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Confidential: For Review O

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Addressing progress and change in Maternal and Child

Health: How has South Asia fared?

Journal: BMJ

Manuscript ID BMJ.2016.037097

Article Type: Analysis

BMJ Journal: BMJ

Date Submitted by the Author: 15-Dec-2016

Complete List of Authors: Akseer, Nadia; Hospital for Sick Children, Centre for Global Child Health Kamali, Mahdis; Hospital for Sick Children, Centre for Global Child Health Arifeen, Shams; International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh, Malik, Ashar; Aga Khan University, Division of Women and Child Health

Bhatti, Zaid; Aga Khan University, Division of Women and Child Health Thacker, Naveen; Deep Children Hospital & Research Centre, Department of Pediatrics of Sahyadri Ramkrishna Speciality Hospital Maksey, Mahesh; Nepal Public Health Foundation D'Silva, Harendra; University of Colombo Faculty of Medicine Bhutta, Zulfiqar; Aga Khan University, Division of Women and Child Health

Keywords: South Asia, Maternal, Child, Health, Determinants

https://mc.manuscriptcentral.com/bmj

BMJ


nlyAddressing progress and change in Maternal and Child Health: How has South Asia fared?

Author list

Nadia Akseer1,2, Mahdis Kamali1, Shams E Arifeen3, Ashar Malik4, Zaid Bhatti4, Naveen

Thacker5, Mahesh Maksey6, Harendra D’Silva7, Zulfiqar A Bhutta1,2,4

Affiliations:

1 Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada

2 Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

3Maternal and Child Health Division (MCHD)

International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)

4 Center of Excellence in Women and Child Health, the Aga Khan University, Karachi,

Pakistan

5Deep Children Hospital and Research Centre, Gandhidham, Gujrat, India

6Nepal Public Health Foundation, Kathmandu, Nepal

7Faculty of Medicine, University of Colombo, Sri Lanka

*Corresponding author

Professor Zulfiqar A Bhutta, FRCPCH, PhD Robert Harding Chair in Global Child Health & Policy Centre for Global Child Health The Hospital for Sick Children Toronto, ON M5G 0A4 Canada [email protected]

Email addresses: NA: [email protected] MK: [email protected] ZB : [email protected] ZAB: [email protected] SEA: [email protected] MKM: [email protected] AM: [email protected] NT: [email protected] HD: [email protected]

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MATERNAL AND CHILD HEALTH IN SOUTH ASIA Page 1

Keywords:

South Asia, Maternal, Child, Health, Determinants

Abstract:

South Asia comprises eight culturally and socioeconomically diverse nations; the region collectively

account for a significant share of the global burden of maternal and child mortality. We explored

progress in reproductive, maternal, newborn, and child health (RMNCH) in the region since the

signing of the MDG declaration. We obtained trend data from national household health and

nutrition surveys, and global data repositories including the UN sources, Institute for Health

Metrics and Evaluation, and World Bank. We also conducted a review of peer-reviewed and grey

literature. South Asia reduced maternal mortality ratio (MMR) by 68% and under-5 mortality

(U5MR) by 60% from 1990 to 2015, with differential progress across countries. Current mortality

rates are exceptionally high in many countries including Afghanistan, Pakistan and Nepal.

Bangladesh made impressive reductions over this time period despite poverty. About 57% of all

under-5 deaths occur are among newborns, and stillbirth rates are also high in the region. South

Asia performs well in delivering antenatal care, skilled birth attendance, and vaccination

interventions on average to its populations, though wide disparities exist across wealth groups and

rural vs urban in many countries. As a whole, interventions on contraceptive use, breastfeeding,

and caring for sick children are lacking in many countries. Social determinants and health

systems/policies are key contributors to observed improvement and differentials in the region.

Despite progress in many countries, key challenges must be addressed for further gains. These

include resolutions and innovative initiatives for the ongoing conflict/insecurity, reduction of

inequities and improving health access to marginalized groups, addressing malnutrition,

encouraging empowerment of girls and women, and supporting better and timely data collection.

As a resilient populous region, South Asia is well posed to make further gains in the SDG era if key

challenges can be addressed.

Introduction:

Over twelve years ago, we explored the status of maternal and child health in South Asia in this very

journal (1). Our review evaluated the status and determinants of the poor performance of the

region in the context of the Millennium Development Goals (MDGs). We highlighted rampant

poverty, malnutrition, and lack of female empowerment as key barriers to change, and placed our

hope in countries making the right choices in terms of policies and implementation. Have things

changed over the last decade? This paper explores the current status and progress in reproductive,

maternal, newborn and child health (RMNCH) related MDGs throughout South Asia, and presents a

snap shot of the regions’ preparedness for the sustainable development goals (SDGs) (2).

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Methods & Data Sources:

We analyzed countries that are active members of the South Asian Association for Regional

Cooperation (SAARC)- a regional geopolitical and economic organization. Member states include

Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka.

Global data sources from the UN and Institute for Health Metrics (IHME) were reviewed for best

estimates of maternal mortality (3), child mortality (newborn, post-neonate and under-5) (4), and

still births (5). We obtained time series data from 1990 to 2015 when available. Cause-specific

death rates by country were retrieved from IHME for mothers (6) and the Child Health

Epidemiology Reference Group (CHERG) for newborns and post-neonates (7).

We constructed the coverage rates for interventions across the continuum of care for mothers,

infants and children in the South Asian Association for Regional Cooperation (SAARC) countries

comprising of India, Pakistan, Bangladesh, Nepal, Sri Lanka, Maldives and Afghanistan. We used

current coverage estimates from various sources including United Nations Population Fund

(UNFPA) (8), World Bank Development Database (9), the UNICEF Global Database (10), the UNICEF

Infant and Young Child Feeding Report(11), the WHO/UNICEF Coverage Estimates for

immunization (12), and the WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and

Sanitation (13). Child nutrition indicators including stunting (<-2 height for age median z-scores)

and wasting (<-2 weight for age median z-scores) measures were retrieved from the WHO/World

Bank/UNICEF Joint Malnutrition estimates (14). Full variable definitions are provided in the

appendix.

We reviewed national household surveys including the multiple indicator cluster surveys (MICS),

the demographic and health surveys (DHS), national nutrition surveys and others (Box 1) to cross-

reference data and to obtain coverage estimates by wealth quintile and for rural vs urban residence.

The surveys and other sources from the United Nations Development Programme (UNDP), World

Bank and WHO (see appendix for full source list) were used to attain additional demographic and

contextual information. Health care financing details were obtained from the most recent national

health accounts (NHA) report (15-22) and other analyses of out of pocket expenditures (23, 24). A

desk review of peer-reviewed and unpublished literature was also undertaken to identify key

health policies, strategies and other initiatives that have impacted RMNCH in the SAARC region (25-

43).

