Health at a Glance

Asia/Pacific 2010

OECD
Copynghted nuBnaJ
Health at a Glance:
Asia/Pacific 2010

OECD
This work is published on the responsibility of the Secretary-General of the OECD. The
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Health at a Glance; Asia/Pacific 2010

© OECD 2010

Foreword

This first edition of Health at a Glance: Asia/Pacific presents a set of key indicators
on health and health systems for 27 Asia/Pacific countries and economies, including
four OECD member countries (Australia, Japan, New Zealand and the Republic of
Korea). It builds on the format used in previous editions of Health at a Glance: OECD
Indicators to present comparable data on health status and its determinants, health
care resources and utilisation, and health expenditure and financing.
Extending the Health at a Glance format to countries in the Asia/Pacific region
presents challenges. Countries in the region are diverse, and their health issues and
levels of health system development often differ. The indicators selected here
present a concise and quantitative overview of health and health systems in the
Asia/Pacific region, using available information. Alongside the resources of the OECD,
the production of Health at a Glance: Asia/Pacific benefitted greatly from the
statistics of the World Health Organization.

This publication was prepared jointly by the OECD Health Division and the
OECD/Korea Policy Centre, under the co-ordination of Luca Lorenzoni and Michael de
Looper. Chapter 1 and Chapter 2 were prepared by Michael de Looper. Chapter 3 was
prepared by Eunjeong Kang (Korean Institute for Health and Social Affairs), Ravi P.

Rannan-Eliya and Ruwanthi Wickramasinghe (Institute for Health Policy, Sri Lanka),

and Michael de Looper, Gaetan Lafortune and Valerie Moran. Chapter 4 was written
by Luca Lorenzoni and Hyoung-Sun Jeong (Yonsei University, Republic of Korea). This
publication benefited from the comments and suggestions of Mark Pearson (Head of
OECD Health Division), Martina Pellny and Christopher James (WHO WPRO), and
Sunil Senanayake (WHO SEARO).

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 3

CopyngnteO t
 TABLE OF CONTENTS

Table of Contents

Introduction 7
Chapter 1. Health Status 11
1.1 Life expectancy at birth 12
1.2 Infant mortality 14
1.3 Under-5 mortality 16
1.4 Mortality from all causes 18
1.5 Mortality from cardiovascular disease 20
1.6 Mortality from cancer 22
1.7 Mortality from injuries 23
1.8 Maternal mortality 26
1.9 Nutrition 28
1.10 Tuberculosis 30
1.11 Malaria 32
1.12 Diabetes 34

Chapter 2. Determinants of Health 37

2.1 Reproductive health 38
2.2 Low birthweight 40
2.3 Breastfeeding 42
2.4 Nutrition 44
2.5 Underweight and overweight 46
2.6 Water and sanitation 48
2.7 Tobacco 50
2.8 Alcohol 52

Chapter 3. Health Care Resources and Utilisation 55

3.1 Doctors and nurses 56
3.2 Consultations with doctors 58
3.3 Hospital beds and average length of stay 60
3.4 Hospital discharges 62
3.5 Pregnancy and birth 64
3.6 Childhood vaccination 66

Chapter 4. Health Expenditure and Financing 69

4.1 Health expenditure per capita 70
4.2 Health expenditure in relation to GDP 72

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 5

INTRODUCTION

4.3 Financing of health care 74

4.4 Health expenditure by function 76
4.5 Health expenditure by provider 78

Annex A: National data sources 81

Annex B; Additional information on demographic and economic contexts 83
Table A.l. Total mid-year population, thousands, 1960 to 2008 83
Table A.2. Share of the population aged 65 and over, 1960-65 to 2005-10 84
Table A.3. Crude birth rate, per 1 000 population, 1960 to 2008 85
Table A.4. Fertility rate, number of children per women
aged 15-49, 1960-65 to 2005-10 86
Table A.5. GDP per capita in 2008 and average annual
growth rates, 1970 to 2008 87

Bibliography 88

6 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010

 TABLE OF CONTENTS

Health at a Glance: Asia/Pacific 2010

© OECD 2010

Introduction

I~Iealth at a Glance: Asia/Pacific 2010 presents a set of key indicators on health and
health systems for 27 Asia/Pacific countries and economies, including four OECD
member countries (Australia, Japan, New Zealand and the Republic of Korea). It builds
on the format used in previous editions of Health at a Glance to present comparable
data on health status and its determinants, health care resources and utilisation, and
health expenditure and financing.
The indicators have been selected on a basis of being relevant to the health
needs of people in the Asia/Pacific region, taking into account the availability and
comparability of existing data. The publication takes advantage of the routine
administrative and programme data World Health Organization,
collected by the
especially the Western Pacific and South-East Asia Regional Offices (WPRO and
SEARO), as well as special country surveys collecting demographic and health
information.
It also draws on the resources of collaborative partnerships of experts and
agencies in the Asia/Pacific region, such as the Asia/Pacific National Health Accounts
Network (APNHAN).
The indicators are presented in the form of easy-to-read figures and explanatory
text.

Structure of the publication

Health at a Glance: Asia/Pacific 2010 is divided into four chapters:
• Chapter 1 on Health Status highlights the variations across countries in life

expectancy, infant and childhood mortality and major causes of mortality and
morbidity, including both communicable and non-communicable diseases.

• Chapter 2 on Determinants of Health focuses on non-medical determinants of health.

It features the health of mothers and babies, through reproductive health issues,

low birthweight and breastfeeding. It also includes lifestyle and behavioural

indicators such as smoking and alcohol drinking, nutrition, and underweight and
overweight, as well as water and sanitation.
• Chapter 3 on Health Care Resources and Utilisation reviews some of the inputs and
outputs of health care systems. This includes the supply of doctors and nurses and
hospital beds, as well as the provision of primary and secondary health care
services, such as doctor consultations and hospital discharges, as well as a range of
services surrounding pregnancy, childbirth and infancy.

• Chapter 4 on Health Expenditure and Financing examines trends in health spending

across Asia/Pacific countries. It also looks at how health services and goods are
paid for, and the different mix between public funding, private health insurance.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 7

INTRODUCTION

and direct out-of-pocket payments by households.

Annex B provides some additional tables on the demographic and economic
context within which different health systems operate.

Asia/Pacific countries

For this first edition of Health at a Glance: Asia/Pacific, T1 regional countries and
economies are compared - 22 in Asia (Bangladesh, Brunei Darussalem, Cambodia,
China, Democratic People’s Republic of Korea, Hong Kong-China, India, Indonesia,
Japan, Lao People’s Democratic Republic, Macao-China, Malaysia, Mongolia, Myanmar,
Nepal, Pakistan, Philippines, Republic of Korea, Singapore, Sri Lanka, Thailand and
Vietnam) and five in the Pacific region (Australia, Fiji, New Zealand, Papua New
Guinea and Solomon Islands).
Four of these countries are OECD members (Australia, Japan, New Zealand and
the Republic of Korea).

Presentation of indicators
Each of the topics covered in this publication is presented over two pages. The
first page defines the indicator and notes any significant variations which might
affect data comparability. It also provides brief commentary highlighting the key
findings conveyed by the data. On the facing page is a set of figures. These typically
show current levels of the indicator and, where possible, trends over time. In some
cases, an additional figure relating the indicator to another variable is included.

Averages
In text and figures, ’Asia-xx’ refers to the unweighted average for Asian countries
and economies, where ‘xx’ is the number of countries for which data are available. It
excludes the five Pacific countries (Australia, Fiji, New Zealand, Papua New Guinea
and Solomon Islands) and the OECD average.
‘OECD’ refers to the unweighted average for the 34 OECD member countries. It

includes Australia, Japan, New Zealand and the Republic of Korea, but excludes the
Asia average. Data for OECD countries are generally extracted from OECD sources,
unless stated otherwise.

Country codes (ISO codes)

Australia AUS Mongolia MNG
Bangladesh BGD Myanmar MMR
Brunei Darussalem BRN Nepal NPL
Cambodia KHM New Zealand N2L
China CHN Pakistan PAK
Democratic People's Republic of Korea PRK Papua New Guinea PNG
Fiji FJI Philippines PHL
Hong Kong-China HKG Republic of Korea KOR
India IND Singapore SGP
Indonesia IDN Solomon Islands SLB
Japan JPN Sri Lanka LKA
Lao People’s Democratic Republic LAO Thailand THA
Macao-China MAC Vietnam VNM

8 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 INTRODUCTION

Malaysia MYS

List of acronyms
ADB Asian Development Bank

AIDS Acquired immunodeficiency syndrome

ALOS Average length of stay

APNHAN Asia/Pacific National Health Accounts Network

ART Antiretroviral treatment

ASEAN Association of Southeast Asian Nations

BCG Bacille Calmette-Guerin

BMI Body mass index

CHE Current health expenditure

DHS Demographic and Health Surveys

DOTS Directly observed treatment - short course

DTP Diphtheria-tetanus-pertussis

FAO Food and Agriculture Organization of the United Nations

GAVI Global Alliance for Vaccines and Immunisation

GBD Global burden of disease

GDP Gross domestic product

GNI Gross national income

GP General practitioner

HIV Human immunodeficiency virus

lARC International Agency for Research on Cancer

IDF International Diabetes Federation

IHD Ischemic heart disease

MDG Millenium Development Goals

MICS Multiple Indicator Cluster Surveys

MMR Maternal mortality ratio

NHA National health accounts

OECD Organisation for Economic Co-operation and Development

PPP Purchasing power parities

SEARO WHO South-East Asia Regional Office

SHA System of Health Accounts

TB Tuberculosis

THE Total health expenditure

UN United Nations

UNAIDS Joint United Nations Programme on HIV/AIDS

UNDESA United Nations, Department of Economic and Social Affairs, Population Division

