72014 Health Equity and Financial Protection Datasheets South Asia Acknowledgements These datasheets were produced by a task team consisting of Caryn Bredenkamp (Task Team Leader, Health Economist, HDNHE), Adam Wagstaff (Research Manager, DECHD), Leander Buisman (consultant), Leah Prencipe (consultant) and Devon Rohr (consultant, graphic design), under the overall supervision of the Sector Manager, HDNHE, Nicole Klingen. The financial contributions of the Rapid Social Results Trust Fund (RSR-MDTF) and the Trust Fund for Environmentally and Socially Sustainable Development (TFESSD) are gratefully acknowledged. Table of contents Bangladesh...................................................................................................5 India.............................................................................................................. 9 Nepal............................................................................................................12 Pakistan.......................................................................................................16 Sri Lanka..................................................................................................... 20 Interpretation of Results Measurement of Indicators HealtH equity and Financial Protection dataSHeet Bangl adesh the Health equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. data are drawn from the demographic and Health Surveys (dHS), World Health Surveys (WHS), Multiple indicator cluster Surveys (MicS), living Standards and Measurement Surveys (lSMS), as well as other household surveys where available. the datasheets use a common set of health indicators for all countries. all analyses are conducted using the health modules of the adePt software. inequalitieS cHild HealtH1a,1b,1c,1d,1e,2,3 q1 q2 q3 q4 q5 total ci in HealtH 1993-94 1a outcoMeS infant mortality rate 127.0 129.1 99.6 98.7 74.7 109.3 -0.091*** under-five mortality rate 204.0 188.5 148.7 132.1 110.2 162.7 -0.117*** diarrhea 12.5% 12.4% 14.1% 12.7% 9.9% 12.4% -0.008 acute respiratory infection 23.6% 25.6% 23.3% 24.4% 21.3% 23.8% -0.006 1996-97 1b infant mortality rate 95.1 112.1 101.0 94.4 61.4 95.0 -0.048*** under-five mortality rate 140.2 170.4 137.8 129.6 81.7 135.8 -0.069*** Stunting 64.5% 68.2% 63.0% 55.2% 39.8% 59.3% -0.074*** underweight 61.0% 60.5% 55.7% 48.9% 34.0% 53.2% -0.088*** diarrhea 9.0% 7.4% 7.6% 7.5% 6.3% 7.7% -0.042 acute respiratory infection 12.5% 15.1% 14.0% 11.3% 10.8% 12.9% -0.027 Fever 31.4% 34.3% 29.9% 29.5% 30.1% 31.2% -0.011 1999-00 1c infant mortality rate 98.8 101.8 79.2 64.3 59.2 84.0 -0.116*** under-five mortality rate 161.5 145.1 107.6 106.8 81.3 125.9 -0.140*** Stunting 60.5% 54.6% 52.8% 45.0% 30.7% 50.4% -0.109*** underweight 54.4% 46.0% 41.6% 34.8% 23.0% 41.8% -0.145*** diarrhea 6.3% 6.5% 5.8% 5.6% 6.6% 6.2% -0.008 acute respiratory infection 21.1% 16.8% 16.9% 14.1% 13.1% 16.9% -0.091*** Fever 39.8% 37 .0% 35.4% 37 .5% 36.2% 37 .4% -0.020** 2003 3 Malaria 2.1% 2.2% 1.0% 0.7% 2.2% 1.6% -0.113 2004 1d infant mortality rate 93.6 66.4 77.3 58.0 67.9 74.5 -0.082*** under-five mortality rate 132.9 107 .7 98.5 86.7 73.7 104.0 -0.124*** Stunting 60.5% 54.7% 49.0% 48.1% 29.6% 49.8% -0.111*** underweight 55.1% 47 .3% 38.2% 38.4% 25.8% 42.5% -0.131*** diarrhea 8.9% 7.4% 7.5% 7.0% 6.1% 7.5% -0.064** acute respiratory infection 21.6% 22.2% 20.9% 15.9% 14.1% 19.3% -0.079*** Fever 42.6% 42.9% 40.3% 36.4% 37.7% 40.3% -0.028*** 2006 2 diarrhea 8.6% 7.6% 7.1% 5.6% 6.1% 7.1% -0.081*** acute respiratory infection 12.7% 13.0% 12.6% 10.8% 9.3% 11.8% -0.058*** 2007 1e infant mortality rate 68.5 70.2 66.2 47.2 36.4 59.5 -0.116*** under-five mortality rate 89.8 99.1 89.1 58.0 44.5 79.1 -0.126*** Stunting 54.8% 51.4% 41.9% 39.0% 28.1% 44.0% -0.127*** underweight 52.0% 47.0% 41.6% 37.9% 27 .0% 41.9% -0.119*** diarrhea 10.2% 9.6% 11.4% 9.4% 8.3% 9.8% -0.034 acute respiratory infection 16.5% 15.5% 12.8% 11.5% 8.2% 13.2% -0.120*** Fever 38.9% 40.0% 38.6% 38.7% 34.8% 38.3% -0.021* 5 inequalitieS adult HealtH1a,1b,1c,1d,1e,3 q1 q2 q3 q4 q5 total ci in HealtH 1996-97 1b outcoMeS obesity among non-pregnant 1.1% 1.5% 0.9% 0.9% 3.6% 1.6% 0.216** (cont.) women 1999-00 1c obesity among non-pregnant 0.4% 0.8% 0.7% 0.6% 3.1% 1.1% 0.430*** women 2003 3 tuberculosis 17 .8% 17 .2% 12.8% 13.0% 10.8% 14.4% -0.104*** road traffic accident 4.6% 4.1% 5.0% 4.5% 6.6% 5.0% 0.085** non-road traffic accident 5.9% 5.1% 5.7% 4.8% 4.4% 5.2% -0.055 angina 4.3% 8.5% 7.2% 9.4% 7.0% 7.2% 0.076** arthritis 12.8% 14.2% 12.8% 10.5% 10.1% 12.1% -0.060** asthma 6.3% 5.5% 4.8% 4.4% 3.9% 5.0% -0.088** depression 1.3% 1.2% 1.7% 1.7% 1.2% 1.4% 0.002 diabetes 1.3% 2.6% 2.1% 2.2% 5.8% 2.8% 0.267*** difficulty with work and 19.3% 14.4% 15.4% 13.6% 10.1% 14.5% -0.109*** household activities Poor self-assessed health 22.3% 19.9% 16.8% 16.8% 9.5% 17.1% -0.140*** status 2004 1d obesity among non-pregnant 0.2% 0.4% 0.5% 1.3% 4.6% 1.4% 0.621*** women 2007 1e obesity among non-pregnant 0.3% 0.2% 0.9% 1.3% 6.0% 1.8% 0.638*** women inequalitieS in riSk FactorS1a,1b,1c,1d,1e,3 q1 q2 q3 q4 q5 total ci riSky BeHaVior 2003 3 Smoking (all) 52.7% 51.4% 47.8% 40.7% 35.8% 45.8% -0.083*** Smoking (women) 29.5% 26.8% 29.2% 23.0% 9.9% 24.1% -0.142*** insufficient intake of fruit and 54.8% 50.3% 44.6% 40.9% 41.2% 46.5% -0.068*** vegetables insufficient physical activity 21.5% 19.8% 17.5% 18.4% 17.2% 18.9% -0.051*** drinking 1.1% 0.9% 1.0% 1.7% 2.2% 1.4% 0.190** concurrent partnerships 0.1% 0.0% 0.3% 0.2% 0.0% 0.1% 0.038 inequalitieS Maternal and cHild HealtH q1 q2 q3 q4 q5 total ci in HealtH care interVentionS1a,1b,1c,1d,1e,2 utiliZation 1993-94 1a Full immunization 49.7% 55.2% 60.1% 64.0% 73.9% 59.4% 0.076*** treatment of diarrhea 52.9% 42.0% 49.0% 44.3% 69.6% 50.3% 0.038 Medical treatment of ari 19.8% 22.8% 24.5% 36.5% 43.5% 27 .9% 0.172*** Skilled antenatal care (4+ visits) 0.3% 0.4% 2.3% 3.8% 25.9% 5.5% 0.747*** Skilled birth attendance 3.6% 3.4% 5.6% 9.7% 32.6% 9.8% 0.501*** 1996-97 1b Full immunization 47 .9% 43.6% 61.9% 56.7% 68.5% 54.3% 0.085*** treatment of diarrhea 63.4% 54.2% 63.1% 61.9% 71.6% 62.0% 0.026 Medical treatment of ari 22.8% 29.4% 32.2% 39.9% 49.4% 32.9% 0.160*** Skilled antenatal care (4+ visits) 1.2% 1.4% 2.3% 4.8% 25.0% 5.8% 0.651*** Skilled birth attendance 1.8% 2.5% 4.1% 8.8% 30.3% 8.2% 0.579*** 1999-00 1c Full immunization 49.9% 55.1% 61.8% 67.7% 75.6% 60.4% 0.089*** treatment of diarrhea 64.9% 79.1% 69.3% 79.5% 80.8% 73.9% 0.040** Medical treatment of ari 32.3% 34.8% 38.9% 45.2% 64.0% 39.7% 0.127*** Skilled antenatal care (4+ visits) 1.9% 3.2% 4.8% 10.0% 38.7% 10.2% 0.595*** Skilled birth attendance 3.5% 5.0% 5.9% 14.2% 42.8% 12.1% 0.528*** 6 inequalitieS Maternal and cHild HealtH q1 q2 q3 q4 q5 total ci in HealtH care interVentionS1a,1b,1c,1d,1e,2 utiliZation 2004 1d (cont.) Full