Box 1: National Survey Sources

Country Source

Afghanistan MICS 2010 (44), Afghanistan Mortality Survey 2010 (45), Afghanistan Household Survey 2012 (46), Afghanistan National Nutrition Survey 2013 (47)

Bangladesh DHS 2004 (48), DHS 2007 (49), DHS 2014 (50)

Bhutan MICS 2010 (51)

India National Family Health Survey 2005/2006 (52), Rapid Survey on Children 2013/2014 (53)

Maldives DHS 2009 (54)

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Nepal DHS 2006 (55), DHS 2011 (56), MICS 2014 (57)

Pakistan DHS 2006/2007 (58), DHS 2012/2013 (59)

Sri Lanka DHS 2006/2007 (60), National Nutrition and Micronutrient Survey 2012 (61)

Note: Final national estimates from India’s National Family Health Survey 2015/2016 were not yet

available.

Results:

Demographic Profile of SAARC Countries

The SAARC region (thereafter called South Asia for clarity) comprises a diverse set of countries

ranging from small nations with less than 1 million population, such as Maldives and Bhutan, to one

of the most populated nations globally- India with more than 1.3 billion people (Table 1). Since

2004, each country therein has experienced population growth ranging from 9% in Sri Lanka to

38% in Afghanistan. As the most rapidly growing state in the region, Afghanistan’s 2.8% annual

population growth rate is primarily attributed to repatriation of Afghan refugees from

neighbouring Pakistan and Iran. All other countries in the region have had moderate growth

ranging from about 1-2% per year. Nepal and Sri Lanka have the least urbanization with about 20%

of the populations live in urban settings. Approximately one-third of the civilians in other SAARC

countries live in urban areas, with the exception of Maldives where this number is almost 46%.

Mortality Trends and Causes of Death

Globally, maternal mortality ratio (MMR) dropped from 385 to 216 deaths per 100,000 live births-

a 44% reduction from 1990 to 2015 (3). Still, an estimated 303,000 mothers die every year, and

about 22% of them are in South Asia alone with India accounting for the bulk of these deaths. All

South Asian countries experienced significant MMR reductions across the MDG period (ranging

from -59% for Pakistan and Sri Lanka, to -90% for Maldives), while the region as a whole reduced

MMR by 68% (Figure 1). Afghanistan had the highest MMR in the region in 1990 (1340/100,000

births) and managed to drop this by 70% by 2015. Despite the gains, however, Afghanistan still has

the highest MMR in South Asia, followed by Nepal with 258 maternal deaths per 100,000 live births

in 2015. The major causes of maternal death vary across South Asia (appendix) though maternal

hemorrhage, hypertensive disorders, obstructed labour and uterine rupture, and

abortion/miscarriage/ectopic pregnancy are leading causes in many countries.

Globally under-five mortality rate (U5MR) reduced by about half from 1990 to 2015 (91 to 43

deaths per 1000 live births) (4). Of the 5.9 million U5 children that died in 2015, almost 1.9 million

(31%) were in South Asia. According to UN estimates, four countries in the region attained the

MDG4 goal of reducing U5MR by two-thirds from 1990 to 2015 (Bangladesh [-74%], Nepal [-75%],

Bhutan [-76%] and Maldives [-91%]) (Figure 1). Pakistan (-42%) and Afghanistan (-50%) reduced

the least over this period, and continue to have the highest U5MR in the region (81 and 91 deaths

per 1000 live births, respectively). The overall U5MR for the region dropped by 60% over this

period i.e. from 129 to 53 deaths per 1000 live births. Despite South Asia making gains in reducing

pneumonia and diarrhea-related deaths over the MDG period (notably, Bangladesh) (7), these two

preventable conditions persist as leading causes of child mortality in South Asia (appendix). About

50% of all deaths are attributed to these preventable conditions across most countries. Accidents

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and injuries are responsible for at least a further 10% of child deaths across all countries.

Congenital anomalies are leading killers of one-third of children in Sri Lanka and the Maldives.

In South Asia, 57% of all U5 deaths in 2015 occurred in the first 28 days of life; this amounts to

more than 1 million newborns dying every year in the region (4). Moreover, of the 2.6 million

stillbirths that occur globally every year, about 37% (almost 1 million) are in South Asia (5).

Newborn mortality rates (NMR) have declined by 49% in South Asia from 1990 to 2015, ranging

between 29% (Pakistan) and 89% (Maldives) (appendix). Stillbirth rates (SBR) have declined much

slower than NMR and across South Asia dropped by 30% from 41 to 29 deaths per 1000 total births

from 2000 to 2015 (appendix). NMR continues to be highest in Pakistan (45.5 deaths per 1000 live

births) and Afghanistan (35.5). The major causes of newborn death are fairly consistent across the

region with preterm birth taking the lead (about one-third), followed by intrapartum related

events, infections including sepsis and meningitis, and congenital anomalies (each contributing to

about one-fifth of newborn deaths) (appendix). Some variation exists across countries. Robust data

on causes of stillbirths were not available for comparison.

Coverage of Essential Interventions

Figure 4 presents the coverage rates for essential interventions across the continuum of MNCH and

indicates wide differentials across the region. . Contraceptive use is about 55% on average and is

lowest in Afghanistan (31%) and highest in Sri Lanka and Bhutan (about 70%). Though the median

demand for family planning is comparatively higher (75%), the distribution by country is similar.

One or more antenatal care visits (ANC1) is about 70% in most countries and reaches almost 100%

in Sri Lanka and Bhutan. ANC 4+ visits and skilled birth attendance are amongst the lesser accessed

interventions (~50% median) and have the widest variation across countries. Gaps of 70% are

noted between Afghanistan (23%) and Sri Lanka (93%) for ANC4+, and similarly for SBA. Post-

natal care within 2 days for both the newborn and mother are low in the region (30-40% median)

with some variation across countries. Data for Sri Lanka was not available.

Breastfeeding interventions (including early initiation and exclusive breastfeeding for 6 months)

exhibit parallel trends with about 50% regional coverage, and 40% gap between the highest (Sri

Lanka, Bhutan for early initiation; Afghanistan for exclusive breastfeeding) and lowest (Pakistan)

countries. The region performs well in the provision of child vaccinations, with about 90% coverage

on average for protection against newborn tetanus, Hib3, measles and DPT3. Country coverage

ranges from about 70% to 100%, with Afghanistan and Pakistan amongst the lowest and Sri Lanka

consistently the highest.

