Accelerating Equitable Achievementof the MDGs: Closing Gaps in Health and Nutrition Outcomes

Accelerating Equitable Achievement of the MDGs Closing Gaps in Health and Nutrition Outcomes

Contents

Foreword vii

Acknowledgements viii

Abbreviations ix

OVERVIEW Accelerating Equitable Achievement of the MDGs: 1Closing Gaps in Health and Nutrition Outcomes

Diagnosing disparities 1

Closing the health gaps 3

Mutual inspiration 5

CHAPTER I

MDGs in Asia and the Pacific: where we stand 7

Asia and the Pacific on the global stage 12

Health – diagnosing the deficits 12

Number of people in off-track countries who will gain 27if targets are reached

Chapter I Endnote 28

CHAPTER II

Diagnosing disparities 29

The extent of disparities 30

Measuring disparities between countries and over time 30

Why some countries do better than others in health 35

Accounting for disparities 40

Disparities within countries 41

Explaining disparities within countries 46

Mining the data 55

Chapter II Endnotes 55

CHAPTER III

Closing the health gaps 57

Mutual inspiration 72

Chapter III Endnotes 73

CHAPTER IV

Way Forward 75 MDGs Beyond 2015 76

Chapter IV Endnotes 77

BIBLIOGRAPHY 78

STATISTICAL APPENDIX 00

Technical Note 1: MDG progress classification 81Technical Note 2: Factors explaining disparities between 85 countries Technical Note 3: Accounting for disparities between 88 countries Technical Note 4: Analysis of disparities within countries 90Technical Note 5: Selected MDG Indicators 97

BOXES

TABLES

FIGURES

viiAsia-Pacific Regional MDG Report 2011/12

Foreword

Noeleen Heyzer Bindu N. Lohani Ajay Chhibber

viii Asia-Pacific Regional MDG Report 2011/12

Acknowledgements

ixAsia-Pacific Regional MDG Report 2011/12

Abbreviations

1Asia-Pacific Regional MDG Report 2011/12

OVERVIEW

Diagnosing disparities

Disparities between countries

Accelerating Equitable Achievement of the MDGs: Closing Gaps in

Health and Nutrition Outcomes

2 Asia-Pacific Regional MDG Report 2011/12

OVERVIEW: Accelerating equitable achievement of the MDGs: closing the gaps in health and nutrition

Disparities within countries



Closing the health gaps

1. Address the social determinants of health

2. Expand access to primary health care

3. Integrate child and maternal health into a continuum of care



4. Act on the health needs of the urban poor

5. Devise sustainable financial strategies

6. Improve the governance of health systems

7. Enhance the affordability of medicines through generics



8. Strengthen international partnership and regional cooperation

Mutual inspiration


CHAPTER IMDGs in Asia and the Pacific:

where we stand


CHAPTER I: MDGs in Asia and the Pacific: where we stand

Box I-1 – Ensuring comparable data

Source: Most of this box is based on E/ESCAP/CST(2)/INF/5, available at http://www.unescap.org/stat/cst/2/CST2-INF5.pdf, paragraphs 4-8. Annex I of E/ESCAP/CST(2)/INF/5 lists the international agencies responsible for the compilation of international data on the official MDG indicators.



Source: Staff calculations based on the United Nations MDG Database and World Population Prospects 2010; UNESCO Institute of Statistics for the education-related indicators under Goals 2 and 3, except ‘Reaching last grade’.

Table I-1 – Country groups on and off track for the MDGs



Box I-2 – Data on HIV

Source: AIDSinfo Database accessed on 24th August 2011.

Burden of HIV 1990-2009, selected Asia-Pacific countries



Table I-2 – Countries on and off track for the MDGs

Source: Staff calculations based on the United Nations MDG Database.



Asia and the Pacific on the global stage

Health – diagnosing the deficits

Feeding our children

Preventing child deaths



Source: Staff calculations based on the United Nations MDG Database and World Population Prospects 2010.

Figure I-1 – Asia and the Pacific compared with Sub-Saharan Africa and Latin America and the Caribbean



Figure I-3 – Progress in reducing the proportion of under-5 children underweight


CountryBangladesh

IndiaAfghanistan

NepalCambodiaLao PDRPakistanViet NamMaldives

PhilippinesIndonesiaMyanmar

DPR KoreaSri LankaThailand

UzbekistanChina

BhutanIran (Islamic Rep. of)

MongoliaVanuatu

AzerbaijanTurkey

KyrgyzstanKazakhstan

GeorgiaArmenia

(Latest year)(2007)(2005)(2004)(2006)(2008)(2006)(2001)(2006)(2001)(2003)(2007)(2003)(2004)(2009)(2005)(2006)(2002)(2008)(1998)(2005)(2007)(2006)(2003)(2005)(2006)(2005)(2005)

Percentage of children under 5 (%)0 10 20 30 40 50 60

Early achiever On-track Slow Regressing/No progress Target

Figure I-2 – The Asia-Pacific share of the developing world’s deprived people




Table I-3 – Rate of progress needed for off-track countries to meet the child nutrition target


Preventing maternal deaths



Figure I-4 – Progress in reducing under-5 mortality

Timor–LesteLao PDR

BangladeshNepal

BhutanPakistan

CambodiaTajikistan

IndiaMyanmarMongoliaMaldives

TurkmenistanAzerbaijan

Papua New GuineaKiribati

IndonesiaTurkey

UzbekistanKyrgyzstan

Iran (Islamic Rep. of)Philippines

TuvaluKazakhstan

Micronesia (F.S.)Armenia

Viet NamMarshall Islands

ChinaGeorgia

DPR KoreaSolomon Islands

NauruVanuatu

PalauThailand

Sri LankaFiji

SamoaRussian Federation

TongaCook Islands

MalaysiaNiue

Brunei DarussalamSingapore

Republic of Korea

0 50 100 150Rate per 1,000 live births

Early achieverESCAP highincome On-track Slow Regressing/

No progress Target

Note: In the high income countries of the region child mortality is only around 4 per thousand live births. Afghanistan, which is not shown in the figure, had an under-5 mortality rate of 209 in 1990 and 149 in 2010. For all countries, the latest year for which data are available is 2010.