immunization 57 .8% 75.8% 74.7% 78.0% 87.4% 73.1% 0.078*** treatment of diarrhea 64.8% 72.6% 77.0% 88.2% 83.5% 75.0% 0.066*** Medical treatment of ari 10.9% 14.9% 18.5% 27.9% 45.0% 20.0% 0.272*** Skilled antenatal care (4+ visits) 3.3% 6.6% 11.6% 17.2% 45.2% 15.4% 0.490*** Skilled birth attendance 3.0% 4.2% 10.6% 17.0% 39.7% 13.2% 0.507*** contraceptive prevalence 69.5% 70.1% 67.5% 67.3% 68.5% 68.5% -0.006 2006 2 Full immunization 82.0% 86.9% 91.1% 93.7% 96.3% 89.5% 0.034*** treatment of diarrhea 66.2% 67.2% 70.1% 78.2% 78.5% 70.6% 0.041*** Medical treatment of ari 33.9% 43.3% 46.4% 64.7% 78.5% 48.9% 0.166*** 2007 1e Full immunization 79.6% 77 .1% 80.8% 87.1% 88.4% 82.5% 0.026*** treatment of diarrhea 75.6% 85.7% 77.9% 83.6% 85.9% 81.2% 0.019 Medical treatment of ari 40.2% 48.9% 61.2% 57.8% 66.5% 52.0% 0.106*** Skilled antenatal care (4+ visits) 6.7% 9.2% 12.9% 25.6% 46.7% 19.3% 0.416*** Skilled birth attendance 4.9% 6.5% 12.9% 23.1% 50.7% 18.2% 0.479*** contraceptive prevalence 59.5% 60.0% 56.4% 57.0% 57.0% 57.9% -0.009 adult PreVentiVe care2,3 q1 q2 q3 q4 q5 total ci 2003 3 tB screening 0.8% 2.6% 1.9% 1.8% 1.6% 1.7% 0.047 Breast cancer screening 0.0% 0.0% 1.1% 0.4% 1.8% 0.6% 0.563** adult curatiVe care3 q1 q2 q3 q4 q5 total ci 2003 3 inpatient or outpatient 74.7% 80.1% 80.0% 77.8% 78.2% 78.1% 0.007 (12 months) inpatient (12 months) 2.8% 4.0% 6.4% 3.8% 7.2% 4.8% 0.155*** inpatient (5 years) 9.5% 9.7% 13.4% 11.5% 17 .9% 12.4% 0.126*** outpatient (12 months) 77.8% 80.7% 82.0% 80.5% 81.1% 80.3% 0.009* threshold share of total household consumption Financial cataStroPHic out-oF- 5% 10% 15% 25% 40% Protection Pocket SPending3 2003 3 Headcount 67.2% 46.1% 30.1% 14.3% 5.4% concentration index 0.033*** 0.055*** 0.105*** 0.261*** 0.389*** threshold share of nonfood consumption cataStroPHic out-oF- 5% 10% 15% 25% 40% Pocket SPending3 2003 3 Headcount 85.0% 78.6% 72.4% 59.7% 43.8% concentration index -0.001 -0.021*** -0.030*** -0.045*** -0.056*** 7 Financial iMPoVeriSHMent3 Protection Poverty line at uS$1.25 per consumption consumption change % change (cont.) capita per day including ooP excluding ooP 2003 3 Percentage in poverty 56.9% 67.5% 10.6 pp 18.6% average shortfall from the $0.23 $0.30 $0.07 32.0% poverty line average shortfall from the $0.40 $0.45 $0.05 11.3% poverty line, among the poor Poverty line at uS$2.00 per consumption consumption change % change capita per day including ooP excluding ooP 2003 3 Percentage in poverty 81.1% 86.6% 5.5 pp 6.8% average shortfall from the $0.77 $0.90 $0.13 16.9% poverty line average shortfall from the $0.94 $1.03 $0.09 9.5% poverty line, among the poor note: the Health equity and Financial Protection datasheets use a standardized selection of indicators (see Measurement of indicators for full list). When (1) data sources are not available or (2) indicator-specific sample size is less than 250 per quintile for mortality indicators or less than 25 per quintile for all others, indicators are not reported for the country under analysis. For analysis of inequalities using WHS, dHS and MicS, quintile ranking is based on an asset index. For all other analyses, ranking is based on household consumption. q = quintile (where quintile 1 is the poorest) ci = concentration index; ranges between -1 and 1; negative sign indicates that the health outcome takes higher values among the poor * Significant at 10%, **Significant at 5%, ***Significant at 1%. Poverty lines are at 2005 purchasing power parity, adjusted to current prices using Bangladesh’s consumer price index. data sources: 1a=1993-94 Bangladesh demographic and Health Survey, 1b=1996-97 Bangladesh demographic and Health Survey, 1c=1999-00 Bangladesh demographic and Health Survey, 1d=2004 Bangladesh demographic and Health Survey, 1e=2007 Bangladesh demographic and Health Survey, 2=2006 Bangladesh Multiple indicator cluster Survey, 3=2003 Bangladesh World Health Survey. recommended citation: World Bank. 2012. Health equity and Financial Protection datasheet - Bangladesh. Washington d.c.: World Bank For more information and the latest versions of the Health equity and Financial Protection reports and datasheets, see: www.worldbank.org/povertyandhealth. Photo credit: thomas Sennett 8 HealtH equity and Financial Protection dataSHeet IndIa the Health equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. data are drawn from the demographic and Health Surveys (dHS), World Health Surveys (WHS), Multiple indicator cluster Surveys (MicS), living Standards and Measurement Surveys (lSMS), as well as other household surveys where available. the datasheets use a common set of health indicators for all countries. all analyses are conducted using the health modules of the adePt software. inequalitieS cHild HealtH1a,1b.1c,2,3 q1 q2 q3 q4 q5 total ci in HealtH 1992-93 1a outcoMeS infant mortality rate 117.4 114.3 92.5 69.2 46.5 92.0 -0.159*** under-five mortality rate 165.7 164.3 124.8 93.2 58.5 127.8 -0.174*** Stunting 63.7% 63.0% 59.7% 54.0% 40.4% 56.9% -0.076*** underweight 59.1% 58.2% 54.1% 43.9% 31.1% 50.4% -0.108*** diarrhea 5.2% 5.4% 5.2% 5.2% 5.0% 5.2% -0.007 acute respiratory infection 3.4% 3.2% 3.0% 2.5% 2.1% 2.9% -0.090*** Fever 21.0% 21.7% 19.8% 19.5% 17.9% 20.1% -0.031*** 1998-99 1b infant mortality rate 105.9 89.3 81.4 58.3 37.7 79.1 -0.166*** under-five mortality rate 146.5 126.2 109.5 74.4 47.1 108.1 -0.183*** Stunting 61.4% 57.5% 51.7% 44.6% 31.4% 50.5% -0.112*** underweight 58.7% 51.3% 45.1% 35.7% 22.0% 44.0% -0.159*** diarrhea 20.3% 19.1% 20.3% 17.8% 16.5% 19.0% -0.034*** acute respiratory infection 21.6% 20.9% 20.2% 17.5% 13.9% 19.2% -0.070*** Fever 30.0% 29.2% 29.4% 29.3% 26.6% 29.0% -0.014** 2003 3 Malaria 13.6% 9.4% 12.1% 7.3% 5.3% 9.6% -0.154*** 2005-06 1c infant mortality rate 88.1 78.0 69.4 52.8 34.9 68.7 -0.144*** under-five mortality rate 127 .6 102.6 89.6 67.6 43.3 93.1 -0.170*** Stunting 59.2% 53.7% 48.4% 40.3% 26.1% 47 .7% -0.127*** underweight 57 .1% 50.5% 42.3% 34.6% 21.1% 43.5% -0.159*** diarrhea 8.8% 9.0% 9.5% 9.5% 8.3% 9.0% 0.000 acute respiratory infection 10.0% 10.3% 9.9% 8.8% 7.2% 9.4% -0.051*** Fever 14.4% 16.0% 15.1% 14.9% 13.8% 14.9% -0.006 adult HealtH1a,1b,1c,3 q1 q2 q3 q4 q5 total ci 1998-99 1b obesity among non-pregnant 0.3% 0.3% 0.8% 2.1% 8.3% 2.4% 0.644*** women 2003 3 tuberculosis 17 .8% 17 .4% 10.1% 9.2% 6.4% 12.2% -0.212*** road traffic accident 4.2% 4.0% 3.3% 3.3% 3.3% 3.6% -0.053 non-road traffic accident 3.9% 5.1% 4.7% 3.1% 3.8% 4.1% -0.067 angina 7.2% 7.8% 8.1% 8.1% 8.5% 7.9% 0.030 arthritis 23.7% 19.9% 22.1% 19.7% 19.6% 21.0% -0.037** asthma 7.4% 5.3% 6.9% 5.3% 4.8% 5.9% -0.073** depression 11.9% 11.6% 14.1% 13.0% 13.5% 12.8% 0.030 diabetes 1.6% 1.2% 1.1% 3.2% 5.1% 2.5% 0.332*** difficulty with work and 16.4% 13.7% 11.2% 11.9% 10.4% 12.7% -0.087*** household activities Poor self-assessed