

The World Health Organization’s ﬁrst Global Reproductive Health Strategy to accelerate progress towards the attainment of international development goals and targets was adopted by the Fifty seventh World Health Assembly in May 2004. The strategy was developed through extensive consultations in all WHO regions with representatives from the ministries of health, professional associations, nongovernmental organizations (NGOs), United Nation’s partner agencies and other key stakeholders. The strategy recognizes the crucial role of sexual and reproductive health in social and economic development in all communities. It aims to improve sexual and reproductive health and targets the following ﬁve core elements:  Improving antenatal, delivery, post-partum and newborn care.  Providing high-quality services for family planning, including infertility services.  Eliminating unsafe abortion.  Combating sexually transmitted infections (STIs), including HIV, reproductive tract infections (RTIs), cervical cancer and other gynaecological morbidities.  Promoting sexual health. The strategy outlines the principal actions necessary to attain the Millennium Development Goals (MDGs) and other international goals relating to reproductive

Table 1: Millennium Development Goal 5 – Targets and Indicators Goal 5: Improve maternal health1 Targets Indicators 5.A: Reduce by three quarters, between 1990 5.1 Maternal mortality ratio and 2015, the maternal mortality ratio 5.2 Proportion of births attended by skilled health personnel 5.B: Achieve, by 2015, universal access to 5.3 Contraceptive prevalence rate reproductive health 5.4 Adolescent birth rate 5.5 Antenatal care coverage (at least one visit and at least four visits) 5.6 Unmet need for family planning Sixty-second UN General Assembly, Ofﬁcial Records, Annex II, Revised Millennium Development Goal Monitoring Framework, United Nations, 2007 1

Introduction

8 A Framework for Implementing the RHS in the South-East Asia Region

 and contribute to life-long disability of those infants who survive4. Pre-term birth and low birth weight are associated with approximately 24% of newborn deaths, commonly due to asphyxia or infections. Immediate and effective professional care before, during and after delivery can make the difference between life and death for both women and their newborns. There are sharp differences in antenatal care coverage (given by doctors, midwives and nurses) in different countries of the Region. Findings of the surveys show that not only are more women receiving antenatal care, they are also seeking more visits than before. A marked increase has been observed in Bangladesh, Indonesia and Maldives over a period of 5-10 years. Urban women are more than twice as likely as rural women to have four or more antenatal visits. In general, however, antenatal care services currently provided in many countries fail to meet the standard recommended by WHO. There is a lot of disparity within the Region with regard to the proportion of deliveries by skilled attendant, which ranges from 13% in Bangladesh and Nepal to almost universal coverage in Sri Lanka, Thailand and DPR Korea. An analysis of the relationship between the proportion of deliveries assisted by skilled birth attendants and maternal/neonatal mortalities in the Region shows that both newborns and mothers have a better chance of survival if they have skilled attendance at birth (Figures 1 and 2). The higher the proportion of deliveries by a health professional, the lower is the maternal mortality ratio and neonatal mortality rate. Maternal morbidities, such as ﬁstula, are also more frequent in countries with a low proportion of deliveries by skilled attendants.

2. 1. Situational Analysis Pregnancy, childbirth, post-partum and health of newborns Pregnancy and childbirth and their consequences are the leading causes of death, disease and disability among women of reproductive age in developing countries – more than any other single health problem. Maternal mortality in developing countries is more than 100 times higher than in industrialized countries. The South-East Asia (SEA) Region accounted for 174,000 maternal2 and 1.4 million neonatal3 deaths in 2000, which were 33% and 35% of the global ﬁgures respectively. Two thirds of the neonatal deaths, about one million, occur within the ﬁrst week of life and two thirds of these, almost 700,000, within the ﬁrst 24 hours. In addition, one million stillbirths occur in the Region. More than 90% of neonatal deaths in the Region occur in Bangladesh, India, Indonesia, Myanmar and Nepal. Globally, 60-80% of maternal deaths are due to obstetric haemorrhage, sepsis (infection), obstructed labour, hypertensive disorders of pregnancy (including eclampsia), and complications of unsafe abortion. In the SEA Region, available data show that the causes of death are similar to the global picture with severe bleeding being a major cause of death in all the countries. Data from three countries of the Region show that 5-8% of pregnancies end in abortion and more than 2% in stillbirths. Neonatal infections, such as sepsis, meningitis, pneumonia, tetanus and congenital syphilis are responsible for 33% of newborn deaths, while birth asphyxia and trauma account for about 28% deaths

2 3 4

Maternal Mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA, WHO, Geneva, 2004 Neonatal and Perinatal Mortality: Country, Regional and Global Estimates, WHO, Geneva, 2006 Strategic Directions to Improve Newborn Health in the South-East Asia, WHO-SEARO, 2004

The Regional Context

Figure 1: Relationship between proportion of births assisted by skilled attendant and maternal mortality ratio 100 90 80 70 60 SBA (%) 50 40 30 20 10 0 800 700 600 500 400 300 200 100 MMR (per 1000 live births) NMR (per 1000 live births)

TH A

INO

IND

TLS

BH U

KR D

BA N

SRL

Proportion of births assisted by skilled attendant (SBA) Source: World Health Statistics 2006, WHO

Maternal mortality ratio (MMR)

Figure 2: Relationship between proportion of births assisted by skilled attendant and neonatal mortality rate 100 90 80 70 60 SBA (%) 50 40 30 20 10 0 50 45 40 35 30 25 20 15 10 5 0

INO

SRL

IND

TLS

BA N

Proportion of births assisted by skilled attendant (SBA) Source: World Health Statistics 2006, WHO

Neonatal mortality rate (NMR)

There is a lot of disparity within the Region with regard to skilled birth attendance (Table 2). Many deaths of neonates are related to the poor health of the woman and inadequate care during pregnancy, childbirth and the postpartum period. It has been argued that nearly three quarters of all neonatal deaths and stillborn could be prevented if women were adequately nourished and received appropriate care during pregnancy, childbirth and

the postpartum period. Furthermore, a mother’s death can seriously compromise the survival of her children. Postpartum care often receives less attention by service delivery systems, especially, after the discharge of women and their newborns from the facility. If the onset of postpartum complications occurs outside the health facility, the role of established active health service delivery practices in the immediate postpartum

10 A Framework for Implementing the RHS in the South-East Asia Region

NE P

Table 2: Maternal and newborn deaths in 2000 and proportion of births attended by skilled personnel in the South-East Asia Region Proportion (%) of births attended by skilled health personnel Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste 14 24 97 43 66 70 56 11 a

Neonatal mortality rate (per 1,000 live births) 36 38 22 43 18 37 40 40 11 13 40

No. of neonatal deaths (000) 153 3 9 1,098 82 <1 48 32 3 14 1

No. of stillbirths (000) 105 2 8 1,049 77 <1 45 19 3 12 -

Maternal mortality ratio (per 100,000 live births) 380 420 67 540 230 110 360 740 b

No. of maternal deaths 16,000 310 260 136,000 10,000 10 4,300 6,000 300 520 140

97 99 24

92 44 660

Source: World Health Report 2005; Maternal Mortality in 2000 – estimates developed by WHO, UNICEF and UNFPA; Neonatal and Perinatal Mortality: Country, Regional and Global Estimates, WHO 2006 a 18.7 (Source: Nepal, DHS 2006) b 81 (Source: Nepal, DHS 2006)

as well as within the period of six weeks becomes crucial. Provision of high quality postpartum care also helps to address post-abortion care and counselling for contraception. Strengthening the supply side should be linked to the efforts focussed on building capacity of individuals, families and communities to help them recognize danger signs and seek timely professional care for both the mother and her newborn.

All countries in the Region support family planning programmes aimed at making contraceptive services widely available at affordable costs. CPR among married women in the 15-49 year age group varies widely among countries. While in 2005 more than 70% of women used any modern method of contraception in Thailand, only 7% are using them in Timor-Leste and about one third are using them in Maldives, Myanmar and Nepal (Figure 3). The use of any method is usually inﬂuenced by availability, or the method promoted by the family planning programme of the country. For example, injectable contraceptives are popular in Indonesia (28% in 2002-2003) and Thailand (22% in 2000), but are not available in India. Female sterilization is the most popular method (34.2%5) used in India. The negligible use of male methods for contraception, such as condoms and male sterilization, is the only similarity in all the countries. This does not, however, include condom use for prevention of STIs and HIV infection.

Family planning It is estimated that guaranteeing access to family planning alone could reduce the number of maternal deaths by 25% and child mortality by up to 20%. The decline in fertility levels in all countries of the Region is a consequence of the increasing use of modern methods of contraception among women. Some countries, for example, Bangladesh, Bhutan, Indonesia, Myanmar and Nepal have demonstrated a marked increase in their contraceptive prevalence rates (CPR). However, in some of these countries, there is a tendency for CPR to stagnate. 5

Reproductive Health Proﬁle, WHO-SEARO, 2003

The Regional Context

Figure 3: Percentage of married women using modern contraception in the SEA Region, 1975 - 2005 80 70 CPR (All Methods) 60 50 40 30 20 10 0 1975 1985 Years Source: World Population Data, 2005

Thailand Indonesia Sri Lanka Bangladesh Nepal Myanmar

DPR Korea

cc India Maldives

Bhutan Timor-Leste 1955 2005

Notwithstanding the increase in contraceptive prevalence in recent years, the large proportion of births in some countries of the Region is unplanned, mistimed or unwanted. Despite the state-supported family planning programmes in many countries and the availability of modern methods of contraceptives free of cost or at subsidized rates, the unmet need is high. The proportion of women reporting unmet need ranged from 8.6% in Indonesia in 2003 to 28% in Nepal in 2001 and 37% in Maldives in 20046.

The legal situation of abortion varies considerably within the SEA Region. Abortion is legal in DPR Korea, India and Nepal, while in most other countries of the Region abortion is permitted only to save a woman’s life. Even when the abortion laws are in place, the access to safe services remains limited for a vast majority of women. For example, in India, where a liberal abortion law is in place since 1972, unsafe abortions, including sex selective abortions, still outnumber safe abortions.

Unsafe abortion A signiﬁcant proportion of unwanted pregnancies result in induced abortion under unsafe conditions. A few studies exploring the context of abortion among young women in the SEA Region indicate a widespread prevalence of unsafe abortions, serious adverse consequences to women’s health and a signiﬁcant contribution to the deaths of women, who are either on the verge of adulthood or are in the prime of their lives. It has been reported that 22 abortions per 1,000 women take place in South-East Asia and unsafe abortion is particularly an issue for young women in some countries of the Region7, while in other countries the majority were older married women.

Sexually transmitted infections, including HIV and reproductive tract infections In general, the rates of STIs are high in the Region. Epidemiological patterns of STIs vary, with some countries reporting high prevalence of curable STIs, and others indicating high rates of ulcerative STIs or high prevalence of gonorrhea and chlamidya. Sexworkers, high-risk men and pregnant women represent high-risk population groups for acquiring and spreading STIs. Overall, STI control programmes in the Region need further strengthening, with particular attention to improving surveillance, which is incomplete in most countries, and intervention coverage with selective approaches based on the country-speciﬁc epidemiological patterns.

6 7

Family Planning Fact Sheets, WHO-SEARO, 2005 Improving Maternal and Neonatal Health, WHO 2005

12 A Framework for Implementing the RHS in the South-East Asia Region

The 2006 report on global AIDS epidemic estimates about 6.9 million people living with HIV in the SouthEast Asia Region with an increase of about 0.5 million since 2003. About two million out of the total cases are women aged 15 plus. About 5.7 million of the total cases are contributed by India. An estimated 0.5 million8 have died due to AIDS in the Region. Although HIV prevalence among pregnant women remains relatively low in many countries in the Region, it has been increasing for several years. In 2004, in Asia there were an estimated 155,400 pregnant women infected with HIV and 46,900 children became infected with HIV while about 31,000 children developed AIDS. The situation will become worse if there is no adequate intervention, because more women of reproductive age are contracting HIV infection. Between 2001 and 2004, the estimated number of HIV-infected women increased by 16% to over two million – compared to the average global increase of about 8%. The ratio of infected women to men is also increasing, from 25% at the end of 2001 to 28% at the end of 2004. The low status of women often makes them especially vulnerable to HIV and makes it difﬁcult for them to protect themselves. There is a great disparity in the countries of the Region about the knowledge related to HIV/AIDS. Women living in countries where the literacy rate is high have better knowledge. Generally, younger men and women are more likely to have this knowledge. A low level of knowledge among ever-married women of India explains high prevalence of HIV in the country. Inequalities exist within the countries. In Bangladesh, for example, only 29% of women belonging to the poorest wealth quintile had heard of HIV/AIDS, compared to 92% in the richest wealth quintile.

urban population has ﬁve times more access to skilled care than the rural. The richest quintile is 14 times more likely to have a skilled birth attendant at delivery than the poorest in Bangladesh. Similarly, poor women are much more likely to deliver at home in India, Indonesia and Nepal.