Table I-4 – Rate of progress needed for off-track countries to meet the under-5 mortality target

Note: The required annual percentage points reduction in rates for several Pacific island countries are: Cook Islands, 0.5; Palau, 1.6; Marshall Islands, 1.8; Tuvalu, 2.8; Niue, 3.5; Kiribati, 4.0; Nauru, 5.3. In these cases because of a lack of relevant population data it is not possible to estimate the number of additional children’s lives that would be saved.




Figure I-5 – Progress in reducing maternal mortality

Note: In the high income countries of the region maternal mortality is around 9.57 per 100,000 live births. Afghanistan, which is not shown in the figure, had a maternal mortality ratio of 1,700 in 1990 and 1,400 in 2008. For all countries, the latest year for which data are available is 2008.


Ratio per 100,000 live births0 200 400 600 800 1000 1200


No progress Target

Lao PDRBhutan

NepalBangladesh

CambodiaTimor–Leste

IndonesiaIndia

MaldivesPakistan

MyanmarPapua New Guinea

DPR KoreaPhilippines

Viet NamIran (Islamic Rep. of)

MongoliaSolomon Islands

TajikistanChina

TurkmenistanSri Lanka

KazakhstanKyrgyzstan

Russian FederationTurkey

AzerbaijanGeorgia

MalaysiaUzbekistan

ArmeniaThailand

FijiBrunei DarussalamRepublic of Korea

Singapore



Table I-5 – Rate of progress needed for off-track countries to meet the maternal mortality target




Note: In the high income countries of the region the proportion of births attended by skilled health personnel is 100 per cent.


Figure I-6 – Progress in increasing skilled birth attendance

0 20 40 60 80 100


No progress Target

CountryTuvalu

Fiji Kazakhstan

ThailandRussian Federation

PalauNiue

Cook IslandsKyrgyzstan

Republic of KoreaBrunei Darussalam

UzbekistanDPR Korea

MongoliaGeorgiaArmenia

TurkmenistanMarshall Islands

Sri LankaChina

Micronesia (F.S.)Malaysia

TongaMaldivesVanuatu

Iran (Islamic Rep. of)Solomon Islands

AzerbaijanTajikistanViet Nam

SamoaTurkeyKiribati

Papua New GuineaPhilippines

MyanmarIndonesia

IndiaCambodia

Timor–LesteLao PDRPakistan

BhutanAfghanistanBangladesh

Nepal

(Latest year) (2007)(2008)(2006)(2009)(2008)(2008)(2008)(2006)(2006)(1997)(2009)(2006)(2009)(2008)(2005)(2007)(2006)(2007)(2007)(2008)(2008)(2007)(2008)(2009)(2007)(2005)(2007)(2006)(2007)(2006)(2009)(2008)(2008)(2006)(2008)(2007)(2008)(2008)(2005)(2010)(2006)(2007)(2007)(2008)(2009)(2006)

Percentage of total births (%)



Table I-6 – Rate of progress needed for off-track countries to meet the skilled birth attendance target

Note: The required annual percentage points reduction in rates for several Pacific island countries are: Cook Islands, 0.19; Kiribati, 4.00; Marshall Islands, 1.57; and Tuvalu, 0.26. In these cases, because of a lack of relevant population data it is not possible to estimate the number of extra births that would be attended.




Figure I-7 – Progress in expanding antenatal care


0 20 40 60 80 100

Early achiever On-track Slow Regressing/No progress Target

Percentage of women with a live birth (%)

CountryBrunei Darussalam

TurkmenistanKyrgyzstanDPR Korea

GeorgiaUzbekistan

KazakhstanMongolia

KiribatiThailand

PhilippinesArmeniaMaldives

Sri LankaPapua New Guinea

Iran (Islamic Rep. of)IndonesiaMyanmarTajikistan

Timor–LesteViet Nam

ChinaAzerbaijan

TurkeyIndia

BhutanAfghanistan

CambodiaLao PDR

BangladeshPakistan

Nepal

(Latest year)(2009)(2006)(2006)(2009)(2005)(2006)(2006)(2006)(2008)(2009)(2008)(2005)(2009)(2007)(2006)(2005)(2007)(2007)(2007)(2010)(2006)(2008)(2006)(2008)(2008)(2007)(2008)(2005)(2006)(2007)(2007)(2006)

Table I-7 – Rate of progress needed for off-track countries to meet the antenatal care target




Table I-8 – Rate of progress needed for off-track countries to meet the safe drinking water target

Note: The required annual percentage points reduction in rates for several Pacific island countries are: Cook Islands, 0.20; Northern Mariana Islands, 0.14; Marshall Islands, 0.50; Palau, 0.65. In these cases because of a lack of relevant population data it is not possible to estimate the number of additional people who would get access.


Providing safe drinking water Ensuring access to basic sanitation



Figure I-8 – Progress in improving access to safe drinking water

Note: In the high income countries of the region the proportion of population using an improved drinking water source is almost 100 per cent.


0 20 40 60 80 100


No progress TargetPercentage of total population (%)

CountryTonga

SingaporeNiue

DPR KoreaGuam

French PolynesiaNorthern Mariana I.

KazakhstanMarshall Islands

Cook IslandsRussian Federation

ArmeniaSamoa

ThailandIran (Islamic Rep. of)

BhutanUzbekistan

TuvaluMaldives

Republic of KoreaMicronesia (F.S.)