health status 19.7% 16.6% 17.1% 17.1% 12.7% 16.7% -0.069*** 2005-06 1c obesity among non-pregnant 0.3% 0.5% 0.9% 2.9% 8.5% 2.8% 0.589*** women HiV positive 0.4% 0.4% 0.4% 0.6% 0.2% 0.4% -0.037*** 9 inequalitieS in riSk FactorS1a,1b,1c,2,3 q1 q2 q3 q4 q5 total ci riSky BeHaVior 2003 3 Smoking (all) 49.0% 39.9% 38.0% 31.1% 21.5% 35.9% -0.153*** insufficient intake of fruit and 77.4% 76.4% 76.2% 74.5% 66.1% 73.8% -0.030*** vegetables insufficient physical activity 4.1% 5.0% 4.0% 5.0% 6.1% 4.8% 0.064* drinking 7.0% 6.6% 7.2% 4.9% 5.4% 6.2% -0.071* 2005-06 1c Smoking (women) 21.7% 14.9% 10.3% 6.6% 3.2% 10.9% -0.342*** concurrent partnerships 0.2% 0.2% 0.2% 0.1% 0.1% 0.2% -0.201*** condom usage (more than 3.9% 1.0% 10.0% 15.7% 48.9% 11.8% 0.552*** one partner) inequalitieS Maternal and cHild HealtH q1 q2 q3 q4 q5 total ci in HealtH care interVentionS1a,1b,1c,2 utiliZation 1992-93 1a Full immunization 17.2% 22.4% 35.1% 49.3% 65.6% 35.8% 0.27*** treatment of diarrhea 8.0% 9.9% 12.7% 16.8% 21.4% 13.0% 0.20*** Medical treatment of ari 70.9% 67 .1% 72.5% 82.1% 91.1% 74.5% 0.05*** Skilled antenatal care (4+ visits) 6.5% 11.3% 20.6% 33.1% 61.6% 24.3% 0.42*** Skilled birth attendance 10.4% 16.7% 28.2% 46.1% 78.4% 33.1% 0.39*** 1998-99 1b Full immunization 21.7% 29.0% 41.8% 53.0% 64.3% 39.9% 0.22*** treatment of diarrhea 20.6% 22.4% 28.8% 32.3% 35.3% 26.8% 0.12*** Medical treatment of ari 50.4% 57.4% 70.2% 75.6% 80.3% 64.0% 0.10*** Skilled antenatal care (4+ visits) 8.9% 15.4% 26.8% 43.6% 69.3% 29.8% 0.39*** Skilled birth attendance 16.8% 26.8% 42.8% 61.2% 84.9% 43.2% 0.31*** 2005-06 1c Full immunization 24.6% 33.5% 47.5% 56.0% 71.6% 43.9% 0.215*** treatment of diarrhea 19.4% 19.7% 25.9% 31.4% 43.3% 26.3% 0.160*** Medical treatment of ari 60.5% 67.8% 70.2% 76.1% 80.4% 69.1% 0.061*** Skilled antenatal care (4+ visits) 11.4% 21.0% 36.5% 53.1% 78.2% 37.0% 0.361*** Skilled birth attendance 19.6% 32.4% 49.7% 67.5% 89.1% 47.3% 0.293*** contraceptive prevalence 86.3% 86.2% 85.8% 84.5% 80.0% 84.2% -0.016*** adult PreVentiVe care2,3 q1 q2 q3 q4 q5 total ci 2003 3 tB screening 3.0% 4.0% 2.5% 1.8% 1.7% 2.6% -0.153*** Voluntary counseling and 0.0% 5.7% 2.2% 16.1% 26.0% 8.5% 0.543*** testing for HiV cervical cancer screening 22.9% 19.4% 19.9% 19.4% 20.9% 20.3% 0.005 Breast cancer screening 0.5% 1.0% 3.4% 2.2% 4.8% 2.4% 0.351*** adult curatiVe care3 q1 q2 q3 q4 q5 total ci 2003 3 inpatient or outpatient 53.3% 57.0% 59.2% 66.3% 64.6% 60.1% 0.043*** (12 months) inpatient (12 months) 6.5% 5.8% 6.6% 8.6% 9.1% 7.3% 0.093*** inpatient (5 years) 15.1% 16.1% 16.4% 19.5% 22.1% 17 .9% 0.082*** outpatient (12 months) 51.4% 56.6% 58.4% 66.5% 63.2% 59.1% 0.044*** 10 threshold share of total household consumption Financial cataStroPHic out-oF- 5% 10% 15% 25% 40% Protection Pocket SPending3 2003 3 Headcount 56.4% 42.8% 32.6% 20.3% 13.3% concentration index 0.086*** 0.080*** 0.097*** 0.150*** 0.275*** threshold share of nonfood consumption cataStroPHic out-oF- 5% 10% 15% 25% 40% Pocket SPending3 2003 3 Headcount 69.7% 66.0% 61.9% 52.8% 44.2% concentration index 0.055*** 0.041*** 0.023*** -0.006 -0.027** iMPoVeriSHMent3 Poverty line at uS$1.25 per consumption consumption change % change capita per day including ooP excluding ooP 2003 3 Percentage in poverty 58.4% 65.5% 7.1 pp 12.1% average shortfall from the $0.32 $0.39 $0.07 22.2% poverty line average shortfall from the $0.52 $0.57 $0.05 9.0% poverty line, among the poor Poverty line at uS$2.00 per consumption consumption change % change capita per day including ooP excluding ooP 2003 3 Percentage in poverty 76.8% 81.2% 4.5 pp 5.8% average shortfall from the $0.87 $0.99 $0.12 13.6% poverty line average shortfall from the $1.07 $1.15 $0.08 7.4% poverty line, among the poor note: the Health equity and Financial Protection datasheets use a standardized selection of indicators (see Measurement of indicators for full list). When (1) data sources are not available or (2) indicator-specific sample size is less than 250 per quintile for mortality indicators or less than 25 per quintile for all others, indicators are not reported for the country under analysis. For analysis of inequalities using WHS, dHS and MicS, quintile ranking is based on an asset index. For all other analyses, ranking is based on household consumption. q = quintile (where quintile 1 is the poorest) ci = concentration index; ranges between -1 and 1; negative sign indicates that the health outcome takes higher values among the poor * Significant at 10%, **Significant at 5%, ***Significant at 1%. Poverty lines are at 2005 purchasing power parity, adjusted to current prices using india’s consumer price index. data sources: 1a=1992-93 india demographic and Health Survey, 1b=1998-99 india demographic and Health Survey, 1c=2005-06 india demographic and Health Survey, 2=n/a Multiple indicator cluster Survey, 3=2003 india World Health Survey. recommended citation: World Bank. 2012. Health equity and Financial Protection datasheet - india. Washington, d.c.: World Bank. For more information and the latest versions of the Health equity and Financial Protection reports and datasheets, see: www.worldbank.org/povertyandhealth. Photo credit: John isaac, 2002 11 HealtH equity and Financial Protection dataSHeet NEPAL the Health equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. data are drawn from the demographic and Health Surveys (dHS), World Health Surveys (WHS), Multiple indicator cluster Surveys (MicS), living Standards and Measurement Surveys (lSMS), as well as other household surveys where available. the datasheets use a common set of health indicators for all countries. all analyses are conducted using the health modules of the adePt software. inequalitieS cHild HealtH1a,1b,1c,1d,2,3 q1 q2 q3 q4 q5 total ci in HealtH 1996 1a outcoMeS infant mortality rate 98.6 116.5 101.7 84.8 65.4 95.8 -0.055*** under-five mortality rate 171.2 194.7 158.1 130.6 93.7 154.9 -0.092*** Stunting 64.2% 60.7% 57.2% 52.2% 40.2% 56.4% -0.073*** underweight 48.7% 46.3% 45.6% 38.4% 21.9% 41.7% -0.101*** diarrhea 32.4% 27 .3% 27.3% 26.8% 20.8% 27.6% -0.068*** acute respiratory infection 34.8% 33.3% 34.7% 37.7% 29.7% 34.3% -0.002 Fever 40.8% 37 .6% 40.4% 40.3% 38.0% 39.5% -0.002 2001 1b infant mortality rate 87.2 90.4 80.5 76.4 55.7 80.1 -0.066*** under-five mortality rate 152.1 141.7 104.6 102.5 85.2 121.5 -0.117*** Stunting 68.6% 59.5% 53.5% 52.7% 40.8% 56.7% -0.086*** underweight 52.3% 46.8% 44.2% 38.5% 26.0% 43.2% -0.102*** diarrhea 22.0% 21.7% 22.2% 19.2% 15.6% 20.6% -0.049*** acute respiratory infection 21.8% 23.7% 25.0% 22.5% 22.6% 23.1% 0.012 Fever 32.1% 32.4% 33.4% 32.8% 29.6% 32.2% -0.004 2003 3 Malaria 2.7% 1.2% 0.7% 1.3% 0.4% 1.3% -0.295 2006 1c infant mortality rate 75.5 61.0 73.4 47.0 34.6 60.8 -0.123*** under-five mortality rate 115.8 90.4 99.1 80.8 50.2 