2020 update Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the South- East Asia Region 9 789290 227885 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region 2020 update Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update ISBN: 978 92 9022 788 5 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization.. Suggested citation. Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update. New Delhi: World Health Organization, Regional Office for South-East Asia; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. 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 WHO 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 and dashed 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 WHO 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 WHO 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 WHO be liable for damages arising from its use. Printed in India iiiMonitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Contents Introduction by the Regional Director 1 PART 1: Progress towards universal health coverage and health-related SDGs in the WHO South-East Asia Region: highlights 5 PART 2: Quality of health care: a snapshot 25 PART 3: Country–specific UHC and SDG data profiles 29 Bangladesh 31 Bhutan 35 Democratic People’s Republic of Korea 39 India 43 Indonesia 47 Maldives 51 Myanmar 55 Nepal 59 Sri Lanka 63 Thailand 67 Timor-Leste 71
1Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Introduction by the Regional Director It gives me great pleasure to introduce our fifth Annual Report on Monitoring progress towards universal health coverage (UHC) and the health-related Sustainable Development Goals (SDGs) in the South-East Asia (SEA) Region. It was decided during the Seventy-first session of the WHO Regional Committee for South-East Asia to produce this update annually until 2030. The emergence and spread of COVID-19 has impacted the delivery of health services and disrupted progress in health across the Region. It is my hope that this report will help maintain attention, commitment and action across the South-East Asia Region towards achieving UHC and the health-related SDGs. For this year’s report we have continued to follow the same format as in earlier years but with some new features, which I highlight below. What is new in this publication? This year’s report is the first time we have highlighted the alignment between monitoring UHC and the health-related SDGs with the indicators used for measuring the outcomes and impacts of WHO’s Thirteenth General Programme of Work (GPW13). All Member States have now embedded the health-related SDG and GPW13 indicators in their national monitoring frameworks, reviewed the availability of data, and are tracking their progress towards national health-related SDG and GPW13 targets. Across all the SDG indicators, progressively more data are available on inequalities and trends in inequalities over time, especially using the familiar stratifiers of age, sex, income and geographical location. Part 1 of this year’s report highlights regional progress towards UHC and health-related SDG targets. New for this year is a summary matrix of relative progress towards the health-related SDGs across all Member States using country-comparable estimates. For UHC, its two dimensions – access to needed health care, and financial protection – are analysed using the United Nations Inter-Agency and Expert Group (IAEG) agreed indicators and methodologies. Access to needed health care is reported using the essential service coverage index; only this year (and going forward) we strictly use the global definition for this index without any SEA Region-specific adjustments and improvements previously used to ensure consistency between global and regional figures. Levels of service coverage vary across Member States from 49% to 82%. Importantly, trend data show that service coverage has improved in all countries since 2010. Adapting to the COVID-19 context and innovating new ways to accelerate progress to reach the SDG targets by 2030 is imperative. Catastrophic health expenditure by households, the indicator used for assessing financial protection, varies between 2% and 25% in countries of the Region. For this indicator, the lower the percentage of households with catastrophic spending, the better. Data on trends in financial protection 2 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update are just beginning to be compiled and frequent measurements are required. Capturing and quantifying foregone care in regular household surveys has also become a priority. Progress continues in reproductive, maternal health, neonatal and child health and most communicable diseases. Five Member States have reached the SDG target for under- five mortality. Tuberculosis remains a major concern in the Region, with estimates of TB mortality rising in three Member States. For NCDs, there is a more complete picture of the current situation on the level and trends in risk factors, and in case detection and treatment. There is an encouraging decline in tobacco use, but this needs to accelerate to reach global targets, using regulatory and policy “best buys” as well as behaviour change practices. There is much less progress on other major risk factors. Case detection and treatment are expanding, but much greater coverage is needed. In the area of health systems and services, there is a definite improvement in the completeness of health workforce data reported by Member States. The availability of doctors, nurses and midwives in the SEA Region has increased by one fifth since 2015. Almost all Member States have improved the overall availability of doctors, nurses and midwives during this time. Nine countries are now above the first WHO health workforce threshold of 22.8 doctors, nurses and midwives per 10 000 population set in 2006 compared with six countries in 2014. However, there remains more to do, as only two countries have reached the current WHO threshold of 44.5 doctors, nurses and midwives per 10 000 population that is derived as the basic density needed to achieve the SDGs. Part 2 of this year’s report provides a snapshot of the quality of health care in the SEA Region using an innovative and dynamic set of indicators that help frame the issues. Despite encouraging recent progress, projections suggest that at the current rate, few countries in the Region will reach 80% essential service coverage by 2030. This is where the renewed attention to primary health care (PHC), especially the quality of health care, comes in. This is even more critical now in the context of the COVID-19 pandemic. Achieving UHC and the health-related SDGs with new models of care and improved quality of care will be key. Countries need to be forward-looking and implement changes such as primary care redesign to deliver effective services that comply with standards for cleaner and safer health facilities. Health workers need the skills to deliver competent and respectful care in an era of chronic diseases. These efforts need to be part of a whole-of-system approach, with other health systems strengthening efforts reinforcing quality health-care improvement. This report is produced annually for many reasons, including the opportunity to amplify the importance of collecting, analysing, reporting and interpreting progress being made towards UHC and the health-related SDGs. As data availability and quality continue to improve it is becoming imperative that health policy and planning are evidence-based. This report makes use of the most recent nationally reported data and estimates reflected in the updated individual Member State health SDG profiles that are in Part 3. This year, the country profiles include several tracer indicators on the quality of health care in terms of effective services and cleaner and safer facilities. This year we have also included additional health-related SDG indicators for tracking that are part of the GPW13 Results Framework and system of measurement. 3Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update The monitoring of progress on UHC and the health-related SDGs is being progressively improved and harmonized at national, regional and global levels. We are almost a third of the way towards 2030, amidst a global pandemic. Looking ahead I anticipate we will be well-positioned to detect, analyse and present the impact that the COVID-19 response is having on progress towards UHC and the health-related SDGs in future annual reports. We will also be exploring innovative ways to forecast progress and the impact of policy measures and interventions to realize UHC and the SDG targets and accelerate health for all over the next 10 years. Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region