MalaysiaPakistan

TurkeyPhilippines

TurkmenistanPalau

GeorgiaKyrgyzstan

BangladeshNepalIndia

IndonesiaAzerbaijan

Solomon IslandsChina

Sri LankaTajikistanViet NamMongoliaVanuatu

MyanmarTimor–Leste

KiribatiLao PDR

Papua New GuineaCambodia

Afghanistan

(Latest year)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2005)(2008)(2008)(2005)(2008)(2000)(2008)(2008)(2008)(2008)(2008)(2005)(2008)(2008)(2008)(2008)(2005)(2005)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2005)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2005)(2008)(2008)(2008)(2008)



Figure I-9 – Progress in expanding access to basic sanitation

Note: In the high income countries of the region the proportion of population using an improved sanitation facility is 100 per cent.


(Latest year)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2005)(2008)(2000)(2008)(2008)(2008)(2005)(2008)(2008)(2008)(2000)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2008)(2005)(2005)(2008)(2008)(2005)(2008)(2008)(2008)(2008)

0 20 40 60 80 100


No progress TargetProportion of the population using improved sanitation facilities (%)

CountryNiue

Republic of KoreaSingapore

GuamSamoa

TurkmenistanFrench Polynesia

TongaKazakhstan

GeorgiaCook Islands

KyrgyzstanTajikistanArmenia

Russian FederationUzbekistan

TurkeyNorthern Mariana I.

MalaysiaIran (Islamic Rep. of)

TuvaluThailand

Sri LankaPalau

MaldivesMarshall Islands

BhutanDPR KoreaPhilippinesAzerbaijan

MongoliaMyanmar

Papua New GuineaChina

Viet NamVanuatu

BangladeshIndonesia

Timor–LesteSolomon IslandsMicronesia (F.S.)

AfghanistanPakistan

KiribatiLao PDR

IndiaNepal

Cambodia



Table I-9 – Rate of progress needed for off-track countries to meet the basic sanitation target

Note: The required annual percentage points reduction in rates for several Pacific island countries are: French Polynesia, 0.14; Kiribati, 2.80; Guam, 0.07; Marshall Islands, 1.29; and Tuvalu, 0.86. In these cases because of a lack of relevant population data it is not possible to estimate the number of additional people that would gain access.




Number of people in off-track countries who will gain if targets are reached

Notes: *Cumulative number of deaths from 2011 to 2015; ** Cumulative number of deaths from 2009 to 2015.


Table I-10 – Potential gains if off-track countries can meet their targets



Chapter I Endnote

Box I-3 – Reproductive health

Figure I-10 – Progress in contraceptive prevalence rate and adolescent birth rate in Asia and the Pacific

Asia-PacificExcluding China and India

South-East AsiaSouth Asia

Excluding IndiaPacific Islands

Excluding Papua New GuineaNorth and Central Asia

Excluding the Russian FederationAsia-Pacific LDCs

Asia-Pacific Low IncomeAsia-Pacific Middle Income

Contraceptive prevalence rate

0 20 40 60 80 100

1990 2000 2008

Adolescent birth rate

0 50 100 150

1990 2000 2008Source: UN Population Division, DESA, 2011.


CHAPTER IIDiagnosing disparities


CHAPTER II: Diagnosing disparities

The extent of disparitiesMeasuring disparities between countries and over time

Figure II-1 – Proportion of population below $1.25 (PPP) per day, per cent, 2004

Source: The United Nations MDG Database and staff estimates.

0

20

40

60

East andNorth-East Asia

China

Thailan

d

Timor-Les

te

Viet Nam

Banglad

esh India

Iran (Is

lamic

Rep. of)

Maldive

sNepa

l

Pakista

n

Sri Lank

aTurk

ey

Armenia

Azerbai

jan

Georgia

Kazakhs

tan

Kyrgyzs

tan

Russian

Tajikista

n

Turkmeni

stan

Uzbekis

tan

Federati

on

Mongolia

Cambod

ia

Indone

sia

Lao PDR

Malaysi

a

Philippi

nes

South-East Asia South and South-West Asia North and Central Asia



0

20

40

60

80

100103


South-East Asia South and South-West Asia North and Central Asia Pacific

China

DPR Korea

Rep of K

orea

Mongolia

Brunei D

arussa

lam

Cambod

ia

Indone

sia

Lao PDR

Malaysi

a

Myanmar

Philippi

nes

Singapo

re

Thailan

d

Timor-Les

te

Viet Nam

Afghani

stan

Banglad

eshBhut

anIndia

Iran (Is

lamic R

ep of)

Maldive

sNepa

l

Pakista

n

Sri Lank

aTurk

ey

Armenia

Azerbai

jan

Georgia

Kazakhs

tan

Kyrgyzs

tan

Russian

Federati

on

Tajikista

n

Turkmeni

stan

Uzbekis

tan FijiKirib

ati

Marshal

l Is.

Micrones

ia (F.S.)

Palau

Papua N

ew GuineaSam

oa

Solomon

Is.Tong

aTuva

lu

Vanuatu

Figure II-2 – Net enrolment in primary education, per cent, 2009


Figure II-3 – Infant mortality rate per 1,000 live births, 2010


Figure II-4 – Under-5 mortality rate per 1,000 live births, 2010


0

20

40

60

80

100

Hong Kong

, Chin

a

Macao, C

hina

Rep of K

orea

Mongolia

Brunei D

arussa

lam

Cambod

ia

Indone

sia

Lao PDR

Malaysi

a

Philippi

nes

Thailan

d

Timor-Les

te

Banglad

eshBhut

an India

Iran (Is

lamic R

ep of)

Maldive

s

Pakista

n

Sri Lank

a

East and North-East Asia


Turkey

Armenia

Azerbai

jan

Georgia

Kazakhs

tan

Kyrgyzs

tan

Tajikista

n FijiKirib

ati

Marshal

l Is.Sam

oa

Solomon

Is.Tong

a

Vanuatu

0

20

40

60

80

100 149



China

DPR Korea

Rep of K

orea

Mongolia

Brunei D

arussa

lam

Cambod

ia

Indone

sia

Lao PDR

Malaysi

a

Myanmar

Philippi

nes

Singapo

re

Thailan

d

Timor-Les

te

Viet Nam

Afghani

stan

Banglad

eshBhut

anIndia

Iran (Is

lamic R

ep of)

Maldive

sNepa

l

Pakista

n

Sri Lank

aTurk

ey

Armenia

Azerbai

jan

Georgia

Kazakhs

tan

Kyrgyzs

tan

Russian

Federati

on

Tajikista

n

Turkmeni

stan

Uzbekis

tan FijiKirib

ati

Marshal

l Is.