Interventions for treatment of sick children for diarrhea and pneumonia are moderately accessed in

the region on average (about 50-60%). Oral rehydration solutions (ORS) and ORS with continued

feeding are least utilized in India and Pakistan, and coverage rates are highest in Bangladesh.

Conversely, care seeking for pneumonia is most utilized in India and Maldives (almost 80%

coverage), and least accessed in Bangladesh (41%).

Coverage Inequalities within countries

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We analyzed socioeconomic and residence inequalities for two key interventions (skilled birth

attendance and measles vaccination) as they represent opposite ends of the continuum of care and

diverse delivery strategies (Figure 3). SBA coverage gaps between the richest and poorest quintiles

are pervasively present in most countries of South Asia, with upwards of 70% gaps noted in India,

Nepal and Bhutan. Sri Lanka and Maldives have minimal to no gaps. Similar country trends are

observed by residence where urban populations always had higher SBA coverage; Afghanistan had

the widest noted disparities. Inequities in measles vaccination were greatest for Pakistan, India and

Afghanistan with lowest coverage rates among the poorest populations and those living in rural

areas. Upwards of 50% coverage gap is noted between the richest and poorest in Pakistan and

Afghanistan; pro- urban gaps were at most 20% percentage points in the same countries. Sri Lanka,

Nepal, Maldives and Bangladesh had minimal to no gaps in measles vacation. Data for Bhutan was

not available.

Social Determinants of Health

Development and Poverty

In 2004, Sri Lanka and Maldives were the most developed nations in the region, with human

development indices (HDI) greater than 0.7 (Table 1). Afghanistan was the least developed

(HDI=0.40). Though this still holds true, Afghanistan has managed to increase its HDI by about 17%

up to 0.47. Nepal (+4% gain in HDI), Bangladesh (+8%), and Bhutan (+13%) have also improved

overall development. HDI has gone down slightly in Pakistan, India and Maldives. Per capita earning

is highest in the Maldives (GDP per capita 7681 USD), followed by Sri Lanka (3926 USD).

Afghanistan is one of the poorest and ranks far below all countries in the region with only 590 USD

per head on average. The proportion of the population living below national poverty lines or $1.08

per day is highest in Afghanistan (36%), with similar levels in Bangladesh, Nepal and Bhutan. Only

7% of Sri Lankans live below this threshold.

Malnutrition

Malnutrition of children and women remains a pervasive issue in South Asia (Figure 3). Since the

early 2000s, the prevalence of under-5 stunting dropped by about one-third in Afghanistan,

Bangladesh, India, Nepal, and Maldives. Pakistan, however, experienced an increase over this

period (from 42% to 45%). Despite progress, current levels of stunting are more than 30% in most

countries in the region, except Sri Lanka (15%) and Maldives (20%). Similar reduction patterns are

noted for childhood underweight, and currently approximately one-third of all children are

underweight in most countries except Bhutan (13%) and Maldives (18%) (appendix). Prevalence of

wasting has varied marginally over the decade, and currently ranges from negligible in Bhutan

(6%) to alarming levels in Sri Lanka (21%) (appendix).

Both over- and under-nutrition are concerns among women age 15-49 years in South Asia (Figure

3). Maternal underweight (defined as body mass index (BMI) < 18.5) is prevalent in about 36% of

women in India- about double that of the next highest countries (Nepal 18% and Bangladesh 19%).

Obesity (BMI>=30) is highest in Pakistan (15%) and Maldives (13%). Afghanistan has comparable

levels of underweight (9%) and obesity (8%) among women. Data for Bhutan was not available.

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Empowerment of Girls and Women

All countries in the region have experienced an overall reduction in fertility rates since 2004,

ranging between 9%-36% (Table 2). Current fertility rates are highest in Afghanistan and Pakistan,

where women are having on average 4.8 and 3.6 children, respectively. Similar patterns are noted

for births among adolescent girls (age 15-19 years) which have declined more than 50% in Bhutan,

Maldives, and India. Pakistan has made the least progress in reducing fertility among adolescent

girls (11% reduction). Current adolescent fertility levels are highest in Bangladesh, Afghanistan and

Nepal as more than 7% of adolescent girls experience their first pregnancy. Average age at first

marriage is lowest in Bangladesh (19.2 years), and highest in Sri Lanka (23.6 years). While most

countries have increased this average age of marriage by 2%-7%, Afghanistan had the fastest rate

of change over the last decade (from 15.0 years in 2006 to 21.2 years in 2011).

Literacy of women (age 15+ years) is greater than 90% in Sri Lanka (92%) and the Maldives (99%),

and about half in other SAARC nations except Afghanistan where only 24% of women are literate.

Literacy of female youth (age 15-24 years) is >85% in all countries, excluding Pakistan (67%) and

Afghanistan (46%).

Access to Improved Water and Sanitation

The availability of improved water is almost universal throughout the region except in Afghanistan

where only 55% of the population has access (Table 1, Figure 4). The country, however, has made

the most dramatic gains in the region, having increased access by 48% from the 2004 coverage

levels (37%). Other countries in the region have increased coverage by 2%-14% from 2004 to

2015. Improved sanitation facilities are less available in the region (about 55% regional median),

and wide variation is noted between the lowest coverage nation (Afghanistan at 32%) and better

off nations (Sri Lanka and Maldives at >90% coverage). Given lower baseline levels in 2004,

countries in the region have made greater gains in improving coverage of this indicator (by 11%-

62%) than improved water.

Investments in Health Systems and RMNCH

The density of health care personnel including physicians, nurses and midwives varies dramatically

across the region (Table 1). Collectively, there approximately 64.5 such health workers per 10,000

population in Maldives, and only 5.7 per 10,000 in Bangladesh, 6.5 in Afghanistan, and 6.7 in Nepal.

These three countries, plus Bhutan (12.4 per 10,000) and Pakistan (14.0 per 10,000) do not meet

the WHO recommended threshold of minimum 23 health workers per 10,000 population. India and

Sri Lanka are at the cusp of the recommended cut-off.

A timeline of key high impact health initiatives implemented in SAARC countries across the MDG

period is presented in Table 3. Cross-national commonalities include: the adaptation of a basic

package of health care services and strategies to expand universally, contracting out delivery of

health care services to NGOs for rapid scale-up, health care financial incentive

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programmes/abolishing user fees, and community-based health care initiatives and training of

midwives.