PART 1 Progress towards universal health coverage and health-related SDGs in the WHO South-East Asia Region: highlights This section provides a regional overview of progress towards universal health coverage (UHC) and the health-related Sustainable Development Goal (SDG) targets. This year, this section includes a summary of health-related SDG indicators for which country-level values are reported as comparable estimates (Fig. 1). 5 6 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Fig. 1: Summary of health-related SDG indicators for which country-level values are reported as comparable estimates1 1 Comparable estimates refer to country values of the same reference year or period, which may be adjusted or modelled to allow comparisons between countries and are produced for countries with underlying primary data and, in some cases, for those without. Shading from dark blue to dark orange represents low to high for mortality, incidence and prevalence indicators; and from high to low for coverage and service index indicators. Health-related SDG indicators SDG target Year Global target Bangladesh Bhutan Maternal mortality ratio (per 100 000 live births) 3.1.1 2017 70 per 100 000 live births 173 183 Proportion of births attended by skilled health personnel (%) 3.1.2 2015-2019 1 59 97.2 Under-five mortality rate (per 1000 live births) 3.2.1 2018 25 per 1000 live births 30.2 29.7 Neonatal mortality rate (per 1000 live births) 3.2.2 2018 12 per 1000 live births 17.1 16.4 New HIV infections (per 1000 uninfected population) 3.3.1 2018 0.02 per 1000 uninfected population 0.01 0.11 Tuberculosis incidence (per 100 000 population) 3.3.2 2018 80% compared with 2015 baseline 221 149 Malaria incidence (per 1000 population at risk) 3.3.3 2018 90% reduction in malaria incidence with 2015 baseline 0.6 4 Hepatitis B surface antigen (HBsAg) prevalence among children under 5 years (%) 3.3.4 2015 Not available, national target may vary 1.38 0.81 Reported number of people requiring interventions against NTDs 3.3.5 2018 Not available, national target may vary 56 339 394 222 639 Probability of dying from any of CVD, cancer, diabetes, CRD between age 30 and exact age 70 (%) 3.4.1 2016 - 2018 1/3 reduction from 2012 baseline 21.6 23.3 Suicide mortality rate (per 100 000 population) 3.4.2 2016 - 2018 No global target but WHA 66 resolution suicide rate decrease by 10% (by 2020) 5.9 11.4 Total alcohol per capita (≥ age 15 years) consumption (litres of pure alcohol) 3.5.2 2016 - 2018 Not available, national target may vary <0.1 0.4339506 Road traffic mortality rate (per 100 000 population) 3.6 2016 - 2018 By 2020, halve the number of global deaths and injuries from road traffic accidents 15.3 17.4 Proportion of women of reproductive age who have their need for family planning satisfied with modern methods (%) 3.7.1 2015-2019 100 77.4 84.6 Adolescent birth rate (per 1000 women aged 15–19 years) 3.7.2 2015-2019 Not available, national target may vary 74 8 UHC essential health services coverage index 3.8.1 2020 100 49 64 People are being pushed into poverty (at US$ 1.90 level) (%) 3.8.2 2015-2018 Not available, national target may vary 7 0.6 Population with household expenditures on health >10% of total household expenditure or income (%) 3.8.2 2015-2018 Not available, national target may vary 24.7 1.8 Age-standardized mortality rate attributed to household and ambient air pollution (per 100 000 population) 3.9.1 2016 Not available, national target may vary 149 124.5 Mortality rate attributed to exposure to unsafe Water, Sanitation and Hygiene (WASH) services (per 100 000 population) 3.9.2 2016 Not available, national target may vary 11.9 3.9 Mortality rate from unintentional poisoning (per 100 000 population) 3.9.3 2016 Not available, national target may vary 0.3 0.6 Prevalence of tobacco smoking among persons aged 15 years and older (%) – Male 3.a 2011-2019 By 2025, reduce global tobacco use by 30% relative to 2010 59.6 33.6 Prevalence of tobacco use among persons aged 15 years and older (%) – Female 3.a 2011-2019 28.3 13.6 Diphtheria-tetanus-pertussis (DTP3) immunization coverage among 1-year-olds (%) 3.b.1 2019 >95% 98 97 Measles-containing-vaccine second-dose (MCV2) immunization coverage by the nationally recommended age (%) 3.b.1 2019 Not available, national target may vary 95 92 Pneumococcal conjugate 3rd dose (PCV3) immunization coverage among 1-year-olds (%) 3.b.1 2019 Not available, national target may vary 97 26 Human papillomavirus (HPV) immunization coverage estimates among 15-year-old girls (%) 3.b.1 2018 Not available, national target may vary 90 7Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste 89 145 177 53 250 186 36 37 142 99.5 81.4 90.9 99.5 60.2 58 99.5 99 56.7 18.2 36.6 25 8.6 46.2 32.2 7.4 9.1 45.8 9.7 22.7 12.7 4.8 23.1 19.9 4.5 5 20.4 0.17 0.2 0.03 0.01 0.09 513 199 316 33 338 151 64 153 498 0.3 0.5 1 4.3 0.4 0.5 0.53 0.51 1.07 0.19 2.03 0.31 0.64 0.17 0.87 5 459 159 696 937 272 100 847 287 3411 41 778 536 14 520 580 55 489 55 073 1 293 316 25.6 23.3 26.4 13.4 24.2 21.8 17.4 14.5 19.9 10.1 3.4 2.3 7.8 8.8 15.1 14.4 4.6 3.8 5.5 0.6 2.2 5.1 2.1 4.1 8.3 2.2 11.5 12.2 0.9 19.9 15.9 14.9 32.7 12.7 89.7 71.9 77.1 29.4 74.9 56.1 74.2 89 46.9 1 10.7 36 10 37 88 21 51 42 72 63 63 62 56 49 66 82 55 0.2 0 0.6 1.7 0.7 0 1 17.3 2.7 2.7 14.4 10.7 5.4 2.2 2.9 207.2 184.3 112.4 25.6 156.4 193.8 79.8 61.5 139.8 1.4 18.6 7.1 0.3 12.6 19.8 1.2 3.5 9.9 1.9 2.4 0.4 <0.1 1.4 0.4 0.4 0.4 0.4 46.1 42.4 67.4 36 79.8 48.3 45.7 38.3 56.6 0 14.2 4.8 4.4 29.1 11.6 5.3 4.3 4.7 97 91 85 99 90 93 99 97 83 98 84 71 99 80 76 99 87 80 15 3 90 83 1 67 8 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Source: Health information platform for WHO South-East Asia Region. In: World Health Organization [online database] (http://hip.searo.who.int/dhis/dhis-web-commons/security/login.action, accessed 20 July 2020) Health-related SDG indicators SDG target Year Global target Bangladesh Bhutan Total net official development assistance to medical research and basic health sectors per capita w (US$), by recipient country 3.b.2 2018 Not available, national target may vary 1.37 1.92 Proportion of health facilities with a core set of relevant essential medicines available and affordable on a sustainable basis (%) 3.b.3 2010–2019 >95% 95 Skilled health professionals density (per 10 000 population) 3.c 2018 Not available, national target may vary 9.9 22.8 Average of 13 International Health Regulations core capacity scores 3.d 2019 Not available, national target may vary 66.846153 59.23077 Domestic general government health expenditure (GGHE-D) as percentage of general government expenditure (GGE) (%) 1.a 2018 Not available, national target may vary 3 7.6 Prevalence of stunting in children under 5 years (%) 2.2.1 2015-2019 40% reduction in the number of children who are stunted, by 2025, from 2012 baseline 28 21.2 Prevalence of wasting in children under 5 years (%) 2.2.2 2015-2019 <5% 9.8 4.3 Prevalence of overweight in children under 5 years (%) 2.2.3 2015-2019 0 increase in prevalence from 2012 baseline 2.4 3.9 Prevalence of anaemia in women of reproductive age (15–49 years) (%) 2.2.4 2016 Not available, national target may vary 39.9 35.6 Proportion of ever-partnered women and girls aged 15 years and older subjected to physical, sexual or psychological violence by a current or former intimate partner in the previous 12 months 5.2 2010–2017 Not available, national target may vary 29 Proportion of population using safely managed drinking-water services (%) 6.1.1 2017 1 27.6 36 Proportion of population using safely-managed sanitation services (%) 6.2.1 2017 1 Proportion of population using a hand-washing facility with soap and water (%) 6.2.2 2017 1 35 Amount of water- and sanitation-related official development assistance that is part of a government-coordinated spending plan (constant 2016 US$ millions) 6.a 2018 Not available, national target may vary 269.54 19.32 Proportion of population with primary reliance on clean fuels and technology (%) 7.1 2018 1 24 77 Annual mean concentrations of fine particulate matter (PM2.5) in urban areas (µg/m3 11.6 2016 Not