Micrones

iaPala

u

Papua N

ew GuineaSam

oa

Solomon

Is.Tong

aTuva

lu

Vanuatu



Figure II-5 – Maternal mortality ratio per 100,000 live births, 2008


Figure II-6 – Incidence of underweight children, per cent, latest year


Figure II-7 – HIV prevalence among population 15-24 years old, per cent, 2009


0

100

200

300

400

500

600

7001,400



China

DPR Korea

Rep of K

orea

Mongolia

Brunei D

arussa

lam

Cambod

ia

Indone

sia

Lao PDR

Malaysi

a

Myanmar

Philippi

nes

Singapo

re

Thailan

d

Timor-Les

te

Viet Nam

Afghani

stan

Banglad

eshBhut

an

Iran (Is

lamic R

ep of) Iran

Maldive

sNepa

l

Pakista

n

Sri Lank

aTurk

ey

Armenia

Azerbai

jan

Georgia

Kazakhs

tan

Kyrgyzs

tan

Russian

Federati

on

Tajikista

n

Turkmeni

stan

Uzbekis

tan Fiji

Papua N

ew Guinea

Solomon

Is.

0

10

20

30

40

50



China, 2

002

DPR Korea,200

4

Mongolia

,200

5

Cambod

ia,2008

Indone

sia,200

7

Lao PDR,

2006

Myanmar,200

3

Philippi

nes,200

3

Thailan

d,200

5

Viet Nam

,200

6

Afghani

stan,200

4

Banglad

esh,200

7Bhut

an,2008

India,

2005

Iran (Is

lamic R

ep of),

Maldive

s,200

1

Nepal, 2

006

Pakista

n,200

1

Sri Lank

a,200

9Turk

ey,2003

Armenia,200

5

Azerbai

jan,200

6

Georgia

,200

5

Kazakhs

tan,200

6

Kyrgyzs

tan,200

5

Uzbekis

tan,200

6

Vanuatu

,200

7199

8

0

0.4

0.8

1.2

1.6


Cambod

ia

Indone

sia

Lao PDR

Malaysi

a

Myanmar

Philippi

nes

Singapo

re

Thailan

d

Viet Nam

Banglad

eshBhut

an India

Iran (Is

lamic R

ep of)

Maldive

sNepa

l

Pakista

n

Sri Lank

aTurk

ey

Uzbekis

tan

Armenia

Azerbai

jan

Georgia

Kazakhs

tan

Kyrgyzs

tan

Russian

Federati

on

Tajikista

n Fiji

Papua N

ewGuin

ea



Figure II-8 – Inter-country disparity in prevalence of underweight children under 5, 1995-2005

Source: Staff calculation based on the United Nations MDG Database.

0

20

40

60

80

100

0 20 40 60 80 100Cumulative per cent share: Countries

199520002005

Cumu

lative

per

cent

shar

e: P

reva

lence

of u

nder

weigh

t chil

dren



Table II-1 – Gini and Theil indices of inter-country distribution of MDG indicators




Why some countries do better than others in health

Figure II-9 – Contribution to disparities by subregion, selected MDG indicators

Note: Country groupings are based on subregional classification used by the Asian Development Bank: Central West Asia includes Afghanistan, Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Pakistan, Tajikistan, Turkmenistan and Uzbekistan; East Asia includes China and Mongolia; The Pacific includes Cook Islands, Fiji, Kiribati, Marshall Islands, Federated States of Micronesia, Nauru, Palau, Papua New Guinea, Samoa, Solomon Islands, Timor-Leste, Tonga, Tuvalu and Vanuatu; South Asia includes Bangladesh, Bhutan, India, Maldives, Nepal, and Sri Lanka; and South-East Asia includes Cambodia, Indonesia, Lao People’s Democratic Republic, Malaysia, Myanmar, Philippines, Thailand and Viet Nam.


0% 20% 40% 60% 80% 100%

TB prevalence

HIV prevalence

Maternal mortality

Infant mortality

Underweight children

Central West Asia East Asia The Pacific South Asia South-East Asia Between



Economic growth

Health expenditure

Better governance

Number of health personnel



Figure II-10 – Cross-country variation in under-5 mortality explained by differences in per capita health spending

Source: The United Nations MDG Database for under-5 mortality and on the World Bank, World Development Indicators online database for health expenditure per capita.

Figure II-11 – Cross-country variation in maternal mortality explained by differences in corruption control

Sources: The Brookings Institution, World Bank Development Economics Research Group, and the World Bank Institute, World Governance Indicators online database for corruption control index and the United Nations MDG Database for maternal mortality ratio.