We evaluated national health care financing in the region and summarize it in Table 4. Health

expenditure as a % of GDP is highest in the Maldives (9.2%) and Afghanistan (8.0%), and lowest in

Pakistan (3.0%). Per capita expenditure on health is highest in the Maldives (561 USD), and lowest

in Nepal (25 USD) and Bangladesh (27 USD). Government health expenditure as a proportion of

total health expenditure (THE) is a high of 71.0% in Bhutan and strikingly low in Afghanistan

(5.6%). Out of pocket (OOP) payments comprise the majority of total health expenditure in

Afghanistan (73.3%), India (64.2%), Bangladesh (63.0%) and Pakistan (60.4%). High OOP health

expenditures annually drag about 4% of the population into poverty in the three most populous

countries of the region i.e. India, Bangladesh and Pakistan. Data for Afghanistan was not available

for comparison. Of the four countries with available data, RMNCH spending constitutes between

9.8% (Sri-Lanka) and 21.0% (Pakistan) of THE. Catastrophic impact (OOP health payments

exceeding 25% of the total expenditure) is highest in Bangladesh (5.0%) and Pakistan (4.5%).

Across the region, Afghanistan, Nepal and Bhutan have the greatest share of official development

assistance in their total health expenditure (about one-fifth of THE).

Discussion:

Despite wide variations, South Asia as a region has made impressive progress in RMNCH over the

last decade. In many countries with widespread conflict and grinding poverty, notably Nepal and

Afghanistan, these gains are quite remarkable. However, the reductions were related to differing

approaches and investments.

Nepal invested heavily in community-based approaches to address community-based detection of

serious childhood illnesses and management of pneumonia (62). A range of innovative approaches

for addressing maternal health and nutrition through women’s groups provided some of the first

bodies of evidence on the role of community empowerment in rural Makwanpur (63). Bangladesh

also saw a range of interventions and changes among which community empowerment,

investments in education and young women and large national roll out of community health

workers including through non-governmental organizations such as BRAC, and was able to rapidly

roll out interventions through a range of community outreach programs (64, 65). However, the

gains in maternal mortality reduction in Bangladesh far outstripped the gains in skilled birth

attendance coverage and facility births (66). Similarly, reductions in child mortality (and especially

diarrheal diseases mortality) have been remarkable, and while there have been major gains in oral

rehydration therapy, care seeking for childhood pneumonia is low and rates of childhood

undernutrition still high (67). It is therefore likely that the role of investments in social

determinants and non-health sectors such as education, especially girls’ education, female

empowerment, reduction in early marriages and high fertility rates, as well as effective

communication strategies are especially important for gains in RMNCH outcomes and must be

sustained moving forwards.

These findings are different elsewhere. In war ravaged Afghanistan, where given the shortage of

skilled public sector workers, the government adopted the model of rolling out services through

contracting NGOs to provide a basic package of primary care services (68). While the transaction

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costs were high, the model allowed for rapid population coverage in difficult to reach rural

populations.

Notwithstanding the above, high rates of newborn mortality (and intrapartum stillbirths) are a

major challenge across the region, and are associated with poor quality of care in both community

and facility settings (69). Further gains in reducing U5MR will need to address the dual challenge of

improving care during pregnancy and child birth in community settings and facilitation of facility

births, as well as improving care of newborns in referral facilities. Pakistan invested in a major

national program of primary care “Lady Health Workers” which now number over a 100,000 and

cover almost two thirds of the rural population (70), and India has also introduced a major public

sector program of community-based ASHA workers. Evidence has shown that there is considerable

opportunity for innovations in facilitating the work of front-line workers in addressing these

challenges (71-74). In other regions of South Asia where there have been relatively rapid gains, we

need to invest in strategies to improve the quality of care in referral facilities, especially those

responsible for secondary care.

Notwithstanding important strides in the region, major challenges remain. The rapid growth of

urban slums, frequently accounting for over a third of the population of mega cities, poses huge

challenges to effective care and governance. These and other marginalized populations, including

indigenous groups and those relegated on the basis of ethnicity, religion or caste systems, will

require innovative targeting to reduce inequities. Further, reaching the poorest and remote

populations in countries with substantial pro-rich and pro-urban RMNCH interventions

inequalities, such as Afghanistan and Pakistan, is critical to achieving universal coverage. Recent

reviews have underscored innovative strategies for reducing such inequities to improve maternal

and child health (75). Conflict and insecurity are an ongoing challenge facing many South Asian

countries (such as Afghanistan and border areas of Pakistan). A focus on identifying sources of

conflict and peace building in the region is critical to sustaining and scaling up RMNCH gains. Post-

conflict settings, such as Northern and Eastern Sri Lanka, especially the Jaffna area, need attention

and dire support to rebuild health systems.

Finally the state and international partners must support and protect women and children who

suffer from risk of gender-based violence, lack of economic security and physical immobility. High

rates of maternal and adolescent malnutrition remain tenacious underlying risk factors for ill health

and mortality in the region. Direct policies and initiatives to improve nutrition of all populations are

critical for health gains in South Asia. Low rates of breastfeeding and complementary feeding are

specifically a concern, and should be prioritized for scale-up. Quality and timely data is

indispensable for effective monitoring, evaluation and rapid feedback. Countries should focus on

efforts to enhance administrative databases, HMIS systems, vital registries and national surveys on

various health and well-being areas to track progress towards the SDGs.

South Asia comprises a substantial chunk of the global population and contains some of the highest

maternal and child mortality rates worldwide. Gains over the last decade provide evidence that

progress is possible, but much more can be done with targeted focus on scaling up evidence-based

interventions and addressing barriers as key investments in reaching the sustainable development

goals.

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67. Rahman AE, Moinuddin M, Molla M, Worku A, Hurt L, Kirkwood B, et al. Childhood diarrhoeal deaths in seven low- and middle-income countries. Bull World Health Organ. 2014;92(9):664-71.

68. Akseer N, Salehi AS, Hossain SMM, Mashal MT, Rasooly MH, Bhatti Z, et al. Achieving maternal and child health gains in Afghanistan: a Countdown to 2015 country case study. The Lancet Global Health.4(6):e395-e413.

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73. Baqui AH, Saha SK, Ahmed ASMNU, Shahidullah M, Quasem I, Roth DE, et al. Safety and efficacy of alternative antibiotic regimens compared with 7 day injectable procaine benzylpenicillin and gentamicin for outpatient treatment of neonates and young infants with clinical signs of severe infection when referral is not possible: a randomised, open-label, equivalence trial. The Lancet Global Health.3(5):e279-e87.

74. Soofi S, Cousens S, Imdad A, Bhutto N, Ali N, Bhutta ZA. Topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of Pakistan: a community-based, cluster-randomised trial. The Lancet.379(9820):1029-36.