available, national target may vary 58.3 35.3 Mortality rate due to homicide (per 100 000 population) 16.1 2017 Not available, national target may vary 2.7 2 Birth registration coverage (%) 16.9.1 2009-2019 1 56 99.9 Completeness of cause-of-death data (%) 17.19 2009-2017 0.8 Number of cases of poliomyelitis caused by wild poliovirus (WPV) GPW13 2019 – 0 0 Age-standardized prevalence of raised blood pressure among persons aged 18+ years (SBP of >140 mmHg and/or DBP >90 mmHg) GPW13 2015 – 24.7 28.1 Prevalence of obesity among children and adolescents (5–19 years) (%) GPW13 2016 – 2.6 3.3 Age-standardized prevalence of obesity among adults (18+ years) (%) GPW13 2016 – 3.6 6.4 9Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste 0.48 0.18 0.3 5.81 1.98 1.97 1.29 0.29 8.93 14.6 43 81.2 25.8 28.4 109.9 16.8 38.6 31.8 35.6 23.9 68.692307 77.692307 73.384613 50.76923 63.615383 34.153847 53.846153 85.153847 36.923077 3.4 8.5 21.4 3.5 4.6 8.3 15 5.4 19.1 38.4 37.2 15.3 29.2 35.8 17.3 10.5 45.6 2.5 21 13.5 9.1 6.9 9.7 15 5.4 22.6 2.3 2.1 11.5 4.9 1.9 1.2 2 8.2 10.6 32.5 51.4 28.8 42.6 46.3 35.1 32.6 31.8 41.3 22 11 11 35 49.6 25.6 90.9 60 64 96 79 48 84 28 1.12 575.19 117.84 10.79 112.28 130.79 173.19 1.56 2.53 10 49 80 >95 28 29 31 79 12 30.4 65.2 15.6 7.6 34.7 94.3 15.3 26.2 17.9 3.9 4.5 1.9 4 2.6 2.8 4.1 4.7 99 85 78 98.8 81.3 56.2 97 99.5 60.4 10 91 87 0 0 0 0 0 0 0 0 0 18.2 25.8 23.8 24.4 24.6 29.4 22.4 22.3 27.6 8.5 2 6.1 7.4 3.7 1.7 4.8 11.3 4.2 6.8 3.9 6.9 8.6 5.8 4.1 5.2 10 3.8 No data available Lowest Highest 10 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Fig. 1 illustrates the highest to lowest relative indicator status of all Member States in the WHO South-East Asia (SEA) Region towards reaching the health-related Sustainable Development Goal targets for which country-level values are reported as comparable estimates. All health-related SDG indicators used in this report have been mapped to and populated according to the United Nations SDG metadata standards.1 Comparable estimates are subject to considerable uncertainty, especially for countries where the availability and quality of the underlying primary data are limited. Noting these constraints, the overall picture suggests that Bhutan, the Democratic People’s Republic of Korea, Maldives, Sri Lanka and Thailand are performing relatively well with the most indicators coloured in darker shades of blue. The remaining countries in the Region present a relatively mixed picture in terms of their status, with high performance in some areas and lower relative achievement to date across many indicators. Clearly, the COVID-19 pandemic has disrupted progress towards UHC and the health-related SDGs, with its impact to be quantified and shared in future annual reports. Universal health coverage Universal health coverage is about all people getting the health care they need, of sufficient quality to be effective, and without financial hardship. In the health SDG monitoring framework, UHC is SDG target 3.8, and has two indicators: one to monitor progress on access to essential health services (3.8.1), and one to monitor financial protection (3.8.2). Coverage of essential health services is measured using the “essential health services coverage index” endorsed by the UN Inter-Agency and Expert Group (IAEG). This was developed in 2015 by WHO and has been used in the WHO SEA Region since 2016. Financial protection is reported using the SDG indicator for financial protection, which measures catastrophic health expenditure. For both indicators, methodologies are being refined and data updated regularly. Together they offer a concise way of tracking progress on UHC. Essential health services coverage The essential health services coverage index was originally made up of four indices calculated on the basis of the geometric mean across four groups, or 16 indicators in all: reproductive, maternal, newborn, and child health; infectious diseases; noncommunicable diseases; and health service capacity and access. It provides a concise way of tracking progress across a range of key services over time. As with all summary indices, it provides an approximate picture of essential service coverage. Currently, only 14 of the essential health services coverage indicators are used globally due to limitations on availability of data. In the WHO SEA Region an additional indicator is 1 United Nations Department of Economic and Social Affairs, Statistics Division. SDG indicators metadata repository. (https://unstats.un.org/sdgs/metadata/, accessed on 20 July 2020) 11Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update not included because no country nationally in the Region is considered high-risk for malaria.2 At the Regional Technical Consultation in November 2019 held in New Delhi, India it was agreed that the SEA Region would conform and use global sub-indicators using the same calculations used globally for consistency. The index’s measurement methods are continuing to evolve. Any change in a country’s index can, therefore, be due to a real change in service coverage but may also be influenced by adjusted methods and data available. Overall, the regional average for the UHC essential health services index is 63% in 2020 compared with 49% in 2010. Fig. 2 shows the improvements in service coverage across Member States from 2010 to 2020. Fig. 2: Changes in coverage of essential health services in Member States of the South-East Asia Region, 2010–2020 U H C s er vi ce c ov er ag e in de x 82 72 66 64 63 62 62 56 55 49 49 0 10 20 30 40 50 60 70 80 90 100 Th ai ln ad D PR K or ea Sr i L an ka Bh ut an In di a In do ne si a M al di ve s M ya nm ar Ti m or -L es te Ba ng la de sh N ep al 2010 Sources: Health information platform for WHO South-East Asia Region. In: World Health Organization [online database] (http://hip.searo.who.int/dhis/dhis-web-commons/security/login.action, accessed 20 July 2020); Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) 2007–2019. Financial protection SDG indicator 3.8.2 is used to report on financial protection in the SEA Region. This indicator is defined as “catastrophic health expenditure”, which is the proportion of the population with household expenditures on health greater than 10% of the total household expenditure/income. Data are now available for 10 Member States of the Region. Seven Member States have levels of catastrophic spending below the global median, and three have levels that are higher, according to the available data (Fig. 3). In addition, 16% of the population in the Region (307.4 million people) experienced catastrophic health spending in 2015. 2 In November 2018 the UN IAEG removed two indicators from the essential health services coverage index: (i) availability of essential medicines, and (ii) cervical cancer screening coverage, as these data are not readily available in many countries globally although previously these indicators were used by the WHO SEA Regional Office for countries where the data was available. The indicator for the coverage of insecticide-treated bednets to mitigate transmission of malaria is not applicable because none of the countries in the SEA Region are considered to be at high-risk nationally although there are at-risk populations in certain areas in some countries that are being monitored. 12 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update In the SEA Region, household spending on medicines is the main driver of financial hardship due to health spending in all but one Member State. Capacity for analysis of financial protection is increasing, with 10 Member States now trained to do this analysis. In 2019, the Regional Office conducted a workshop among officials from the ministries of health and the Statistics Offices on the measurement of financial protection to increase regional capacity to produce and interpret data for this indicator. Looking at the two dimensions of UHC together Fig. 3 puts the two dimensions of UHC together for Member States of the Region.3 To show how the Region stands in relation to the global situation, global median figures from 2019 for both dimensions are included (red lines).4 Thailand and Sri Lanka are in the top right box of the graph because they lie on or above the global median for both UHC essential services coverage and financial protection. Fig. 3: Comparison of health services coverage and financial protection in Member States of the South-East Asia Region by income level, 2020 m or e is b et te r U H C es se nt ia l s er vi ce c ov er ag e in de x 20 20 Global median=66 G lo ba l m ed ia n= 12 .7 Maldives (2009) Thailand (2017) India (2011) Nepal (2014) Myanmar (2015) Bangladesh (2016) Bhutan (2017) Sri Lanka (2016) Indonesia (2018) Timor-Leste (2014) Population with household expenditure on health >10% of total household expenditure/income (%) less is better 25 20 15 10 5 0 100 80 60 40 20 0 Lower middle-income Upper middle-income Source: Health information platform for the WHO South-East Asia Region. New Delhi: World Health Organization; 2019 (http://hip.searo.who.int/dhis). Regional highlights of UHC Essential health service coverage continues to improve in all Member States since 2010. There is a need to accelerate: at the current rate of progress, under half of 3 The year of the catastrophic health expenditure data used is in parentheses. 