ARMAZE

BGD

KHM

CHN

GEO

IND

IDNKAZ

KGZLAO

MYS

MDV

MNGNPL PAK

PNG

PHL

RUS

SGP

LKA

TJK

THATUR

UZBVNM

0.0

1.0

2.0

3.0

4.0

5.0

2.0 3.0 4.0 5.0 6.0 7.0 8.0ln (Health expenditure per capita)

ln (U

nder

-5 m

orta

lity)

ARM

AZE

BGD KHM

CHN

INDIDN

KAZ

KOR

KGZ

LAO

MDVMNG

NPL PAK

PNG PHL

RUS

SGP

LKAMYS

TJKTHA

TURUZB

VNM

-1.0

0.5

2.0

3.5

5.0

6.5

8.0

-2.0 -1.0 0.0 1.0 2.0 3.0

Corruption control index

ln (M

ater

nal m

orta

lity)



Gender equality and women’s development Infrastructure

Figure II-12 – Cross-country variation in maternal mortality explained by differences in percentage of births attended by skilled health personnel


ARM

AZE

BGD

KHM

CHN

IND

IDN

KAZ

KOR

KGZ

LAO

MYS

MDV

MNG

NPL

PAK

PNG

PHL

RUS

SGP

LKA

TJK

THA

TUR

UZB

VNM

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

2.5 3.0 3.5 4.0 4.5 5.0

ln (Skilled birth attendance)

ln

(M

ate

rn

al m

orta

lity ra

te

)



Figure II-13 – Cross-country variation in child mortality explained by differences in gender development

Sources: United Nations Development Programme, Human Development Report, various issues for gender-related development index and the United Nations MDG Database for child mortality.

Figure II-14 – Births attended by skilled health personnel and the extent of paved roads

Sources: The World Bank, World Development Indicators online database for GDP per capita, electricity consumption, and per cent of paved road networks, and the United Nations MDG Database for skilled birth attendance, access to sanitation and safe drinking water.

ARM

AZEBGD

KHM

CHN

GEO

INDIDN

KAZKGZ

LAO

MYS

MDV

MNGNPL

PAK

PNG

PHL

RUS

SGP

LKA

TJK

THA TUR

UZB

VNM

0.0

1.0

2.0

3.0

4.0

5.0

-1.0 -0.8 -0.6 -0.4 -0.2 0.0ln (Gender-related development index)

ln (U

nder

-5 m

orta

lity)

ARM

AZE

BGD

KHM

CHN

GEO

IND

IDN

KAZ

MYS

MNG

NPL

PAK

PHL

LKA

THA

TKM

UZB

2.0

2.5

3.0

3.5

4.0

4.5

5.0

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5

ln (Paved road per 10,000 population)

ln (S

killed

birth attendance)



Child immunization

Sanitation and water supplies

Population growth

Literacy

Accounting for disparities



Figure II-15 – Contributions to inter-country disparities for three MDG health-related indicators

Sources: Staff calculations based on data from the United Nations MDG Database; Asian Development Bank (ADB), Asian Development Outlook; ADB, Key Indicators (various issues); World Bank, World Development Indicators online database.

Disparities within countries

0% 10% 20% 30% 40% 50%

Skilled birth attendanceAccess to sanitation

Per capita GDP

Maternal mortalityPer capita GDP

Access to sanitation

ImmunizationInfant mortality

Asia-Pacific subregion

Access to sanitation

Public health expenditureUnderweight children



Figure II-17 – Health-related disparities across jurisdictions in two small countries

Source: Staff calculations using DHS data from respective countries and years.

Mid!westernFar!western

WesternCentralEastern

0 20 40 60 80 100 120 140

Under!5 mortality, Nepal 2006

Rate per 1,000 live births

OecussiAinaro

ErmeraManufahi

LiquicaAileu

ViquequeBobonaro

LautemBaucau

ManatutoCova Lima

Dili

0 10 30 50 70 90

Skilled birth attendance, Timor!Leste 2009


Figure II-16 – Health disparities across sub-national jurisdictions in two large countries

Note: Abbreviations in Indonesia: DI = Daerah Istimewa (special region), DKI = Daerah Khusus Ibukota (special capital region). In the Philippines: MIMAROPA, Occidental Mindoro, Marinduque, Romblon and Palawan; SOCCSKARGEN, South Cotabato, Cotabato, Sultan Kudarat, Sarangani and General Santos City; ARMM – Autonomous Region of Muslim Mindanao; CALABARZON, Cavite, Laguna, Batangas, Rizal, and Quezon.

Source: Staff calculations using DHS data from respective countries and years.

Sulawesi BaratMaluku

West Nusa TenggaraEast Nusa Tenggara

South KalimantanMaluku Utara

GorontaloCentral Sulawesi

North SumatraBengkulu

PapuaWest Sumatra

Southeast SulawesiPapua Barat

West KalimantanBanten

Kep Bangka BelitungLampung

South SulawesiSouth Sumatra

West JavaRiau

JambiBangka Belitung

DI AcehEast Java

North SulawesiEast Kalimantan

BaliDKI Jakarta

Central KalimantanCentral Java

DI Yogyakarta

0 2 0 4 0 6 0 8 0 100 120 140

Under!5 mortality, Indonesia 2007

Rate per 1,000 live births

ARMMSOCCSKSARGEN

Zamboanga PeninsulaMIMAROPA

Eastern VisayasNorthern Mindanao

Bicol RegionCaraga

Davao PeninsulaCagayan Valley

Western VisayasCentral Visayas

Cordillera Admin RegionCALABARZON

Ilocos RegionCentral Luzon

National Capital Region

Skilled birth attendance, Philippines 2008

0 10 30 50 70 90




Table II-2 – Factors considered to explain disparities for selected MDG indicators

Notes: *Two education variables are used for modelling access to improved water and sanitation. The first is the attainment level of the best-educated household member. The second is the percentage of people in the village or neighbourhood with at least primary education.



Figure II-18 – Disparities and attainment in health-related MDG targets

Notes: 1) All child mortality rates are calculated using the DHS method for a five-year period before the survey. 2) Estimates using the new standards were not available in earlier surveys, therefore, the underweight and stunting status of the child were calculated using the NCHS/CDC/WHO standard, which is different from the WHO Child Growth Standards 2006 used for the calculation of the prevalence of underweight children in Chapter 1. 3) In the case of Viet Nam for under-5 mortality, the results are based on the DHS survey from 2002. 4) See Technical Note 4 in the Statistical Appendix for details of attainment levels and disparities. 5) The levels of attainment and inequality as shown in the chart are based on household survey data from various sources. As such, the assessments of individual countries are not comparable to that based on the United Nations MDG Database.