UNESCAP United Nations Economic and Social Commission for Asia and the Pacific

UNICEF United Nations Children's Fund

WHO World Health Organization

WPRO WHO Western Pacific Regional Office

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 9

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 Health at a Glance; Asia/Pacific 2010
© OECD 2010

Chapter 1

Health Status

1.1 Life expectancy at birth

1.2 Infant mortality

1.3 Under-5 mortality

1.4 Mortality from all causes
1.5 Mortality from cardiovascular disease

1.6 Mortality from cancer

1.7 Mortality from injuries

1.8 Maternal mortality

1.9 HIV/AIDS
1.10 Tuberculosis

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 11

1.1. LIFE EXPECTANCY AT BIRTH

expectancy at birth continues to increase

Life countries with similar income per capita. Vietnam
remarkably in Asia/Pacific countries, reflecting sharp and Japan have higher, and Brunei and Thailand
reductions in mortality rates at all ages. These gains lower life expectancies than would be predicted by
in longevity can be attributed to a number of factors, theirGNI per capita alone. The socioeconomic status
including rising living standards, and better nutrition, and educational level of women play an important
water and sanitation. Improved lifestyles, increased role in life expectancy, with improvements in the
education and greater access to quality health educational background and living conditions of
services also play an important role (OECD, 2004). mothers contributing to infant and child survival.
Life expectancy at birth for the whole Developing countries continue to struggle to
population across 22 Asian countries reached 71.6 overcome mortality causes that are linked to poorer
years on average in 2008, a gain of more than 14 years socio-economic conditions, while post-industrial
since 1970, For comparison, OECD countries gained countries face emerging health threats stemming
nine years during the same period (Figure 1.1.1). from rapid environmental and lifestyle changes
However, a large regional divide persists in life
(UNESCAP, 2005).
expectancy at birth. The country with the longest life

expectancy in 2008 was Japan, with a combined value For further reading
for men and women of 82.7 years. Hong Kong-China, WHO (2008), Health in Asia and the Pacific, World
Australia, Macao-China, Singapore and New Zealand Health Organization, Regional Office for Southeast
all exceeded 80 years for total life expectancy. In Asia, New Delhi.
contrast, a number of countries in the Asia/Pacific
region have combined life expectancies of less than
70 years, and in Cambodia, Papua New Guinea and
Definition and measurement
Myanmar, a child born in 2008 can expect to live an Life expectancy at birth is the best known
average of less than 62 years of life. Generally, Eastern measure of a population’s health status, and is
Asian countries (China, Japan, the Republic of Korea) often used to gauge countries’ health
had higher life expectancies at birth than Southeast development. It measures how long, on average,
Asian countries (Cambodia, Indonesia, Malaysia, the a newborn infant would live if the prevailing
Philippines, Thailand, Vietnam) and Southern Asia patterns of mortality at the time of birth were to
countries (India, Pakistan, Bangladesh). stay the same throughout their lifetime. As the

Despite health improvements, there are still

factors which affect life expectancy do not

disparities in life expectancy between men and change overnight, variations are best assessed
women and within countries. Women live longer over long periods of time.
than men, and have greater rates of survival to age 65, Age-specific mortality rates are required to
regardless of the economic status of the country construct life tables from which life

(Figures 1.1.2 and 1,1.4). The gender gap in life expectancies are derived. Countries calculates
expectancy stood at 4.4 years on average across Asian expectancy according to methodologies that
life

countries in 2008, less than the OECD country average can vary somewhat, and these can lead to
of 5.6 years. differences of fractions of a year. Some countries

Higher national income (as measured by GNI base their life expectancies on estimates derived
per capita) is generally associated with higher life
from censuses and surveys, and not on accurate
registration of deaths.
expectancy at birth (Figure 1.1.3), although there are
some notable differences in life expectancy between

12 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 1.1. LIFE EXPECTANCY AT BIRTH

1.1.1. Life expectancy at birth, total population, 1.1.2. Life expectancy at birth, by sex, 2008
1970 and 2008

Japan
Hong Kong-China
Australia

Macao-China
Singapore
New Zealand
Korea, Rep.
OECD
Brunei Darussalam

Malaysia
Vietnam
Sri Lanka
China
Philippines

Asia-22
Indonesia

Fiji

Thailand

Korea. DPR
Nepal
Mongolia
Pakistan
Solomon Islands

Bangladesh
Lao PDR
India

Myanmar
Papua New Guinea
Cambodia

40 50 60 70 80 90
Years

1.1.3. Life expectancy at birth and GNI per 1.1.4. Survival rate to age 65, 2008
capita, 2008
Life expectancy in years

GNI per capita (PPP Int. $)

/ /
Sources: OECD Health Data 2010; The World Bank, World Development Indicators Online.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 13

1.2. INFANT MORTALITY

Infant mortality reflects the effect of economic reductions in infant mortality across the Asia/Pacific
and social conditions on the health of mothers and region.
new-borns, as well as the effectiveness of health Infant mortality can be reduced through
systems. Around two-thirds of the deaths that occur relatively inexpensive public health campaigns, such
during the first year of life in the region are neonatal as immunization, and offering clean water and
deaths (i.e. during the first four weeks of life). Factors sanitation. Oral rehydration therapy helps to save
such as the health of mothers, maternal care and many young lives, and is a cheap and effective means
birth weight are important determinants of infant to offset the debilitating effects of diarrhoea, one of
mortality. Diarrhoea, pneumonia and undernutrition the main causes of infant deaths. But to minimise the
of both mothers and babies are the causes of many avoidable tragedy of infant deaths, renewed efforts
deaths. willbe required on a sustainable basis (WHO, 2008a).
Countries with higher levels of economic While it is widely agreed that eradicating poverty is a
development generally have lower infant mortality key factor in reducing mortality rates, debate
rates. In 2008, OECD countries averaged five infant continues as to whether mortality declines are linked
deaths per 1 000 live births; among 19 Asian countries, to better nutritionand improvements in preventing
the average was 30 deaths (Figure 1.2.1). premature deaths, or whether more specific
Geographically, infant mortality lower in eastern
is government programmes play a central role in
Asian countries, and higher in South and Southeast changing the health behaviour of individuals (UNICEF,
Asia. Singapore, Japan, the Republic of Korea and 2008b).
Australia had rates lower
than five deaths per 1 000
live births in whereas rates in Pakistan,
2008, For further reading
Myanmar, Cambodia, Papua New Guinea and India UNICEF Tracking Progress in Maternal,
(2008),
were greater than 50. Newborn and Child Suruiual: the 2008 Report, UNICEF,
Infant mortality rates have fallen dramatically New York.
in the Asia/Pacific region over the last 30 years, with
many countries, including China, India and Indonesia,
experiencing declines of between 50 and 70% (Figures Definition and measurement
1.2.2 and 1.2.3). In Singapore, Malaysia, the Republic The infant mortality rate is one of the most
of Korea, Vietnam and Thailand, rates have fallen by important statistics for measuring the health of
three-quarters. Falls in Myanmar, the Solomon a population. It is defined as the number of
Islands,Cambodia, Papua New Guinea and Pakistan children who die before reaching their first

have been less pronounced, even though these birthday in a given year, expressed per 1 000 live
countries had high levels of infant mortality in 1980. births.
This has led to growing gaps between these countries Some countries base their infant mortality
and others in the region.
rates on estimates derived from censuses and
Inequalities in infant mortality rates also exist surveys, and not on accurate registration of
within countries (Figure 1.2.4), with the richest births and deaths. Differences among countries
population quintile gaining access to key health in registering premature infants may also add
interventions more quickly than the poorest. slightly to international variation in rates.
Reducing both types of inequity - between and
within countries - is crucial for achieving lasting

14 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 1.2. INFANT MORTALITY

1 2 1 Infant mortality rates,

. . . 2008 1.2.2. Decline in infant mortality rates,
1980-2008

Pakistan

Myanmar
Cambodia
Papua New Guinea
India

Lao PDR
Bangladesh
Korea, DPR
Nepal
Mongolia
Indonesia
Asia-19
Solomon Islands

Philippines

China
Fiji

Sri Lanka
Thailand

Vietnam
Brunei Darussalam

Malaysia
New Zealand
OECD
Australia

Korea. Rep.
Japan
Singapore

80 60 40 20 0 0 25 50 75 100
Deaths per 1 000 live births % Change over period

Source: OECD Health Data 2010; UNICEF Childinfo.

1 2 3 Infant mortality rates,

. . . 1 2 4 Infant mortality rate ratios
. . . by wealth quintiles,
selected countries, 1980-2008 selected countries and years

• Auslralia
I
—China •

Deaths per 1 QOO live births

Source; OECD Health Data 2010; UNICEF Childinfo. Sources: DHS 2006-2009; Gwatkin et al., 2007.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 15