4 The global median used here comes from Primary health care on the road to universal health coverage: 2019 monitoring report (https://www.who.int/healthinfo/universal_health_coverage/report/uhc_report_2019.pdf). 13Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update the SEA Region Member States are projected to achieve at least 80% coverage by 2030. Now more than ever, in the context of the COVID-19 pandemic, it is critical to increase resources and focus attention on maintaining and enhancing the delivery of quality essential health services. Data on trends on financial protection are just beginning to be compiled and frequent measurements are required. Capturing and quantifying foregone care in regular household surveys has become a priority as well. Only two Member States in the Region now lie above the global median for both service coverage and financial protection. Strategic public investments in health have played a significant role in helping countries to move towards UHC by reducing out-of-pocket and catastrophic health expenditure. This has been the case in Thailand, which has prioritized government health spending within the public budget and now experiences low catastrophic expenditure and financial protection above the global mean. Other SDG health-related targets: regional highlights Reproductive, maternal and child health Between 2000 and 2017, the South-East Asia Region experienced the largest decline in maternal deaths, witnessing a 57.3% reduction in maternal mortality ratio (MMR) compared with a global decline of 38%.5 Meanwhile, under-five mortality and neonatal mortality also continued to decline.6 The under-five mortality rate in the Region reduced by 2 points from 36 per 1000 live births in 2018 to 34 in 2019, while neonatal mortality further declined to 20 per 1000 live births. The progress in reducing maternal mortality in the Region indicates that Nepal and Timor-Leste are both on track to achieve the SDG country target of a two third reduction in MMR since 2010. In addition, five Member States (DPR Korea, Indonesia, Maldives, Sri Lanka and Thailand) have reached an under-five mortality rate below the 2030 SDG target of at least 25 per 1000 live births. Table 1 highlights the progress of all 11 Member States towards achieving targets in reducing maternal, newborn and child mortality and stillbirths. 5 Maternal mortality: levels and trends 2000–2017 (https://www.who.int/reproductivehealth/publications/ maternal-mortality-2000-2017/en/) 6 Levels and trends in child mortality. United Nations Inter-Agency Group for Child Mortality Estimation Report 2019 (https://www.unicef.org/reports/levels-and-trends-child-mortality-report-2019) 14 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Table 1: Status of maternal, newborn and child mortality and stillbirths in the SEA Region, 2019 Maternal mortality ratio (per 100 000 live births) Stillbirth rate (deaths per 1000 births) Neonatal mortality rate (deaths per 1000 live births) Under-five mortality rate (deaths per 1000 live births) Bangladesh 173 25 17 30 Bhutan 183 16 16 30 DPR Korea 89 14 10 18 India 145 23 23 37 Indonesia 177 13 13 25 Maldives 53 8 5 9 Myanmar 250 20 23 46 Nepal 186 18 20 32 Sri Lanka 36 5 4 7 Thailand 37 5 5 9 Timor-Leste 142 18 20 46 SEA Region 152 21 20 34 = Achieved the SDG/EPMM/ENAP/Global Strategy Target in 2018 = Expected to achieve the SDG/EPMM/ENAP/Global Strategy Target by 2030 = Need to increase current efforts and attain faster annual rate of reduction (ARR) Sources: Maternal mortality: levels and trends 2000–2017 Levels and trends in child mortality; United Nations Inter-Agency Group for Child Mortality Estimation Report 2019; The Lancet: National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. Immunization rates remain relatively high. NineMember States have achieved more than 90% coverage for DTP3 (Fig. 4). In 2017, mortality due to measles had declined by 75% from 2000. Five Member States in the SEA Region – Bhutan (2017), DPR Korea (2018), Maldives (2017), Sri Lanka (2019) and Timor-Leste (2018) – have eliminated endemic measles. Currently, all 11 Member States of the Region are administering two doses of measles-containing vaccine (MCV) in routine immunization (Fig. 4). The estimated coverage with the first dose of measles-containing vaccine (MCV1) in the Region in 2019 was 94% compared with 63% in 2000. In 2019, seven Member States of the Region – Bangladesh, Bhutan, DPR Korea, India, Maldives, Sri Lanka and Thailand – achieved 95% or more coverage for MCV1, while the remaining four – Indonesia, Myanmar, Nepal and Timor-Leste – reported coverage between 84% to 94%. 15Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Fig. 4: Trends in DTP3 and MCV1 immunization coverage in the WHO South-East Asia Region 0 20 40 60 80 100 2000 2005 2010 2015 DPT3 MCV1C ov er ag e (% ) Source: WHO-UNICEF estimates of DTP3 and MCV1 coverage. Geneva: World Health Organization; 2019 (https://apps.who.int/immunization_monitoring/globalsummary/timeseries/tswucoveragedtp3.html, accessed 20 July 2020) According to estimates, globally there are 144 million stunted, 47 million wasted and 38 million overweight children under five years of age. The WHO South-East Asia Region bears much of this burden, with 52 million children stunted (over a third of the global burden), 25 million wasted (over half of all cases of global wasting) and 5 million overweight (nearly one seventh of the total global cases of overweight)7 (Fig. 5). Around 24.2 % children are born with a low birth weight. An estimated 7.4 % children (38.4 million) aged 5–19 years in the Region are overweight in 2020, and 22.5 % are thin. The trend of overweight among children has been rising rapidly across all age groups since 2000, while there has been a slow decline in stunting. Trends in wasting have remained stagnant in most countries. Infectious diseases The WHO South-East Asia Region continues to account for 44% of the global TB incidence. However, there was a slight decline (3%) in estimated incidence between 2017 and 2018.8 More than 650 000 people are estimated to have died of TB and TB/ HIV co-infection in 2018. Estimated TB incidence rates have been decreasing in most Member States, though they are relatively constant in Bangladesh, Nepal, Sri Lanka and Timor-Leste since 2015. In 2018, estimates of TB mortality increased for Nepal, Thailand and Timor-Leste. 7 Joint child malnutrition estimates: levels and trends, 2020 edition. Geneva: UNICEF, WHO, The World Bank Group, 2020. https://www.who.int/nutgrowthdb/estimates/en/, accessed 28 July 2020. 8 Global tuberculosis report 2019. Geneva: World Health Organization; 2019. 