Source: Staff calculations based on data from DHS and MICS from respective countries and years.

Vanuatu 2007

Uzbekistan 2006Tajikistan 2005

Kyrgyzstan 2005Kazakhstan 2006

Georgia 2005Azerbaijan 2006

Armenia 2005

Turkey 2003Pakistan 2006

Nepal 2006Maldives 2009

India 2005Bangladesh 2007

Viet Nam 2006Timor!Leste 2009

Thailand 2005Philippines 2008

Lao PDR 2006Indonesia 2007Cambodia 2005

Mongolia 2005

Pacific

North and Central Asia

South and South!West Asia

South!East Asia

East and North!East Asia

Underweig

ht child

ren

Stunted

childr

en

Under!5

mortalit

y

Skilled b

irth att

endanc

e

Antenat

al care

>=1 v

isits

Antenat

al care

>=4 v

isits

Improved

water

Improved

sanita

tion

Small disparity Large disparity

High attainment Medium attainment Low attainment Poor attainment

1 4 5 7Goals



Raising the attainment levels while reducing disparities



Figure II-19 – Drivers of disparities in underweight prevalence among under-5 children

Vanuatu 2007


Kyrgyzstan 2005Kazakhstan 2006Azerbaijan 2006

Armenia 2005

Turkey 2003Nepal 2006

Maldives 2009India 2005

Bangladesh 2007

Timor!Leste 2009Thailand 2005Lao PDR 2006

Cambodia 2005

Mongolia 2005

Pacific



South!East Asia


Urban

(compar

ed to r

ural)

Wealth i

ndex

(5th qu

intile c

ompar

ed

to 1st q

uintile

)Prop

ortion

of fem

ale

househ

old mem

bers

(5th qu

intile c

ompar

ed

to 1st q

uintile

)

Househo

ld head

being

male

(compar

ed to f

emale

)

Educatio

n of m

other

(highes

t level

compar

ed

to low

est lev

el)

Child be

ing a b

oy

(compar

ed to g

irl)

0 0 0 0 0 050 50 50 50 50 50

Disparity < Change in disparity


Explaining disparities within countries



Figure II-20 – Drivers of disparities in the prevalence of under-5 mortality

Azerbaijan 2006

Armenia 2005

Turkey 2003

Pakistan 2006

Nepal 2006

Maldives 2009

India 2005

Bangladesh 2007

Viet Nam 2002

Timor!Leste 2009

Philippines 2008

Indonesia 2007

Cambodia 2005



South!East Asia

Urban

(compar

ed to r

ural)

Wealth i

ndex

(5th qu

intile c

ompar

ed

to 1st q

uintile

)

Educatio

n of m

other

(highes

t level

compar

ed

to low

est lev

el)

Skillled

assista

nce at

delive

ry

(compar

ed to n

ot havi

ng

been a

ssiste

d)

Child be

ing a b

oy

(compar

ed to g

irl)

0 0 0 0 0 0100 100 100 100 100 600


Child ha

ving b

een bre

astfed

av

(compar

ed to n

ot hing

been b

reastfe

d)

for at l

east 6

months

Source: Staff calculations based on data from DHS from respective countries and years.




Figure II-21 – Drivers of disparities in the coverage of antenatal care (at least one visit)

Vanuatu 2007

Tajikistan 2005Azerbaijan 2006

Armenia 2005





Philippines 2008Lao PDR 2006

Indonesia 2007Cambodia 2005

Pacific



South!East Asia

Urban

(compar

ed to r

ural)

Wealth i

ndex

(5th qu

intile c

ompar

ed

to 1st q

uintile

)Prop

ortion

of fem

ale

househ

old mem

bers

(5th qu

intile c

ompar

ed

to 1st q

uintile

)

Househo

ld head

being

male

(compar

ed to f

emale

)

Educatio

n of m

other

(highes

t level

compar

ed

to low

est lev

el)

Educatio

n of fa

ther

(highes

t level

compar

ed

to low

est lev

el)

0 0 0 0 0 0100 100 100 100 100 100




Urban-rural gaps

Figure II-22 – Drivers of disparities in access to improved sanitation


Vanuatu 2007


Kyrgyzstan 2005Kazakhstan 2006

Georgia 2005Azerbaijan 2006

Armenia 2005





Thailand 2005Philippines 2008

Lao PDR 2006Indonesia 2007Cambodia 2005

Mongolia 2005

Pacific



South!East Asia


Urban

(compar

ed to r

ural)

Wealth i

ndex

(5th qu

intile c

ompar

ed

to 1st q

uintile

)

Househo

ld size

(5th qu

intile c

ompar

ed

to 1st q

uintile

)Prop

ortion

of fem

ale

househ

old mem

bers

(5th qu

intile c

ompar

ed

to 1st q

uintile

)

Househo

ld head

being

male

(compar

ed to f

emale

)

Educatio

n

(highes

t level

compar

ed

to low

est lev

el)

0 0 0 0 0 0100 100 100 100 100 100





Figure II-23 – Under-5 children underweight, urban and rural, by household wealth, India and Nepal

!3 !2 !1 0 1 2 3

0

20

40

60

80

100India 2005

Wealth index

Perce

ntag

e of

child

ren

unde

r 5 (%

)

Urban wealth quintiles

!3 !2 !1 0 1 2 3

0

20

40

60

80

100 Nepal 2006

Wealth index

Perce

ntag

e of

child

ren

unde

r 5 (%

)Rural wealth quintiles



Figure II-24 – Access to water and sanitation, urban and rural, by household wealth, the Philippines and Indonesia

!3 !2 !1 1 20 3

0

20

40

60

80

100Improved water, Philippines 2008

Wealth index

Prop

ortio

n of

tota

l pop

ulatio

n (%

)