1.3. UNDER-5 MORTALITY

The under-5 mortality rate is another sensitive also Indicator 1.2, “Infant mortality”). Since mortality
indicator of both the level of child health and the rates for the post-neonatal period and between ages
development and well-being of a population. In 1950- one and four have limited further scope for
1955, almost one-quarter of all children bom improvement, a substantial decline in neonatal
worldwide did not reach their fifth birthday. By 1990, deaths will need to occur to meet UN targets for 2015.
this had been lowered to less than one-in-ten. As part As is the case for infant mortality, inequalities
of their Millennium Development Goals, the United in under-5 mortality rates exist both between and
Nations has set a target of further reducing under-5 within countries, with good care being less accessible
mortality by two-thirds between 1990 and 2015 to the needy, whether this is measured by rural-
(United Nations, 2009a). urban regions, by level of wealth or by level of
In 2008, 8.8 million children died worldwide maternal education (Figure 1.3.4). For some countries,
before their fifth birthday, and one-third of these the difference in the under-5 mortality rates between
deaths (2.9 million) occurred in the Asia/Pacific region the poor and rich is vast. For example, in India,
(Black et al., 2010). The average under-5 mortality rate children in the poorest 20% of the population are
across 20 Asian countries was 39 deaths per 1 000 live three times more likely to die before their fifth
births (Figure 1.3.1). Singapore, Japan and the birthday than those in the richest 20%. In recent
Republic of Korea had achieved very low rates (five or decades, no country for which trend data are
under), these being lower than the average across available has managed to reduce inequalities while
OECD countries (6 deaths per 1 000 live births). reducing child mortality (WHO, 2008a). Significant
Mortality rates in Pakistan, Cambodia and Myanmar, progress in reducing under-5 mortality will depend
however, were high, approaching 100. Rates are on gains made among the poorest people in the
generally lower for females than males, although this highest mortality countries.
isnot the case in China, India and the Republic of
Korea (WHO, 2008a). For further reading
Deaths from causes occurring during the UNICEF (2008), The State of Asia/Pacific's Children
neonatal period (the first four weeks of life), along 2008: Child Suruiual, UNICEF, New York.
with diarrhoea, pneumonia and injuries are leading
causes of death among children aged under five years
(Figure 1.3.2), Around half of all under-5 deaths occur Definition and measurement
during the neonatal period in the region, and in Under-5 mortality is defined as the probability
Brunei Damssalam, New Zealand, Singapore and of a child born in a given year dying before
Thailand, more than 60%. reaching their fifth birthday, and is expressed
Substantial progress has been made in reducing per 1 000 live births. Since under-5 mortality is

under-5 mortality across Asian countries over recent derived from a life table, it is, strictly speaking,

decades (Rajaratnam et al, 2010). From an average of not a rate but a probability of death.
around 100 deaths per 1 000 live births in 1980, rates Age-specific mortality rates are required to
have fallen to the current value of 39 (Figure 1.3.3). construct life tables from which under-5
Improvements in China, India and Indonesia are mortality is derived. Some countries base their
noteworthy, with current rates less than half of 1980 estimates on censuses and surveys, and not on
values. However, much of the fall occurred among accurate registration of deaths.
infants older than four weeks, with very little
reduction in the neonatal period (WHO, 2008a; see

16 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 1.3. UNDER-5 MORTALITY

1.3.1. Under-5 mortality rates, 2008 1.3.2. Distribution of causes of death among children
aged under 5 years, 2008 (%)
Myanmar
Cambodia
Pakistan
India

Papua New Guinea

Lao PDR
Korea, DPR
Bangladesh
Nepal
Indonesia
Mongolia
Asia-20
Solomon Islands
Philippines

China
Fiji

SrI Lanka
Thailand
Vietnam
Brunei Darussalam

OECD
Australia

Malaysia

New Zealand
Korea, Rep.
Japan
Singapore

0 25 50 75 100
Deaths per 1 000 live CMrths Neonatal Diarrhoea Pneumonia
oinjuries aOther

Source: UNICEF Ghildinfo. Source: WHO. 2010d.

1.3.3. Under-5 mortality rates, selected countries, 1.3.4. Under-5 mortality rate ratios,
1980-2008 selected countries and years
China intia — indoneaia Rate ratio
— ---Asia-20 OECD
Deaths per 1 000 live births

Source: UNICEF Childinfo; World Bank WDI. Sources; WHO, 2010d; DHS 2006-2009.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 17

1.4. MORTALITY FROM ALL CAUSES

Mortality rates are one of the most common region (Figure 1.4.3). Increasing development in
measures of population health. Statistics on countries brings an ‘epidemiological transition’,
important life events such as birth and death remain whereby communicable diseases are replaced by
the most widely available and comparable sources of non-communicable diseases, and early deaths by late
health information across whole populations, deaths (WHO, 2008a).
although the coverage, completeness and reliability
of these data are problematic for many countries in For further reading
the Asia/Pacific region. The World Health
WHO Health in Asia and the Pacific,
(2008),
Organization uses available data and information to
World Health Organization, Regional Office for
derive comparable estimates of mortality and its
Southeast Asia, New Delhi.
causes.

There are wide disparities in adult mortality in

the region. For males in 2008, the probability of dying Definition and measurement
between ages 15 and 60 ranged from a low of 81 per Mortality rates are calculated by dividing
1 000 population in Australia, to 368 per 1 000 in annual numbers of deaths by mid-year
Myanmar (Figure 1.4.1). It also exceeded 300 per 1 000 population estimates. Rates have been age-
population in the Lao PDR and Sri Lanka, and was standardised to the World Standard Population
less than 100 not only in Australia, but also in to remove variations arising from differences in
Singapore, Japan and New Zealand. Across 20 Asian age structures across countries.
countries, the average probability of dying for males Complete vital systems do not
registration
aged 15-60 in 2007 was 221 per 1 000 population, exist in many developing countries, and about
almost twice the average in OECD countries (115). one-third of countries in the region do not have
Among females, the probability ranged from 43 recent data (WHO, 2008a). Misclassification of
per 1 000 population in Japan and the Republic of causes of death is also an issue. A general

Korea to a high of 304 in Myanmar. Probabilities also assessment of the coverage, completeness and
exceeded 200 in the Lao PDR, Nepal, Papua New reliability of causes of death data has been
Guinea, Bangladesh and Cambodia. They were less published by WHO (Mathers et al, 2005).
than 50 not only in Japan, but also the Republic of The WHO Global Burden of Disease project
Korea, Australia and Singapore, Across 20 Asian draws on a wide range of data sources to
countries, the average probability of dying for females quantify global and regional effects of diseases,
aged 15-60 in 2008 was 155 per 1 000 population, injuries and risk factors on population health.
more than two and a half times the average in OECD The latest assessment of GBD is for 2004. WHO
countries (58). Disparities between countries for has also developed life tables for all Member
females were greater than those for males. States, based on a systematic review of all
Estimates of mortality rates by cause of death available evidence on mortality levels and
are available for the year 2004. Non-communicable trends. The probability of dying between 15 and
diseases such as cardiovascular diseases and cancers 60 years of age (adult mortality rate) derive from
are the most common causes of death, being these life tables.

responsible for about two-thirds of all deaths, on Mortality rates reported here represent the
average, across 20 Asian countries (Figure 1.4.2). In best estimate of WHO - based on evidence
OECD countries, the average is higher at 86% (see also available in 2008 - rather than official estimates
Indicator 1.5, "Mortality from cardiovascular of their Member States. The estimates have been
diseases”, and Indicator 1.6, “Mortality from cancer”). calculated using standard categories and
Injuries are responsible for between 5-10% of all
methods to ensure cross-national comparability.
deaths, but this figure rises when widespread natural Therefore, they are not always the same as
disasters such as the 2004 tsunami occur, as official national estimates, nor necessarily
happened in Sri Lanka (see Indicator 1.7, “Mortality endorsed by Member States. Official Korean
from injuries”). national estimates, for example, are lower than
Communicable diseases such as respiratory WHO estimates.
infections, diarrhoeal diseases and tuberculosis,
along with maternal and perinatal conditions, remain
major causes of death among many countries in the

18 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 1.4. MORTALITY FROM ALL CAUSES

1 . 4 1 Adult mortality rate, 2008 (probability of dying between 15 and 60 years per 1 000 population)
. .

Source; WHO, 2010d.

1 4 2. . . Estimated mortality rates by cause, 2004 1 . 4 3 Estimated mortality rates due to communicable
. .

diseases, 2004

Cambodia
Lao PDR
Myanmar
Nepal
Papua New Guinea
Sri Lanka
Bangladesh
Pakistan
India

Indonesia
Mongolia
Korea, DPR
Asia-20
Fiji

Solomon Islands
Philippines

Vietnam
Malaysia
Thailand
China
Korea, Rep.
Brunei Darussalam
OECD
Singapore
New Zealand
Australia

Japan

2 000 1 500 1 000 500 0

0 100 200 300 400 500 600 700
Age-standardised rates per 100 000 population Age-standardised rates per 100 000 population

Source; WHO Global Burden of Disease, 2008.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 19

1.5. MORTALITY FROM CARDIOVASCULAR DISEASE

Cardiovascular disease has long been the main As the proportion of aged persons increases in
cause of death in developed countries, but it has the Asia/Pacific region, up to half of the world's
become increasingly prevalent in recent decades in cardiovascular burden can be expected to occur in
Asia/Pacific countries as well. It now accounts for the area (Sasayama, 2008). Increases in total
about one-third of all deaths across the region. cholesterol and blood pressure, along with smoking,
Cardiovascular disease covers a range of diseases overweight/obesity and diabetes highlight the need
related to the circulatory system, including ischaemic for management of risk factors to forestall an
heart disease (known as IHD, or heart attack) and epidemic of cardiovascular disease.
cerebrovascular disease (or stroke). Together, IHD and
stroke comprise over 70% of all cardiovascular deaths For further reading
in the twenty Asian countries included here. Ueshima, H. et “Cardiovascular
al. (2008),
Estimates for the year 2004 indicate high levels Disease and Risk Factors in Asia: A Selected Review”,
of death from cardiovascular disease exceeding 400 - No. 25, pp. 2702-2709.
Circulation, Vol. 118,
deaths per 100 000 population - in a large group of
countries, including Mongolia, Lao PDR and Fiji
(Figure 1.5.1). This is in contrast to a group of
Definition and measurement
developed countries (Japan, Australia, New Zealand, Mortality rates are calculated by dividing
Singapore, Republic of Korea) where death rates were annual numbers of deaths by mid-year
below 200 per 100 000 population. Mortality rates population estimates. Rates have been age-
from cardiovascular disease are half as much again in standardised to the World Standard Population
Asian countries as in OECD countries (314 versus 201 to remove variations arising from differences in
deaths per 100 000 population). age structures across countries.
Rates of cardiovascular disease increase with Complete registration systems do not
vital
age (Figure 1.5.3). Among younger age groups (0-29 exist in many
developing countries, and about
years), rates are higher in Southeast Asian countries, one-third of countries in the region do not have
but rates of mortality among middle- and older-aged recent data (WHO, 2008a). Misclassification of
persons are higher in European countries. Mortality causes of death is also an issue. A general

rates are lower at all ages in Western Pacific region assessment of the coverage, completeness and
countries. reliability of causes of death data has been