16 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Fig. 5: Prevalence of overweight in children in the Region and estimated numbers affected 3.0% 7.4% 7.0% 5.0 12.7 25.2 0.0 5.0 10.0 15.0 20.0 25.0 30.0 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% Under 5 years (2019) 5-10 years (2016) 10-19 years (2016) N um be r of c hi ld re n (m ill io n) Pr ev al en ce ( % ) Prevalence of overweight/obesity Number of children who are overweight/obese Source: Joint child malnutrition estimates: levels and trends, 2020 edition. Geneva: UNICEF, WHO, The World Bank Group, 2020 (https://www.who.int/nutgrowthdb/estimates/en/, accessed 28 July 2020) New HIV infections and deaths from AIDS continue to decline in the Region. The proportion of people living with HIV who receive life-saving antiretroviral therapy (ART) has steadily increased in the Region, up from 20% in 2010 to 60% receiving ART in 2019. Thailand and Maldives have both been validated for elimination of mother-to-child transmission of HIV and syphilis. The Region has also made substantial progress in reducing malaria, with a 69% reduction in reported confirmed malaria cases, and a 70% reduction in deaths, between 2010 and 2018. In 2018, the Region had almost 8 million estimated cases and about 11 600 estimated deaths. Three countries accounted for 98% of the total reported cases in the Region, India having the largest share (58%) followed by Indonesia (30%) and Myanmar (10%). Two of the 11 countries in the Region – Maldives and Sri Lanka – were certified as malaria-free in 2015 and 2016 respectively, and continue to maintain this status. Timor-Leste has had no indigenous cases since July 2017 while Bhutan had only six indigenous cases in 2018 (and two in 2019 as per provisional data) (Fig. 6). The WHO South-East Asia Region has the world’s second-highest burden of neglected tropical diseases (NTDs). In the past few years, the Region has made tremendous progress towards eliminating NTDs, changing the global NTD landscape significantly. Visceral leishmaniasis (kala-azar), trachoma and lymphatic filariasis (LF) have all been slated for elimination as public health problems, and yaws for eradication, by the end of 2020. In 2016, for example, India was declared yaws-free. In the same year, Maldives and Sri Lanka eliminated LF as a public health problem and, not long after, Thailand had the same success. In 2018, Nepal eliminated trachoma as a public health problem. The Region 17Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update continues to bear the highest burden of leprosy globally, with 148 495 new cases and 2.84 grade-2 disability cases per million reported in 2018. From 2015 to 2019, dengue cases in the SEA Region increased by 46% (from 451 442 to 658 301), whereas deaths decreased by 2% (from 1584 to 1555), representing a case-fatality rate reduction from 0.35% to 0.24%. Fig. 6: Trends in communicable diseases in Member States of the WHO South-East Asia Region, 2000–2018 0 50 100 150 200 250 300 350 0 5 10 15 20 25 2000 2005 2010 2015 2016 2017 2018 Malaria Incidence / 1000 population at risk HIV / TB co-infection(%) TB incidence/100000 TB i nc id en ce M al ar ia in ci de nc e / H IV /T B co in fe ct io n ra te Sources: Global TB report 2019, World malaria report 2019, Geneva: World Health Organization and UNAIDS portal (http://aidsinfo.unaids.org/, accessed 13 July 2020). Noncommunicable diseases and injuries Trends in risk factors Tobacco use remains the single largest preventable cause of morbidity and mortality in the SEA Region. It is a risk factor for all four major NCD groups, as well as for communicable diseases such as tuberculosis. Estimates suggest it kills more than 1.6 million people a year in the Region. The Region continues to advance towards effective tobacco control with focus on implementing “best buy” interventions. There are signs of declining tobacco use in most Member States by both men and women. However, some Member States may still not achieve the 2030 target of 30% reduction in tobacco use for men (Fig. 7), while being on track to achieve a 30% relative reduction of tobacco use prevalence among adult women (15+ years of age) by 2025. 18 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Fig. 7: Trends in estimated tobacco use (%) among males aged 15+ years in Member States of the WHO South-East Asia Region Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2000 2005 2010 2015 2020 2025 Pe rc en ta ge o f m al e to ba co u se rs 1 5+ y ea rs o f ag e Source: Global tobacco epidemic report 2019. The picture is less positive for four other risk factors: alcohol, obesity, hypertension and salt consumption. Eight Member States show rising alcohol consumption that is projected to continue until 2030 (Fig. 8). There are also rising levels of obesity in adults, in both men and women, and a projected rise in raised blood pressure and blood sugar levels based on current trends. Fig. 8: Trends and projections to 2030 of alcohol use per capita among total population (15+ years) in Member States of the WHO South-East Asia Region Bangladsh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste 0.0 2.0 4.0 6.0 8.0 10.0 1990 2010 2017 2030 Pe rc en ta ge o f al co ho l u se p er c ap ita a m on g to ta l p op ul at io n (1 5+ y ea rs ) (% ) Source: Global alcohol exposure between 1990 and 2017 and forecasts until 2030: a modelling study. Manthey, Jakob et al. The Lancet, Volume 393, Issue 10190, 2493–2502. 19Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Air pollution and other environmental determinants of disease There is an increasing awareness of the importance of the environmental determinants of disease for both noncommunicable and communicable diseases associated with poor water and sanitation. This is reflected in nine of the health-related SDG indicators captured in this report. Many health facilities lack access to clean energy and safe water and sanitation. The United Nations High-Level Meeting on NCDs, held in New York in September 2018, signaled a shift from a focus that considered purely behavioural risk factors to the inclusion of environmental risk factors, including household (indoor) and ambient (outdoor) air pollution, water and soil pollution, and climate change. Aligning its NCD prevention and control agenda with that of the United Nations, WHO included air pollution as a fifth risk factor for NCDs in its Global Strategy on the prevention and control of NCDs. In the SEA Region, air pollution accounts for 20% of all NCD deaths – making it the single largest risk factor across the Region. Household air pollution (HAP) remains a critical issue arising from the lack of access to clean fuel for household energy needs. According to data from 2016, HAP was attributed to 21% of cases of ischaemic heart disease, 19% of stroke, 36% of lung cancer, and 38% of chronic obstructive pulmonary disease (COPD) in the Region. Ambient air pollution in many countries in the Region is among the highest in the world, manifold above the WHO Guideline value of 10µg/m3.9 Half the Region’s population still lacks clean household energy and rely on burning wood and other biomass for cooking purposes. Detection and control of NCDs Many Member States are introducing screening programmes and treatment for selected NCDs – hypertension, diabetes and select cancers such as cervical cancer. Across the Region 45% to 93% of people with hypertension are undiagnosed, and between 43% and 95% of people with diabetes. Even among those who are diagnosed, in most Member States, hypertension or diabetes is under control in relatively few people. Cervical cancer is one of the most common cancers among women in the Region. Over half the women at risk in Bhutan, Democratic People’s Republic of Korea (DPR Korea) and Thailand are now screened, but coverage with cervical cancer screening programmes remains low in most Member States (Fig. 9). India is also screening for breast and oral cancer. 9 WHO air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide. Geneva: World Health Organization; 2005. 20 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Fig. 9: Latest estimates of coverage of cervical cancer screening among women 30–49 years of age in Member States of the WHO South-East Asia Region 6.1 66.1 88.4 7.7 4.4 8.2 23.0 50.4 1.0 Ba ng la de sh ( 20 18 ) Bh ut an ( 20 1 9) D PR K or ea * (2 0 16 ) In do ne si a* ** (2 0 16 ) M ya nm ar (2 0 14 ) N ep al ( 20 19 ) Sr i L an ka (2 0 15 ) Th ai la nd * ( 20 14 ) Ti m or -L es te (2 01 4 ) C ov er ag e in P er ce nt ag e (% ) *women 30-44 years; ** women aged 20 years or older Sources: Calculated from WHO STEP surveys. Geneva and New Delhi: World Health Organization; 2014–2019 (respective years in parentheses by country) and for Indonesia (Sirkenas 2016 Health indicator survey report) and Thailand (NHES, 2014). Mortality due to NCDs, risk factors, suicide and injuries The probability of premature mortality due to NCDs (SDG 3.4.1) is lower among females than males according to estimates since 2000 (Fig. 10).10 Alcohol is a major risk factor for both communicable diseases (tuberculosis) and NCDs (cardiovascular diseases, liver cirrhosis), and causes more than 650 000 deaths each year in the Region. Depression is the most common comorbid psychiatric disorder among people who die by suicide, and 39% of global suicides occur in the South-East Asia Region. Only five Member States in the Region have a written national strategy and/or action plan for the prevention of suicide, either standalone or as part of an integrated plan. In terms of injuries, rates of road traffic death have increased from 19.8 per 100 000 population in 2013 to 20.7 in 2016.11 10 Global health observatory. Geneva: World Health Organization; 2020. 