Adolescents’ exposure to risks A large proportion of girls marry early in Bangladesh, India, Nepal and Indonesia. More than half of girls are married before they are 18 years old bearing the risks associated with early sexual activity, i.e. sexuallytransmitted infections and pregnancy. Adolescents lack information and skills and often engage in risky behaviours including higher proportion of sexual experiences before marriage, high unprotected sexual activity, low rates of condom use, and unsafe injection practices among injecting drug users (IDUs), thus making them one of the most vulnerable groups in terms of growing HIV infection. In Thailand, the 2001 estimates of HIV prevalence among youth of age group 15-24 years were as high as 0.88% among males and 1.32% among females; and 0.22% and 0.46% respectively in India in 20019. Data in 2005 showed that childbirth among women aged less than 20 years was highest in Bangladesh, Timor-Leste, Thailand and India, ranging from 15% to 25%. For both physiological and social reasons, girls aged 15-19 years are twice as likely to die in childbirth as those in their 20s as observed in Bangladesh, India and Indonesia. In Nepal, 19% of maternal deaths occur during adolescence. Girls under 15 are ﬁve times as likely to die as those in their 20s.

Expenditure on reproductive health Often a sufﬁcient proportion of GDP is not made available for expanding the availability of reproductive health services. Adequate ﬁnancing and efﬁcient management of those resources is not observed in countries with the poorest reproductive health status. Total government expenditure on health in 2004 ranged from 2.2% to 11.2% of GDP in countries of the Region10. In many countries, out-of-pocket expenditure

2.2. Barriers to Progress

Inequalities related to access to skilled health care Besides disparities among countries in the Region, a marked difference can be observed in access to skilled attendance at birth by urban and rural populations and the rich and the poor within the countries. In Nepal the 8

As per 2006 AIDS Epidemic Update, although the proportion of people living with HIV in India is lower than previously estimated, the epidemic continues to affect large number of people (between 2 million and 3.1 million in 2006) 9 Health Related Millennium Development Goals 2005, WHO 10 World Health Statistics 2007, WHO

The Regional Context

on health constitutes a large percentage of total health expenditure. The poor are particularly vulnerable having to spend large proportions of their income on health. Nevertheless, some countries, for example Maldives and Thailand, provide social security on health to their people and contribute a large proportion of general government expenditure to provide services.

Human resource for reproductive health It is generally agreed that appropriately trained human resources in the right quantity in both the public and private sectors, and their optimal use is key to the provision of comprehensive health care. The correlation between the number of workforce and coverage of health interventions, such as deliveries by skilled birth attendants, shows that the health of the population suffers when the workers are scarce. According to international estimates, 2.28 health care providers (doctors, nurses and midwives) per 1,000 population is a threshold to achieve 80% coverage for skilled attendance during deliveries11. Four countries of the SEA Region (Bangladesh, Bhutan, Nepal and Indonesia)12 have less than one health care provider per 1000 population. Weak and poorly skilled health workers are often a reality in countries of the SEA Region. The work environment and conditions of employment, training and supervision, including the levels of remuneration are also inadequate in some settings. The resulting poor motivation means that retaining skilled health personnel becomes a problem. Migration of the health workforce in the context of SEA Region began several years ago, particularly from India, Sri Lanka, Bangladesh, and Nepal. Recent studies indicate that out of the annual output of qualiﬁed medical professionals in India, 2.8% had gone abroad for employment. In Sri Lanka, out of a total of 826 graduates, 22% (185) did not return from their postgraduate training abroad during 1993-2000.

Added to the problems of supply and distribution of the health workforce, inadequate skill-mix, lack of cultural and interpersonal skills, inadequate technical knowledge and skills are also major challenges in many countries of the Region. Health staff in some countries of the Region are not able to rely on a functioning health infrastructure that can ensure suitable facilities, continuous availability of reproductive health commodities, essential medicines and supplies.

Inequalities related to gender Violence, which includes physical, sexual and emotional abuse against women, often persists and sometimes may start during pregnancy, with serious implications for the mother and child. Studies in the Region show that in some countries, 4-10% of women who had ever been pregnant had experienced physical violence during their pregnancies or physical abuse became worse during a pregnancy. In almost all cases the perpetrator was an intimate partner.

Organization of health service delivery While each country in the Region has its own problems in organization of service delivery, there are a few common features related to the provision of reproductive health services. Inefﬁcient use of resources is one of the issues. Often, allocation of resources in the health sector is heavily skewed, with major regional disparities and with most resources spent on in-patient care. In some countries the full package of essential reproductive health services is not available at primary health care level with some elements missing or given less attention (i.e. safe abortion, prevention of STIs/ HIV infection, management of STIs, etc). Further, there is a poor functioning referral system. Lack of linkages between reproductive health and other health programmes and services, including nutrition, prevention and treatment of frequent diseases, such as malaria is common.

11 12

World Health Report 2006, WHO World Health Statistics 2006, WHO

14 A Framework for Implementing the RHS in the South-East Asia Region



The goal of this document is to provide a strategic framework and guidance to countries of the Region for implementing the Global Reproductive Health Strategy to improve sexual and reproductive health programmes in the context of the South-East Asia Region. The speciﬁc objectives are to:  provide an information base for understanding the reproductive health situation and challenges in countries of the Region;  facilitate an analysis of the situation and challenges of reproductive health programme in countries of the Region; and  facilitate identiﬁcation of priority reproductive health issues, needs and problems and formulate strategies for accelerated action in countries of the Region.

Goal and Objectives

16 A Framework for Implementing the RHS in the South-East Asia Region

  the reproductive health situation and the vital health systems functions. Priority actions:  Policy level:  ensure that reproductive health is a central element of national planning and strategy development processes, including its incorporation into poverty reduction strategy papers (PRSPs), sector-wide approaches (SWAp) and WHO country cooperation strategies (CCS);  adequate and sustainable funding should be made available to foster comprehensive, good quality and accessible reproductive health services; and  all stakeholders should be actively involved in decision-making and in identifying priorities throughout the development, planning, implementation and evaluation stages.  Human resources:  determine essential requirements at all health care levels for numbers, skill mix and distribution of staff needed to provide a comprehensive reproductive health service package;  develop a national plan for human resources for health and collaborate with the education sector to ensure a steady supply of new entrants;  maximize existing human resources, through improved deployment, supportive supervision, management and strengthening of skills and capabilities of existing staff;  develop, review or update policies that enable health professionals to use their skills to the full;  update curricula for health professionals to include disciplines such as epidemiology and

For implementing the Global Reproductive Health Strategy each country needs to: i) identify problems, ii) set priorities, and iii) formulate strategies for accelerated action. Each country has a unique health system infrastructure, organization of reproductive health services, regulatory framework and capacity of providers. These need to be taken into consideration when setting priorities and formulating strategies for accelerated action. Many countries in the Region have developed a reproductive health strategy. An effort has been made to study the country’s reproductive health strategy and assess it in the light of ﬁve key action areas outlined in the global strategy. The following are the ﬁve key areas for action and partnerships.

4.1. Strengthening Health Systems Capacity The existence of functioning systems of essential health care at the primary, secondary and tertiary levels is a prerequisite for attaining the MDGs relating to maternal and child survival, prevention of HIV/AIDS, as well as broader reproductive and sexual health goals. Planning at national level for reproductive and sexual health is closely related to the performance of the health systems. There are three functions in health systems that are crucial for improving its performance: i) human resource provision, ii) service delivery organization and iii) ﬁnancing. To oversee these three vital functions, effective stewardship is also required. The priority improvements that are needed within each of these functions to address reproductive and sexual health are described below. Country-speciﬁc adaptation will be required based on the analysis of

Areas of Action and Partnership



public health, health promotion, and theory and practice of counselling skills, as well as appraisal of practices and skills and costeffectiveness of care;  strengthen training in reproductive and sexual health at pre-service and post-graduate teaching institutions in addition to a system of continuous education and in-service training;  assess and improve work environments and human resources management including conditions of employment and supervision; and  put in place efforts to motivate and retain skilled health personnel. Service delivery organization:  ensure that: i) basic reproductive health commodities are included in the general health investment plan of the government; ii) a supply system is in place to guarantee continuous replenishing and adequate maintenance of health commodities at all levels of the health care system; iii) the national essential drug list is regularly updated to reﬂect the needs and standards;  ensure appropriate referral and linkages of reproductive health care with STI/HIV infection, nutrition and other related programmes, with special attention to the needs of adolescents and disadvantaged groups; and  integrate evidence-based standards and quality improvement mechanisms in provision of reproductive health services and in social health insurance schemes. Financing:  design and set up ﬁnancing mechanisms that facilitate universal access to reproductive health care, especially among the poor and other vulnerable groups.

and social vulnerability. Improved data collection and analysis, including information about costs and costeffectiveness, are essential for selecting priorities and for aiming health system interventions at targets that are most likely to make a difference within the limits of available resources. Priority actions:  Research capacity strengthening:  improve national research capacities to plan, collect, analyze and distribute results on multifaceted determinants of reproductive and sexual health; and  improve health system capacities to carry out operations research, collect and analyze data/ information in order to identify best practices for programme development and management, including priority-setting and identiﬁcation of subpopulations with special needs.  Use of data/information for programme development and management:  strengthen capacity of the national, subnational and local management for using all available reproductive health data for planning and decision making and promote an ethos of evidence-based decision-making to change practices of policy-makers, managers, educators and clinicians; and  strengthen dissemination strategies to assure that information is shared and analyzed with key actors at all levels so as to assure that information is used for increasing awareness and decision-making.

4.3. Mobilizing Political Will Creating a dynamic environment of strong international, national and local support for rights-based reproductive and sexual health initiatives will help to overcome inertia, galvanize investment and establish high standards and mechanisms for performance accountability. This requires the involvement of not only ministries of health, but also ministries of ﬁnance, education and possibly other sectors, and their counterparts at district and local levels. Political commitment and advocacy must be sufﬁciently strong to sustain good policies and programmes, particularly for underserved groups.

4.2. Improving Information for Priority-setting Analysis of epidemiological and social science data is needed to understand the type, severity and distribution of reproductive and sexual risks exposure and ill health in the population, to interpret the dynamics that drive poor reproductive and sexual health, and to highlight the links between such ill-health and poverty, gender

18 A Framework for Implementing the RHS in the South-East Asia Region

Priority actions:  Advocacy:  consolidate advocacy efforts among donors, international standards bodies, and key inﬂuential players within the government infrastructure to build a constituency that can promote political and social commitment for attainment of reproductive health; and  develop evidence-based strategies for creating awareness of the scale of and consequences to reproductive health and building broadbased support among all key stakeholders in government, academic institutions and nongovernmental organizations, as well as community, women's and young people’s groups.  Mobilization of public and private stakeholders:  establish or revitalize high-level national and sub-national multidisciplinary taskforces or committees, with the responsibility to take action and inﬂuence policy change, as well as co-ordinate and oversee stakeholders’ efforts towards improving reproductive and sexual health;  work with private health providers to expand and improve their services, ensuring that these contribute to the national strategies and meet national standards; and  build partnership with mass media and other effective channels to highlight the importance of sexual and reproductive health.

Priority actions:  Review/assess laws and policies as necessary related to reproductive health in collaboration with key ministries and:  modify laws and policies to protect reproductive and sexual health and rights, especially taking into consideration interests of vulnerable and disadvantaged groups (e.g. unmarried girls, adolescents, poor, misplaced populations, victims of rape and sexual abuse); and  develop regulatory procedures (accreditation, licensing and certiﬁcation) and establish practical enforcement mechanisms, including civil and criminal laws.  Review/assess the overall regulations related to reproductive health in order to:  ensure that regulations and guidelines meet international quality standards and facilities/ supplies are available on a consistent and equitable basis; and  reinforce and if necessary modify administrative regulations in the ministries, local/district health authorities, hospitals/clinics and professional organizations to remove unnecessary barriers to reproductive health services, information and education.