The types of cardiovascular diseases that are published by WHO (Mathers et al, 2005).
fatal to persons in the region differ across countries. The WHO Global Burden of Disease project
In countries such as Japan, the Republic of Korea, draws on a wide range of data sources to
China, Thailand, Vietnam and Mongolia, morbidity quantify global and regional effects of diseases,
and mortality from stroke is greater than from injuries and risk factors on population health.
ischaemic heart disease (Figure 1.5.2). In European The latest assessment of GBD is for 2004.
and North American countries, but also in Singapore, Mortality rates reported here represent the
India, Pakistan and Bangladesh, the opposite is true best estimate of WHO - based on evidence
(Ueshima et al, 2008). This can largely be explained by available in 2008 - rather than official estimates
differences in levels of risk factors for cardiovascular of their Member States. The estimates have been
disease across countries. In most Asian countries, calculated using standard categories and
cholesterol levels tend to be lower than European
and methods to ensure cross-national comparability.
North American countries, but up to two-thirds of Therefore, they are not always the same as
cardiovascular disease can be attributed to official national estimates, nor necessarily
hypertension, reinforcing the importance of blood endorsed by Member States, Official Korean
pressure often accompanies high salt intake, whereas national estimates, for example, are lower than
low cholesterol levels are associated with lower fat WHO estimates.
intake. In China, average daily salt intake for men in
2002 was 12g per day, approximately twice the level
recommended by Chinese dietary guidelines (Herd et
al.,2010)

20 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 1.5, MORTALITY FROM CARDIOVASCULAR DISEASE

1.5.1. Cardiovascular disease, estimated mortality 1.5.2. Proportion of cardiovascular diseases, 2004
rates, 2004

Mongolia
Lao PDR
Fiji

Nepal
Papua New Guinea
Myanmar
Bangladesh
Pakistan
India

Cambodia
Solomon Islands
Korea. DPR
Indonesia
Philippines
Asia-20
Sri Lanka
Vietnam
China
Malaysia
OECD
Brunei Darussalam
Korea. Rep.
Thailand
Singapore
New Zealand
Australia
Japan

500 400 300 200 100 0

Age-standardised rates per 100 000 population

Per cent

1.5.3. Cardiovascular disease, age-specific mortality rates by region, 2004

Europe Southeast Asia ——— Western Pacific

Per 100 000 population
(log scale)

Age group

Source; WHO Global Burden of Disease, 2008.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 21

1.6. MORTALITY FROM CANCER

Cancer is a leading cause of death worldwide. services are inaccessible to large numbers of women
Cancer was the cause of an estimated 3.6 million in the region (WHO, 2008a).
deaths (or 13% of total deaths) in Asia/Pacific As with cardiovascular disease, an ageing
countries in 2008. Cancer deaths in the region total population will lead to many more cases of cancer in
almost half of all worldwide cancer deaths (Boyle and coming decades, and Asia alone can expect up to five
Levin, 2008). million annual cancer deaths by 2030, taxing
Countries with higher cancer mortality rates, underprepared health systems. Since the drugs and
based on 2004 estimates, include the Republic of technologies for treating patients are expensive,
Korea, Cambodia, China and the Lao PDR, all with cancer control planning in the Asia/Pacific region
over 140 deaths per 100 000 population (Figure 1.6.1). might more effectively target smoking, physical
However, the country with the highest rate was activity, overweigh t/obesity and nutrition.
Mongolia, at almost 300 deaths per 100 000
population. A large proportion of this was due to For further reading
deaths from liver cancer, precipitated by hepatitis B Boyle, P. and B. Levin (eds.) World Cancer
(2008),
infection.
Report 2008, WHO/IARC, Lyon.
Cancer deaths were less common in the
Solomon Islands, Fiji, the Philippines, the Democratic
People’s Republic of Korea and India, with 100 deaths Definition and measurement
per 100 000 population or less. The average rate of Mortality rates are calculated by dividing
death in twenty Asian countries was slightly lower annual numbers of deaths by mid-year
than that in OECD countries (129 versus 141 deaths population estimates. Rates have been age-
per 100 000 population). Cancer also accounts for a standardised to the World Standard Population
much higher proportion of deaths in OECD countries, to remove variations arising from differences in
at 27% in 2006 (OECD, 2009). age structures across countries.
Age-specific mortality European
rates in Complete vital registration systems do not
countries are similar to those in the Western Pacific exist in many developing countries, and about
region (Figure 1.6.3). Rates in Southeast Asian one-third of countries in the region do not have
countries are lower than for Europe and the Western recent data (WHO, 2008a). Misclassification of
Pacific after the age of 30. causes of death is also an issue. A general
Lung cancer remains the main cause of cancer assessment of the coverage, completeness and
mortality, averaging 17% of all cancers in 20 Asian reliability of causes of death data has been
countries. Rates are comparatively high in published by WHO (Mathers et al, 2005).
Bangladesh, Myanmar and Singapore (Figure 1.6.2). It The WHO Global Burden of Disease project
is anticipated that rates will continue to rise if strong draws on a wide range of data sources to
anti-smoking initiatives are not undertaken. quantify global and regional effects of diseases,
Mortality from stomach cancer is also common, injuries and risk factors on population health.
largely caused by Helicobactor pylori infection, with The latest assessment of GBD is for 2004.
deaths more prevalent in the Democratic People’s Mortality rates reported here represent the
Republic of Korea, China and the Republic of Korea. best estimate of WHO - based on evidence
Besides Mongolia, liver cancer deaths occur available in 2008 - rather than official estimates
more frequently in Thailand, Lao PDR and China. of their Member States. The estimates have been
Incidence is expected to fall in coming decades, with calculated using standard categories and
increased immunization for hepatitis B. Colorectal methods to ensure cross-national comparability.
cancer deaths are higher in Singapore, New Zealand Therefore, they are not always the same as
and Malaysia. Breast cancer deaths, the most official national estimates, nor necessarily
common cause among women, are responsible for endorsed by Member States. Official Korean
more than 10% of all cancer deaths in Pakistan, Fiji, national estimates, for example, are lower than
the Philippines and Indonesia. Although early WHO estimates.
detection and therapy can reduce mortality, these

22 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 1.6. MORTALITY FROM CANCER

1 6 1 All cancers,
. . . estimated mortality rates, 2004 1 6 2
. . . Proportion of cancers, 2004

Mongolia
Korea, Rep.
Cambodia
China
OECD
LaoPDR
Malaysia
New Zealand
Thailand
Asia-20
Indonesia
Australia

Japan
Nepal
Vietnam
Sri Lanka
Papua New Guinea
Singapore
Myanmar
Bangladesh
Brunei Darussalam
Pakistan
India

Korea, DPR
Philippines
Fiji

Solomon Islands

0 20 40 60 80 100
Stomach Colorectal Liver
Age-standardised rates per 100 000 population
Lung Breast All other

Per cent
WHO estimates are significantly higher than official national estimates (130).

1 6 3 All cancers, age-specific mortality rates

. . . by region, 2004

Per 100 000 population _ —«»

-• Europe u
Southeast.a
Asia
•

Western «
v., r-
Pacific

Source; WHO Global Burden of Disease, 2008.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 23

Ccpynghwa I
1.7. MORTALITY FROM INJURIES

Injury is a leading cause of death and disability et al., 2002). Some countries, including China, have

for all age groups up to age 60 years, causing around developed national policies and programmes for
six million deaths annually. In the Asia/Pacific region, prevention, and others have begun public awareness
it isestimated that injuries caused about 3.1 million campaigns. ASEAN countries, for instance, in
deaths in 2004, or over 8 600 deaths daily, which collaboration with the Asian Development Bank, are
constituted 55% of worldwide injury deaths. However, implementing action plans for road safety (WHO,
the magnitude of the problem varies considerably 2008a). However, injury mortality remains a
across countries by cause, age, sex, and income group. significant public health problem in the region.

Developing countries have injury-related

mortality rates that are higher than developed For further reading
countries. Among a group of 20 Asian countries, Peden, M., K. McGee and E. Kmg (eds.) (2002),
average injury mortality was estimated to be over 100 Injury, A Leading Cause of the Global Burden of Disease,
deaths per 100 000 population in 2004 (Figure 1.7.1). 2000, World Health Organization, Geneva.
Sri Lanka and Indonesia both had high mortality
rates in this year, although this was largely due to the
effects of the catastrophic December 2004 tsunami, Definition and measurement
which killed over 230 000 persons. But even if these Mortality rates are calculated by dividing
countries are excluded, injury mortality in Asian annual numbers of deaths by mid-year
countries averages more than twice that in OECD population estimates. Rates have been age-
countries. Among a group of largely developed standardised to the World Standard Population
countries, including Singapore, Australia and Japan, to remove variations arising from differences in
injury mortality was lower than 50 deaths per 100 000 age structures across countries.
population. Complete registration systems do not
vital
Over half of all injury-related mortality occurs exist in many
developing countries, and about
in the 5-44 years age group. Countries in the one-third of countries in the region do not have
European and Western Pacific region (which includes recent data (WHO, 2008a). Misclassification of
Japan, New Zealand and Australia) have largely causes of death is also an issue. A general

similar age-specific mortality rates (Figure 1.7.3). assessment of the coverage, completeness and
Mortality rates in the Southeast Asian region tend to reliability of causes of death data has been
be higher than in these other two regions from the published by WHO (Mathers et al, 2005).
age of 45 years onwards. The WHO Global Burden of Disease project
The causes of injury deaths differ across draws on a wide range of data sources to
countries in the region. In Brunei Darussalam, quantify global and regional effects of diseases,
Mongolia and Malaysia, one-third or more of all injuries and risk factors on population health.
injury deaths are due to road traffic accidents (Figure The latest assessment of GBD is for 2004.
1.7.2). However because of their population size, the
Mortality rates reported here represent the
two leading countries with the highest numbers of best estimate of WHO - based on evidence
road traffic deaths worldwide are China and India available in 2008 - rather than official estimates
(WHO, 2009a). In Japan, Singapore and the Republic of of their Member States. The estimates have been
Korea, self-inflicted injuries are the leading cause of calculated using standard categories and
injury mortality. In Nepal, acts of war were methods to ensure cross-national comparability.
responsible for many deaths in 2004. Deaths from Therefore, they are not always the same as
interpersonal violence are more common in the official national estimates, nor necessarily
Philippines, Democratic People’s Republic of
the endorsed by Member States, Official Korean
Korea and Cambodia. Apart from road traffic injuries, national estimates, for example, are lower than
drowning and fire-related bums are also leading WHO estimates.
causes of injury-related deaths among children in the
region (Peden et al., 2008).