90.6 -0.130*** Stunting 61.4% 55.2% 50.9% 39.7% 31.6% 49.7% -0.121*** underweight 47 .3% 44.7% 42.0% 31.5% 19.7% 38.8% -0.136*** diarrhea 13.4% 12.0% 10.7% 11.7% 11.7% 12.0% -0.032 acute respiratory infection 7.6% 6.9% 8.4% 8.5% 10.2% 8.2% 0.062* Fever 16.2% 15.8% 16.7% 16.8% 21.6% 17.1% 0.046 2011 1d infant mortality rate 62.1 59.2 55.5 53.3 30.9 54.2 -0.090*** under-five mortality rate 80.1 76.1 64.9 74.8 38.2 69.2 -0.090*** Stunting 55.2% 45.0% 34.3% 30.4% 24.4% 40.1% -0.165*** underweight 40.6% 32.6% 29.6% 20.7% 11.2% 29.1% -0.199*** diarrhea 12.9% 14.3% 17.3% 12.8% 11.8% 13.9% -0.005 acute respiratory infection 7.5% 10.3% 13.3% 11.5% 8.1% 10.1% 0.066*** Fever 13.6% 19.6% 21.2% 23.4% 18.2% 18.8% 0.082*** 12 inequalitieS adult HealtH1a,1b,1c,1d,3 q1 q2 q3 q4 q5 total ci in HealtH 1996 1a outcoMeS obesity among non-pregnant 0.1% 0.1% 0.0% 0.0% 0.6% 0.1% 0.516* (cont.) women 2001 1b obesity among non-pregnant 0.2% 0.7% 0.5% 0.4% 3.6% 1.0% 0.569*** women 2003 3 tuberculosis 24.5% 18.0% 13.9% 12.3% 10.8% 15.9% -0.169*** road traffic acciden 1.5% 1.6% 2.4% 2.4% 3.0% 2.2% 0.137*** non-road traffic accident 4.3% 3.7% 2.2% 3.1% 2.8% 3.2% -0.114*** angina 4.8% 3.6% 4.9% 5.8% 10.3% 5.9% 0.197*** arthritis 18.4% 16.1% 15.3% 13.8% 12.1% 15.1% -0.077*** asthma 4.6% 4.4% 3.7% 4.4% 5.8% 4.6% 0.047 depression 33.1% 35.6% 30.9% 36.9% 32.1% 33.7% 0.002 diabetes 0.7% 1.5% 0.8% 2.4% 8.7% 2.9% 0.514 difficulty with work and 17.5% 16.3% 13.3% 14.9% 12.1% 14.8% -0.069*** household activities Poor self-assessed health 10.1% 11.4% 8.5% 9.6% 8.0% 9.5% -0.055** status 2006 1c obesity among non-pregnant 0.0% 0.2% 0.1% 0.9% 3.1% 0.9% 0.656*** women 2011 1d obesity among non-pregnant 0.7% 0.6% 1.1% 2.1% 6.0% 2.2% 0.517*** women inequalitieS in riSk FactorS1a,1b,1c,1d,2,3 q1 q2 q3 q4 q5 total ci riSky BeHaVior 2003 3 Smoking (all) 58.3% 44.9% 39.7% 35.2% 24.8% 40.6% -0.158*** insufficient intake of fruit and 98.8% 99.2% 98.3% 98.4% 97.8% 98.5% -0.003 vegetables insufficient physical activity 38.4% 35.3% 36.4% 34.4% 25.7% 34.0% -0.062*** drinking 15.5% 10.1% 11.7% 10.1% 10.7% 11.6% -0.073*** 2006 1c Smoking (women) 34.9% 22.5% 20.3% 14.6% 7.6% 19.6% -0.270*** concurrent partnerships 0.0% 0.1% 0.0% 0.1% 0.1% 0.0% -0.024 2011 1d Smoking (women) 30.2% 16.5% 11.1% 8.5% 4.0% 13.4% -0.361*** concurrent partnerships 0.1% 0.0% 0.3% 0.1% 0.2% 0.1% 0.086 13 inequalitieS Maternal and cHild HealtH q1 q2 q3 q4 q5 total ci in HealtH care interVentionS1a,1b,1c,1d,2 utiliZation 1996 1a Full immunization 32.6% 35.1% 40.3% 51.4% 71.8% 43.5% 0.160*** treatment of diarrhea 20.9% 23.7% 29.4% 22.6% 43.6% 25.9% 0.116*** Medical treatment of ari 12.0% 15.9% 18.4% 22.3% 27.5% 18.2% 0.169*** Skilled antenatal care (4+ visits) 2.3% 4.8% 6.4% 9.1% 31.7% 9.2% 0.505*** Skilled birth attendance 3.0% 5.0% 6.9% 8.5% 35.3% 9.8% 0.490*** 2001 1b Full immunization 54.2% 62.0% 66.0% 74.5% 82.8% 65.9% 0.084*** treatment of diarrhea 26.6% 26.7% 32.2% 37.9% 48.7% 32.2% 0.116*** Medical treatment of ari 22.9% 23.6% 26.3% 24.3% 38.0% 26.1% 0.083*** Skilled antenatal care (4+ visits) 4.5% 5.0% 12.0% 17.2% 45.0% 14.6% 0.471*** Skilled birth attendance 3.7% 5.3% 10.0% 14.5% 46.3% 13.3% 0.500*** 2006 1c Full immunization 68.2% 82.9% 86.7% 90.9% 93.8% 83.0% 0.068*** treatment of diarrhea 17 .8% 29.5% 29.6% 39.2% 39.2% 29.3% 0.155*** Medical treatment of ari 31.4% 27.5% 30.8% 47.3% 35.6% 34.3% 0.061 Skilled antenatal care (4+ visits) 11.2% 19.7% 28.8% 38.7% 60.6% 29.8% 0.319*** Skilled birth attendance 9.9% 17.4% 20.0% 33.3% 62.6% 25.7% 0.361*** contraceptive prevalence 25.0% 31.7% 38.0% 36.0% 40.0% 34.4% 0.081*** 2011 1d Full immunization 84.5% 84.8% 82.9% 91.0% 97.1% 87.0% 0.024*** treatment of diarrhea 46.6% 43.0% 39.7% 55.8% 43.4% 45.1% 0.021 Medical treatment of ari 29.5% 36.4% 55.5% 44.0% 50.1% 43.2% 0.092*** Skilled antenatal care (4+ visits) 28.2% 39.5% 48.8% 66.6% 84.1% 50.4% 0.218*** Skilled birth attendance 18.5% 35.3% 49.3% 62.5% 86.5% 45.5% 0.285*** contraceptive prevalence 28.4% 32.3% 34.1% 34.5% 35.5% 33.2% 0.040*** adult PreVentiVe care2,3 q1 q2 q3 q4 q5 total ci 2003 3 tB screening 3.9% 8.0% 11.8% 14.7% 12.8% 9.0% 0.252*** cervical cancer screening 20.2% 29.3% 20.9% 36.5% 34.2% 30.3% 0.081 Breast cancer screening 0.4% 1.5% 0.7% 2.7% 5.6% 2.1% 0.425*** adult curatiVe care3 q1 q2 q3 q4 q5 total ci 2003 3 inpatient or outpatient 31.9% 32.9% 38.4% 42.2% 48.1% 38.7% 0.094*** (12 months) inpatient (12 months) 5.0% 5.2% 4.9% 5.3% 7.5% 5.6% 0.079 inpatient (5 years) 11.3% 13.0% 12.2% 14.2% 20.9% 14.3% 0.123*** outpatient (12 months) 27.4% 28.4% 34.2% 38.6% 42.3% 34.0% 0.101*** threshold share of total household consumption Financial cataStroPHic out-oF- 5% 10% 15% 25% 40% Protection Pocket SPending3 2003 3 Headcount 34.9% 24.2% 17.6% 10.2% 5.3% concentration index 0.113*** 0.147*** 0.194*** 0.327*** 0.485*** threshold share of nonfood consumption cataStroPHic out-oF- 5% 10% 15% 25% 40% Pocket SPending3 2003 3 Headcount 45.6% 40.6% 36.7% 28.1% 19.9% concentration index 0.083*** 0.067*** 0.054*** 0.052*** 0.074*** 14 Financial iMPoVeriSHMent3 Protection Poverty line at uS$1.25 per consumption consumption change % change (cont.) capita per day including ooP excluding ooP 2003 3 Percentage in poverty 49.3% 56.0% 6.7 pp 13.6% average shortfall from the $0.20 $0.23 $0.04 18.9% poverty line average shortfall from the $0.40 $0.41 $0.02 4.7% poverty line, among the poor Poverty line at uS$2.00 per consumption consumption change % change capita per day including ooP excluding ooP 2003 3 Percentage in poverty 76.3% 80.4% 4.1 pp 5.4% average shortfall from the $0.69 $0.77 $0.08 11.2% poverty line average shortfall from the $0.90 $0.95 $0.05 5.5% poverty line, among the poor note: the Health equity and Financial Protection datasheets use a standardized selection of indicators (see Measurement of indicators for full list). When (1) data sources are not available or (2) indicator-specific sample size is less than 250 per quintile for mortality indicators or less than 25 per quintile for all others, indicators are not reported for the country under analysis. For analysis of inequalities using WHS, dHS and MicS, quintile ranking is based on an asset index. For all other analyses, ranking is based on household consumption. q = quintile (where quintile 1 is the poorest) ci = concentration index; ranges between -1 and 1; negative sign indicates that the health outcome takes higher values among the poor * Significant at 10%, **Significant at 5%, ***Significant at 1%. Poverty lines are at 2005 purchasing power parity, adjusted to current prices using nepal’s consumer price index. data sources: 1a=1996 nepal demographic and Health Survey, 1b=2001 nepal demographic and Health Survey, 1c=2006 nepal demographic and Health Survey, 1d=2011 nepal demographic and Health Survey, 2=n/a nepal Multiple indicator