4.5. Strengthening Monitoring, Evaluation and Accountability Monitoring and evaluation are essential for learning what does and does not work, and why. This may also reveal the changing needs and unexpected impacts, both positive and negative. Priority actions:  Ensure that appropriate priority is given continuously to reproductive health at policy level:  monitor health-sector reforms, sector-wide approaches, national health accounts and the implementation of other ﬁnancing mechanisms (such as poverty reduction strategy papers/ PRSPs, cost-sharing and direct budget support) in order to ensure equitable services at all levels; and  set performance standards, monitoring and accountability mechanisms for provision of

4.4. Creating Supportive Legislative and Regulatory Frameworks Removal of unnecessary restrictions (from policies and regulations), to create a supportive framework for reproductive and sexual health, is likely to contribute signiﬁcantly to improved access to services. Regulations are needed to ensure that commodities (medicines, equipment and supplies) are made available on a consistent and equitable basis and that they meet international quality standards. In addition, an effective regulatory environment is needed to ensure public and private sector accountability for providing high-quality care for the entire population.

Areas of Action and Partnership



health services by establishing targets and benchmark in a complementary action among the public and private sectors, as well as international and nongovernmental agencies. Strengthen monitoring and evaluation process/ mechanism:  identify appropriate sets of indicators for monitoring progress;  strengthen capacity for collecting and analyzing data on reproductive health, its underlying determinants and the functioning of health services at local, district and national levels;



ensure that attention is paid to equitable access, especially for the poor and marginalized groups, among others by disaggregating data that reﬂects inequity; and  establish independent accountability mechanisms, including oversight by representatives of civil society. Improve monitoring and information systems:  strengthen surveillance systems for reproductive health status; and  ensure that monitoring and reporting systems are coordinated and streamlined. 

20 A Framework for Implementing the RHS in the South-East Asia Region

   

The framework for the Global Reproductive Health Strategy provides a comprehensive list of indicators that are commonly used in monitoring and evaluation of programmes, structured according to the ﬁve core elements of sexual and reproductive health. There is a wide array of monitoring and evaluation tools and guidelines developed by WHO and partners to advise policy-makers and programme managers on the generation, interpretation and analysis of data. The set of indicators proposed herewith is neither comprehensive nor does it include descriptions of methodological and practical considerations. Detailed information on indicators for monitoring of reproductive health can be found in many other publications, including, among others, the “Reproductive Health Indicators – Guidelines for their generation, interpretation and analysis for global monitoring” published by the World Health Organization in 2006. The list of common indicators for monitoring and evaluation of reproductive health programmes provided includes indicators at different levels, such as input/ process/output and outcome/impact indicators. The list should facilitate the development of monitoring and evaluation plans in countries according to the local situation and needs.



 

Number of facilities per 500,000 population providing comprehensive EOC. Percentage of population living within one hour travel time of health services offering EOC. Percentage of women attended at least once during pregnancy by skilled health personnel for reasons relating to pregnancy; percentage attended by skilled health personnel at least four times. Percentage of pregnant women counselled and tested for HIV. Percentage of births attended by skilled health personnel. Percentage of births taking place in a health facility. Caesarean sections as percentage of all live births. Percentage of all women with major obstetric complications treated in EOC facilities (met obstetric need).

Outcome/impact indicators 



5.1 Improving Antenatal, Delivery, Postpartum and Newborn Care Input/process/output indicators 



 

Number of facilities per 500,000 population providing basic essential obstetric care.

Case-fatality rates (CFR) for obstetric complications. Maternal mortality ratio (number of maternal deaths per 100,000 live births). Percentage of live births with low birth weight (less than 2500 grams), by sex. Number of HIV-positive women provided with antiretroviral therapy during pregnancy. HIV prevalence among pregnant women aged 15–24 years. Prevalence of positive syphilis serology in pregnant women attending for antenatal care. Number of neonatal tetanus cases. Rate of congenital syphilis (number of congenital syphilis cases per 100,000 live births).

Indicators for Evaluating Progress

5.2 High-quality Services for Family Planning Input/process/output indicators 

5.3 Eliminating Unsafe Abortion Input/process/output indicators 



Number of family planning service delivery points (SDP) per 500,000 population offering a full range of contraceptive information, counselling and supplies (at least six methods, including male and female, temporary and permanent, emergency contraception). Number of family planning SDPs located within a ﬁxed distance (e.g. 30 km) or travel time (e.g. two hours) of a given location (e.g. a community). Percentage of primary health care (PHC) facilities providing family planning services. Number of other sources of contraceptive information, supplies and services (pharmacies, private physicians, etc.) per 500,000 population. Percentage of family planning SDPs offering counselling on dual protection (protection from STIs and unwanted pregnancies). Percentage of family planning SDPs offering diagnosis and treatment of STIs. Percentage of family planning SDPs offering voluntary HIV counselling and testing (VCT). Percentage of family planning SDPs with written, clinical family planning protocols. Percentage of PHC and family planning facilities offering treatment or referrals for infertility. Number of individuals accepting a modern contraceptive method for the ﬁrst time (new acceptors).



Number/percentage of SDPs providing postabortion care services, by type and geographical distribution. Percentage of SDPs using vacuum aspiration or medical termination for procedures, by gestational age. Number/percentage of practitioners trained in Post-Abortion Care, by type (of specialty) and geographical distribution. Number/percentage of SDPs that offer family planning to patients receiving PAC. Percentage of obstetric and gynaecological admissions owing to abortion.

Outcome/impact indicators 



Abortion rate (number of induced abortions occurring per 1000 women of reproductive age). Percentage of maternal deaths attributed to abortion. Percentage of unintended pregnancies (mistimed or unwanted) terminated within 8 and 12 weeks of gestation and beyond 12 weeks.

5.4. Combating Sexually Transmitted Infections, Cervical Cancer and other Gynaecological Morbidities Input/process/output indicators 

Outcome/impact indicators 



 

Percentage of women at risk of pregnancy who are using (or whose partner is using) a contraceptive method (contraceptive prevalence rate and methodspeciﬁc contraceptive prevalence rate). Percentage of women at risk of pregnancy (currently married or in union who are fecund) and who desire to either terminate or postpone childbearing, but are not currently using a contraceptive method (unmet need). Total fertility rate (TFR). Age-speciﬁc fertility rate.



Number of SDPs per 500,000 population with trained personnel, laboratory equipment and medicines appropriate for the diagnosis and treatment of bacterial and viral STIs and RTIs, including HIV/AIDS. Number of condoms available for distribution nationwide (during the preceding 12 months) per individual aged 15–49 years. Percentage of family planning SDPs offering counselling on dual protection from STIs/HIV and unwanted pregnancies. Percentage of PHC and family planning facilities offering VCT. Percentage of PHC facilities offering routine screening for cervical and prostate cancer. Percentage of women screened for breast cancer within the past ﬁve years.

22 A Framework for Implementing the RHS in the South-East Asia Region



Percentage of women screened for cervical cancer within the past ﬁve years.

5.5. Promoting Sexual Health Input/process/output indicators 

Outcome/impact indicators 



 

Percentage of relevant population groups who correctly identify the three major ways of preventing the sexual transmission of HIV and who reject three major misconceptions about HIV transmission or prevention, by sex. HIV prevalence in subpopulations with high-risk behavior, by sex. Percentage of men and women who report using a condom the last time they had sex with a nonmarital, non-cohabiting partner (in the last 12 months). Percentage of condom users who report consistent use of the method, by sex. Percentage of women with cervical cancer. Percentage of women and men with secondary infertility.



 

Percentage of health and family planning providers trained to detect (and ask users about) signs of sexual abuse or violence, or of anxiety, shame, anger or depression related to sexual relations. Percentage of SDPs equipped to provide appropriate medical, psychological and legal support for victims of rape or incest. Percentage of SDPs branded “youth-friendly”. Percentage of adolescents who have received sexual health education in schools, by sex.

Outcome indicators   



Age at marriage (for men and women). Age at ﬁrst intercourse (for men and women). Percentage of women who have undergone female genital mutilation. Percentage of sexually active adolescents who consistently use condoms, by sex.

Indicators for Evaluating Progress

24 A Framework for Implementing the RHS in the South-East Asia Region

 uses the ﬁve key action areas outlined in the Strategy: i) strengthening health systems capacity; ii) improving information for priority-setting; iii) mobilizing political will; iv) creating supportive legislative and regulatory frameworks; and v) strengthening monitoring, evaluation and accountability. The role of health ministries is to provide leadership to their national reproductive health communities, the private sector and other stakeholders to reinforce commitments and streamline priority actions in these ﬁve key areas. WHO will continue to provide technical assistance to countries based on a considerable body of knowledge that provides the evidence base for establishing and implementing international norms and standards in reproductive health.

For implementing the Global Reproductive Health Strategy and attaining international reproductive health goals, including MDGs, each country needs to identify problems, set priorities and formulate strategies for accelerated action. National reproductive health strategies for many countries in the Region are in place. While programmes may vary based on the country situation, the common approach, however, is to foster a wide-range of collaboration and commitment to accelerate the reproductive health agenda by translating global strategies into concrete actions in countries based on their priorities and situation. This framework provides guidance for implementing the Global Reproductive Health Strategy keeping in mind the efforts made by countries of the Region as reﬂected in their reproductive health strategies. It

Conclusion

26 A Framework for Implementing the RHS in the South-East Asia Region

 1. United Nations. Revised millennium development goal monitoring framework, including new targets and indicators, as recommended by the Inter-Agency and Expert Group on Millennium Development Goal Indicators. New York: UN, 2007. 2. Maternal mortality in 2000: estimates developed by WHO, UNICEF and UNFPA. Geneva: World Health Organization, 2004 (http://www.who. int/reproductive-health/publications/maternal_ mortality_2000/mme.pdf - accessed 18 June 2008). 3. World Health Organization. Neonatal and perinatal mortality : country, regional and global estimates. Geneva: WHO, 2006 (http://whqlibdoc.who.int/pub lications/2007/9789241596145_eng.pdf - accessed 19 June 2008). 4. World Health Organization, Regional Ofﬁce for South-East Asia. Strategic directions to improve newborn health in the South-East Asia Region. New Delhi: WHO SEARO, 2004. 5. World Health Organization, Regional Ofﬁce for South-East Asia. Country reproductive health proﬁles. New Delhi: WHO SEARO, 2003 (http://searo.who. int/en/Section13/Section36/Section1579.htm accessed 23 June 2008). 6. World Health Organization, Regional Ofﬁce for South-East Asia. Family planning saves lives: an investment in development, country fact sheets. New Delhi: WHO SEARO, 2004 (http://searo. who.int/EN/Section13/Section36/Section1726. htm#ban - accessed 23 June 2008). 7. World Health Organization. Regional Ofﬁce for South-East Asia. Improving maternal and newborn health - the role of family planning : report of a regional consultation, Chiang Mai, Thailand, 19-21 November 2003. New Delhi: WHO SEARO, 2004. Document SEA-MCH-FP-110. 8. UNAIDS. The 2006 report on the global AIDS epidemic. Geneva: UNAIDS, May 2006. 9. World Health Organization. Health-related Millennium Development Goals: update after the high-level plenary meeting of the United Nations General Assembly (September 2005): report by the Secretariat. Geneva: WHO, 2006. 10. World Health Organization. World health statistics 2007. Geneva: WHO, 2007 (http://whqlibdoc.who. int/publications/2007/9789241563406_eng.pdf accessed 19 June 2008). 11. World Health Organization. World health report: 2006: working together for health. Geneva: WHO, 2006 http://whqlibdoc.who.int/publications/2006 /9241563176_eng.pdf - accessed 19 June 2008). 12. World Health Organization. World health statistics 2006. Geneva: WHO, 2006 (http://whqlibdoc.who. int/publications/2006/9241563214_eng.pdf accessed 23 June 2008. 13. World Health Organization. Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. Geneva: WHO, 2004 (http://whqlibdoc. who.int/hq/2004/WHO_RHR_04.8.pdf - accessed 19 June 2008). 14. World Health Organization. Accelerating progress towards the attainment of international reproductive health goals : a framework for implementing the WHO Global Reproductive Health Strategy. Geneva: WHO, 2006. Document WHO/RHR/06.3 (http:// whqlibdoc.who.int/hq/2006/WHO_RHR_06.3_eng. pdf - accessed 19 June 2008). 15. World Health Organization. The World health report: 2005: make every mother and child count. Geneva: WHO, 2005 (http://www.who.int/whr/2005/ whr2005_en.pdf - accessed 19 June 2008). 16. United Nations. World population policies 2005. New York: UN Department of Economic and Social Affairs UN, 2006.