Injury deaths, both intentional and

unintentional, are largely preventable events (Peden

24 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 1.7. MORTALITY FROM INJURIES

1 7 1 Injuries,
. . . estimated mortality rates, 2004 1 7 2
. . . Proportion of injuries, 2004

458 Sri Lanka

233 Indonesia

129 Lao PDR

119 Nepal

116 India

Asia-20
Papua New Guinea
Bangladesh
96 Myanmar
92 Thailand

91 Pakistan

86 Mongolia

73 China

73 Cambodia
67 Korea, Rep.

64 Vietnam

62 Korea, DPR
59 Philippines

53 Malaysia

EH OECD
39 Japan
39 New Zealand
36 Fiji

36 Solomon Islands

32 Australia

29 Brunei Darussalam

27 Singapore

500 400 300 200 100 0

0 20 40 60 80 100
n Road traffic accidents Self-inflicted injuries
Age-standardised rates per 1X 000 population Falls Violence
All other injuries

Per cent

Note; High rates in Sri Lanka and Indonesia are due to the catastrophic tsunami of December 2004.

1 7 3 Injuries, age-specific mortality rates

. . . by region, 2004

Per 100 000 population

Europe Southeast Asia ——— Western Pacific

Source; WHO Global Burden of Disease, 2008.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 25

1.8. MATERNAL MORTALITY

In different countries and to varying extents, Lanka and Thailand are attended by skilled health
pregnancy and childbirth have inherent risks. professionals, there are several countries in the
Maternal mortality - the death of a woman during region (including Bangladesh, Lao PDR and Nepal)
pregnancy, childbirth, or in the weeks after delivery - where the proportion is less than one in five (see
is an important indicator of woman’s health and Indicator 3,4). The lack of social status for girls and
status. It shows clearly the differences between rich women in some countries in turn limits their
and poor, with the vast majority of deaths occurring prospects for education, economic resources and
in developing countries (WHO, 2009d). Fertility and decision making. Renewed efforts will need to be
maternal mortality have strong associations with undertaken by countries in the region if the WHO
economic development and GDP. Millennium Development Goal of reducing MMR by
In developed countries, the maternal mortality three-quarters from 1990 to 2015 is to be met.

ratio (MMR) averages around ten deaths per 100 000

live births; in disadvantaged countries, it is an order For further reading
of magnitude greater (Figure 1.8.1). Estimates for 2008 WHO (2010), Trends in Maternal Mortality: 1990 to
show a small group of countries (Japan, Australia, 2008, World Health Organization, Geneva.
Singapore, New Zealand, Republic of Korea, Brunei
Hogan, M. C. et al. (2010), “Maternal Mortality for
Darussalam, Fiji) with very low MMR, and a second
181 Countries, 1980-2008: A Systematic Analysis of
group, including China, Sri Lanka, Thailand, Vietnam
Progress Towards Millennium Development Goal 5”,
and the Philippines, with MMR between 30-100 (WHO, The Lancet, Vol. 375, No. 9726, pp. 1609-1623,
2010b). A larger group of countries, including India,
Indonesia, Pakistan and Bangladesh, have MMR above
200 deaths per 100 000 live births. Definition and measurement
Almost 360 000 maternal deaths were estimated Maternal mortality is defined as the death of a
to have occurred worldwide in 2008. More than one- woman during pregnancy or childbirth or in the
quarter of the world’s maternal mortality burden (100 42 days after delivery from any cause that was
000 deaths) occurred in India, Pakistan, Bangladesh related to or aggravated by the pregnancy (WHO,
and Indonesia alone. Large numbers of maternal 2007a). This includes direct deaths from
deaths also occurred in China (Figure 1.8.2). obstetric complications of pregnancy,
However, significant progress in reducing interventions, omissions or incorrect treatment.

maternal mortality has occurred in the region over It also includes indirect deaths due to previously

the last two decades (Figure 1.8.3). Average MMR existing diseases, or diseases that developed

across 20 Asian countries has been halved, from an during pregnancy, where these were aggravated
estimated 340 deaths per 100 000 live births in 1990, by theeffects of pregnancy.

to 162 in 2008, although this figure is affected by Maternal mortality is here measured using the
countries with very high MMR. India, Pakistan, maternal mortality ratio (MMR), i.e. the number
Bangladesh, Indonesia and China have all seen of maternal deaths in a population divided by
significant falls in maternal mortality; in China’s case the number of live births. MMR assesses the risk
falling by two-thirds, from 110 deaths per 100 000 live of maternal death relative to the number of live
births in 1990 to 38 in 2008. The Democratic People’s births.
Republic of Korea and Papua New Guinea have seen There are difficulties in identifying maternal
less progress.
deaths precisely. Many countries in the region do
Increased fertility presents a greater lifetime not have complete and accurate vital
risk for women in Asia/Pacific countries. Yet maternal registration systems, and so the MMR is derived
death is not inevitable, and can be reduced through from other sources, including censuses,
increased use of contraception, better access to high- household surveys, sibling histories, verbal
and greater education and status
quality health care, autopsies and statistical studies. Because of this,
forwomen. Although almost all births in countries estimates should be treated cautiously.
such as the Democratic People’s Republic of Korea, Sri

26 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 1,8. MATERNAL MORTALITY

1.8.1. Estimated maternal mortality ratio^ 2008

Per 100 000 live births

1.8.2. Estimated number of maternal deaths in 1.8.3. Estimated maternal mortality ratios,
5 leading countries, 2008 selected countries, 1980-2008

Indie Indone^ie Chine Asle-20

PerlOO 000 live

births

Source; WHO, 2010c.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 27

1.9. HIV/AIDS

Although the first cases of AIDS in Asia were awareness programmes to inform the public about
reported in 1984 and 1985, the more extensive spread the threat of HIV/AIDS. But the level of HIV
of HIV began late compared with the rest of the world, knowledge among young people varies markedly
occurring in Cambodia, India, Myanmar and Thailand across countries according to surveys (Figure 1.9.3). A
in the early 1990s (Ruxrungtham et al, 2004). But by majority of young people at higher risk knew that
2007, 4.7 million people in the region were living with condoms can protect against sexual HIV transmission,
HIV/AIDS, with about half of these in India. In this although fewer than half of young people surveyed in
year alone, there were 420 000 new infections and 293 Papua New Guinea reported using a condom during
000 deaths. their last sexual encounter (UNAIDS, 2009).

Asia second only to sub-Saharan Africa as the

is Around one-third of persons needing
location with the greatest number of people with HIV. antiretroviral treatment (ART) in Asia receive it.
Most of Asia’s epidemic occurs among sex workers However, this figure varies markedly across countries,
and their clients, men who have sex with men and from less than 10% in Pakistan, Nepal and
injecting drug users. Gay men in Asia face odds of Bangladesh, to almost all people (95%) in the Lao PDR
nearly one in five of being infected with HIV during (Figure 1.9.4). The Lao PDR’s National Socioeconomic
their lifetime. However, HIV is also spreading through Development Plan for 2006-2010 addressed HIV/AIDS,
transmission to the sexual partners of those at risk. and indicated the government's commitment to
About 0.3% of the adult population in the expanding the national response to the disease. In
have HIV infection. Prevalence in
Asia/Pacific region India, the country with the greatest disease burden,

Pacific countries is generally very low, although only 10% of people living with advanced HIV infection
Papua New Guinea is an exception at 1.4% of the receive ART.

population (Figure 1.9.1). Thailand is the only other

Asia/Pacific country where adult HIV prevalence For further reading

exceeds 1%. Cambodia and Myanmar have UNAIDS (2009), AIDS Epidemic Update: Nouember
comparatively high rates, greater than 500 per 100 2009, Joint United NationsProgramme on HIV/AIDS
000 population. This is in contrast to a number of (UNAIDS) and World Health Organization, Geneva.
countries where rates are less than one-tenth of that
figure - Japan, Bangladesh, the Philippines, Sri Lanka,
the Republic of Korea and New Zealand - all at less
Definition and measurement
than 50 per 100 000 population. Acquired immunodeficiency syndrome, or
AIDS, is a disease of the body's immune system
More than 2.4 million people in India were
living with HIV in 2007, a number greater than in all caused by the human immunodeficiency virus
(HIV). A person who tests positive for HIV is
OECD countries combined (Figure 1.9.2). China (700
000), Thailand (610 000) and Vietnam, Indonesia and
considered to have progressed to AIDS when a
Myanmar (each more than 200 000) face significant laboratory test shows that their immune system
is severely weakened by the virus, or when they
disease burdens. It is estimated that fewer than one
in three people living with HIV in China has been develop at least one of a number of different
diagnosed (UNAIDS, 2009). HIV prevalence is opportunistic infections.