11 Global status report on road safety 2018. Geneva: World Health Organization; 2018. Licence: CC BYNC- SA 3.0 IGO. 21Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Fig. 10: Probability (%) of dying between ages of 30 and 70 from any of cardiovascular disease, cancer, diabetes, or chronic respiratory illness in the SEA Region, 2000–2016 Source: Global health observatory. Geneva: World Health Organization; 2020. Regional highlights on noncommunicable diseases Risk factors and determinants of health: there are encouraging signs of declining tobacco use in most Member States, by both men and women. However, some Member States may still not achieve the 2030 target. The rise in alcohol consumption is likely to result in further increase in alcohol related diseases and deaths in the Region. Addressing poor water, sanitation and energy availability in health facilities, the lack of clean household energy, and reliance on burning solid fuels wood remain a high priority. Case detection: Screening programmes for cervical cancer are at different stages of introduction, with three Member States having over 50% coverage. In all Member States, a significant proportion of people with hypertension and diabetes are still undiagnosed. Treatment: At best, only around 30% of those with hypertension and just over 20% of those with diabetes are diagnosed, treated and controlled. Most Member States have not reached these levels yet. Mortality: NCDs account for almost 69% of all deaths in the Region, an estimated half of which are premature. The substantial premature mortality from NCDs in the economically productive age group (30–70 years of age) accounting for more than one fourth of all deaths (nearly 4 million) – including the premature mortality associated with different preventable risk factors such as alcohol use and injuries – remains a substantial developmental and public health concern. The Region has yet to make much progress in implementing comprehensive mental health action plans or in lowering national suicide rates. 22 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Health systems SDG health indicators include indicators for access to medicines and the health workforce. Last year’s report highlighted the availability of essential medicines with the limited data available for four countries. There is a need to capture this information on a regular basis from all countries as it is the single biggest component of out-of-pocket expenditure in most countries in the Region. With regard to health workforce, 10 countries have reported on the availability of primary health care workers. This is a considerable achievement, given the different categories of frontline health workers across the Region’s countries. As a Region, the average density of doctors, nurses and midwives here has increased from 21.5 to 26.0 per 10 000 population since the Decade of health workforce strengthening in the South-East Asia Region 2015–2024 began. This is a 21% increase. The overall availability of doctors, nurses and midwives has improved in most countries, but to varying degrees. Nine SEA Region countries are now above the original 2006 WHO threshold of 22.8 doctors, nurses and midwives per 10 000 population12 compared with six in 2014. However, only two countries are placed above the 2016 revised WHO threshold of 44.5 health workers per 10 000 population that is estimated to be needed for achieving the SDGs13 (Fig. 11). Fig. 11: Trends in availability of doctors, nurses and midwives in Member States of the WHO South-East Asia Region, 2014–2018 0 20 40 60 80 100 120 M al di ve s* D PR K or ea N ep al * Th ai la nd * Sr i L an ka In do ne si a In di a* Ti m or -L es te Bh ut an M ya nm ar Ba ng la de sh * D en si ty o f do ct or s, n ur se s an d m id w iv es p er 1 0 00 0 po pu la ti on 2014 or before 2015 or 2016 2018 44.5/10 000: Global Strategy on HRH 2016 22.8/10 000: World Health Report 2006 Note: *National health professional and medical councils data Source: Country data reported to the WHO Regional Office for South-East Asia, through the National Health Workforce Accounts online platform as of 15 December 2019 (main data sources are the ministries of health and *national health professional councils). 12 World Health Organization. The world health report 2006: working together for health. Geneva: World Health Organization; 2006. 13 World Health Organization. Global Strategy on human resources for health: workforce 2030. Geneva: World Health Organization; 2016. 23Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update The need for more reliable vital statistics on births, deaths and causes of death remains a priority in the Region, and particularly now more than ever given the COVID-19 pandemic. Birth registration coverage is above 50% in all countries, but more than 80% in only seven countries in the Region. Death registration coverage lags behind birth registration coverage across the Region. Cause-of-death (CoD) data availability varies considerably in the Region and is mostly of poor quality. Several countries continue to use sample vital registration sites and surveys (such as Bangladesh, India, Indonesia and Nepal), in the absence of fully functioning civil registration and vital statistics (CRVS) systems capable of generating adequate CoD data and statistics for policy and planning. On Core Capacity for the International Health Regulations, in 2019, all Member States reported using the new State Parties Annual Self-Assessment Reporting (SPAR) tool. The reported preparedness index for the Region rose from 56% in 2018 to 61% in 2019. Emergency preparedness and response, including health systems, around the world are being challenged in an unprecedented manner by the ongoing COVID-19 pandemic, and Member States of the Region are no exception. Increased demands placed on health systems and service delivery for clinical care of the rapidly increasing number of COVID-19 patients in the Region has overwhelmed systems to a point of breaking up; and several countries were compelled to reprioritize and make difficult decisions on meeting these demands through shutting down almost entire economies, suspending routine health services delivery, and putting some national public health programmes including immunization campaigns on hold till emergency procurements and other necessary arrangements were made. This has been hard on those seeking health care, especially the most vulnerable population groups such as women, children, adolescents and the elderly, and those in fragile and conflict-affected settings. Strategic issues, conclusions and the way forward On UHC, there is improvement in coverage in essential health services in all Member States of the Region, but a need to accelerate. High and further increasing levels of household catastrophic health spending are a major barrier to achieving UHC. There is an enormous need to enhance public funding for health in several countries with highly strategic and targeted investments to increase and sustain the gains made and address unmet needs. Well-functioning delivery of quality health care and essential services cannot be compromised in the context of the COVID-19 pandemic if most of today’s health needs are to be safely met. Among other SDG targets, five Member States now have under-five mortality rates below the SDG target. The SEA Region has the largest reduction in maternal mortality among WHO regions. Multisectoral policies and plans in countries usually focus on undernutrition. Broadening policy measures to include interventions to address childhood overweight/obesity is required urgently. Simultaneously, there is a need to promote and support policies that facilitate the existence of an optimum food and physical environment. The Region continues to make progress on many communicable diseases. Drug- resistant TB remains a priority. To sustain the gains made in malaria, cross-border 24 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update