75. Yuan B. What interventions are effective on reducing inequalities in maternal and child health in low- and middle-income settings? A systematic review. BMC Public Health. 2014;14.

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Confidential: For Review Only

Tables and Figures: MNCH in South Asia Page 1 Table 1: Demographics of South Asian Countries

Country Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka

Total population (current, 2015) 32526562 160995642 774830 1311050527 409163 28513700 188924874 20966000

Total population (baseline, 2004) 23499850 23499850 23499850 23499850 23499850 23499850 23499850 23499850

Population change (%) +38.4 +14.3 +22.2 +16.4 +31.1 +13.2 +25.7 +9.0

Population growth (annual %) (2015) 2.8 1.2 1.3 1.2 2.0 1.2 2.1 0.9

Urban population (% of total) (2015) 26.7 34.3 38.6 32.7 45.5 18.6 38.8 18.4

Human development index (current, 2014) 0.465 0.570 0.605 0.609 0.706 0.548 0.538 0.757

Human development index (baseline, 2004) 0.399 (2005) 0.530 0.538 0.611 0.739 0.527 0.539 0.755

Human development change (%) +16.5 +7.6 +12.5 -0.3 -4.5 +4.0 -0.2 +0.3

GDP per capita (US$) (2015) 590.3 1211.7 2532.5 1581.6 7681.1 732.3 1429.0 3926.2

Population living below national poverty line/$ 1.08 a day (% total)

35.8 (2011)

32.0 (2010)

31.5 (2012)

21.9 (2011)

15.7 (2009)

33.0 (2010)

22.5 (2013)

6.7 (2012)

Density of physicians, nurses and midwives (per 10,000 population)

6.5 (2012)

5.74 (2011)

12.4 (2012)

24.54 (2011)

64.5 (2010)

6.69 (2004)

14.0 (2010)

23.21 (2010)

Improved drinking water sources (current, 2015) 55.3 86.9 100 94.1 98.6 91.6 91.4 95.6 Improved drinking water sources (baseline, 2004) 37.3 79.1 89.1 84.5 96.6 81.2 89.3 84.2

Improved drinking water sources change (%) +48.3 +9.9 +12.2 +11.3 +2.1 +12.8 +2.3 +13.5

Improved sanitation facilities (current, 2015) 31.9 60.6 50.4 39.6 97.9 45.8 63.5 95.1

Improved sanitation facilities (baseline, 2004) 25.7 49.7 37.4 29.6 87.3 28.3 44.1 85.4

Improved sanitation facilities change (%) +24.2 +22.0 +34.9 +33.8 +12.1 +62.1 +44.0 +11.4

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Tables and Figures: MNCH in South Asia Page 2 Figure 1: Mortality Trends in South Asian Countries, 1990-2015 A) Maternal

B) Under-5

*Sri Lanka’s 2004 U5MR estimate was smoothed using linear interpolation

0

200

400

600

800

1000

1200

1400

1600

19901991 19921993 1994 19951996 19971998 19992000 20012002 20032004 20052006 2007 20082009 20102011 20122013 20142015

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Year

Afghanistan

Bangladesh

Bhutan

India

Maldives

Nepal

Pakistan

Sri Lanka

Global

South Asia

0

20

40

60

80

100

120

140

160

180

200

19901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015

Un

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Tables and Figures: MNCH in South Asia Page 3 Figure 2: Coverage of Essential Interventions in South Asian Countries (best recent estimates)

*Bar height denotes median coverage

0

10

20

30

40

50

60

70

80

90

100

Co

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Use

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%

Afghanistan

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Bhutan

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Sri Lanka

Pregnancy Birth Post-natal

CareInfancy Childhood Water and

SanitationPre-

Pregnancy

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Tables and Figures: MNCH in South Asia Page 4 Figure 3: Inequalities in Skilled Birth Attendance and Measles Vaccination by Country

A) Skilled Birth Attendance

B) Measles Vaccination

0

10

20

30

40

50

60

70

80

90

100

Ind

ia (

20

05

)

Ne

pa

l (2

01

4)

Bh

uta

n (

20

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)

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(2

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%

Poorest Quintile Quintile 2 Quintile 3 Quintile 4 Richest Quintile

0

10

20

30

40

50

60

70

80

90

100

Afg

ha

nis

tan

(2

01

0)

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pa

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)

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20

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)

Ba

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Pa

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(20

09

)

Sri

La

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(2

00

7)

%

Urban Rural

0

10

20

30

40

50

60

70

80

90

100

Pa

kis

tan

(2

01

2)

Ind

ia (

20

05

)

Afg

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)

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%

Poorest Quintile Quintile 2 Quintile 3 Quintile 4 Richest Quintile

0

10

20

30

40

50

60

70

80

90

100

Pa

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Tables and Figures: MNCH in South Asia Page 5 Figure 4: Malnutrition Trends in South Asian Countries Note: Baseline is the earliest estimate between 1999-2004; current is the most recent estimate between 2009-2015

A) Child Stunting B) Maternal Malnutrition

*Maternal malnutrition graphs: India’s Rapid Survey on Children (RSOC) 2013-2014 National Report only included child malnutrition estimates; therefore DHS 2005-2006 was used for maternal malnutrition estimates; Nepal’s MICS 2014 does not include maternal BMI therefore DHS 2011 was used; Examined Sri Lanka’s DHS 2006-07, Nutrition and food security survey 2009 by WFP and the National nutrition and micronutrient survey 2012 and estimates were comparable across all, the definition for women used is women of 18-59 years of age

59.3

50.854.2

31.9

57.1

41.5

18.4

40.9

36.133.6

38.7

20.3

37.4

[VALUE].0

14.7

0

10

20

30

40

50

60

70

%

Baseline Current

9.2

18.6

35.6

7.5

18.2

13.9 14.9

8.3

4.42.8

13.1

2.2

15

6.9

0

5

10

15

20

25

30

35

40

45

50

%

Low BMI (<18.5) Obesity (>= 30)

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Tables and Figures: MNCH in South Asia Page 6 Table 2: Women and Girls Empowerment Indicators in South Asian Countries Country Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka

Fertility rate (average births per woman) (current, 2014)

4.8 2.2 2.0 2.4 2.1 2.2 3.6 2.1

Fertility rate (average births per woman) (baseline, 2004)

7.0 2.8 3.0 3.0 2.4 3.4 4.1 2.3

Fertility rate change (%) -30.7 -21.7 -31.6 -20.1 -12.2 -35.2 -12.4 -8.6

Adolescent fertility rate (average births per woman aged 15-19) (current, 2014)