increasing in some parts of the region, including The HIV prevalence rate is the total number of
Bangladesh, Pakistan and Papua New Guinea. Women persons estimated to be living with the disease
are also increasingly likely to be affected, rising from at a particular time, per 100 000 population.
19% of those living with HIV in 2000, to 35% in 2008
(UNAIDS, 2009).
Almost all countries have instituted HIV

28 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 1.9. HIV/AIDS

1 9 1
. . . Prevalence of HIV among adults aged 1 9 2 . . . Estimated number of people
15 years or more, 2007 living with HIV, 2007

Per 100 000 population Number

1 9 3 Young people aged 15-24

. . . 1 9
. . 4 Persons with advanced HIV infection
.

with comprehensive knowledge of HIV/AIDS receiving antiretroviral therapy (ART),

2006-2007
Percent Males Females LaoPDR
60 1 CamBotJia

Thailand
50
Papua New Guinea
Malaysia

Philippines

Vietnam

China

Indonesia

Myanmar
Sri Lanka
India

Bangladesh
Nepal

Pakisian

40 60 80
Percent

Source; UNAIDS, 2008.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 29

1.10. TUBERCULOSIS

One of the most widespread infectious diseases 000 population fell from 330 to 220 (Figure 1.10.3).

in Asia and the Pacific is tuberculosis. About five China and Indonesia have seen significant declines,
million cases occur in the region every year, claiming although progress in India has slowed.
the lives of 800 000 people, more than all other The treatment strategy for TB is the “directly
infectious diseases combined (WHO, 2008a). In observed treatment - short course” program, or DOTS.
addition, some two million cases are undetected and High-quality TB services have expanded throughout
untreated. Over half of the world’s burden of the region, and case detection had exceeded 69% by
tuberculosis (around six million prevalent cases) is
2008.DOTS treatment success rates have consistently
found in the region. surpassed 85% since 2003 (Nair et ah, 2010) (Figure
TB is a disease of poverty and is most common 1.10.4).

during people’s productive years. It has a huge The region faces important challenges to TB
economic, as well as social impact. In 2006, TB caused control, including providing services to those in
India to lose an estimated 23.7 billion US dollars (Nair greatest need, especially the poor and vulnerable.
et a!., can lead to catastrophic out-of-pocket
2010). It
HIV-TB co-infection, the emergence of drug-resistant
expenditure, with 3-4 months lost wages due to strains and the need for greater technical expertise in
illness-related absence from work not uncommon. developing countries all threaten to halt progress.
Hiberculosis was declared a global health emergency
by WHO in 1993. For further reading
New cases of TB occurred most often in WHO (2008), Health in Asia and the Pacific, World
Cambodia and Myanmar, at over 400 new detections Health Organization, Regional Office for Southeast
per 100 000 population in 2008 (Figure 1.10.1).
Asia, New Delhi.
Incidence rates were also high in the Democratic
People’s Republic of Korea, the Philippines and Papua
New Guinea. In 2008, Cambodia and the Philippines Definition and measurement
were the countries with the greatest TB disease Hiberculosis (TB) is a contagious disease, most
burden, with prevalence rates of 680 and 542 per 100 often caused by the Mycobacterium tuberculosis
000 population respectively. Myanmar, Bangladesh bacteria in humans. Tuberculosis usually attacks
and Pakistan also had rates over 300 per 100 000 the lungs but can also affect other parts of the
population in 2008. The average prevalence rate body. It is spread through the air, when people
across 22 Asian countries was 176, more than 20 who have the disease cough, sneeze, talk or spit.
times that in OECD countries. Australia, New Zealand Most infections in humans are latent and
and Japan had TB prevalence rates of less than 20. without symptoms, with about one in ten latent
But in terms of sheer numbers, India and China infections eventually progressing to active
were the countries with largest number of persons disease. If left untreated, active TB kills more
with TB (Figure 1.10.2). In India, 2.2 million persons than 50% of its victims.
were living with the disease, and in China, 1.2 million. The TB incidence rate is the number of new
Bangladesh, Pakistan, the Philippines and Indonesia cases of the disease reported in a year, per 100
also had half a million or more sufferers. 000 population. The TB prevalence rate is the
The Asia/Pacific region is rising to the total number of persons with the disease at a
challenges presented by TB, with incidence, particular time, per 100 000 population.
prevalence and mortality declining steadily since
1990. Between 1998 and 2008, the prevalence per 100

30 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 1.10. TUBERCULOSIS

1.10.1. Hiberculosis prevalence and incidence, 1 . 10 2. . Numbers of persons with tuberculosis,

2008 2008
Cambodia
Philippines

Myanmar
Bangladesh
Pakistan
Vietnam
DPR
Korea,
UaoPDR
Indonesia
India

Asia-22
Nepal
Thailand
Solomon Islands
Mongolia
Papua New Guinea
Malaysia
China
Sri Lanka
Hong Kong - China
Korea, Rep.
Macao - China
Brunei Darussalam
Singa|X>re
Fiji

Prevalence Japan
Incidence OECD
New Zealand
Australia

300 400 200

Per 100 000 papulation Per 1 000 cases

1 . 10 3 IViberculosis prevalence rates^

. . 1 10 . . 4 IXiberculosis treatment success under DOTS,
.

selected countries, 1990-2008 selected countries, 2000-2007

-----Australia
*"• — China
India

Southeast Asia
Indonesia
—
-----Australia
—China
India

Southeast Asia
Indonesia

% success

1990 1995 2000 2005

Source; WHO TB data, www.who.int/tb/country.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 31

1.11. MALARIA

Malaria is endemic in many countries in the better detection rather than an increase in the
Asia/Pacific region. It is particularly associated with underlying incidence (WHO, 2010a) (Figure 1.11.3).
specific ecological zones such as forests in tropical Some key interventions to control malaria
and subtropical Southeast Asia, but it is also found in include prompt treatment with artemisinin-based
more temperate areas of the region. Among the combination therapies, the use of insecticide-treated
population living in affected areas, mobile and nets by people at risk and indoor residual spraying
migrant populations as well as infants, young with insecticide to control mosquitoes (Figure 1.11.4).
children and pregnant women are especially Overall mosquito net coverage in the region has
vulnerable. Around 85% of those who die from increased from 6% in 2005 to 17% in 2008. But malaria
malaria are children. control efforts are hampered by increased resistance
Malaria especially affects the poor in remote of mosquitoes to insecticides, and uncontrolled
rural areas who cannot afford treatment or have population movement leading to more frequent
limited access to health care. Malaria causes epidemics. The growing problem of multidrug
significant economic losses, more than 1% ofGDP in resistance is also more severe in Asia than in any
countries with high levels of transmission. In some other part of the world. Successful malaria control
heavy-burden countries, the disease accounts for up depends on long-term, sustained commitments by
to 40% of public health expenditures, and a national governments.
significant proportion of hospital admissions and
outpatient health clinic visits. For further reading
Around three-quarters of the total population in WHO (2009), World Malaria Report 2009, World
Asia/Pacific countries are at risk of malaria. In 2008, Health Organization, Geneva.
malaria was confirmed (through microscopy or rapid
diagnostic tests) in 2.6 million cases, but probable
malaria cases in the region number around 24-29 Definition and measurement
million annually (WHO, 2010a). Most of the Malaria is a tropical disease caused by a
population at moderate-to-high risk live in parasite transmitted by the bites of infected
Bangladesh, Cambodia, India, Indonesia, Myanmar, female Anopheles mosquitoes. After a period
Papua New Guinea and Thailand, which together spent in the liver, malaria parasites multiply
contribute 95% of confirmed malaria cases annually within red blood cells, causing symptoms such
(Figure 1.11.1). The vast majority of confirmed cases as fever, headache and vomiting. In severe cases,
occur in India (over 1.5 million in 2008), whereas the disease can be fatal. Malaria is preventable
Myanmar registered the highest number of deaths and curable, although no vaccine currently
(over 1 000 in 2008) (Figure 1.11.2). In the Pacific exists.
region, the Solomon Islands has high recorded rates Microscopy or rapid diagnostic tests are
of malaria, and Papua New Guinea recorded a large
recommended to confirm malaria infection in
number of deaths (628 in 2008). suspected patients. In addition to confirmed
Although a number of countries in the region cases reported to health authorities, many
such as the Democratic People’s Republic of Korea, Sri probable cases occur annually. Underreporting of
Lanka and Thailand have shown a significant cases and deaths remain a major challenge in
reduction in recorded incidence in recent years, countries with inadequate and limited access to
others, including India and Indonesia, have remained health services and weak surveillance systems
static or have even increased. However, this is due to (WHO, 2008a).

32 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 1.11. MALARIA

1 11 1
. . . ConHimed malaria cases, 2008 1 11 2
. . . Confirmed malaria deadis, 2008
India

Myanmar
Indonesia

Bangladesh
Papua New Guinea
Cambodia
Solomon Islands

Thailand

Philippines

Lao PDR
China
Vietnam
Korea, DPR
Malaysia

Nepal

Korea. Rep.