cluster Survey, 3=2003 nepal World Health Survey. recommended citation: World Bank. 2012. Health equity and Financial Protection datasheet - nepal. Washington, d.c.: World Bank. For more information and the latest versions of the Health equity and Financial Protection reports and datasheets, see: www.worldbank.org/povertyandhealth. Photo credit: curt carnemark 15 health eQUity aNd FiNaNCial PROteCtiON dataSheet Pak istan the health equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. data are drawn from the demographic and health Surveys (dhS), World health Surveys (WhS), Multiple indicator Cluster Surveys (MiCS), living Standards and Measurement Surveys (lSMS), as well as other household surveys where available. the datasheets use a common set of health indicators for all countries. all analyses are conducted using the health modules of the adePt software. iNeQUalitieS Child health1a,1b,2,3 Q1 Q2 Q3 Q4 Q5 total Ci iN health 1990-91 1a OUtCOMeS infant mortality rate 102.4 124.3 121.3 101.9 66.1 104.5 -0.068*** Under-five mortality rate 118.6 155.9 152.1 120.1 72.2 126.4 -0.071*** Stunting 63.0% 60.2% 57 .9% 52.3% 38.7% 53.8% -0.093*** Underweight 53.0% 43.5% 39.8% 33.8% 24.4% 38.4% -0.145*** diarrhea 6.6% 5.1% 4.8% 7.9% 6.9% 6.3% 0.052 acute respiratory infection 4.2% 4.8% 6.1% 5.5% 4.2% 5.0% -0.002 Fever 31.7% 28.5% 31.5% 30.9% 27 .6% 30.0% -0.017 2003-04 3 Malaria 15.5% 18.9% 10.8% 9.7% 14.1% 14.1% -0.083 2006-07 1b infant mortality rate 95.8 86.9 77.3 69.2 55.4 79.1 -0.106*** Under-five mortality rate 115.0 101.6 85.6 94.2 59.5 94.2 -0.098*** diarrhea 12.7% 13.4% 12.6% 11.3% 13.6% 12.7% -0.005 acute respiratory infection 20.8% 19.7% 18.4% 21.3% 18.4% 19.8% -0.019 Fever 29.7% 29.7% 29.1% 33.3% 33.7% 30.9% 0.027** adUlt health1a,1b,3 Q1 Q2 Q3 Q4 Q5 total Ci 2003-04 3 tuberculosis 11.5% 12.1% 12.6% 29.9% 6.9% 14.6% 0.036 Obesity among non-pregnant 25.1% 32.9% 30.1% 26.1% 11.1% 24.3% -0.102** women Road traffic accident 0.9% 2.5% 2.2% 1.2% 1.9% 1.8% 0.048 Non-road traffic accident 0.8% 2.0% 1.3% 1.8% 2.5% 1.7% 0.183** angina 3.7% 2.5% 1.9% 2.1% 3.0% 2.6% -0.028 arthritis 15.8% 14.1% 13.0% 8.9% 12.7% 12.9% -0.075 asthma 4.8% 4.5% 4.1% 3.0% 2.6% 3.8% -0.103* depression 1.7% 3.2% 1.4% 1.3% 3.0% 2.1% 0.021 diabetes 1.2% 2.0% 1.8% 4.0% 5.8% 3.0% 0.339*** difficulty with work and 4.1% 5.3% 4.4% 4.9% 7.3% 5.2% 0.083 household activities Poor self-assessed health 5.1% 5.8% 3.8% 2.1% 3.8% 4.1% -0.114** status iNeQUalitieS iN RiSk FaCtORS1a,1b,2,3 Q1 Q2 Q3 Q4 Q5 total Ci RiSky BehaViOR 2003-04 3 Smoking (all) 25.5% 24.3% 29.8% 41.4% 16.6% 27.5% -0.010 Smoking (women) 5.6% 6.0% 4.8% 4.1% 0.7% 4.2% -0.227 insufficient intake of fruit and 99.6% 99.6% 99.4% 99.1% 98.7% 99.3% -0.002** vegetables insufficient physical activity 27.5% 23.2% 23.7% 15.9% 23.1% 22.7% -0.062** drinking 0.0% 0.1% 0.3% 0.1% 0.2% 0.1% 0.241 Concurrent partnerships 0.0% 2.2% 0.6% 0.3% 1.0% 0.8% 0.073 16 iNeQUalitieS MateRNal aNd Child Q1 Q2 Q3 Q4 Q5 total Ci iN health CaRe health iNteRVeNtiONS1a,1b,2 UtiliZatiON 1990-91 1a Full immunization 22.6% 27 .1% 31.0% 42.2% 56.9% 36.2% 0.182*** treatment of diarrhea 23.8% 37 .1% 30.2% 58.3% 55.9% 41.8% 0.173*** Medical treatment of aRi 67 .5% 73.2% 68.1% 72.1% 93.4% 74.2% 0.054** Skilled antenatal care (4+ visits) 2.3% 2.1% 3.4% 14.6% 48.2% 14.2% 0.618*** Skilled birth attendance 4.9% 5.6% 5.7% 21.1% 55.2% 18.6% 0.525*** 2006-07 1b Full immunization 26.8% 41.6% 53.6% 60.2% 65.0% 48.7% 0.171*** treatment of diarrhea 45.3% 47.3% 48.0% 47.2% 49.9% 47.3% 0.020 Medical treatment of aRi 51.4% 63.2% 67.2% 77.5% 85.4% 67.5% 0.103*** Skilled antenatal care (4+ visits) 9.9% 14.4% 21.0% 37.9% 64.7% 28.3% 0.380*** Skilled birth attendance 15.9% 25.4% 36.4% 52.4% 79.1% 39.7% 0.312*** Contraceptive prevalence 59.4% 51.2% 54.9% 53.5% 55.2% 54.6% 0.001 adUlt PReVeNtiVe CaRe2,3 Q1 Q2 Q3 Q4 Q5 total Ci 2003-04 3 tB screening 0.6% 2.2% 4.3% 1.1% 1.9% 2.0% 0.051 Cervical cancer screening 13.3% 10.2% 10.0% 11.2% 25.0% 14.8% 0.191** Breast cancer screening 0.0% 0.0% 0.5% 0.5% 1.2% 0.4% 0.544 adUlt CURatiVe CaRe3 Q1 Q2 Q3 Q4 Q5 total Ci 2003-04 3 inpatient or outpatient 54.0% 62.0% 63.2% 72.6% 65.3% 63.4% 0.045*** (12 months) inpatient (12 months) 6.0% 7.4% 6.3% 4.1% 6.8% 6.1% -0.012 inpatient (5 years) 10.2% 12.9% 14.3% 8.1% 15.8% 12.2% 0.054 Outpatient (12 months) 52.9% 60.6% 63.1% 74.3% 67 .1% 63.6% 0.054*** BeNeFit UtiliZatiON - PUBliC Q1 Q2 Q3 Q4 Q5 total Ci iNCideNCe FaCilitieS3 aNalySiS 2003-04 3 Outpatient health center and 5.2% 2.4% 4.3% 4.1% 4.7% 4.1% 0.024 health post Outpatient hospital 1.4% 2.4% 2.9% 2.6% 4.3% 2.7% 0.172*** inpatient hospital 2.7% 2.3% 2.3% 4.5% 3.3% 3.0% 0.083 FeeS Paid at PUBliC Q1 Q2 Q3 Q4 Q5 Ci FaCilitieS (ShaReS)3 2003-04 3 Outpatient health center and 7.0 9.5 27.2 35.1 21.1 0.202*** health post Outpatient hospital 7.7 10.8 18.7 21.8 41.0 0.318*** inpatient hospital 16.9 14.9 24.2 16.1 27.9 0.101 17 BeNeFit health CaRe SUBSidieS (ShaReS)3,4 iNCideNCe 2003-04 3 aNalySiS total Constant Unit Cost Method Q1 Q2 Q3 Q4 Q5 Ci Share (CONt.) (lCU) Outpatient health center and 26.5 11.6 20.4 18.8 22.8 7096 0.011 16.7% health post Outpatient hospital 13.4 20.8 21.3 18.3 26.2 331 0.087 0.8% inpatient hospital 18.0 15.1 13.2 32.1 21.6 35230 0.086 82.6% total subsidies 19.3 14.6 14.5 29.8 21.9 42657 0.073 100% total Constant Unit Subsidy Method Q1 Q2 Q3 Q4 Q5 Ci Share (lCU) Outpatient health center and 25.1 11.4 20.9 19.9 22.7 7096 0.024 16.7% health post Outpatient hospital 10.6 17.6 21.5 18.8 31.5 331 0.172*** 0.8% inpatient hospital 17.9 15.1 15.0 29.7 22.2 35230 0.083 82.6% total subsidies 19.0 14.5 16.1 28.0 22.4 42657 0.074 100% total Proportional Cost Method Q1 Q2 Q3 Q4 Q5 Ci Share (lCU) Outpatient health center and 7.0 9.5 27.2 35.1 21.1 7096 0.202*** 16.7% health post Outpatient hospital 7.7 10.8 18.7 21.8 41.0 331 0.318*** 0.8% inpatient hospital 16.9 14.9 24.2 16.1 27.9 35230 0.101 82.6% total subsidies 15.2 14.0 24.6 19.3 26.9 42657 0.119 100% threshold share of total household consumption FiNaNCial CataStROPhiC OUt-OF- 5% 10% 15% 25% 40% PROteCtiON POCket SPeNdiNg3 2003-04 3 headcount 67.0% 45.1% 27.2% 12.2% 5.6% Concentration index 0.017 0.036* 0.102*** 0.242*** 0.370 threshold share of nonfood consumption CataStROPhiC OUt-OF- 5% 10% 15% 25% 40% POCket SPeNdiNg3 2003-04 3 headcount 77.1% 73.0% 67.6% 49.4% 31.3% Concentration index 0.009 -0.002 -0.016 0.017 0.039* iMPOVeRiShMeNt3 Poverty line at US$1.25 per Consumption Consumption Change % change capita per day including OOP excluding OOP 2003-04 3 Percentage in poverty 54.8% 64.2% 9.4 pp 17.2% average shortfall from the $0.24 $0.30 $0.06 26.6% poverty line average shortfall from the $0.44 $0.47 $0.03 8.0% poverty line, among the poor Poverty line at US$2.00 per Consumption Consumption Change % change capita per day including OOP excluding