76.7 83.5 22.7 25.7 7.3 72.5 39.2 15.4

Adolescent fertility rate (average births per woman aged 15-19) (2004)

134.7 101.1 61.7 54.0 20.1 104.1 44.2 25.7

Adolescent fertility rate change (%) -43.0 -17.5 -63.2 -52.4 -63.7 -30.4 -11.4 -40.1

Age at first marriage (mean, current) 21.2 (2011) 19.2 (2013) 21.4 (2010) 20.7 (2011) 22.4 (2009) 20.7 (2014) 23.1 (2013) 23.6 (2007)

Age at first marriage (mean, baseline) 15.0 (2006) 18.7 (2004) 21.8 (2005) 20.2 (2006) 22.9 (2006) 19.4 (2006) 22.3 (2003) Data not available

Age at first marriage change (%) +41.3 +2.7 -1.8 +2.5 -2.2 +6.7 +3.6 --

Female adult literacy rate (% of females ages 15 and above) (current, 2015)

23.9 58.3 55.1 63.0 98.9 54.8 42.7 91.7

Female adult literacy rate (% of females ages 15 and above) (baseline)

Data not available

Data not available

38.7 (2005) 50.8 (2006) 98.4 (2006) Data not available

35.4 (2005) 89.1 (2006)

Female adult literacy rate change (%) -- -- +42.4 +23.9 +0.5 -- +20.7 +2.9

Youth Female Literacy Rate (% of female ages 15-24) (current, 2015)

46.1 85.9 90.4 87.3 99.5 87.4 66.8 99.2

Youth Female Literacy Rate (% of female ages 15-24) (baseline)

Data not available

Data not available

68.0 (2005) 74.4 (2006) 99.4 (2006) Data not available

53.1 (2005) 97.9 (2006)

Youth Female Literacy Rate change (%) +33.0 +17.3 +0.1 +25.8 +1.3

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Tables and Figures: MNCH in South Asia Page 7

Table 3. Key Health Policies and Reforms in South Asian Countries

Country Reform Year started

Focus

Afghanistan Midwifery training program 2002 Provided pre services training to midwife for community care and hospital based care.

Basic package of health services

2004 Basic primary care services including maternal health and family planning.

Contracting of primary health services to NGO

2004 Capitation based (USD 3.8 to USD 5.1 per capita) contracts with providers through a bidding process.

Bangladesh

BRAC Shasthya Shebikas Community health workers

1970* Scaled up to all 64 districts: from 1080 CHWs to 91000 CHW by 2010

SWAp 1998* A shift from project-based planning to sector-wide planning, management and financing.

Bangladesh national strategy for maternal health

2001 Adopted community based skilled birth attendant to supplement institution based care.

Demand side financing 2007 Maternal health voucher scheme Current converge in 53 upazilas.

Bhutan

Universal access to health services

2008 In the constitution of 2008 health is recognized as human right and as one of the nine domains of gross national happiness.

Health policy 2012 Pledges universal health access to modern and traditional care, 90% population living within three hours walking distance to a health facility.

India National rural health mission 2004 Integration of vertical reproductive and maternal health programs and health system strengthening in 18 states.

Janani Suraksha Yojana 2005 Conditional cash transfer to pregnant women Accredited Social Health Activist (ASHA)

2006 820000 community health workers (ASHA) as of 2012

Rashtriya Swasthya Bima Yojna

2008 In patient (including maternity) coverage for the poor. 41.3 million People covered by 2016.

Maldives Madhana 2008 Publically funded health insurance scheme initially covering public employees and the elderly.

Aasandha 2012 Universal health coverage (up to Rf 100,000) including treatment in neighboring countries.

Nepal National safe motherhood plan 2002 Increase the access of poor and marginalized people on the reproductive health services.

Free healthcare policy 2006 Abolishing user’s fee at public facilities. By 2009 free essential health services including maternity services.

National safe motherhood/ neonatal health plan

2006 Birth preparedness package.

Community based neonatal care package

2007 Piloted in 10 districts and planned to scale up to 35 more districts by 2013

Pakistan Social Action Program I & II National Program for family planning and primary healthcare

1992/1998 1994

Sector wide approach for primary and secondary healthcare Currently over 100000 lady health workers covering more than 80% of rural population

People’s primary healthcare initiative

2004 Contracting of primary healthcare facilitates to NGOs. Implemented in 75 districts (out of 113).

Community midwife program 2005 New cadre of community midwife is introduced.

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Tables and Figures: MNCH in South Asia Page 8

18th constitutional amendment 2010 Devolution of health sector to the provinces National health insurance scheme

2014 Financial protection from health shocks to the population living below poverty line for inpatient care including maternity services.

Sri Lanka National maternal and child healthcare program

1965* Family Planning and reproductive health were integrated

Strategic framework for health development 2004-2015

2003 Health master plans and health development plan were implemented

National health development plan

2012 World Bank assisted project for out-sourcing non-clinical services and other financing reforms

*Key initiatives that were further accelerated post-2000

Table 4: Health Care Financing Overview in South Asian Countries (best recent estimate)

India Bangladesh Pakistan Afghanistan Sri-Lanka Nepal Bhutan Maldives

Health expenditure as % of GDP 4.0% 3.5% 3.0% 8.0% 3.2% 5.3% 3.7% 9.2%

Per capita health expenditure in USD 59 27 40 56 97 25 107 561

Share of government health expenditure in total health expenditure 28.6% 23.0% 32.1% 5.6% 55.0% 21.0% 71.0% 44.0%

Share of out-of-pocket health payments in total health expenditure 64.2% 63.0% 60.4% 73.3% 37.9% 54.8% 11.0% 49.0%

Share of RMNCH expenditure in total health expenditure - 12.0% 21.0% 16.0% 9.8% - - -

Share of official development assistance in total health expenditure 0.3% 8.3% 7.0% 20.8% 1.5% 18.9% 18.0% 3.0% Percentage points of population impoverished due to OOP health payments 3.7% 3.8% 3.8% - 0.3% 3.0% - - Percentage of population with OOP health expenditure greater than 25% of total expenditure 1.8% 4.5% 5.0% - 0.5% 1.2% - - Source: National health accounts for India (2013-14), Bangladesh (2012), Pakistan (2013-14), Sri Lanka (2013), Afghanistan (2011-12), Maldives (2011), Nepal (2008-09), Bhutan (2009-10). Dooslear et al (2006) for Impoverishment impact of OOP health payments (except Pakistan Malik, 2016) and Doorslaer (2007) for OOP health payments exceeding 25% of the household total expenditure

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Web Appendix 1Box 1: Indicators and definitions with their source

Indicator Definition Source Links

Contraceptive

use (any

method)

Prevalence of current contraceptive use among

married women 15-49 years old, any method

(%).