References

  

 Table-1: Demographic features Indicators Total population (in million)1 Annual population growth rate (%) Total fertility rate (TFR) 2 2

Year 2004 2001 2004 2004 2002 1999-2003 2000 1999-2003 4

140 1.54 3.0 47.3 390 41 27 65 <25

Contraceptive prevalence rate (%) (modern methods)1 Maternal mortality ratio (MMR)2 per 100,000 live births Neonatal mortality rate (NNMR)1 per 1000 live births Early neonatal mortality rate3 per 1000 live births Infant mortality rate per 1000 live births 1

Coverage of vital registration of death (%)

2002

Source: 1. Bangladesh Demographic Health Survey 2004, Ministry of Health, Bangladesh; 2. Millennium Development Goals: Bangladesh Progress Report 2005, Government of Bangladesh, Dhaka. 3. World Health Report 2006, WHO, Geneva; 4. World Health Statistics 2006.

Table-2: Health Systems: Human Resources and Financing Human resources, 2004 Physicians per 10,000 population Nurses per 10,000 population Midwives per 10,000 population Community workers per 10,000 population Health Expenditure, 2003 Total expenditure on health as % of gross domestic product Private expenditure on health as % of total expenditure on health Out-of-pocket expenditure as % of private expenditure on health Out-of-pocket expenditure as % of total expenditure on health Social security expenditure on health out of general govt. expenditure on health (%) Source: World Health Statistics 2006.

2.6 1.4 1.8 3.1 3.4 68.7 85.8 64.2 0.0

Table-3: Maternal health indicators, 2004 Antenatal care coverage, at least once during pregnancy1 (%) 4+ visits (%) Proportion of births attended by skilled health personnel1 (%) Postnatal care coverage (%) 1

56 16 13 17.8 16 18.4

Median age at marriage, women aged 20-24

Median age at ﬁrst birth, women aged 20-241 Per cent TFR attributed to birth by ages 15-19 2

Source: 1. Bangladesh Demographic Health Survey 2004, Ministry of Health, Bangladesh; 2. World youth 2000, Population Reference Bureau.

RH Data: Bangladesh

Figure-1: Maternal mortality ratio (deaths per 100,000 live births), 1990-2005 700 600 500 MMR 400 300 200 100 0 1990 2000 Year 2005 2015 MDG target 143

Figure-2: Trends in neonatal mortality rate, 1993-2004 60 52

574 NMR 400 390

50 40 30 20 10 0 1993-94

1996-97 1999-2000 Year NMR trends

2004

Source: Millennium Development Goals: Bangladesh Progress Report 2005, Government of Bangladesh.

Source: Bangladesh Demographic Health Survey 2004, Ministry of Health, Bangladesh.

Figure-3: Trends in antenatal care, 1996-2004 60 50 Per cent 40 30 20 10 0 1996-97 1999-2000 2004 33.3 29 48.7

Figure-4: Proportion of births assisted by skilled attendant: trends, 1996-2004 80 70 60 Per cent 50 40 30 20 10 0 1996-97 1999-2000

12.1

13.4

2004

2015 MDG target

Source: Bangladesh Demographic Health Survey 2004, Ministry of Health, Bangladesh.

Figure-6: Trends in Total Fertility Rates, 1989-2004 6

Figure-5: Types of assistance during delivery, 2004 Untrained birth attendant, 63%

5 4 3 2 1 0

5.1 4.3 3.4 3.3 3.3

3.0

Traditional birth attendant, 13.8% Nurse/midwife, 5.7%

Relative/friend, 8.7% Qualified doctor, 7.5%

1989

1991 1993-94 1996-97 19992000 TFR trends

2004

Source: Demographic Health Survey 2004, Ministry of Health, Bangladesh.

32 A Framework for Implementing the RHS in the South-East Asia Region

Figure-7: Contraceptive prevalence rate (CPR)-modern methods: trends, 1975-2004 50 40 Percent 30 20 10 0 1975 5 1983 1985 1989 1991 1993-94 1996-97 1999-2000 2004 13.8 23.2 18.4 36.2 31.2 41.5 43.4 47.3

Years of Survey Any modern method Source: Bangladesh Demographic Health Survey 2004, Ministry of Health, Bangladesh.

Figure-8: Contraceptive method mix among currently married women, 1989-2004 30 25 Per cent 20 15 10 5 0 Pill 13.9 17.4 20.8 23.0 26.2

0.6 2.6 4.5 6.2 7.2 9.7

1.4 1.8 2.2 1.8 1.2 0.6

1.8 2.5 3.0 3.9 4.3 4.2

0.1 0.5 0.8

8.5 9.1 8.1 7.6 6.7 5.2 Female Male Sterilization Sterilization 1.2 1.2 1.1 1.1 0.5 0.6 RH Data: Bangladesh

9.6

IUD

Injectables

Condom

Implants

Contraceptive methods 1989 1996-97 Source: Demographic Health Survey 2004, Ministry of Health, Bangladesh.

1991 1999-2000

1993-94 2004

Figure-9: Maternal and newborn health care coverage, 2004 60 50 40 Per cent 30 20 10 0 ANC(any) Skilled attendant at birth 13 9.3 36.2 56

Births at health facility

Breast feeding

Source: Demographic Health Survey 2004, Ministry of Health, Bangladesh.

Figure-10: Inequities in reproductive health (a) rural-urban disparities (%), 2004 80 70 60 50 40 30 20 10 0 74.8 50.9 29.6 9.4 ANC 6.2 CPR 51.6

(b) poorest-richest quintiles, 2004 100 80 60 40 20 0 ANC 33.7 3.4 Skilled attendant at birth Poorest 39.6 30.3 2.0 Births at health facility Richest CPR 44.7 84.1

46 21.9

50.0

Skilled Births at attendant at health facility birth Rural Urban

Source: Demographic Health Survey 2004, Ministry of Health, Bangladesh.

Table-4: HIV Prevalence, 2005 Estimated HIV prevalence1 Youth (15-24) HIV prevalence rate (%) 20013 Male Female 0.01 0.01 <0.1

Table-5: Estimated number of people living with HIV Adults (15+) 2005 11000 2003 7500 Women (15+) 2005 1400 2003 <500

Source: 2006 Report on Global AIDS Epidemic, UNAIDS 2006.

Source: 1. 2006 Report on Global AIDS Epidemic, UNAIDS 2006; 2. Young people and HIV/AIDS: Opportunity in crisis, UNICEF.

Table-6: Childbearing in married adolescents aged 15-19, 2004 Background information Age 15 16 17 18 19 Location Urban Rural Total 25.5 37.0 34.7 26.1 37.4 32.7 Per cent who have begun childbearing 1999-2000 15.9 26.0 36.5 45.0 57.3 2004 11.5 22.2 37.2 42.8 58.8

Source: Demographic Health Survey 2004, Ministry of Health, Bangladesh.

34 A Framework for Implementing the RHS in the South-East Asia Region

Figure-12: Trend in age-speciﬁc fertility rate (per 1000 women) among girls aged 15-19, 1989-2004 Figure-11: Causes of maternal death, 2001 200 15.80% 14.90% 26.60% ASFR 150 100 50 0 1989 1999-2000 Year Source: Demographic Health Survey 2004, Ministry of Health, Bangladesh.

182 144 135

16.60% Haemorrhage Eclampsia Other direct causes

23.90% Indirect causes Not classified

2004

Source: Bangladesh Maternal Health Services and Maternal Mortality Survey 2001.

RH Data: Bangladesh

36 A Framework for Implementing the RHS in the South-East Asia Region

 Table-1: Demographic features Indicators Total population 1

Year 2004 2000 2004 3

752,700 2.50 4.2 19 255 38 18 40 <25

Annual population growth rate (%)1 Total fertility rate (TFR)2 Contraceptive prevalence rate (%)- modern methods 4 5

2004 2000 2000 2000 2005 2002

Maternal mortality ratio (MMR) per 100,000 live births Neonatal mortality rate (NNMR) per 1000 live births Early neonatal mortality rate5 per 1000 live births Infant mortality rate per 1000 live births 4

Coverage of vital registration of death (%)

Source: 1. Millennium Development Goals: Progress Report 2005, Bhutan; 2. Annual Health Bulletin 2006, Royal Government of Bhutan, Ministry of Health, Thimpu, Bhutan; 3. World Health Report 2006. World Health Organization, Geneva; 4. Annual Health Bulletin 2006, Royal Government of Bhutan, Ministry of Health, Thimpu, Bhutan; 5. World Health Report 2005. World Health Organization, Geneva.

Table-2: Health Systems: Human Resources and Financing Human Resources, 2004 Physicians per 100,000 population Nurses per 100,000 population Midwives per 100,000 population Community workers per 100,000 population Health Expenditure, 2003 Total expenditure on health as % of gross domestic product Private expenditure on health as % of total expenditure on health Out-of-pocket expenditure as % of private expenditure on health Out-of-pocket expenditure as % of total expenditure on health Social security expenditure on health out of general govt. expenditure on health (%) Source: World Health Statistics 2006.

5.0 14.0 8.0 20.0 3.1 16.5 100 0.00

Table-3: Maternal health indicators, 2005 Antenatal care coverage at least once during pregnancy (%) Proportion of births attended by skilled health personnel (%) Source: MoH, 2005, Royal Government of Bhutan, Ministry of Health, Thimpu, Bhutan.

70 51

RH Data: Bhutan

Figure-1: Maternal mortality ratio (deaths per 100,000 live births), 1990-2000 600 500 300 200 100 0 1990 2000 Year Source: Annual Health Bulletin 2006, Royal Government of Bhutan, Ministry of Health, Thimpu, Bhutan.

Figure-2: Proportion of births assisted by skilled attendant: trends, 1990-2005 120 100 100

560

255 140

Per cent

400 MMR

80 60 40 20 15 24 51

2015 MDG target

0 1990 2000 Year 2005 2015 MDG target

Source: Millennium Development Goals: Progress Report 2005, Bhutan.

Figure-3: Maternal and newborn health care coverage, 2005 80 70 60 Per cent 50 40 30 20 10 0 ANC, any Skilled attendant Births at at birth health facility 70 51

Figure-4: Trends in Total Fertility Rate, 1975-2005 8 6 4 2 0 1975 1985 Year Source: World Population Data, 2005.

5.9

5.6 4.4

28.4

1995

2005

Source: MoH, 2005, Royal Government of Bhutan, Ministry of Health, Thimpu, Bhutan.

Figure-5: Age-speciﬁc fertility rate (per 1000 women) among girls aged 15-19, 1993 300 250 200 ASFR 150 100 50 0 15-19 20-24 25-29 30-34 35-39 40-44 Source: World Fertility Report 2003, Population Division and DESA, UN.

Table-4: Prevalence of HIV, 2005 Estimated HIV prevalence (number) Male Female 105 55 50

267

242 195 174

Source: MoH , 2005, Royal Government of Bhutan, Ministry of Health, Thimpu, Bhutan.

120

38 A Framework for Implementing the RHS in the South-East Asia Region

  Table-1: Demographic features Indicators Total population (in million) Annual population growth rate (%) Total fertility rate (TFR) Contraceptive prevalence rate % (modern methods) Maternal mortality ratio (MMR) per 100,000 live births Neonatal mortality rate (NNMR) per 1000 live births 1

Year 2003 2000-03 2003 2002 2002 2002 2003 1

23.4 0.71 2.0 69 97 8.6 21 >90

Infant mortality rate per 1000 live births Coverage of vital registration of death (%)

2006

Sources: 1. MOH DPRK, 2007; 2. 2002 Reproductive Health Survey, DPR Korea, UNFPA; Summary of the Health System and the Information of Health Situation in the Period 2001-2003 in DPR Korea, EHI (HSD), WHO SEARO, New Delhi.

Table-2: Health Systems: Human Resources and Financing Human resources, 2003 Physicians per 10,000 population1 Nurses per 10,000 population1 Midwives per 10,000 population1 Health expenditure, 2003 Total expenditure on health as % of gross domestic product2 Private expenditure on health as % of total expenditure on health2 Out-of-pocket expenditure as % of private expenditure on health2 Social security expenditure on health out of general government expenditure on health (%) Source: 1. World Health Statistics 2006; 2. MOH, DPR Korea 2007. 1

32.9 38.5 2.7 6.3 8.8 0.0 0.0

Table-3: Maternal health indicators, 2002 Antenatal care coverage at least once during pregnancy (%) Proportion of births attended by skilled health personnel (%) Postnatal care coverage Prevalence of anaemia among pregnant women (%)1 Mean age at ﬁrst marriage for women Mean age at ﬁrst birth 2 2

98 98 98.8 33.8 24.8 25.9

Source: 1. 2002 Reproductive Health Survey, DPR Korea, UNFPA; Summary of the Health System and the Information of Health Situation in the Period 2001-2003 in DPR Korea, WHO, EHI (HSD), SEARO, New Delhi.