!3 !2 !1 1 20 3

0

20

40

60

80

100Improved sanitation, Philippines 2008

Wealth indexPr

opor

tion

of to

tal p

opula

tion

(%)

!3 !2 !1 1 20 3

0

20

40

60

80

100Improved water, Indonesia 2007

Wealth index

Prop

ortio

n of

tota

l pop

ulatio

n (%

)


!3 !2 !1 1 20 3

0

20

40

60

80

100Improved sanitation, Indonesia 2007

Wealth index

Prop

ortio

n of

tota

l pop

ulatio

n (%

)

Rural wealth quintiles






Figure II-25 – Access to antenatal care, urban and rural, by household wealth, Azerbaijan and Timor-Leste

!3 !2 !1 0 1 2 3

0

20

40

60

80

100Azerbaijan 2006

Wealth index

Perce

ntag

e (%

)


!3 !2 !1 0 1 2 3

0

20

40

60

80

100Timor!Leste 2009

Wealth indexPe

rcent

age

(%)


Figure II-26 – Access to skilled birth attendants, urban and rural, by household wealth, Maldives and Bangladesh

!3 !2 !1 0 1 2 3

0

20

40

60

80

100Maldives 2009

Wealth index

Perce

ntag

e (%

)


!3 !2 !1 0 1 2 3

0

20

40

60

80

100Bangladesh 2007

Wealth index

Perce

ntag

e (%

)




Caste, ethnicity and language group

The importance of economic status

Regional differences in policies and programmes



Figure II-27 – The potential for reducing regional disparities within countries

Note: The lines with arrows represent the difference in the MDG indicator between the state/province/district and the best-performing jurisdiction in the country after taking into account various household and individual characteristics. They can be interpreted as the effects of differences in the policies and programmes bewteen the best-performing jurisdiction and each of the rest of the jurisdictions.

Source: Staff calculations using DHS and MICS data from respective countries and years.

NagalandUttar Pradesh

JharkhandBihar

Arunachal PradeshAssam

MeghalayaMadhya Pradesh

UttaranchalRajasthan

ChhattisgarhOrissa

Himachal PradeshWest Bengal

TripuraHaryana

SikkimManipurGujarat

DelhiMizoram

PunjabMaharashtra

KarnatakaAndhra Pradesh

Tamil NaduGoa

0 100Disparity with Kerala

< Change in disparity

Skilled birth attendance, India 2005

Banteay Mean CheyPreah Vihear & Steung Treng

Mondol Kiri & Rattanak KiriBattambang & Krong Pailin

KandalKampot & Krong Kep

KratieTakeo

Kampong ThomPursat

Kampong ChhnangOtdar Mean Chey

Kampong SpeuSiem Reap

Krong Preah Sihanouk & Kaoh KongKampong Cham

Phnom PenhPrey Veng

0 100Disparity with Svay Rieng


Improved water, Cambodia 2005

WesternKhangaiCentralEastern

0 100Disparity with Ulaanbaatar


Improved water, Mongolia 2005

OecussiErmera

BobonaroAinaro

Cova LimaBaucau

ManufahiViqueque

AileuLiquicaLautem

Manatuto

0 100Disparity with Dili


Under!5 underweight, Timor!Leste 2009



Mining the data

Chapter II Endnotes


1. Address the social determinants of health

CHAPTER IIIClosing the health gaps


CHAPTER III: Closing the health gaps

Box III-1– Unlikely alliances for reducing HIV-related stigma

Source: UNICEF EAPRO, 2010 – Achieving the MDGs with Equity.



2. Expand access to primary health care

Box III-2 – Primary health care in China



Box III-3 – Expenditure on preventive and public health

Source: Data for the most recent year with data available in the 2000-2009 period from National Health Accounts, World Health Organization (2011a).

EAST & NORTH-EAST ASIAChin

a

Repubbl

ic of K

orea

Mongolia

SOUTH-EAST ASIA

Cambod

ia

Malaysi

a

Myanmar

Philippi

nes

Singapo

re

Thailan

d

Viet Nam

SOUTH & SOUTH-WEST ASIA

Banglad

eshBhut

an India

Nepal

Sri Lank

aTurk

ey

PACIFIC FijiKirib

atiPala

uNiue

Papua N

ew Guinea

Micrones

ia (F.S.)

Cook Isla

ndsSam

oaTong

aTuva

lu

Vanuatu

35

30

25

20

15

105

0

Per c

ent

Box III-4 – New facilities reduce infant mortality in Bihar, India

Source: Swapna Majumdar, India: Newborn care units fight infant mortality in Bihar, 24 May 2011 (http://www.propoor.org/news/?n=49548).



3. Integrate child and maternal health into a continuum of care



4. Act on the health needs of the urban poor



5. Devise sustainable financial strategies

Box III-5 – Mongolia’s success in reducing maternal mortality

Source: ADB resident mission in Mongolia, based on: Implementation of National Reproductive Health Programme, 2010; UNDP Mongolia, The 3rd National Report on the Millennium Development Goals, 2009; and Current status of emergency obstetric and essential newborn care in Mongolia, 2010.



Box III-6 – Total health expenditures as a share of gross domestic product

Source: Data for 2009 from National Health Accounts, World Health Organization (2011a).

EAST & NORTH-EAST ASIAChin

a

Republic

of Kore

a

Mongolia

SOUTH-EAST ASIA

Cambod

ia

Brunei D

arussa

lam

Malaysi

a

Lao PDR

Indone

sia

Myanmar

Philippi

nes

Singapo

re

Thailan

d

Viet Nam

Timor-Les

te

SOUTH & SOUTH-WEST ASIA

Afghani

stan

Banglad

eshBhut

anIndia

Iran (Is

lamic R

ep. of)

Maldive

sNepa

l

Pakista

n

Sri Lank

aTurk

ey

NORTH & CENTRAL ASIA

Armenia

Azerbai

jan

Georgia

Kazakhs

tan

Kyrgyzs

tan

Russian

Federati

on

Tajikista

n

Turkmeni

stan

Uzbekis

tan

PACIFIC FijiKirib

atiPala

uNiue

Nauru

Papua N

ew Guinea

Micrones

ia (F.S.)