World Bank http://data.worldbank.org/indicator/SP.D

YN.CONU.ZS

Demand for

family

planning

satisfied

Demand for Family Planning Satisfied:

Percentage of total demand for family planning

among married or in-union women aged 15 to

49 that is satisfied (contraceptive prevalence

divided by total demand for family planning).

United Nations

Population Fund

(UNFPA)

http://www.unfpa.org/sites/default/files/sowp/dow

nloads/The_State_of_World_Population_2016_-

_English.pdf

Antenatal care

1+ visit

Percentage of women attended at least once

during pregnancy by skilled health personnel.

UNICEF Global

Database

https://data.unicef.org/topic/maternal-

health/antenatal-care/

Antenatal care

4+ visits

Percentage of women attended four or more

times during pregnancy by any provider.

UNICEF Global

Database


health/antenatal-care/

Protection

against

newborn

tetanus

Percentage of mothers who’s last live birth in the

five-year period before the survey was protected

from neonatal tetanus.

World Bank http://data.worldbank.org/indicator/SH.V

AC.TTNS.ZS

Skilled birth

attendance

Percentage of live births attended by skilled

health personnel.

UNICEF Global

Database


health/delivery-care/

Post-natal care

for newborns

within 2 days

Percentage of newborns who received postnatal

care within two days of birth.

UNICEF Global

Database


health/newborn-care/

Post-natal care

for mothers

within 2 days

Percentage of mothers who received postnatal

care within two days of childbirth.

UNICEF Global

Database


health/newborn-care/

Initiation of

breastfeeding

within 1

hour of birth

Percentage of newborns put to the breast within

one hour of birth.

UNICEF Global

Database

https://data.unicef.org/topic/nutrition/inf

ant-and-young-child-feeding/

Exclusive

breastfeeding

for 0-5 months

Exclusive breastfeeding refers to the percentage

of children less than six months old who are fed

breast milk alone (no other liquids) in the past

24 hours.

World Bank http://data.worldbank.org/indicator/SH.S

TA.BFED.ZS

Introduction of

solid and semi-

solid food soft

food

Percentage of infants ages 6–8 months who

receive solid, semi-solid or soft foods.

UNICEF Global

Database

https://data.unicef.org/topic/nutrition/inf

ant-and-young-child-feeding/

Children who

received three

doses of

Haemophilus

influenzae type

B vaccine

The percentage of 1 year olds who have received

three doses of Haemophilus influenzae type B

vaccine in a given year.

World Health

Organization and

United Nations

Children’s Fund

estimates of

national

immunization

coverage

https://data.unicef.org/topic/child-

health/immunization/

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Web Appendix 2Children who

are immunized

against

measles

The percentage of children aged 12-23 months

who have received at least one dose of measles-

containing vaccine in a given year.

World Health

Organization and

United Nations

Children’s Fund

estimates of

national

immunization

coverage



Children who

received 3

doses of

diphtheria,

pertussis,

tetanus

vaccine

The percentage of one-year-olds who have

received three doses of the combined diphtheria,

tetanus toxoid and pertussis (DTP3) vaccine in a

given year.

World Health

Organization and

United Nations

Children’s Fund

estimates of

national

immunization

coverage



Oral

rehydration

with continued

feeding for

diarrhea

treatment

Percentage of children under age five ill with

diarrhea during the two-week period before the

survey and, among children ill with diarrhea, the

percentage who received ORT and continued

breastfeeding.

UNICEF Global

Database


health/diarrhoeal-disease/

Oral

rehydration

salts for

diarrhea

treatment

Percentage of children under age five ill with

diarrhea during the two-week period before the

survey and, among children ill with diarrhea, the

percentage who received ORS (ORS packet or

pre-packaged ORS fluid).

UNICEF Global

Database


health/diarrhoeal-disease/

Care seeking

for suspected

pneumonia

Percentage of children under age five with

symptoms of acute respiratory illness (ARI)

during the two-week period before the survey

and, among children with symptoms of ARI, the

percentage who were taken to an appropriate

health provider.

World Bank https://data.unicef.org/topic/child-

health/pneumonia/

Use of

improved

drinking water

sources

Percentage of the population using improved

drinking water sources (piped on premises or

other improved drinking water sources).

Joint Monitoring

Programme for

Water and

Sanitation

http://www.wssinfo.org/data-estimates/

Use of

improved

sanitation

facilities

Percentage of the population using improved

sanitation facilities.

Joint Monitoring

Programme for

Water and

Sanitation

http://www.wssinfo.org/data-estimates/

Total

Population

Total population of a country counting all

residents, regardless of legal status of

citizenship.

World Bank http://data.worldbank.org/indicator/SP.P

OP.TOTL

Population

Growth

Annual population growth rate, expressed as a

percentage.

World Bank http://data.worldbank.org/indicator/SP.P

OP.GROW

Urban

Population

Percentage of people living in urban areas as

defined by national statistical offices.

World Bank http://data.worldbank.org/indicator/SP.U

RB.TOTL.IN.ZS

Human A summary measure of average achievement in United Nations http://hdr.undp.org/sites/default/files/20

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Web Appendix 3Development

Index

key dimensions of human development: life

expectancy at birth, education (mean years of

schooling and expected years of schooling) and

gross natural income per capita. The HDI ranges

between 0 and 1 and higher HDI values indicate

higher levels of human development.

Development

Programme

15_human_development_report.pdf

GDP per capita

(US$)

Gross domestic product (GDP) is the sum of

gross value added by all resident producers in

the economy plus any product taxes and minus

any subsidies not included in the value of

products. Data are in current U.S. dollars.

World Bank http://data.worldbank.org/indicator/NY.G

DP.PCAP.CD

GINI Index Measures the extent to which the distribution of

income (or, in some cases, consumption

expenditure) among individuals or households

within an economy deviates from a perfectly

equal distribution. A GINI index of 0 represents

perfect equality, while an index of 100 implies

perfect inequality.

World Bank http://data.worldbank.org/indicator/SI.PO

V.GINI

Fertility rate

(average births

per woman)

Total fertility rate represents the number of

children that would be born to a woman if she

were to live to the end of her childbearing years

and bear children in accordance with age-

specific fertility rates of the specified year.

World Bank http://data.worldbank.org/indicator/SP.D

YN.TFRT.IN?