OOP 2003-04 3 Percentage in poverty 81.8% 87.0% 5.2 pp 6.3% average shortfall from the $0.77 $0.89 $0.12 15.6% poverty line average shortfall from the $0.93 $1.02 $0.08 8.8% poverty line, among the poor 18 Note: the health equity and Financial Protection datasheets use a standardized selection of indicators (see Measurement of indicators for full list). When (1) data sources are not available or (2) indicator-specific sample size is less than 250 per quintile for mortality indicators or less than 25 per quintile for all others, indicators are not reported for the country under analysis. For analysis of inequalities using WhS, dhS and MiCS, quintile ranking is based on an asset index. For all other analyses, ranking is based on household consumption. Q = quintile (where quintile 1 is the poorest) Ci = concentration index; ranges between -1 and 1; negative sign indicates that the health outcome takes higher values among the poor * Significant at 10%, **Significant at 5%, ***Significant at 1%. Poverty lines are at 2005 purchasing power parity, adjusted to current prices using Pakistan’s consumer price index. data sources: 1a=1990-91 Pakistan demographic and health Survey, 1b=2006-07 Pakistan demographic and health Survey, 2=n/a Multiple indicator Cluster Survey, 3=2003-04 Pakistan World health Survey, 4=2005-06 Pakistan National health accounts. Recommended citation: World Bank. 2012. health equity and Financial Protection datasheet - Pakistan. Washington, d.C.: World Bank. For more information and the latest versions of the health equity and Financial Protection reports and datasheets, see: www.worldbank.org/povertyandhealth. Photo credit: Curt Carnemark, 1994 19 HealtH equity and Financial Protection dataSHeet SRI L ANK A the Health equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. data are drawn from the demographic and Health Surveys (dHS), World Health Surveys (WHS), Multiple indicator cluster Surveys (MicS), living Standards and Measurement Surveys (lSMS), as well as other household surveys where available. the datasheets use a common set of health indicators for all countries. all analyses are conducted using the health modules of the adePt software. inequalitieS cHild HealtH1,2,3 q1 q2 q3 q4 q5 total ci in HealtH 2003 3 outcoMeS Malaria 1.5% 0.3% 0.1% 0.0% 0.0% 0.4% -0.724*** adult HealtH1,3 q1 q2 q3 q4 q5 total ci 2003 3 tuberculosis 10.6% 5.2% 7.4% 6.7% 6.8% 7.3% -0.044 obesity among all women 12.9% 12.8% 12.7% 17.0% 20.7% 15.3% 0.102* road traffic accident 2.0% 0.8% 1.4% 0.9% 1.3% 1.3% -0.083 non-road traffic accident 2.6% 1.6% 1.7% 1.1% 0.8% 1.6% -0.214*** angina 6.7% 3.2% 1.8% 1.7% 3.6% 3.3% -0.133 arthritis 12.4% 5.6% 7.3% 4.8% 5.2% 7.0% -0.159*** asthma 7.3% 4.8% 2.5% 2.2% 2.9% 3.9% -0.217*** depression 0.7% 0.9% 0.9% 1.3% 1.3% 1.0% 0.097 diabetes 4.0% 1.6% 1.6% 3.1% 5.3% 3.1% 0.134 difficulty with work and 8.1% 4.4% 5.8% 5.0% 2.8% 5.2% -0.171*** household activities Poor self-assessed health 6.8% 3.4% 5.1% 4.1% 2.1% 4.3% -0.168*** status inequalitieS in riSk FactorS1,2,3 q1 q2 q3 q4 q5 total ci riSky BeHaVior 2003 3 Smoking (all 29.5% 20.3% 22.2% 21.3% 12.4% 21.0% -0.123*** Smoking (women) 5.7% 2.7% 1.8% 1.3% 0.8% 2.4% -0.362*** insufficient intake of fruit and 76.7% 74.9% 71.1% 63.8% 56.4% 68.4% -0.065*** vegetables insufficient physical activity 0.0% 0.1% 0.1% 0.2% 0.3% 0.1% 0.334 drinking 18.9% 10.5% 15.0% 17.0% 18.3% 15.9% 0.042 concurrent partnerships 0.1% 0.1% 1.4% 0.5% 0.4% 0.5% 0.101 inequalitieS adult PreVentiVe care2,3 q1 q2 q3 q4 q5 total ci in HealtH care 2003 3 utiliZation tB screening 0.9% 1.0% 0.9% 0.8% 0.5% 0.8% -0.104 Breast cancer screening 0.0% 1.2% 3.1% 0.8% 2.0% 1.4% 0.184 adult curatiVe care3 q1 q2 q3 q4 q5 total ci 2003 3 inpatient or outpatient 54.6% 47.4% 55.7% 57.4% 67.9% 56.6% 0.053*** (12 months) inpatient (12 months) 12.9% 9.5% 12.9% 8.8% 8.5% 10.5% -0.061 inpatient (5 years) 28.9% 21.6% 26.0% 20.4% 20.9% 23.5% -0.063** outpatient (12 months) 47.5% 41.4% 49.4% 54.9% 67 .4% 52.5% 0.082*** 20 threshold share of total household consumption Financial cataStroPHic out-oF- 5% 10% 15% 25% 40% Protection Pocket SPending3 2003 3 Headcount 40.6 21.5 13.0 5.3 2.6 concentration index -0.027 -0.064** -0.068** -0.078* -0.168** threshold share of nonfood consumption cataStroPHic out-oF- 5% 10% 15% 25% 40% Pocket SPending3 2003 3 Headcount 60.2 51.8 40.8 26.7 15.7 concentration index 0.016 -0.022 -0.071*** -0.107*** -0.172*** iMPoVeriSHMent3 Poverty line at uS$1.25 per consumption consumption change % change capita per day including ooP excluding ooP 2003 3 Percentage in poverty 32.3% 36.3% 4.0 pp 12.5% average shortfall from the $0.13 $0.15 $0.02 18.2% poverty line average shortfall from the $0.39 $0.41 $0.02 5.1% poverty line, among the poor Poverty line at uS$2.00 per consumption consumption change % change capita per day including ooP excluding ooP 2003 3 Percentage in poverty 62.8% 65.7% 2.9 pp 4.6% average shortfall from the $0.50 $0.55 $0.05 11.0% poverty line average shortfall from the $0.78 $0.83 $0.05 6.1% poverty line, among the poor note: the Health equity and Financial Protection datasheets use a standardized selection of indicators (see Measurement of indicators for full list). When (1) data sources are not available or (2) indicator-specific sample size is less than 250 per quintile for mortality indicators or less than 25 per quintile for all others, indicators are not reported for the country under analysis. For analysis of inequalities using WHS, dHS and MicS, quintile ranking is based on an asset index. For all other analyses, ranking is based on household consumption. q = quintile (where quintile 1 is the poorest) ci = concentration index; ranges between -1 and 1; negative sign indicates that the health outcome takes higher values among the poor * Significant at 10%, **Significant at 5%, ***Significant at 1%. Poverty lines are at 2005 purchasing power parity, adjusted to current prices using Sri lanka’s consumer price index. data sources: 1=n/a demographic and Health Survey, 2=n/a Multiple indicator cluster Survey, 3=2003 Sri lanka World Health Survey. recommended citation: World Bank. 2012. Health equity and Financial Protection datasheet - Sri lanka. Washington, d.c.: World Bank. For more information and the latest versions of the Health equity and Financial Protection reports and datasheets, see: www.worldbank.org/povertyandhealth. Photo credit: ray Witlin 21 I nterpre tatIon of results InequalItIes In health outcomes, rIsky behavIor and health care utIlIzatIon the tables in this section show how health outcomes, risky behaviors and health care utilization vary across asset (wealth) quintiles and periods. the quintiles are based on an asset index constructed using principal components analysis. the tables show the mean values of the indicator for each