cooperation needs to be institutionalized. The need for concerted attention to the risk factors for NCDs remains high, especially tobacco and alcohol, and for better screening, case detection and control. Despite encouraging signs of reduced tobacco use, some Member States may not reach the 2030 SDG target. Health determinants such as household and health facility water and sanitation services as well as ambient and indoor air quality remain significant concerns. The overall availability of health workers has improved by one fifth since the Decade (2015–2024) began, but at current rates of progress most countries will not reach the SDG human resources for health (HRH) threshold of 44.5 per 10 000 population by 2030. Investment in HRH data is paying dividends. Demand for new types of data for decision-makers, such as on labour market dynamics and facility workloads, is rising. These will help to improve health workforce governance and management. Actions to improve HRH data, and use it to track progress, need to be maintained. The COVID-19 crisis has amplified the need for continuous monitoring of the delivery of essential services and providing timely information for decision-makers, both technical and financial, to aid in addressing vulnerable, underserved and poor populations. In addition to this annual review of progress, easy access to UHC and health-related SDG data and indicators, query and analytical tools, and monitoring dashboards, is supported through the online health information platform of the WHO South-East Asia Region: http://hip.searo.who.int/dhis/ PART 2 Quality of health care: a snapshot This part highlights a few critical issues that deserve attention, using available data on selected tracer quality indicators, such as the availability of basic and safe water and sanitation services, regular electricity, availability of essential medicines, availability of national care guidelines based on quality and safety standards, and analysis of effective services. 25 26 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update Poor-quality health care remains common, especially in developing countries, and extracts a heavy toll on the health and economy. Progress towards UHC and the health-related SDGs will be seriously constrained without improvement in the quality of health-care delivery at all levels. Almost all SEA Region countries have developed and begun implementing policies and strategies to improve the quality and safety of health care. However, the reality is that even after many years, access to adequate quality care remains a major challenge. COVID-19 has brought increased focus to the importance of maintaining functioning and quality essential health services during a crisis and recovery. The World Health Assembly through its resolution WHA72.6 mandated the formulation of the Global Patient Safety Action Plan (GPSAP) in consultation with Member States and relevant stakeholders for submission to the Seventy-fourth World Health Assembly in 2021. This Region’s Member States had endorsed the Regional Strategy for Patient Safety in the SEA Region (2016–2025) (resolution SEA/RC68/R4 of the Regional Committee for SE Asia in September 2015). Disadvantaged groups are particularly affected by poor quality of health care. The 2018 Lancet Global Health Commission on High Quality Health Systems states: “Poor quality care is now a bigger barrier to reducing mortality than insufficient access; 60% of deaths from conditions amenable to health care are due to poor-quality care.”14 The SDGs also place more emphasis on monitoring equity, for example, for critical subpopulations, such as people living in rural areas and the poor. There is also more emphasis on accountability for progress. Monitoring service quality is beginning to get more attention. Assessments of quality of care involve many dimensions, all of which suffer from severe data limitations in low- and middle-income countries. SEA Region countries are no exception: vaccination coverage data are quite commonly used as crude proxies for quality, but this is not enough. Just measuring service utilization does not give any information about those needing care but not getting it. Coverage data for conditions needing repeated contact with the health system, such as antenatal care and detection and control of hypertension, are also useful as rough proxies for continuity of care, which is one dimension of quality. Current data on effective service coverage as well as quality and safety are scarce and can be unreliable. All measurement metrics, but especially those for quality, can easily become detailed and complicated, as well as expensive, fragmented and burdensome. Fewer and better metrics are needed that can capture effective coverage, competent care processes, confidence in health systems and quality impacts. The private sector, where many seek care, needs to be included – a challenge for all monitoring exercises. There is really no single measure or indicator that is adequate alone or could possibly be sufficient to address the multiple dimensions of quality of health care. A fit-for-service dashboard of quality of health-care indicators to address various dimensions of effective services, and cleaner and safer health facilities, has been included in each of the individual country-specific UHC and SDG data profiles in Part 3 of this 14 Kruk et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health Commission on High Quality Health Systems in the SDG Era. Lancet. 2018; http://dx.doi. org/10.1016/S2214-109X(18)30386-3 27Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update report. A regional fit-for-service dashboard (Fig. 12) provides regional averages for numerical indicators calculated by weighing the sizes of population of Member States, and are based on the availability of national-level indicators. Fig. 12: Quality of health care: summary of effective services, cleaner and safer health facilities in the WHO South-East Asia Region , Quality of health care: cleaner and safer health facilities Regular electricity National Frontline service Vacancy rate Doctors Nurses Essential medicines available National Frontline service IPC committee or focal point National Frontline service 46% 69% 19% 6% 58% 5 NA NA 5% Effective services Safe facility National policy on quality/safety of health care exists Yes National guidelines exist: Yes Partly No Surgial care Child birth Injection Medication Blood Medical devices Outpatient visit/ person/year 1.33 of indicators are monitored and reported 57% Progress towards UHC will be seriously constrained without improvement in the quality of health care Health care associated infection rate Children prescribed antibiotics for common cold Antenatal care coverage (4 visits) Children with diarrhoea received ORS or equivalent advice TB treatment success rate for new and relapse case Hypertensives are treated and controlled NA NA 58% 61% 75% 8% Clean facility More is better Less is better Water Sanitation Wastemanagement Cleaning National Non- hospital National Non- hospital National Non- hospital National Non- hospital 0 20 40 60 80 100 11 9 35 31 Basic WASH services at health facilities Basic service Limited service No service NA NA Sources: Country data reported to the WHO Regional Office for South-East Asia, 2018–2019, and other publically available databases specified in each country data profile in Part 3 In nearly all Member States a national policy on quality/safety of health care exists. However, coverage with effective services remains relatively low, with the exception of certain programmes, such as TB treatment success rate coverage. Ensuring clean and safe health facilities remains a challenge in most Member States. The individual country profiles provide more details for each Member State where data are available. Countries are also taking action on quality improvement in specific health programme areas. The Regional Office has prepared a point-of-care quality improvement (POCQI) model focusing on facility-level maternal, newborn and child care services. This model supports health-care teams in undertaking improvement processes at the facility (hospital) level based on local data on measures such as compliance with standard treatment protocols, hand hygiene, etc. India has used the POCQI model to ensure continuous quality improvement in its national labour room improvement programme. POCQI has also been