Marshal

l Island

s

Solomon

Islands

Cook Isla

ndsSam

oaTong

aTuva

lu

Vanuatu

1816141210

86420

Per c

ent



Box III-7 – Out-of-pocket expenses as a share of private health expenditures

Note: • low (<65 per cent); • medium (<65-79.9 per cent); • high (80-94.9 per cent); • very high (95-100 per cent). Small circle: negative change (1999-2009); large circle: zero or positive change (1999-2009).

Source: Data for 1999-2009 from National Health Accounts, World Health Organization (2011a).



Figure III-1 – Under-5 mortality and per capita expenditure on health

Source: Based on World Bank Development Indicators and the United Nations MDG Indicators.

501

451

401

351

301

251

201

151

101

50

11 10

y = 727.49xR2 = 0.7526

-0.6293

100Public health expenditure per capita, PPP

(constant 2005 international $)

Children under fivemortality rate per 1,000live births

1,000 10,000



Figure III-2 – Association between public health expenditure and GDP, selected countries

Source: Staff calculations based on World Bank Development Indicators and United Nations MDG Database.

GDP per capita, PPP (constant 2005 international $)

Healt

h ex

pend

iture

, pub

lic (%

of G

DP)

100 1,000 10,000 100,000

8

7

6

5

4

3

2

1

0

Predicted India China Indonesia Thailand Russian Federation Malaysia Japan



Box III-8 – Health expenditure gaps

Health expenditure gaps, as per cent of GDP

Source: Data from World Bank Development Indicators.

PublicPrivate

6 4 2 0 -2 -4 -6 -8 -10

SingaporeIndonesiaBrunei DarussalamBangladeshTurkmenistanArmeniaPakistanFijiRussian FederationSri LankaPhilippinesChinaKazakhstanThailandIndiaMongoliaPapua New GuineaVanuatuLao PDRUzbekistanMalaysiaIran, Islamic Rep.AzerbaijanBhutanTajikistanNepalCambodiaAustraliaKyrgyzstanViet NamSolomon IslandsTurkeyJapanTongaMaldivesGeorgiaSamoaNew ZealandTimor-LesteMicronesia, Fed. Sts.



6. Improve the governance of health systems

Box III-9 – Marginal budgeting for bottlenecks in Pakistan

Source: UNICEF EAPRO, 2010.



7. Enhance the affordability of medicines through generics



8. Strengthen international partnership and regional cooperation



Mutual inspiration



Chapter III Endnotes


CHAPTER IV: Way Forward

CHAPTER IVWay Forward



MDGs Beyond 20151



Chapter IV Endnotes


BIBLIOGRAPHY

BIBLIOGRAPHY


BIBLIOGRAPHY


BIBLIOGRAPHY


STATISTICAL APPENDIX

STATISTICAL APPENDIXTechnical Note 1: MDG process classification

Data sources

Determining the progress in achieving a MDG target



Setting the target value

Using cut-off values

Calculating regional and country group aggregates and the affected population

Regional and country group aggregates



Table 1. Cut-off values for selected MDG indicators

Note: Protected area and Forest cover are marked “not applicable” as they tend to stay constant / show very little variation for most of the time and hence quadratic or other polynomial functional forms cannot be fitted.

Affected population



Table 2. Data series names and responsible agency



Data and Methodology Results

Technical Note 2: Factors explaining disparities between countries



Tab

le 1

. Cro

ss c

ount

ry re

gre

ssio

ns

of s

elec

ted

hea

lth

ou

tcom

es a

nd

exp

lan

ator

y fa

ctor

s



Tab

le 2

. Rel

atio

nsh

ip o

f hea

lth

ou

tcom

es to

bas

ic in

fras

tru

ctu

re



Technical Note 3: Accounting for disparities between countries



References



Definitions

i. Child nutrition status

ii. Child mortality

iii. Use of maternal health care services

Technical Note 4: Analysis of disparities within countries



iv. Access to improved drinking water source and improved sanitation facility

Data sources



Table 1. Surveys used in the analysis

Covariates considered in the model



Table 2. Sources of disparity assessed for selected MDG indicators

Notes: *. Two education variables are used for modelling access to improved water and sanitation. The first is the attainment level of the best-

educated household member. The second is the percentage of people in the village or neighbourhood with at least primary education.

Figure 1 – Conceptual framework on the causes of child malnutrition, death and disability

Source: UNICEF, The State of the world’s children 1998, accessed from http://www.unicef.org/publications/files/pub_sowc98_en.pdf



Method

i. Model

ii. Child mortality



iii. Disparity

iv. Levels of attainment

v. Simulations

Table 4. Base, reference and simulation for each covariate

Table 3. Criteria used to classify the attainment level of a country



Technical Note 4 Endnotes



Goal 1: Eradicate extreme poverty and hunger

Note: The number in parenthesis is the year of the data point. Source: United Nations MDG Database.

Technical Note 5: Selected MDG Indicators



Goal 2: Achieve universal primary education




Goal 3: Promote gender equality and empower women




Goal 4: Reduce child mortality




Goal 5: Improve maternal health




Goal 6: Combat HIV and AIDS, malaria and other diseases

Note: The number in parenthesis is the year of the data point; * Less than 0.1 Source: United Nations MDG Database.



Goal 7: Ensure environmental sustainability

Note: The number in parenthesis is the year of the data point. Source: United Nations MDG database.



Goal 7: Ensure environmental sustainability


Documents

Accelerating Equitable Achievementof the MDGs: Closing Gaps in Health and Nutrition Outcomes