quintile, as well as for the sample as a whole. also shown are the concentration indices which capture the direction and degree of inequality. a negative value indicates that the variable (e.g. stunting or skilled birth attendance) is more concentrated among the poor, while a positive value indicates that the variable is concentrated among the better off. the larger the index in absolute size, the more inequality there is. the statistical significance of the concentration index is also shown, at 1% (***), 5% (**) and 10% (*) significance levels. For example, if stunting has a concentration index of -0.121***, then stunting is significantly concentrated among the poor. beneFIt-IncIdence analysIs benefit-incidence analysis (bIa) shows whether, and by how much, government health expenditure disproportionately benefits the poor. there are three tables showing, respectively, the distribution of service utilization across consumption quintiles for different types of care, the distribution of user fees, and the distribution of the estimated subsidies. all tables also show the concentration indices which capture the direction and degree of inequality. a negative value indicates that the variable (i.e. utilization, fees or subsidies) is more concentrated among the poor, while a positive value indicates that the variable is concentrated among the better off. the larger the index in absolute size, the greater is the inequality. For example, if the concentration index of subsidies to hospitals is positive, the non-poor benefit more than the poor from government spending on hospital services. the distribution of subsidies depends on the assumptions made to allocate subsidies to households. under the constant unit cost assumption, each unit of utilization is assumed to cost the same and is equal to total costs incurred in delivering this type of service (i.e. subsidies plus user fees) divided by the number of units of utilization. under the constant unit subsidy assumption, the unit subsidy is assumed to be constant, equal to total subsidies for the service in question divided by the number of units of utilization of that service. under the proportional cost assumption, higher fees are indicative of a more costly type of care; specifically, it is assumed that unit costs and fees are proportional to one another. If the concentration index is negative, then the subsidy to the particular level of care is pro-poor and if the concentration index is positive, then the subsidy is pro-rich. the column labeled “share� shows the distribution of the total subsidy across different levels of care. FInancIal protectIon: catastrophIc and ImpoverIshIng expendIture measures of financial protection relate out-of-pocket spending to a threshold. one approach is to classify spending as ‘catastrophic’ if it exceeds a certain fraction of household income or consumption or nonfood consumption. catastrophic payments are defined as health care payments in excess of a predetermined percentage (i.e. 5% to 40%) of their total household spending or nonfood spending. the first line of the first table shows the catastrophic payment “headcount�, i.e. the proportion of households with a health payment budget share greater than the given threshold. For example, if the “headcount� figure given in the last column of the first table is 6%, then 6% of households spend more than 40% of their pre-payment income on health payments. the concentration indices in the second line of each table show whether there is a greater tendency for the better off to have out-of-pocket spending in excess of the payment threshold (in which case it takes on a positive value), or whether the poor are more likely to have out-of-pocket spending exceeding the threshold (in which case it takes on a negative value). another approach is to classify health spending as ‘impoverishing’ if it is sufficiently large to make the household cross the poverty line, i.e. the household would not have been poor had it been able to use for general consumption the money it was forced to spend on health care. the extent of impoverishment due to health care expenditure is measured by comparing the extent of poverty computed using household consumption gross and net of out-of-pocket health spending. the table shows three measures of poverty. the first line of the table shows the percentage of the population living below the poverty line, i.e. the poverty “headcount�. the second line shows the population’s average shortfall from the poverty line, i.e. the “normalized poverty gap�; the normalization is useful when making comparisons across countries with different poverty lines and currency units. Finally, the last line shows the average shortfall from the poverty line, among those who are poor, i.e. the normalized mean positive poverty gap. the last column shows the percentage increase in poverty, the percentage increase in the average shortfall from the poverty line and the percentage increase in the average shortfall from the poverty line among the poor due to out-of-pocket health spending, respectively. progressIvIty oF health FInancIng the table in this section reports whether overall health financing, as well as the individual sources of finance, is regressive (i.e. a poor household contributes a larger share of its resources than a rich one), progressive (i.e. a poor household contributes a smaller share of its resources than a rich one) or proportional. the 1st through 5th columns show the distribution of consumption and different sources of health care financing. the 6th column shows the summary measures of inequality; in the case of consumption, this is the gini coefficient and in the case of other sources of financing it is the concentration index. In the 7th column, the kakwani index (defined as the concentration index less the gini coefficient) takes on a positive value, then payments are more concentrated among the better off than consumption, and is a sign that payments are progressive. If the kakwani index is negative, then payments are regressive. the last column shows the contribution of each financing source to total health care financing (obtained from national health accounts data). For more guIdance on InterpretatIon oF results, see: o’donnell, o., e. van doorslaer, a. Wagstaff and m. lindelow. (2008). analyzing health equity using household survey data: a guide to techniques and their implementation. Washington, d.c.: World bank. Wagstaff, a., m. bilger, z. sajaia and m. lokshin. (2011). health equity and financial protection: streamlined analysis with adept software. Washington, d.c.: World bank. Me asureMent of In dIcators IndIcator MeasureMent data chIld health number of deaths among children under 12 months of age per 1,000 live births (note: mortality Infant mortality rate rate