Sri Lanka

0 300 600 900 1 200 1 500

Number of cases Number of deaths

1 11 3
. . . Confirmed malaria cases, 1990-2008 1 11 4
. . . Estimated coverage of insecticide-treated nets
and indoor residual spraying, 2008

---—Bangladesh China % coverage

India — Indonesia
II Papua New Guinea

Number of cases (log scale)

Source; WHO, 2009e.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 33

1.12. DIABETES

is now one of the most common non-

Diabetes varies markedly between countries, from more than
communicable diseases globally. It is a chronic USD and Japan, to less than USD 30
3 000 in Australia
metabolic disease, characterised by high levels of in Bangladesh, the Democratic People’s Republic of
glucose in the blood. It occurs either because the Korea, Myanmar and Pakistan.
pancreas stops producing the hormone insulin (type As developing countries undergo
1 diabetes), or through a combination of the pancreas
epidemiological transitions with rapid changes in
having reduced ability to produce insulin alongside lifestyle, and overweight, diseases such as
diet
the body being resistant to its action (type 2 diabetes). diabetes no longer diseases of the wealthy.
are
People with diabetes are at a greater risk of Countries with often limited resources must cope
developing serious complications, including with a double burden of infectious diseases and an
cardiovascular diseases, renal failure, foot damage epidemic of diabetes. The high prevalence in
and sight loss. Singapore, Hong Kong-China and Macao-China
It is estimated that over 140 million people, or indicate what might occur in China as it rapidly
5.9% of the adult population in the Asian region have urbanises and expands economically (Cheng, 2010).
diabetes (Figure 1.12.1). The highest prevalence occurs The urgent need is for governments to translate the
among small Pacific island countries including Nauru, evidence on preventive initiatives into affordable and
with almost one-third (31%) of the total adult sustainable programmes, as well as investing in
population, and in Tonga at 13%. Among the diabetes care and management (IDF, 2009).
countries included here, Brunei Darussalam, Malaysia,
Sri Lanka and have prevalence
Singapore all For further reading
estimates over 10%. Conversely, less than 5% of the
IDF (2009), IDF Diabetes Atlas, 4tb Edition,
adult population in Mongolia, China and Indonesia,
International Diabetes Federation, Brussels.
and several other countries have diabetes. Average
diabetes prevalence across the Asia/Pacific region
remains lower than in OECD countries. Dehnition and measurement
Although China’s prevalence is comparably The sources and methods used by the
moderate, the country still has over 40 million people International Diabetes Federation for publishing
with diabetes (Figure 1.12.2). India has an even larger national prevalence estimates of diabetes are
number, at over 50 million people. More than five outlined in their Diabetes Atlas, 4th Edition (IDE,
million people have diabetes in each of Pakistan, 2009). Country data were derived from studies
Japan, Indonesia and Bangladesh. Of the ten published between 1980 and 2009, and were only
countries worldwide with the largest number of included if they met several criteria for
people with diabetes, five are in the Asia/Pacific Estimates for several countries (Brunei
reliability.

region. Darussalam, the Democratic People’s Republic of

Type 1 diabetes is most often diagnosed in
Korea, Lao PDR, Macao-China, Myanmar, Papua

children and young people. It occurs in less than 5% New Guinea, Solomon Islands) are derived from
of diabetic cases in the region, except in Australia and neighbouring countries. Data should be
New Zealand, where around 10-15% of diabetes is
interpreted cautiously as general indicators of

type 1 (Figure 1.12.3). Because of its large population, diabetes frequency.

some 30% of the world’s total of 480 000 children with Prevalence rates were adjusted to the World
type 1 diabetes come from Asia/Pacific countries, Standard Population to facilitate cross-national
with 114 000 in India alone (IDF, 2009). comparisons.
Around USD 40 expected to be spent
billion is
on diabetes care in the region in 2010, with most
occurring in India. The amount spent per person

34 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 1.12. DIABETES
1.12.1. 1.12.2.
Prevalence estimates of diabetes, Estimated number of adults aged
adults aged 20-79 years, 2010 20-79 years with diabetes, 2010

Brunei Darussalam
Malaysia
Sri Lanka
Singapore
Fiji

Pakistan
Hong Kong - China
Macau - China
Korea, Rep.
OECD
India
Philippines
Thailand
Bangladesh
Asia-23
Australia
Lao PDR
Korea, DPR
Cambodia
New Zealand
Japan
Indonesia
China
Nepal
Vietnam
Solomon Islands
Myanmar
Papua New Guinea
Mongolia
1.12.3.

Per cent '000 people

Incidence estimates of Type 1 diabetes, children aged 0-14 years, 2010

Per 100 000 population

4.2 4.2 4.2

2.5 2.4

nil
2.0 2.0
0.6 0.6 0.6 0.5 0.3 0.3 0.3 0.3 0.3 0.3 0.3 0.3 0.1 0.1 0.1

^ rt*?* ^ ^

eft''

Source; ]

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 35

CopyngnteO t
 Health at a Glance Asia/Padfic 2010
© OECD 2010

Chapter 2

Determinants of Health

2.1 Reproductive health

2.2 Low birthweight

2.3 Breastfeeding

2.4 Nutrition

2.5 Underweight and overweight

2.6 Water and sanitation
2.7 Tobacco
2.8 Alcohol

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 37

2.1. REPRODUCTIVE HEALTH

Reproductive health can involve having a contraceptives also reported wanting to delay or
responsible and safe sexual life, along with the cease having any more children. Unmet needs were
freedom to make decisions about reproduction. This lowest in China, Thailand and Vietnam, countries
includes accessing methods of fertility regulation and where contraceptive use was most prevalent.
appropriate health care services, so as to provide Around 26 million unwanted pregnancies were
parents with the best chance of having a healthy baby. terminated in the Asia/Pacific region in 2003 (Sedgh et
In the Asia/Pacific region, the leading risk factor a!., 2007). Of these, it was estimated that 9.8 million

for death and disability among women of (38%) were unsafe, occurring outside national legal
reproductive age is unsafe sex (WHO, 2009d). Women systems. About one-third of all maternal deaths
who have access to contraception can protect worldwide are due to unsafe abortions (WHO, 2008a).
themselves from unwanted pregnancy, and lower the Alarmingly high rates of unsafe abortion occur in
risk of abortion-related deaths and disability. Spacing Southern and Southeast Asian countries (Figure 2.1.3).
births can also have positive benefits on both the Abortion is legally restricted in Bangladesh, Indonesia,
reproductive health of the mother and the overall the Lao PDR, Malaysia, Myanmar, the Philippines, Sri
health and well-being of the child. Lanka, Thailand and most South Pacific island

The quality of reproductive health varies widely countries.

across the region. Among 68.4 million births in 2008,

maternal mortality estimates ranged from five per For further reading
100 000 births in Australia to 376 in Pakistan (see WHO (2008), Health in Asia and the Pacific, World
Indicator 1.8 “Maternal mortality”). Infant mortality Health Organization, Regional Office for Southeast
rates also differed widely (see Indicator 1.2 “Infant Asia, New Delhi.
mortality”).

In China, the Republic of Korea, Thailand and

Definition and measurement
Vietnam, more than three-quarters of all women of
reproductive age, or their partners, report using Contraceptive prevalence is the percentage of

contraceptives (Figure 2.1.1). This proportion was women who are currently using, or whose
higher than the OECD Asian
average. But across all
sexual partner is currently using at least one

countries, only 60% of couples reported using method of contraception, regardless of the
contraceptives, and this included 8% who use method used. It is usually reported as a
traditional methods such as rhythm, withdrawal and percentage of married or in union women aged
folk methods. In Papua New Guinea, Pakistan and the 15 to 49.

Lao PDR, less than one-third of couples report using Women with unmet need for family planning
any method of contraception. are those who are fecund and sexually active but

Contraceptive use is less prevalent among are not using any method of contraception, and

poorer women in a number of countries including report not wanting any more children or

Cambodia, Nepal and Pakistan (Figure 2.1.2). In

India, wanting to delay the birth of their next child. It
is also reported as a percentage of married or in
Pakistan, a country reporting low use of
contraceptives, prevalence is especially low among union women aged 15 to 49.
women in the lowest wealth quintile. Other countries Information on contraceptive use and unmet
such as Bangladesh, Indonesia, Mongolia, Thailand need for family planning is generally collected
and Vietnam, however, indicate relatively equal use of through nationally representative household
contraceptives by women, regardless of wealth. surveys. Estimates of safe and unsafe abortion

The lower that is contraceptive prevalence are derived from administrative and hospital

among countries in the region, the higher is the rate data, as well as from national and household

of unmet needs for family planning (Figure 2.1.1). In

surveys. Survey years and age groups surveyed

the Lao PDR, Pakistan, Cambodia and Nepal, one- differ across countries.

quarter or more of all women not using

38 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 2A. REPRODUCTIVE HEALTH

2.1.1. Contraceptive prevalence and unmet need for family planning, latest available estimate

Contraceptive prevalence Unmet need for family planning

China (2001)
Korea. Rep. (2003)
Hong Kong - China (2002)
Thailand (2006)
Vietnam (2006)
New Zealand (1995)
OECD
Australia (2001-02)

Korea. DPR (2002)

Sri Lanka (2006-07)
Mongolia (2005)
Singapore (1997)
Indonesia (2007)
Asia-20
India (2005-06)

Bangladesh (2007)
Malaysia (1994)
Japan (2005)
Philippines (2005-06)

Nepal (2006)
Cambodia (2005)
Myanmar (2001)
Lao PDR (2000)
Pakistan (2006-07)
Papua New Guinea (1996)

Percent

Source: United Nations, 2009b.