RH Data: DPR Korea

Figure-1: Maternal mortality ratio (deaths per 100,000 live births), 1996-2002

Figure-2: Proportion of births assisted by skilled attendant: trends, 1995-2002 100 95 Per cent

110 105 MMR 100 95 90

105

90 85

1996 Year

2002

1995-96

1999 Year

2002

Source: Summary of the Health System and the Information of Health Situation in the Period 2001-2003 in DPR Korea. WHO, EHI (HSD), SEARO, New Delhi.

Source: Summary of the Health System and the Information of Health Situation in the Period 2001-2003 in DPR Korea, WHO, EHI (HSD), SEARO, New Delhi.

Figure-3: Trends in Total Fertility Rate, 1975-2005

Figure-4: Contraceptive prevalence rate - modern methods: trends, 1997-2002 69

5 4 3 2 1 0

3.9 2.8 2.3

68.5 68 CPR 2 67.5 67 66.5 67.3

68.6

1975

1985 Year

1995

2005

1997 Year

2002

Source: World Population Data, 2005.

Source: 2002 Reproductive Health Survey, DPR Korea, UNFPA.

Figure-5: Contraceptive method mix among currently married women, 2002 45 40 35 30 25 20 15 10 5 0 42.8

Per cent

3.7 Pill IUD

5.8 Condom Contraceptive methods

4.4 Female Sterilization

0.8 Male Sterilization

Source: 2002 Reproductive Health Survey, DPR Korea, UNFPA.

40 A Framework for Implementing the RHS in the South-East Asia Region

Figure-6: Age speciﬁc fertility rate (per 1000 women), 2002 250 200 150 100 50 0 0 15-19 20-24 25-29 30-34 Year 2002 Source: 2002 Reproductive Health Survey, DPR Korea, UNFPA.

Figure-7: Maternal and newborn health care coverage, 2001-03 120 100 Per cent 98 98 81

220 192 145

80 60 40

48.8 6 35-39 40-44

20 0 ANC, any Skilled attendant Births at at birth health facility

Source: Summary of the Health System and the Information of Health Situation in the Period 2001-2003 in DPR Korea, WHO, EHI (HSD), SEARO, New Delhi.

Figure-8: Coverage of maternal and newborn health services (%): rural-urban, 2002 100 95 90 85 80 75 Skilled attendant at birth Rural Births at health facility Urban 84.0 89.7 96.5 97.1

Table-4: Prevalence HIV, 2002

RTIs,

STIs

including 9.7 0.0

Percentage of women with any RTI symptoms (%) Estimated HIV prevalence (%) Source: 2002 Reproductive Health Survey, DPR Korea, UNFPA.

Source: 2002 Reproductive Health Survey, DPR Korea, UNFPA.

RH Data: DPR Korea

42 A Framework for Implementing the RHS in the South-East Asia Region

 Table-1: Demographic features Indicators Total population (in million)1 Annual population growth rate (%) Total fertility rate (TFR) 3 3 2

Year 2005 2001 2005-06 2005-06 2001-03 2002 2000 2005 7 4

1094.6 1.96 2.68 48.5 301 37 33 58 <25

Contraceptive prevalence rate % (modern methods) 5

Maternal mortality ratio (MMR) per 100,000 live births Neonatal mortality rate (NNMR) per 1000 live births Early neonatal mortality rate6 per 1000 live births Infant mortality rate4 per 1000 live births Coverage of vital registration of death (%)

2000

Source: 1. World Development Report 2006, World Bank, Washington, DC; 2. Health Information of India 2005, Central Bureau of Health Intelligence, Directorate General of Health Services, Ministry of Health and Family Welfare, India; 3. National Family Health Survey-III (provisional data)., 2005-2006, International Institute of Population Sciences, Mumbai; 4. Sample Registration System Bulletin, October 2006, Registrar General, New Delhi; 5. Sample Registration System 2003, Registrar General, New Delhi; 6. World Health Report 2004, World Health Organization, Geneva; 7. World Health Statistics 2006.

Table-2: Health Systems: Human Resources and Financing Human Resources, 2004-2005 Physicians per 10,000 population Nurses per 10,000 population Midwives per 10,000 population Community workers per 100,000 population Health Expenditure, 2003 Total expenditure on health as % of gross domestic product Private expenditure on health as % of total expenditure on health Out-of-pocket expenditure as % of private expenditure on health Out-of-pocket expenditure as % of total expenditure on health Social security expenditure on health out of general govt. expenditure on health (%) Source: World Health Statistics 2006.

6.0 8.0 4.7 5.0 4.8 75.2 97 77.5 4.2

Table-3: Maternal health indicators, 2005-06 Antenatal care coverage at least once during pregnancy1 (%) Proportion of births attended by skilled health personnel1 (%) Postnatal care coverage (%) 1

50.7 48.3 36.4 57.9 44.5 19.8 years 19

Prevalence of anaemia among pregnant women (%) 1

Women aged 20-24 married by age 18 (%)

1 1

Median age at ﬁrst birth (for women aged 25-29)

Per cent of TFR attributed to birth by ages 15-192

Source: 1. National Family Health Survey-III (provisional data), 2005-06, International Institute of Population Sciences, Mumbai, 2. Population Reference Bureau, The world youth 2000, Washington D. C., 2000.

RH Data: India

Figure-1: Trends in neonatal mortality rate, 1995-2003 60 50 NMR 40 30 20 10 0 1995 2000 Year NMR trends Source: Sample Registration System Bulletin, October 1995, 2000, 2003. Registrar General, New Delhi.

Figure-2: Maternal mortality ratio (deaths per 100,000 live births), 1991-2003 500 437 407 301

44 37 MMR

400 300 200 100 0

109

2003

1991

1998

2001-03

2015 MDG target

Year Source: Sample Registration System Bulletin, October 2006 Registrar General, New Delhi.

Figure-3: Proportion of births assisted by skilled attendant: trends, 1992-2006 100 80 Per cent 60 40 20 0 1992-93 1998-99 2005-06 2015 MDG target Traditional birth attendant, 36% Nurse/midwife/ Family health worker, 12% 33.0 42.4 48.3 Relative/friend 22% Other, 0.3% Qualified doctor, 30%

84.0

Figure-4: Types of birth attendant during delivery, 1998-99

Year

Source: National Family Health Survey-III (provisional data), 2005-06. International Institute of Population Sciences, Mumbai.

Source: National Family Health Survey-II, 1998-99. International Institute of Population Sciences, Mumbai.

Figure-5: Trends in Total Fertility Rate, 1992-2006 4 3 2.5 2 1.5 1 0.5 0 1992-93 1998-99 2005-06 2.9

Figure-6: Contraceptive prevalence rate: trends, 1992-2006 60

2.7

CPR (All Methods)

3.5

3.4

50 40 30 20 10 0 1992-93 36.5

42.8

48.5

1998-99 Year

2005-06

Source: National Family Health Survey-III (provisional data), 2005-06. International Institute of Population Sciences, Mumbai.

Source: National Family Health Survey-III (provisional data), 2005-06, International Institute of Population Sciences, Mumbai.

44 A Framework for Implementing the RHS in the South-East Asia Region

Figure-7: Contraceptive method mix among currently married women, 1992-2006 40 35 30 25 20 15 10 5 0 34.1 27.4 37.3

Per cent

3.1 1.2 2.1 Pill

1.9 1.6 1.8 IUD 1992-93

2.4 3.1

5.3

3.5 1.9 1.0 Female Sterilization 2005-06 Male Sterilization

Condom Contraceptive methods 1998-99

Source: National Family Health Survey-III (provisional data), 2005-06, International Institute of Population Sciences, Mumbai.

Figure-8: Age-speciﬁc fertility rate (per 1000 women) among girls aged 15-19, 1992-99 120 115 ASFR 110 105 100 1992-93 Year Source: National Family Health Survey-II, 1998-99, International Institute of Population Sciences, Mumbai.

Figure-9: Maternal and newborn health care coverage, 2005-06 60 50.7

116 Per cent

50 40 30 20 10 1998-99 0

48.3 40.7

46.3

107

ANC

Skilled Births at Breastattendant at health facility feeding birth

Source: National Family Health Survey-III (provisional data), 2005-06, International Institute of Population Sciences, Mumbai.

Figure-10: Inequities in reproductive health (a) rural-urban disparities (%), 2005-06 80 60 40 20 0 ANC Skilled Births at health CPR attendant at facility birth Rural Urban 42.8 73.8 75.2 69.4 45.3 31.1 55.8

(b) poorest-richest quintiles, 2000 100 80 60 40 20 0 ANC Skilled attendant at birth Poorest Births at health facility Richest CPR 21.1 29.3 16.4 11.7 81.0 84.4 74.7 54.6

39.1

Source: National Family Health Survey-III (provisional data), 2005-06. International Institute of Population Sciences, Mumbai.

Source: Socio-economic Differences in Health, Nutrition, and Population in India, 2nd ed. Washington, D.C.: The World Bank, 2000.

RH Data: India

Figure-11: Causes of maternal mortality in rural India, 1998 Malposition, 7%

Table-4: HIV prevalence Estimated HIV prevalence1, 2005 Male Female 0.9a 1.1 0.7 1.6

Others, 14% Anaemia, 24%

Percentage of HIV+ pregnant women receiving antiretroviral prophylaxis1 (%) Youth (15-24) HIV prevalence rate (%) 20012 Male Female

Pueperal sepsis, 10% Toxemia, 10% Abortion, 12%

Haemorrhage, 23%

0.22 0.46

Source: Registrar General of India, Survey of causes of death (rural), 1998.

Source: 1. 2006 Report on Global AIDS Epidemic, UNAIDS 2006; 2. Health Related Millennium Goals, 2005, WHO. a 0.36% (new estimates)

Table-5: Estimated number of people living with HIV Adults (15+) 2005 5,600,000 2003 5,200,000 Women (15+) 2005 1,600,000 2003 1,500,000

Source: 2006 Report on Global AIDS Epidemic, UNAIDS 2006.

46 A Framework for Implementing the RHS in the South-East Asia Region

 Table-1: Demographic features Indicators Total population (in million)1 Annual population growth rate (%) Total fertility rate (TFR) 1 2 2

Year 2006 2000-05 2003 2005 2000 2000 2000 2005 4

222.05 1.34 2.6 74 307 18 14 30 <25

Contraceptive prevalence rate (%) - modern methods Neonatal mortality rate (NNMR)4 per 1000 live births Early neonatal mortality rate per 1000 live births 5

Maternal mortality ratio (MMR)3 per 100,000 live births

Infant mortality rate per 1000 live births 1

Coverage of vital registration of death (%)

2002

Source: 1. Selected Indicators of Indonesia. Ed. Directorate of Statistical Dissemination, June 2006, Badan Pusat Statistik, Indonesia; 2. Selected Indicators: Social-Economic of Indonesia, July 2006, Badan Pusat Statistik, Indonesia; 3. Indonesia Demographic and Health Survey 2002-03; 4. World Health Report 2006, WHO, Geneva; 5. World Health Report 2005, WHO, Geneva.

Table-2: Health Systems: Human Resources and Financing Human Resources, 2003 Physicians per 10,000 population2 Nurses per 10,000 population 1 2 2

1.8 6.2 3.2 0.0 3.1 1

Midwives per 10,000 population Health Expenditure, 2003

Community workers per 1000 population

Total expenditure on health as % of gross domestic product1 Private expenditure on health as % of total expenditure on health Out-of-pocket expenditure as % of private expenditure on health1 Out-of-pocket expenditure as % of total expenditure on health Source: 1. World Health Report 2006. World Health Organization, Geneva; 2. Sub-national Health System Performance Assessment, MOH-WHO, 2005. 1 1

64.1 74.3 48.7 10

Social security expenditure on health out of general government expenditure on health (%)

Table-3: Maternal health indicators, 2002-2003 Antenatal care coverage at least once during pregnancy (%)1 4+ visits (%) Proportion of births attended by skilled health personnel (%), 2004 Postnatal care coverage 1

95.4 81 72 62 20.2 21.9 9.9

Median age at marriage for women aged 25-291, 2002-2003 Median age at ﬁrst birth for women aged 25-291 Per cent of TFR attributed to birth by ages 15-19 2

Source: 1. Indonesia Demographic and Health Survey 2002-03; 2. Welfare Statistics 2004, National Socio-economic Survey, Indonesia, Badan Pusat Statistik, Indonesia.

RH Data: Indonesia

Figure-1: Trends in neonatal mortality rate, 1988-2002 35 30 25 NMR Trends 20 15 10 5 0 1988-92 1993-97 Year Source: Indonesia Demographic and Health Survey 2002-03.