calculated using the true cohort life table approach; the dhs reports use the synthetic cohort dhs life table approach) number of deaths among children under 5 years of age per 1,000 live births (note: mortality rate under-five mortality rate calculated using the true cohort life table approach; the dhs reports use the synthetic cohort life dhs table approach) % of children with a height-for-age z-score <-2 standard deviations from the reference median stunting dhs, MIcs (note: z-score calculated using Who 2006 child Growth standards) % of children with a weight-for-age z-score <-2 standard deviations from the reference median underweight dhs, MIcs (note: z-score calculated using Who 2006 child Growth standards) diarrhea % of children with diarrhea (past two weeks) dhs, MIcs diarrhea % of children with diarrhea (past two weeks; youngest child) Whs acute respiratory infection % of children with an episode of coughing and rapid breathing (past two weeks) dhs, MIcs acute respiratory infection % of children with an episode of coughing and rapid breathing (past two weeks; youngest child) Whs Fever % of children with fever (past two weeks) dhs, MIcs Fever % of children with fever (past two weeks; youngest child) Whs Malaria % of children with an episode of malaria (past year; youngest child) Whs adult health tuberculosis % of adults who reported tuberculosis symptoms (past year) Whs obesity among non-pregnant women % of women aged 15 to 49 with a BMI above 30 dhs obesity among all women % of women aged 18 to 49 with a BMI above 30 Whs road traffic accident % of adults involved in a road traffic accident with bodily injury (past year) Whs % of adults who suffered bodily injury that limited everyday activities, due to a fall, burn, poisoning, non-road traffic accident Whs submersion in water, or by an act of violence (past year) angina % of adults ever diagnosed with angina or angina pectoris Whs arthritis % of adults ever diagnosed with arthritis Whs asthma % of adults ever diagnosed with asthma Whs depression % of adults ever diagnosed with depression Whs diabetes % of adults ever diagnosed with diabetes Whs difficulty with work and household % of adults who have severe or extreme difficulties with work or household activities (past 30 days) Whs activities (note: this indicator was created from an ordinal variable with five categories) % of adults who rate own health as bad or very bad (note: this indicator was created from an Poor self-assessed health status Whs ordinal variable with five categories) hIV Positive Percentage of adults aged 15 to 49 whose blood tests are positive for hIV 1 or hIV 2. dhs rIsk Factors smoking (all) % of adults who smoke any tobacco products such as cigarettes, cigars or pipes Whs smoking (women) % of women aged 15 to 49 who smoke cigarettes, pipe or other tobacco dhs smoking (women) % of women aged 18 to 49 who smoke cigarettes, pipe or other tobacco Whs Insufficient intake of fruit and vegetables % of adults who have insufficient intake of fruit/vegetables (less than 5 servings) Whs Insufficient physical activity % of adults who spend < 150 minutes on walking/ moderate activity/vigorous activity (past week) Whs drinking % of adults who consume ≥5 standard drinks on at least one day (past week) Whs concurrent partnerships % of women aged 15 to 49 who had sexual intercourse with more than one partner (past year) dhs, MIcs concurrent partnerships % of women aged 18 to 49 who had sexual intercourse with more than one partner (past year) Whs % of women aged 15 to 49 who had more than one partner in the past year and used a condom condom usage (more than one partner) dhs, MIcs during last sexual intercourse % of women aged 18 to 49 who had more than one partner in the past year and used a condom condom usage (more than one partner) Whs during last sexual intercourse Mosquito net use by children % of children who slept under an (ever) insecticide treated bed net (Itn) (past night) dhs, MIcs % of pregnant women aged 15 to 49 who slept under an (ever) insecticide treated bed net (Itn) Mosquito net use by pregnant women dhs (past night) Maternal and chIld health InterVentIons % of children aged 12-23 months who received BcG, measles, and three doses of polio and dPt, Full immunization dhs, MIcs either verified by card or by recall of respondent treatment of diarrhea % of children with diarrhea given oral rehydration salts (ors) or home-made solution dhs, MIcs % of children with a cough and rapid breathing who sought medical treatment for acute respiratory Medical treatment of arI dhs, MIcs infection (past 2 weeks) % of mothers aged 15 to 49 who received at least 4 antenatal care visits from any skilled personnel skilled antenatal care (4+ visits) dhs (doctor, nurse/midwife, auxiliary midwife, feldsher, family nurse, trained birth attendant) skilled birth attendance % of mothers aged 15 to 49 that were attended by any skilled personnel at child’s birth dhs contraceptive prevalence % of women aged 15 to 49 who currently use a modern method of contraception dhs, MIcs adult PreVentIVe care tB screening % of adults who were tested for tuberculosis (past year) Whs Voluntary counseling and testing for hIV % of women aged 18 to 49 who were tested for hIV and were told the results of the test Whs,MIcs cervical cancer screening % of women aged 18 to 69 who received a pap smear during last pelvic examination (past 3 years) Whs Breast cancer screening % of women aged 40 to 69 who received a mammogram (past 3 years) Whs adult curatIVe care Inpatient or outpatient (12 months) % of adults who used any inpatient or outpatient health care (past year) Whs Inpatient (12 months) % of adults who used any inpatient health care (past year) Whs Inpatient (5 years) % of adults who used any inpatient health care (past 5 years) Whs % of adults who used any outpatient health care (past year; conditional on having not used any outpatient (12 months) Whs inpatient care past 5 years) note: unless otherwise noted, all children are under the age of 5 and all adults are aged 18 and older About the Health Equity and Financial Protection datasheets The Health Equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. Topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. Data are drawn from the Demographic and Health Surveys, World Health Surveys, Multiple Indicator Cluster Surveys, Living Standards and Measurement Surveys, as well as other household surveys, and use a common set of health indicators for all countries in the series. All analyses are conducted using the health modules of the ADePT software. Also available are Health Equity and Financial Protection country reports. The most recent versions of the Health Equity and Financial Protection reports and datasheets can be downloaded at www.worldbank.org/povertyandhealth.