Adolescent

fertility rate

(births per

1000 women

aged 15-19)

Adolescent fertility rate is the number of births

per 1,000 women ages 15-19.

World Bank http://data.worldbank.org/indicator/SP.A

DO.TFRT

Age at first

marriage

(female, mean)

The average length of single life expressed in

years among those females who marry before

age 50.

World Bank

Gender Statistics

http://databank.worldbank.org/data/repo

rts.aspx?source=gender-

statistics&Type=TABLE&preview=on

Age at first

birth (median,

ages 25-49)

Percentage of women ages 25-49 median age at

first birth.

Demographic

Health Survey

https://dhsprogram.com/What-We-

Do/survey-

search.cfm?pgtype=main&SrvyTp=country

Female adult

literacy rate (%

of females ages

15 and above)

Percentage of the female population age 15 and

above who can, with understanding, read and

write a short, simple statement on their

everyday life.

World Bank http://data.worldbank.org/indicator/SE.A

DT.LITR.FE.ZS

Female youth

literacy rate (%

of females ages

15-24)

Percentage of females ages 15-24 who can both

read and write with understanding a short

simple statement about their everyday life.


DT.1524.LT.FE.ZS

Male youth

literacy rate (%

of males ages

15-24)

Percentage of males ages 15-24 who can both

read and write with understanding a short

simple statement about their everyday life.


DT.1524.LT.MA.ZS

Density of

physicians,

Density of physicians, nurses and midwives per

10 000 population.

Global Health

Observatory

http://apps.who.int/gho/data/node.main.

A1444?lang=en

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Web Appendix 4nurses and

midwives (per

10,000)

Figure 1: Mortality Trends in South Asian Countries, 1990-2015

A) Stillbirth

0

10

20

30

40

50

60

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Sti

llb

irth

ra

te (

pe

r 1

00

0 t

ota

l b

irth

s)

Year

Afghanistan

Bangladesh

Bhutan

India

Maldives

Nepal

Pakistan

Sri Lanka

Global

South Asia

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Web Appendix 5

B) Neonatal

0

10

20

30

40

50

60

70

80

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

20

14

20

15

Ne

on

ata

l d

ea

ths

pe

r 1

00

0 l

ive

bir

ths

Year

Afghanistan

Bangladesh

Bhutan

India

Maldives

Nepal

Pakistan

Sri Lanka

Global

South Asia

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Web Appendix 6Figure 2: Causes of Death in South Asian Countries, 2015

A) Maternal

B) Neonatal

30.2

41.7

7.4 10.3 13.78.0

38.9

24.3

10.7

6.5

3.9

2.2

6.67.2

3.9

1.6

7.2

3.5

17.1

17.6

21.3

18.5

20.4

13.4

21.6

22.2

6.8

8.5

5.7

6.1

14.6

22.8

21.1

1.312.2

1.1

11.5

11.2

16.0

13.0

14.2

5.6

15.0 10.3

51.5

11.26.1

6.7

11.5

9.2

24.4

8.86.9

4.4

2.4 1.6

3.4

2.4

1.5

3.1

0.72.9

0.4

0.8

12.2

36.8

23.0

10.9

20.512.1 14.0

21.5

11.9

0.0 0.0 0.1 0.1 0.0 0.0 0.0

0

10

20

30

40

50

60

70

80

90

100Maternal deathsaggravated by HIV/AIDS

Other maternal disorders

Late maternal deaths

Indirect maternal deaths

Maternal abortion,miscarriage, and ectopicpregnancyMaternal obstructed laborand uterine rupture

Maternal hypertensivedisorders

Maternal sepsis and othermaternal infections

Maternal hemorrhage

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Web Appendix 7

C) Post-Neonatal

6.0 6.5 6.0 4.9 5.2 2.6 5.8 5.9 3.1

35.2 32.4 30.3 35.842.6

39.5 31.339.0

36.2

23.6 26.2

22.720.8

19.4

10.5 23.2

21.1

12.5

15.018.0

20.4 17.3

14.4

7.9

18.7

17.7

3.9

1.32.3

0.5 0.40.9

0.0

0.7

2.6

1.5

7.0

7.0

7.2 6.25.7

10.5

6.8

6.6

16.9

11.46.3

12.1 14.2 11.0

28.9

12.95.8

25.8

0.7 1.2 0.7 0.4 0.7 0.0 0.7 1.3

0

10

20

30

40

50

60

70

80

90

100

Global Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka

Diarrhea

Congenital

Other disorders

Tetanus

Sepsis/meningitis

Intrapartumrelated events

Preterm

Pneumonia

23.328.1 28.8 26.1 28.4

13.8

29.5 26.5

9.9

3.4

4.2 3.34.3

4.9

3.4

2.82.9

4.0

1.8

1.0 1.7 1.61.2

6.9

2.32.5

2.8

3.5

4.1 4.12.7

4.2

3.4

4.22.8

1.8

20.1

24.3 22.4 27.1 17.8

27.6

18.2 25.1

30.9

6.3

4.0 3.86.9

6.0

31.0

4.04.3

30.615.6

19.514.8

13.3 22.2

3.4

14.3

19.6

4.5

2.3

1.7

5.0 0.5

4.50.0

2.6

1.6 0.010.0

11.1 14.5 13.87.8 10.3

14.9

11.9 12.99.4

0.0 0.60.0 1.3

0.00.1 0.02.6 0.1 0.0 3.2 0.8

0.80.1 0.51.7 1.8 1.0 0.8

6.42.6 2.1

0

10

20

30

40

50

60

70

80

90

100

Global Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka

Pertussis

AIDS

Malaria

Injury

Measles

Diarrhea

Congenital

Other disorders

Meningitis

Intrapartumrelated eventsPreterm

Pneumonia

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Web Appendix 8Figure 3: Malnutrition Trends in South Asian Countries

Note: Baseline is the earliest estimate between 1999-2004; current is the most recent estimate between 2009-2015

A) Child Wasting

B) Child Underweight

8.6

12.5

17.1

13.4

11.3

14.2

15.5

9.5

14.3

5.9

15.1

10.211.3

10.5

21.4

0

5

10

15

20

25

Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka

Wa

stin

g P

rev

ale

nc

e (

%)

Baseline Current

32.9

42.3

46.3

25.7

43

31.3

22.825

32.6

12.8

29.4

17.8

30.131.6

26.3

0

5

10

15

20

25

30

35

40

45

50

Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka

Un

de

rwe

igh

t P

rev

ale

nc

e (

%)

Baseline Current

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Confidential: For Review Only€¦ · 12/16/2015 · Confidential: For Review Only Addressing...

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