Figure-2: Maternal mortality ratio (deaths per 100,000 live births), 1992-2003 450 400 350 300 250 200 150 100 50 0 390 334 307

26 20 MMR

100

1998-2002

1992

1995

2002-03 Year

2015 MDG target

Source: Indonesia: Progress Report on the Millennium Development Goals, February 2004.

Figure-3: Proportion of births assisted by skilled attendant: trends, 1992-2004 100 80 Per cent 60 40 20 0 1992 1996 2000 Year 2004 2015 MDG target No one, 0.3% 41 49 Qualified doctor, 11% 67 72 Nurse/midwife, 55.3

Figure-4: Types of assistance during delivery (%), 2002-03

Traditional birth Relative/friend, 1% attendant, 31.5%

Source: Indonesia: Progress Report on the Millennium Development Goals, February 2004; Welfare Statistics 2004. National Socio-economic Survey, Indonesia, Badan Pusat Statistik, Indonesia.

Source: Indonesia Demographic and Health survey 2002-03.

Figure-5: Trends in Total Fertility Rate, 1991-2003 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 1991 1994 Year Source: Indonesia Demographic and Health Survey 2002-03. 3.0 2.9 2.8 2.6

Figure-6: Trends of contraceptive prevalence rate modern methods: 1992-2005 80 60 CPF 40 20 0 50 55 55 52 74

1997

2003

1992

1995

1998 Year

2001

2005

Source: Selected Indicators: Social-Economic Survey, Indonesia, July 2006, Badan Pusat Statistik, Indonesia; Indonesia: Progress Report on the Millennium Development Goals, February 2004.

48 A Framework for Implementing the RHS in the South-East Asia Region

Figure-7: Contraceptive method mix among currently married women, 1991-2003 20 18 16 14 12 10 8 6 4 2 0 28 21 15 17 15 13 13 10 8 6 1 1 1 1 Pill IUD Injectables Condom 3 15 1991 1994 1997 2002-2003

Per cent

5 6

3 3 3 4 Female Sterilization

1 1 0 0 Male Sterilization

Implants

Contraceptive methods Source: Indonesia Demographic and Health Survey 2002-03.

Figure-8: Maternal and newborn health care coverage, 2002-03 120 100 Per cent 80 60 40 20 0 ANC Skilled Births at PNC (home Breastattendant health del-within 2 feeding at birth facility days of del) 40.0 95.4 67.0 62.0 39.5

Source: Indonesia Demographic and Health Survey 2002-03.

Figure-9: Inequities in reproductive health (a) rural-urban, 2002-2003 120 100 80 60 40 20 0 ANC Skilled attendant at birth Births at health facility CPR 55 22.5 93.6 97.6 79 59.6 56.5 57

(b) poorest-richest quintiles, 2000 Urban 120 100 80 60 40 20 0 ANC Skilled attendant at birth Births at health facility CPR

Rural

99.3 76.6

Poorest

Richest

89.0

81.5 48.6 58.0

21.0

12.5

Source: Indonesia Demographic and Health survey 2002-03.

Source: Country Proﬁles for Population and Reproductive Health: Policy Developments and Indicators 2005, UNFPA and PRB 2005.

RH Data: Indonesia

Figure-11: Trend in age-speciﬁc fertility rate (per 1000 women) among girls aged 15-19, 1970-2003 Figure-10: Causes of maternal mortality, 2001 Haemorrhage, 28% Eclampsia, 24% ASFR Other, 11% Obstructed embolism, 3% Obstructed labour, 10% Abortion, 5% Infection, 11% Postpartum complications, 8% 140 120 100 80 60 40 20 0 1970 1980 Year Source: Indonesia Demographic and Health Survey 2002-03.

124

75 61 51

1990

2002-03

Source: Household Health Survey 2001 quoted in the presentation of Director of Maternal Health.

Table-4: HIV prevalence Estimated HIV prevalence1 Percentage of HIV+ pregnant women receiving antiretroviral prophylaxis1 (%) HIV prevalence rate (%) among young people of age 15-24 years old, 20012 Male Female 0.08 0.09 0.1 0.7

Source: 1. 2006 Report on Global AIDS Epidemic, UNAIDS 2006; 2. Young people and HIV/AIDS: Opportunity in Crisis, UNICEF, UNAIDS, WHO, 2002.

Table-5: Estimated number of people living with HIV Adults (15+) 2005 170,000 2003 110,000 Women (15+) 2005 29,000 2003 15,000

Table-6: Childbearing in married adolescents aged 15-19, 2002-2003 Background information Age 15 16 17 18 19 Location Urban Rural Total 7.3 13.7 10.4 1.2 2.5 6.6 16.0 24.7 Per cent who have begun childbearing

Source: 2006 Report on Global AIDS Epidemic, UNAIDS 2006.

Source: Indonesia Demographic and Health Survey 2002-03.

50 A Framework for Implementing the RHS in the South-East Asia Region

 Table-1: Demographic features Indicators Total population 1 2

Year 2006 1995-2000 1995-2000 2004 2003 2003 2005 2003 2005 4

298,842 1.96 2.8 34 70 10 12 42 0.1

Annual population growth rate (%) Total fertility rate (TFR)2

Contraceptive prevalence rate (% ) - modern methods3 Maternal mortality ratio (MMR) per 100,000 live births Neonatal mortality rate (NNMR) per 1000 live births 5

Infant mortality rate per 1000 live births 1

Coverage of vital registration of death (%)6 Estimated HIV prevalence (%) 7

Source: 1. Maldives Key Indicators - 2006, Ministry of Planning and National Development - Statistics Section; 2. Maldives Health Proﬁle 2004. Ministry of Health, Republic of Maldives; 3. Reproductive Health Survey 2004, Maldives; 4. Millennium Development Goals. Maldives Country Report 2005; 5. The Maldives Health Report 2004, Ministry of Health, Republic of Maldives; 6. World Health Statistics 2006; 7. 2006 Report on Global AIDS Epidemic, UNAIDS, 2006.

Table-2: Health Systems: Human Resources and Financing Human Resources, 2004 Physicians per 10,000 population Nurses per 1000 population Midwives per 1000 population Community workers per 1000 population Health Expenditure, 2003 Total expenditure on health as % of gross domestic product Private expenditure on health as % of total expenditure on health Out-of-pocket expenditure as % of private expenditure on health Out-of-pocket expenditure as % of total expenditure on health Social security expenditure on health out of general govt. expenditure on health (%) Source: World Health Statistics 2006.

9.2 2.7 6.2 11.0 100 12.3 22.9

Table-3: Maternal health indicators, 2004 Antenatal care coverage at least once during pregnancy (%) 4+ visits (%) Proportion of births attended by skilled health personnel (%) Median age at marriage Source: Reproductive Health Survey 2004, Maldives.

100 91 87 19

RH Data: Maldives

Figure-1: Maternal mortality ratio (per 100,000 live births), 1990-2005 600 500 400 MMR 500

Figure-2: Trends in neonatal mortality, 1991-2003 25 20 15 NMR 125 10 5 2015 MDG target 0 1991 1995 Year Source: The Maldives Health Report 2004, Ministry of Health, Republic of Maldives. 13 10 22 23

300 200 100 0 1991 2000 Year 2005 78 70

1999

2003

Source: Millennium Development Goals, Maldives Country Report 2005.

Figure-3: Proportion of births assisted by skilled attendant: trends, 2000-2005 100 80 Per cent 60 40 20 0 2000 Year Source: Millennium Development Goals, Maldives Country Report 2005. 70 87

Figure-4: Types of assistance during delivery, 2003

Other, 20%

Doctor, 49%

2005

Nurse, 31%

Source: The Maldives Health Report 2004, Ministry of Health, Republic of Maldives.

Figure-5: Contraceptive prevalence rate - modern methods: trends, 1999-2004 40 35 30 25 CPR 20 15 10 5 0 1999 Year Source: Reproductive Health Survey 2004, Maldives.

Figure-6: Trends in Total Fertility Rate, 1975-2005 8 7 6.8 6 4.3 4 2 0

2004

1975

1985 Year

1995

2005

Source: World Population Data, 2005.

52 A Framework for Implementing the RHS in the South-East Asia Region

Figure-7: Contraceptive method mix among currently married women, 1999-2004 14 12 10 Per cent 8 6 4 2 0 Pill IUD Injectables Condom Implants Contraceptive methods Source: Reproductive Health Survey 2004, Maldives. 13 13

1999 9 6 3 3 4 10 8 7

2004

1 1 Female Sterilization Male Sterilization

Figure-8: Maternal and newborn health care coverage, 2004 105 100 Per cent 95 90 85 80 ANC, any Year Source: Reproductive Health Survey 2004, Maldives.

Figure-9: Trend in age-speciﬁc fertility rate (per 1000 women) among girls aged 15-19, 1990-2005 120 106 103 70.4 54

100

100 80 ASFR 60 40 20 Skilled attendant at birth 0 1990 1995 Year Source: For the year 1990-World Fertility Report 2003, Population Division, and DESA, United Nations; for rest of the period - Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2004 Revision and World Urbanization Prospects: The 2003 Revision, http://esa.un.org/unpp, 17 April 2006.

2000

2005

RH Data: Maldives

54 A Framework for Implementing the RHS in the South-East Asia Region

 Table-1: Demographic features Indicators Total population (in million)1 Annual population growth rate (%) Total fertility rate (TFR) 2 3 1

Year 2005-06 2005-06 2005 2001 2002-03 2003 2000 2003 6

55.4 2.02 2.4 32.8 316 16.3 11.08 49.7 <25

Contraceptive prevalence rate (%) - modern methods Maternal mortality ratio (MMR)5 Neonatal mortality rate (NMR)4 Early neonatal mortality rate Infant mortality mate 4 4

Coverage of vital registration of death (%)

2000

Source: 1. Health in Myanmar 2007, Ministry of Health, Myanmar; 2. Myanmar Fertility and Reproductive Health Survey, 2001; 3. Millennium Development Goals 2006, Myanmar; 4. Overall and Cause Speciﬁc Under Five Mortality Survey, 2002 -2003; 5. Nationwide Cause Speciﬁc Maternal Mortality Survey, 2004-2005; 6. World Health Statistics, 2006, WHO.

Table-2: Health Systems: Human Resources and Financing Human Resources, 2004 Physicians per 10,000 population Nurses per 10,000 population Midwives per 10,000 population Community workers per 10,000 population Health Expenditure, 2003 Total expenditure on health as % of gross domestic product Private expenditure on health as % of total expenditure on health Out-of-pocket expenditure as % of private expenditure on health Out-of-pocket expenditure as % of total expenditure on health Social security expenditure on health out of general govt. expenditure on health (%) Source: World Health Statistics 2006.

3.6 3.8 6.0 9.9 2.8 80.6 99.7 81.3 1.3

Table-3: Maternal health indicators Antenatal care coverage during pregnancy (%)1, 2001, 3+ visits Proportion of births attended by skilled health personnel (%)1, 2001 Per cent of ever married adolescents aged 15-191, 2006 Per cent of TFR attributed to birth by ages 15-19 , 2002 2

65.9 57 8.4 3.37 18.4 18

Median age at ﬁrst birth, women aged 20-24

1 2

Per cent TFR attributed to birth by ages 15-19

Source: 1. Myanmar Fertility and Reproductive Health Survey, 2001; 2. Myanmar Reproductive Health Baseline Community Survey

RH Data: Myanmar

Figure-1: Maternal mortality ratio (per 100,000 live births), 1994-2003 350 300 250 MMR 200 150 100 50 0 1994 1999 2002-03 2015 MDG target 57.5 232 255

Figure-2: Proportion of births assisted by skilled attendant: trends, 1990-2003 80 68 60 NMR 40 20 0 51 57

316

1990

2001 Year

2003

Year Source: Millennium Development Goals 2005, Myanmar.

Source: Millennium Development Goals 2006, Myanmar.

Figure-3: Contraceptive method mix among currently married women, 2001 16 14 12 Per cent 10 8 6 4 2 0 Pil l

Figure-4: Maternal and newborn health care coverage, 2001 80 70 68

9 Per cent 5 1.9 0.5 1.3

60 50 40 30 20 10 0 AN C, any Ski ant nd irth e t at at b lled lth hea ility t a fac rth

s le le m IUD table do ema tion Ma ation c F za on z e C j rili In rili Ste Ste

Contraceptive methods Source: Myanmar Fertility and Reproductive Health Survey 2001.

Source: Myanmar Fertility and Reproductive Health Survey 2001.