used in newborn care units in several states of India and 17 districts in Bangladesh. Networks of hospitals 28 Monitoring progress on universal health coverage and the health-related Sustainable Development Goals in the WHO South-East Asia Region: 2020 update have adopted POCQI in other countries in the South-East Asia and African Region, as well as in the People’s Republic of China and Uzbekistan. Strategic issues and the way forward Various transitions are needed to improve the quality of health care and services to respond to today’s health needs in the SEA Region, particularly now as COVID-19 consumes time, energy and valuable resources and may inhibit progress on quality improvement to achieve effective service coverage. The concepts of person-centred and integrated care remain highly relevant. Many Member States are introducing and rolling out essential service packages to facilitate change, but these interventions cannot stand alone. Changes in service delivery models should link to primary health care workers, medicines and financing. Health workers need to learn new competencies and perform new roles to be better care coordinators rather than gatekeepers. Hospitals and primary care services must work better together, through vertical integration, aligning incentives and regulations. Policy- makers need to tackle the politics of implementing change, manage vested interests and build from the current reality by creating a social movement and igniting demand for cleaner, safer health facilities among parliamentarians, the public, health workers and managers. PART 3 Country–specific UHC and SDG data profiles This section provides country-specific data profiles of the 11 Member States of the WHO South- East Asia Region. A set of health-related SDG indicators and select service delivery indicators are presented. Each four-page country profile includes sections to address the latest demographics, overall progress using healthy life expectancy (HALE), detailed set of quality of health care indicators, and a summary of UHC and health-related SDG indicators including several with trend data. For each Member State there is a comprehensive list of references showing data source and year. The profiles are presented in alphabetical order below. Bangladesh Bhutan Democratic People’s Republic of Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste 29
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3HUFHQWDJH 3UHYDOHQFHRIREHVLW\DPRQJDGXOWV ïñ \HDUV $GGLWLRQDO6'*LQGLFDWRUVXVHGWRPRQLWRUWKH*3:LPSDFW References 1.World population prospects: the 2019 revision. New York: United Nations, Department of Economic and Social Afairs, Population Division; 2019 (htps:/population.un.org/wpp/, accessed 30 June 2020). 2. World urbanization prospects: 2018 revision. New York: United Nations, Department of Economic and Social Afairs, Population Division; 2018 (htps:/population.un.org/wpp/, accessed 30 June 2020). 3.World Bank. (htps:/data.worldbank.org/, accessed 28 July 2020). 4.Global health expenditure database. Geneva: World Health Organization; June 2020. 5.Global health estimates 2016: Life expectancy, 2000–2016. Geneva: World Health Organization; 2018 (htps:/www.who.int/gho/mortality_burden_disease/life_tables/en/, accessed 29 June 2020). 6. Bangladesh Demographic and Health Survey 2017-2018: Key Indicators. Dhaka, Bangladesh, and Rockvile, Maryland, USA: NIPORT, and ICF International; 2019. 7. WHO/UNICEF estimates of national immunization coverage (htp:/apps.who.int/immunization_monitoring/globalsummary/countries?countrycriteria%5Bcountry%5D%5B%5D=BGD, accessed 29 June 2020). 8. Global tuberculosis report 2019. Geneva: World Health Organization; 2019 (htps:/www.who.int/tb/publications/global_report/en/, accessed 20 April 2020). 9. UNAIDS/AIDSINFO [Online database]. (htp:/aidsinfo.unaids.org/, accessed 2 May 2020). 10. Progress on drinking-water, sanitation and hygiene – 2017 update and SDG baselines. Geneva and New York: World Health Organization and United Nations Children’s Fund; 2017. (htps:/washdata.org/sites/default/files/documents/reports/2019-05/JMP-2017-report-final.pdf, accessed 31 March 2020). 11. Primary Health Care on the Road to Universal Health Coverage: 2019 Monitoring report. Geneva: World Health Organization; 2019 (htps:/www.who.int/healthinfo/universal_health_coverage/report/uhc_report_2019.pdf?ua=1, accessed 7 August 2020). 12. The tobacco atlas: perspectives from the South-East Asia Region. New Delhi: World Health Organization. Regional Ofice for South-East Asia; 2020 (htps:/apps.who.int/iris/handle/10665/331441, accessed 29 July 2020). 13. WHO. Global Health Observatory (GHO) (htps:/www.who.int/gho/en/,accessed 29 June 2020). For IHR compliance, the 2018 estimate is used for SDG 3.8.1 to be consistent with the global UHC essential service coverage index figure and the 2019 estimate is used for SDG 3.d. 14. SEARO staf estimates from (Bangladesh) Household Income and Expenditure Survey 2016. 15. Fit-for-service dashboard: Cleaner safer health care facilities (Draft version 1.1). New Delhi: World Health Organization. Regional Ofice for South-East Asia. 16. Trends in maternal mortality: 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2019 (htps:/www.who.int/reproductivehealth/publications/maternal-mortality-2000-2017/en/, accessed 22 June 2020). See for Maternal Mortality Ratio. Country reported value:2019=165, 2018=169, 2017=172; 2016=178, 2015=181, 2014=193, 2013=197 Data source: Bangladesh Sample Vital Statistics. 17. Bangladesh DHS Survey 2004, Bangladesh DHS Survey 2007, Bangladesh DHS Survey 2011 and Bangladesh DHS Survey 2014. 18. Progotir Pathey, Bangladesh Multiple Indicator Cluster Survey 2019, Survey Findings Report. Dhaka, Bangladesh: Bangladesh Bureau of Statistics and UNICEF. 19.Levels and trends in child mortality. Report 2019. Estimates developed by the UN Inter-agency Group for Child Mortality Estimation. United Nations Children’s Fund, World Health Organization, World Bank Group and United Nations Population Division. New York: United Nations Children’s Fund; 2019 (htps:/www.unicef.org/reports/levels-and-trends-child-mortality-report-2019, accessed 22 June 2020). See for under-five mortality. Country reported value:2019=27, 2018=29 2017=31, 2016=35, 2015=35;2014=38, 2013=41 Data source: Bangladesh Sample Vital Statistics. See for neonatal mortality rate. Country reported value: 2019=15, 2018=16, 2017=17, 2016=19, 2015=20, 2014=21, 2013=20.Data Source: Bangladesh Sample Vital Statistics. 20 Calculated. World Malaria Report 2019. Geneva: World Health Organization; 2019 (htps:/www.who.int/publications/i/item/9789241565721, accessed 15 June 2020). 21. World Health Statistics 2020: Monitoring health for the SDGs. Geneva: World Health Organization; 2020 (htps:/www.who.int/gho/publications/world_health_statistics/2020/en/, accessed 15 June 2020). 22. See for suicide mortality rate. Country reported value: 2019=7.56. Data Source: Public Security Division, Ministry of Home Afairs 23. See for road trafic mortality rate. Country reported value: 2018=1.65. Data Source: Public Security Division, Ministry of Home Afairs 24. Bangladesh NCD Risk Factor Survey 2018. Dhaka, Bangladesh: NIPSOM, MoFHW and WHO (htps:/www.nipsom.gov.bd/wp-content/uploads/2020/05/steps-2018-results_factsheet_english.pdf, accessed 6 August 2020). 25. HRH unit, World Health Organization. New Delhi: World Health Organization. Regional Ofice for South-East Asia 26. See for Proportion of ever-partnered women and girls aged >=15 years subjected to physical, sexual or psychological violence by a curent or former intimate partner in the previous 12 months. Country reported value: 2015= 54.7; Data Source= Violence against women survey, 2015. 27. See of Proportion of population using safely managed sanitation services. Country reported value: 2019=74.8. Data Source: Bangladesh MICS 2019. 28. See for Amount of water-and sanitation-related oficial development assistance that is part of a government-coordinated spending plan. Country reported value: 2018-2019: MU$ 526.6. Data Source: Economic Relation Division, Ministry of Finance 29. See for Annual mean concentrations of the particulate mater. Country reported value: 2014=107, 2015=94, 2013=57. Data Source: Administrative Data from Ministry of Environment and Forest. 30. See for Mortality rate due to homicide. Country reported value: 2019=1.39. 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