Figure-5: Trends in Total Fertility Rate, 1991-2005 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 1991 1997 Year Source: Myanmar Fertility and Reproductive Health Survey 2001; UNICEF Myanmar, http://www.unicef.org/infobycountry/myanmar_ statistics.html

Figure-6: Trend in age-speciﬁc fertility rate (per 1000 women) among girls aged 15-19, 1971-2001 50

2.9

2.7

2.4

2.2 ASFR

40 30 20 10

40 29

22.7

2001

2005

0 1971 1996 Year Source: For the year 1971 and 1996 - World Fertility Report 2003, Population Division, and DESA, United Nations; for 2001- Myanmar Fertility and Reproductive Health Survey 2001, Ministry of Immigration and Population, Yangon 2003.

2001

56 A Framework for Implementing the RHS in the South-East Asia Region

Figure-7: Causes of maternal mortality, 2004-2005 Indirect cause, 16.90% Postpartum haemorrhage, 30.98%

Embolism, 1.41% Ruptured uterus, 4.23% Antepartum haemorrhage, 4.23% Prolonged and obstructed labour 8.46%

Abortion related, 9.86% Eclampsia, 11.27% Hypertensive disease of pregnancy, 5.63%

Puerperal sepsis, 7.04% Source: Nationwide Cause Speciﬁc Maternal Mortality Survey (2004-2005), DOH/UNICEF.

Table-4: HIV prevalence, 2005 Estimated HIV prevalence Male Female Percentage of HIV+ pregnant women receiving anti retroviral prophylaxis (%) 1.2 1.7 0.7 4.8

Table-5: Estimated number of people living with HIV Adults (15+) 2005 350,000 2003 380,000 Women (15+) 2005 110,000 2003 120,000

Source: 2006 Report on Global AIDS Epidemic, UNAIDS 2006.

Source: 1. 2006 Report on Global AIDS Epidemic, UNAIDS 2006; 2. Young people and HIV/AIDS: Opportunity in crisis, UNICEF.

Figure-8: Prevalence of reported selected STIs per 100,000 population, 1992-2001 Prevalence per 100 000 population 30 25 20 15 10 05 0 1992 Syphills 1993 1994 Gonorrhoea 1995 1996 Year Non-GC urethritis/cervicitis Chancroid 1997 1998 1999 2000 2001

Source: HIV Sentinel Surveillance (HSS), NAP, Department of Health, 2004.

RH Data: Myanmar

58 A Framework for Implementing the RHS in the South-East Asia Region

 Table-1: Demographic features Indicators Total population (in million)1 Annual population growth rate (%) Total fertility rate (TFR) Contraceptive prevalence rate (%) - modern methods 3 2

Year 2004-2005 2001 2003-2005 2006 2000 2002-2006 2000 2005 25.1 2.25 3.1 44 415a 34 29 61 <25

Maternal mortality ratio (MMR)2 per 100,000 live births Neonatal mortality rate (NMR)2 per 1000 live births Early neonatal mortality rate per 1000 live births 4

Infant mortality rate per 1000 live births 2

Coverage of vital registration of death (%)

Source: 1. Annual Report, Department of Health Services 2003/04, Ministry of Health, Kathmandu; 2. Nepal Millennium Development Goals: Progress Report 2005; 3. Nepal Demographic Health Survey 2006: Preliminary Report; 4. World Health Statistics 2006, WHO. a 281 (Source: Nepal DHS 2006).

2.1 2.2 2.4 6.3 5.3 72.2 92.2 67.1 0.0

Table-3: Maternal health indicators, 2003-2004 Antenatal care coverage at least once during pregnancy1 (%) Proportion of births attended by skilled health personnel (%) 1

66 20 16.8 19.9

Median age at ﬁrst marriage, women aged 20-24 Median age at ﬁrst birth, women aged 20-242

Source: 1. Annual Report, Department of Health Services 2003/04, Ministry of Health, Kathmandu; 2. Nepal Millennium Development Goals: Progress Report 2005.

RH Data: Nepal

Figure-1: Maternal mortality ratio (deaths per 100,000 live births), 1990-2000 600 500 400 MMR 300 200 100 0 1990 2000 Year Source: Nepal Millennium Development Goals: Progress Report 2005.

Figure-2: Trends in neonatal mortality rate, 1992-2006 60 51 45 34

515 415 MMR 134 2015 MDG target

50 40 30 20 10 0 1992-96 NMR trends

1997-01 Year

2002-06

Source: Nepal Demographic Health Survey 2006: Preliminary Report. Population Division, Ministry of Health and Population, Nepal.

Figure-3: Proportion of births assisted by skilled attendant: trends, 1990-2005 80 60 Per cent 40 20 7 0 1990 11 20 60

Figure-4: Types of assistance during delivery, 2001

Relative/friend, 55% No one, 8.60% Doctor, 7.80% 2000 Year 2005 2015 MDG target Nurse/midwife/HW, 5% Traditional birth attendant, 23.40% Source: Nepal Demographic and Health Survey, 2001.

Source: Nepal Millennium Development Goals: Progress Report 2005.

Figure-5: Maternal and newborn health care coverage, 2006 70 60 50 Per cent 40 30 20 10 0 ANC Skilled attendant at birth Births at health facility Breastfeeding 20 66 53

Figure-6: Trends in Total Fertility Rate, 1985-2004 6 5 4 3 5.1 4.8 4.6 4.1 3.1

2 1 0 1985 1990 1994 Year 1999 2004

Source: Nepal Demographic Health Survey 2006: Preliminary Report.

Source: Nepal Demographic Health Survey 2006: Preliminary Report. Population Division, Ministry of Health and Population, Nepal.

60 A Framework for Implementing the RHS in the South-East Asia Region

Figure-7: Contraceptive prevalence rate - modern method: trends, 1996-2006 5 4 3 CPR 2 1 0 1996 2001 Year 2006 26 35.4 44.2

Source: Nepal Demographic Health Survey 2006: Preliminary Report.

Figure-8: Contraceptive method mix among currently married women, 1996-2006 20 18 16 14 12 10 8 6 4 2 0 18 15 12.1 8.4 3.5 0.3 0.4 0.7 IUD Injectables 4.5 1.9 10.1 4.8 2.9 0.4 0.6 0.8 Implants Female Sterilization Male Sterilization 5.4 6.3 6.3

1996

2001

2006

Per cent

1.4 1.6 Pill

Condom

Contraceptive methods Source: Nepal Demographic Health Survey 2006: Preliminary Report.

Figure-9: Inequities in reproductive health (a) rural-urban, 2001 100 80 60 40 20 0 ANC 9.9 Skilled attendant at birth 8 Birth at health facility CPR 46.6 82.4 51 Rural Urban 56.3 46 33.2

(b) poorest-richest quintiles, 2000 100 80 60 40 20 0 ANC 30.4 3.6 Skilled attendant at birth Birth at health facility CPR 79.5 Poorest Richest 55.2 23.8

45.1

Source: Nepal Millennium Development Goals: Progress Report 2005.

RH Data: Nepal

Table-4: HIV prevalence, 2005 Estimated HIV prevalence1 Male Female Percentage of HIV+ pregnant women receiving anti retroviral prophylaxis (%)2 Youth (15-24) HIV prevalence rate (%)2 Male Female 0.5 0.7 0.3 0.9

Table-5: Estimated number of people living with HIV Adults (15+) 2005 74,000 2003 64,000 Women (15+) 2005 16,000 2003 13,000

Source: 2006 Report on Global AIDS Epidemic, UNAIDS 2006.

0.17 0.18

Table-6: Childbearing in married adolescents aged 15-19, 2001 Background information Age 15 1.5 9.3 17.5 34.0 40.5 12.6 22.5 21.4 Per cent who have begun childbearing

Source: 1. Nepal Millennium Development Goals: Progress Report 2005; 2. 2006 Report on Global AIDS Epidemic, UNAIDS 2006.

Figure-10: Trends in age-speciﬁc fertility rate (per 1000 women) among girls aged 15-19, 1986-2006 25 20 ASFR 15 10 5 0 1986 1991 Year Source: Nepal Demographic and Health Survey, 2001; Nepal Demographic Health Survey 2006: Preliminary Report.

16 17 18 19 Location Urban

110

101 98

Rural Total

Source: Nepal Demographic and Health Survey, 2001.

2001

2006

62 A Framework for Implementing the RHS in the South-East Asia Region

 Table-1: Demographic features Indicators Total population (in million)1 Annual population growth rate (%)1 Total fertility rate (TFR) 1 2

Year 2004 2004 2000 2000 2004 2001 2000 2003 3

19.46 1.2 1.9 49.5 38 13 9 11

Contraceptive prevalence rate (%) - modern methods Neonatal mortality rate (NMR)3 per 1000 live births Early neonatal mortality rate per 1000 live births 3

Maternal mortality ratio (MMR) per 100,000 live births

Infant mortality rate

Source: 1. Time Trend of Poverty Indicators on Population, Employment and Socio-Economic Situation 1981-2004, Department of Census & Statistics, Ministry of Finance & Planning, Colombo, Sri Lanka; 2. Sri Lanka DHS 2000; 3. Sri Lanka Health Atlas, 2003, Ministry of Health, Nutrition & Welfare, Sri Lanka; 4. World Health Statistics 2006, World Health Organization, Geneva.

Table-2: Health Systems: Human Resources and Financing Human Resources, 2004 Physicians per 10,000 population Nurses per 10,000 population Midwives per 10,000 population Health Expenditure, 2003 Total expenditure on health as % of gross domestic product Private expenditure on health as % of total expenditure on health Out-of-pocket expenditure as % of private expenditure on health Out-of-pocket expenditure as % of total expenditure on health Social security expenditure on health out of general govt. expenditure on health (%) Source: World Health Statistics 2006.

5.5 15.8 1.6 3.5 55 88.9 48.7 0.3

Table-3: Maternal health indicators, 2000 Antenatal care coverage at least once during pregnancy (%) Proportion of births attended by skilled health personnel (%) Median age at marriage, women aged 25-29 Median age at ﬁrst birth, women aged 25-29 Source: Sri Lanka Demographic and Health Survey 2000.

98 96 21.8 22.6

Table-4: Childbearing in married adolescents aged 15-19, 2000 Age at ﬁrst birth <15 15-17 18-19 Per cent of married 20-24 year olds who had ﬁrst child by speciﬁc ages 0.6 4.7 8.4

Source: Sri Lanka Demographic and Health Survey 2000.

RH Data: Sri Lanka

Figure-1: Trends in neonatal mortality rate, 1980-2001 25 20 NMR 22.7

Figure-2: Maternal mortality ratio (deaths per 100, 000 live births), 1996-2004 70 60 50 MMR 40 30 20 10 0 1996 1998 2000 Year 2001 2004 2015 MDG target 60

57 47 38 36

15 10 5 0 1980 NMR trends

12.9

1992 Year

2001

Source: Annual Health Bulletin 2002, Department of Health Services, Sri Lanka.

Source: World Development Report 2006, World Bank, Washington, DC. http://econ.worldbank.org; MOH, Sri Lanka, 2004.

Figure-3: Proportion of births assisted by skilled attendant: trends, 1980-2000 120 100 Per cent 80 60 40 20 0 1980 1990 Years Source: Poverty Statistics Indicators for Sri Lanka. Department of Census and Statistics, Sri Lanka. http://www.statistics.gov.lk/poverty/PovertyStatistics.pdf

96 47

Figure-4: Types of assistance during delivery, 2000 Relataive/friend, 22%

Others, 0.3% Qualified doctor, 30%

2000

2015 MDG target

Traditional birth attendant, 36%

Nurse/midwife/Family health worker, 12%

Source: Sri Lanka Demographic and Health Survey 2000.

Figure-5: Trends in Total Fertility Rate, 1982-2000 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 1980 1990 Year Source: Sri Lanka Demographic and Health Survey 2000.

Figure-6: Trend in age-speciﬁc fertility rate (per 1000 women) among girls aged 15-19, 1987-2000 4.0 38 27

3.7 2.8 2.3 1.9 ASFR 2000 2000

TFR trends (in per cent)

3.0 2.0 1.0 0 1987 Year

2000

Source: Sri Lanka Demographic and Health Survey 2000.

64 A Framework for Implementing the RHS in the South-East Asia Region

Figure-7: Contraceptive prevalence rate - modern methods: trends, 1975-2000 6.0 5.0 4.0 CPR 3.0 2.0 1.0 0 1975 1982 1987 Year Source: Sri Lanka Demographic and Health Survey 2000.

49.5 40.6 31.9 20.2 43.7

1993

2000

Figure-8: Contraceptive method mix among currently married women, 1982-2000 35 30 25 Per cent 20 15 11 5 0 Pill IUD Injectables Condom Contraceptive methods Source: Sri Lanka Demographic and Health Survey 2000.

1982

1987

1993

2000

29.8 22

27.2 23.1

10.8 2.7 4.1 5.5 6.7 2.9 2.1 3.0 5.1 1 2.7 4.6 3.3 1.9 3.3 3.7

0.1 0.1 Implants Sterilization

Figure-9: Maternal and newborn health care coverage, 2000 100 95 Per cent 90 85 80 75 ANC (any) Skilled attendant at birth Births at health facility Breastfeeding 83 98 96 96

Figure-10: Inequities in coverage of reproductive health interventions, 2000 120 100 80 Per cent 60 40 20 0 ANC Skilled attendant at birth Births at health facility CPR 98 98 90 99 Rural 98.4 81.7 53.5 42.2 Urban

Source: Sri Lanka Demographic and Health Survey 2000.

RH Data: Sri Lanka

Table-5: HIV Prevalence Estimated HIV prevalence1, 2005 Male2 Female2 Youth (15-24) HIV prevalence rate (%)2 Male Female <0.1 59% 41% 0.02 0.03

Table-6: Estimated number of people living with HIV Adults (15+) 2005 5,000 2003 3,100 Women (15+) 2005 <1,000 2003 <1,000

Source: 1. 2006 Report on Global AIDS Epidemic, UNAIDS 2006.

Source: 1. 2006 Report on global AIDS epidemic, UNAIDS 2006; 2. Health related Millennium Development Goals 2005, UNAIDS.

Figure-9: Maternal and newborn health care coverage, 2000 100 95 Per cent 90 85 80 75 ANC (any) Skilled attendant at birth Births at health facility Breastfeeding 83 98

Figure-10: Inequities in coverage of reproductive health interventions, 2000 120 Rural 98 98 90 99 98.4 81.7 53.5 42.2 Urban

100 80 Per cent 60 40 20 0

ANC

Skilled attendant at birth

Births at health facility

CPR

Source: Sri Lanka Demographic and Health Survey 2000.

66 A Framework for Implementing the RHS in the South-East Asia Region

 Table-1: Demographic features Indicators Total population (in million)1 Annual population growth rate (%)1 Total fertility rate (TFR) 2 3

Year 2003 2001 2003 2006 2003 2005 2005 2005 2002 4

63.1 0.8 1.6 79 20.6 4.5 3.1 7.6 91

Contraceptive prevalence rate (%) - modern methods Neonatal mortality rate (NNMR)5 per 1000 live births Early neonatal mortality rate per 1000 live births 5

Maternal mortality ratio (MMR) per 100,000 live births

Infant mortality rate per 1000 live births 5

Coverage of vital registration of death (%) 6

Source: 1. Thailand Health Proﬁle 2001-2004, Ministry of Public Health, Thailand; 2. Mahidol Population Gazette, Vol. 16, January 2007; 3. National Statistical Ofﬁce. Report of 2006 Reproductive Health Survey; 4. Maternal and Child Health Group, Bureau of Health Promotion. Maternal and Child Health Situation, 2001 – 2003; 5. Health Information Unit, Bureau of Health Policy and Strategy, Ministry of Public Health, 2005; 6. World Health Statistics 2006.

Table-2: Health Systems: Human Resources and Financing Human Resources, 2000 Physicians per 10,000 population Nurses per 10,000 population Midwives per 100,000 population Community workers per 100,000 population Health Expenditure, 2003 Total expenditure on health as % of gross domestic product Private expenditure on health as % of total expenditure on health Out-of-pocket expenditure as % of private expenditure on health Out-of-pocket expenditure as % of total expenditure on health Social security expenditure on health out of general govt. expenditure on health (%) Source: World Health Statistics 2006.

3.7 28.2 1.0 6.0 3.3 38.4 74.8 23.0 32

Table-3: Maternal and newborn health indicators Antenatal care coverage1: 4+ visits during pregnancy (%), 2003 Proportion of births attended by skilled health personnel (%) , 2006 2

73.7 98.4 23 24 20

Average age at ﬁrst marriage for girls

3 3

Per cent of women giving birth by age 20

Per cent of TFR attributed to birth by ages 15-193

Source: 1. Maternal and Child Health Group, Bureau of Health Promotion. Maternal and Child Health Situation, 2001 – 2003; 2. National Statistical Ofﬁce. Report of 2006 Reproductive Health Survey; 3. Population Reference Bureau (2000), The World Youth 2000. Washington, DC.

RH Data: Thailand

Figure-1: Maternal mortality ratio (deaths per 100,000 live births), 1990-2003 40 35 30 25 20 15 10 5 0 36.2

Figure-2: Proportion of births assisted by skilled attendant: trends, 1990-2001 100 99 98 94

MMR

16.8

20.6 14.2 9

Per cent

95 91 90

85 1990 1996 1999 Year 2003 2015 MDG target 1990 1995 1998 Year 2001 2015 MDG target

Source: Thailand Millennium Development Goals Report 2004.

Figure-3: Maternal and newborn health care coverage, 2006 120 100 Per cent 80 60 40 20 0 ANC, any Skilled attendant at birth Year Source: National Statistical Ofﬁce, Report of 2006 Reproductive Health Survey.

Figure-4: Trends in Total Fertility Rate, 1976-2007 6

98.4 73.7

98.6

5 4 3 2

4.9 3.7 2.3

2.1

1.9

1.7

1.6

Births at health facility

1 0 1976 1981 1987 1991 1994 2000 2003 2007 Year Source: 1976-1991 National Statistical ofﬁce; 1994-2003 Institute for Population and Social Research, Mahidol University; 2007 Mahidol Population Gazette, Vol. 16, January 2007.

Figure-5: Contraceptive prevalence rate - modern methods: trends, 1981-2000 100 80 60 CPR 40 20 0 56.3 62.0 68.5 72.0 74.8 79.0

1981

1984

1987

1993 Year

1995

2000

Source: Thailand Reproductive Health Proﬁle 2003, Regional Ofﬁce for South-East Asia , New Delhi, WHO.

68 A Framework for Implementing the RHS in the South-East Asia Region

Figure-6: Contraceptive method mix among currently married women, 1993-2000 30 25 20 Per cent 15 10 5 0 Pill 1993 1995 IUD 2000 Injectables Condom Contraceptive methods 5.6 4.5 4.1 1.01.0 1.7 0.5 1.4 1.5 Implants Female Sterilization 2.8 1.7 1.2 14.3 27.2 26.8 24.2 18

22.0

22.922.6 19.8

Male Sterilization

Source: Thailand Reproductive Health Proﬁle 2003, Regional Ofﬁce for South-East Asia, New Delhi, WHO.

Figure-8: Trend in age-speciﬁc fertility rate (per 1000 women) among girls aged 15-19, 1967-1995 100 89 70 ASFR 50

Figure-7: Causes of maternal mortality, 2004 Hemorrhage 34%

Other 24%

Hypertension 11% Sepsis 17%

Embolism 14%

0 1967 Year Source: 1976-1991 National Statistical ofﬁce; 1994-2003 Institute for Population and Social Research, Mahidol University; 2007 Mahidol Population Gazette, Vol. 16, January 2007.

1995

Source: 1976-1991 National Statistical ofﬁce; 1994-2003 Institute for Population and Social Research, Mahidol University; 2007 Mahidol Population Gazette, Vol. 16, January 2007.

Table-5: HIV Prevalence, 2005 Estimated HIV prevalence1 Male Female Percentage of HIV+ pregnant women receiving anti retroviral prophylaxis (%)1 Youth (15-24) HIV prevalence rate (%) 2001 Male Female 1.5 2.1 1.1 89.6

Table-6: Estimated number of people living with HIV Adults (15+) 2005 560,000 2003 570,000 Women (15+) 2005 220,000 2003 220,000

Source: 2006 Report on Global AIDS Epidemic, UNAIDS 2006.

0.88 1.3

Source: 1. 2006 Report on Global AIDS Epidemic, UNAIDS 2006; 2. Health Related Millennium Goals, 2005, WHO

RH Data: Thailand

70 A Framework for Implementing the RHS in the South-East Asia Region

 Table-1: Demographic features Indicators Total population1 Annual population growth rate (%) Total fertility rate (TFR) 3 4 2

Year 2004 2002 2002 2003 2002 2000 2000 2002 2002 924,642 3.93 7.1 7 800 40 30 64 <25

Contraceptive prevalence rate (%) - modern methods Neonatal mortality rate (NNMR)5 per 1000 live births Early neonatal mortality rate per 1000 live births 6

Maternal mortality ratio (MMR)2 per 100,000 live births

Infant mortality rate per 1000 live births 2

Coverage of vital registration of death (%) 6

Source: 1. Population Counts (Provisional). Census Timor-Leste 2004, United Nations Population Fund; 2. Health Proﬁle. Democratic Republic of Timor-Leste, 2002. Dili, Timor-Leste; 3.Timor-Leste Millennium Development Goals Report, 2004; 4. Timor-Leste Demographic and Health Survey 2003; 5. UNICEF - At a glance: Timor-Leste – Statistics; 6. World Health Statistics 2006. World Health Organization, Geneva.

Table-2: Health Systems: Human Resources and Financing Human Resources, 2004-05 Physicians per 10,000 population Nurses per 10,000 population Midwives per 10,000 population Community workers per 10,000 population Health Expenditure, 2003 Total expenditure on health as % of gross domestic product Private expenditure on health as % of total expenditure on health Out-of-pocket expenditure as % of private expenditure on health Out-of-pocket expenditure as % of total expenditure on health Source: World Health Statistics 2006.

1.0 17.9 4.0 20.2 9.6 24.1 25.6 18.7

Table-3: Maternal health indicators, 2003 Antenatal care coverage at least once during pregnancy (%) 4+ visits (%) Proportion of births attended by skilled health personnel (%) Postnatal care coverage (%) Median age at ﬁrst birth (for women aged 20-24) Median age at ﬁrst birth (for women aged 20-24) Source: Timor-Leste Demographic and Health Survey, 2003.

62 27 18 12.4 20.5 20.7

RH Data: Timor-Leste

Figure-1: Maternal and newborn health care coverage, 2003 70 60 50 Per cent 40 30 20 10 0 ANC (any) Skilled attendant at birth Births at health facility 18 9.8 1.3 Breastfeeding No one, 1.5% Qualified doctor, 2.9% Haemorrhage 34% Nurse/midwife/Family health worker, 15.5% Relative/Friend, 61.7% 61

Figure-2: Types of assistance during delivery, 2003

Source: Timor-Leste Demographic and Health Survey 2003.

Figure-3: Trends in Total Fertility Rate, 1975-2005 10 8 6 4 2 0 1975 1985 Year Source: World Population Data, 2005.

7.8 6.2 5.4 4.8

1995

2005

Figure-4: Contraceptive method mix among currently married women, 2003 6 5 4 Per cent 3 2 1 0 Pill Injectables Implants Contraceptive methods Source: Timor-Leste Demographic and Health Survey 2003.

5.5

0.8 0.1

0.6 Female Sterilization

72 A Framework for Implementing the RHS in the South-East Asia Region

Figure-5: Inequities in reproductive health service coverage (a) rural-urban, 2003 100 80 60 40 20 0 ANC 11 Skilled attendant at birth 57.7 40 27 4.5 Birth at health facility 13 14.5 CPR 79.5

(a) poorest-richest, 2003 100 80 60 40 20 0 ANC 6.9 Skilled attendant at birth Richest 2.6 Birth at health facility 48 47.6 31.8 6.8 15.3

CPR

Rural

Urban

Poorest

Source: Timor-Leste Demographic and Health Survey 2003.

Figure-6: Trend in age-speciﬁc fertility rate (per 1000 women) among girls aged 15-19, 1991-2003 140 120 100 ASFR 80 60 40 20 0 1991-94 1995-96 Year Source: Timor-Leste Demographic and Health Survey 2003.

119 105

117 84

1996-99

2000-2003

RH Data: Timor-Leste

This publication is adapted from WHO’s Accelerating progress towards the attainment of international reproductive health goals: A framework for implementing the WHO Global Reproductive Health Strategy. It provides guidance to countries in the South-East Asia Region in implementing the Global Reproductive Health Strategy considering the regional context, country situations and needs. The publication also provides country reproductive health data sheets, which would be useful in understanding the reproductive health challenges in each country of the Region.

World Health House Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110002, India 9 789290 223290

2 A Framework for Implementing the RHS in the South-East Asia Region

Основные сведения

Организация Всемирная организация здравоохранения (ВОЗ / WHO)

Тип документа Publications

Дата принятия 31 декабря 2008 г.

Источник Всемирная организация здравоохранения