2.1.2. Current contraceptive use among women, 2.1.3. Estimated rate of safe and unsafe abortions,
by wealth quintile, selected countries and years by region, 2003

Per 1 000 women aged 15-44

50 -

Safe

"Unsafe

Source: Sedgh et al., 2007.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 39

2.2. LOW BIRTHWEIGHT

Low birthweight is the result of many factors. In OECD average, although China's large population size
countries where mothers face difficult socioeconomic means that the number of children affected is high,
conditions, poor nutrition and health during with an estimated one million newborns with low
pregnancy are closely associated with low birthweight each year.
birthweight. Occurring from either restricted foetal Low birthweight in Japan has increased rapidly
growth or from pre-term birth, low birthweight over the past decades, from around 6% in the mid-
infants have a greater risk of poor health or death, 1980s to close to 10% in mid- 2000s. A number of risk
need a longer time in hospital and are
after birth factors have contributed to this increase, including
more likely to develop disabilities (UNICEF and WHO, the rising prevalence of smoking among young
2004). Some of the mothers’ risk factors for low women together with a significant move towards
birthweight include poor nutrition or a low body latermotherhood. Despite the increase in low
mass index (BMI), low socioeconomic status or birthweight babies, Japanese medical care for
minority race, being a young mother, smoking and newborns has been particularly successful in
excessive alcohol consumption, having had in-vitro reducing infant mortality.
fertilisation treatment and having a previous history
Low birthweight is an important indicator of
of low weight births.
infant health because of the close relationship
Among twenty Asian countries, an average of between birthweight and later morbidity and
13% of births (about one in seven) were low mortality. It is an underlying factor in 60-80% of
birthweight. This is nearly double the OECD average neonatal deaths, with low birthweight babies 20
of 7% (Figure 2.2.1). There is a significant regional times more likely to die in infancy. Countries
divide between countries in Eastern Asia (such as reporting a higher incidence of low birthweight report
China, the Republic of Korea and Mongolia) and greater infant mortality (Figure 2.2.4).
Southern Asia (Bangladesh, India, Nepal, Pakistan and
Sri Lanka). The incidence of low birthweight ranges
For further reading
from an average of 6% in Eastern Asia to 24% in
Southern Asia. A total of 19 million newborns each
UNICEF and WHO (2004), Low Birthuieight: Country,
year in the developing world weigh less than 2 500
Regional and Global Estimates, UNICEF, New York.
grams, and more than half are born in Southern Asia
- India alone has more than seven million annually.
Dehnition and measurement
Southern Asia also has the highest proportion of
Low birthweight is defined by the World
newborns not weighed at birth, at around 70%,
Health Organization as the weight of an infant
Trend analysis of low birthweight is difficult at birth of less than 2 500 grams (5.5 pounds)
because of a lack of comparable estimates both irrespective of the gestational age of the infant.
within and between countries. Available surveys This figure is based on epidemiological
indicate that the incidence of low birthweight in the observations regarding the increased risk of
region has remained roughly constant since the death to the infant and serves for international
1990s. (UNICEF Childinfo, 2010). Both India and comparative health statistics. The number of low
Indonesia show little change (Figures 2.2.2 and 2.2.3). weight births is then expressed as a percentage
Large reported declines in Vietnam, Papua New of total live births.
Guinea and Bangladesh may result from differences
In developed countries, the main information
in survey samples and methodology.
sources are national birth registers. For
China, however, has shown a steady decline, developing countries, low birthweight estimates
with children greatly benefitting from the country's are primarily derived from mothers participating
rapid and sustained economic growth over recent in national household surveys, as well as routine
decades. Access to food, and diets in general have reporting systems (UNICEF and WHO, 2004).
improved in many provinces. Low birthweight
prevalence had fallen to 3.7% in 2003, well below the

40 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 .

2.2. LOW BIRTHWEIGHT

2 2 1
. . . Low birthweight infants, 2006-2007 2 2 2. . Change in proportion of low birthweight infants,
(or nearest year available) 1986-1987 to 2006-2007

China (1999*2003)
Korea, Rep.
New Zealand
Mongolia (2005)
Australia
OECD
Korea. DPR (2002)
Vietnam
Singapore (2000)
Indonesia
Malaysia (2002)
Thailand (2005-2006)
.
Japan .

Papua r^w Guinea (2005)

Brunei Darussalam (1999)
Fiji (2004)
Lao PDR
Solomon Islands
Asla-20
Cambodia (2005)
Myanmar (2000)
Sri Lanka
Philippines (2003)
Nepal
Bangladesh
India (2005-2006)
Pakistan

Percentage of newborns weighing less than 2 500 g % change over period

Note; Large declines in Vietnam, Papua New Guinea and Bangladesh

may reflect differences in survey methodologies.

2 2 3
. . Trends in low birthweight infants, selected 2 2 4
. . Low birthweight and infant mortality, 2006-2007
countries, 1985-2007 (or nearest year available)

Infant mortality (deaths per 1 000 live births)

— — — --India— • — Indonesia OECD ••••••• China

Percentage of newborns weighing less than 2 500 g

Low birth weight (%)

Source: OECD Health Data 2010; UNICEF Childinfo, World Bank WDI.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 41

2.3. BREASTFEEDING

Mothers breastfeeding their babies is one of the Cambodia is a notable exception. In June 2004,
best ways to ensure child health and survival. Breast the Government of Cambodia declared that early and
milk gives infants the nutrients they need for healthy exclusive breastfeeding would be the top priority
development, including the antibodies that help intervention to assist in reducing child mortality.
protect them from common childhood illnesses such Over the next 18 months, a number of diverse
as diarrhoea and pneumonia, the two primary causes activities and messages contributed to a national
of child mortality worldwide. Breastfeeding is also breastfeeding movement. Breastfeeding practices
linked with later good health. Adults who were were established in hospitals, and community-based
breastfed as babies often have lower blood pressure volunteers convinced expecting and new mothers to
and lower cholesterol, as well as lower rates of breastfeed their infants. Exclusive breastfeeding rates
overweight, obesity and type-2 diabetes. Estimates for babies under six months rose from 7% in 2000 to
suggest that more than one million child deaths 60% in 2005, and correspondingly the number of
could be avoided each year with improved infants receiving both breast milk and plain water fell
breastfeeding practices (WHO, 2008b). from 67% to 28% (UNICEF, 2008a).

Breastfeeding benefits mothers through Feeding practices after the age of six months
assisting in fertility control, reducing the risk of vary across A majority of mothers
countries.
breast and ovarian cancer in later life and lowering introduce complementary foods from 6-9 months,
rates of obesity. The World Health Organization but are also still breastfeeding their infants at 12-15
recommends exclusive breastfeeding for the first six months of age (Figure 2.3.3). Breastfeeding rates at
months of life, followed by other foods to this age remain high, at above 90%, in South Asia
complement continuing breastfeeding for up to two (Nepal, Bangladesh and Sri Lanka), as well as in
years or more. Cambodia.
Globally, less than 40% of infants under six
months of age are exclusively breastfed (UNICEF, For further reading
2009). In the Asia/Pacific region, around half of the UNICEF (2009), The State of the World’s Children,
countries that are supplying data have exclusive Special Edition, UNICEF, New York.
breastfeeding rates greater than 40% (Figure 2.3.1).
Three quarters of infants are exclusively breastfed in
Sri Lanka and the Solomon Islands, around half in
Definition and measurement
India and Nepal, and around one-third in the Infants who are exclusively breastfed
Philippines, Indonesia and Malaysia. Exclusive consume only human milk without any
breastfeeding rates are low, at less than 20%, in supplementation by water, juice, formulas, non-
Thailand, Myanmar and Vietnam. human milk or other foods. Vitamins, minerals,
Exclusive breastfeeding is more common and medications are allowed.
among poorer women in many countries in the The usual sources of information on the
region, including Bangladesh, India, Indonesia, percentage of infants who are exclusively
Pakistan and the Philippines (Figure 2.3.2). Less than breastfed are household surveys.
one-fifth of wealthier women in Pakistan and the
Philippines exclusively breastfeed for the first three
months.

42 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 2.3. BREASTFEEDING

2 3 1 Infants exclusively breastfed for the Hrst six

. . . months of life, 2007 or nearest year available
Per cent

60

70

50

40

30

20

10

Source; UNICEF, 2009.

2 3 2 Exclusive breastfeeding of infants 0-3

. . . months, 2 3 3 Feeding after
. . . age 6 months,
by wealth quintile, selected countries and years selected countries and years

Breastfed with complemaitary fixid, 6-9 months

Rate ratio
Lowwealth 2nd >Middle i4th
•Still breastfed, 12-15 months

Note: High wealth = 1,0

Per cent
100 —
80

60 -

40 - - -

ll ll ll 1
"1
0.0

Sources: Gwatkin et al., 2007; MICS 2006-2008. Source; UNICEF 2009.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 43

2.4. NUTRITION

National development is largely dependent on large increases in the domestic price of rice
healthy and well-nourished people. Food security throughout 2008. The situation in the Democratic
means being able at all times to access sufficient, People’s Republic of Korea is even more precarious.
safe and nutritious food which meets food Sustained famine ravaged the population in the 1990s,
preferences and dietary needs for an active and and the economic crisis threatens to extend its
healthy life. Yet this basic need is not met for many reliance on food aid.
people in the Asia/Pacific region. Chronic hunger has Consecutive food, fuel and economic crises may
devastating effects on health and well-being, both lead the poor in the Asia/Pacific region to further
now and among future generations. reduce their dietary intake, as well as their spending
More than half a billion people in the on essential items such as education and health care.
Asia/Pacific region (566.2 million, or 16% of the Investments in the agriculture sector, and social
population) were undernourished in 2004-06 (FAO, protection for people without access to food will
2009). The prevalence of undernourishment exceeded assist in providing an economic, employment and
25% in Cambodia, Bangladesh, Mongolia and the health buffer, especially for poorer countries in the
Democratic People’s Republic of Korea, and was region (FAO, 2009).
greater than 10% in two-thirds of the countries
examined here {Figure 2.4.2). In China and India alone, For further reading
almost 380 million people were undernourished in
FAO (2009), The State of Food Insecurity in the World;
2004-06.
Economic Crises - Impacts and Lessons Learned, Food and
Daily dietary energy consumption among 19 Agriculture Organization of the United Nations, Rome.
Asian countries is around 2 500 kcal per person,
compared to an average of 3 400 in OECD countries
(Figure 2.4.1). Australia, New Zealand, the Republic of Definition and measurement
Korea and Fiji have high-energy diets. Food available FAO (Food and Agriculture Organization of the
for consumption provides less energy for persons United Nations) consumption estimates are
Democratic People's Republic of Korea,
living in the based on annual estimates of the production
Lao PDR, Cambodia and Bangladesh. Compared to and trade of food commodities as supplied by
diets in OECD countries, food in Asian countries national Ministries of Agriculture and Trade.
provides two-third the amount of protein, and less Dietary consumption of energy measures the
than half the amount of fat (Figure 2.4.4). amount of food available for human
Food available for consumption has risen across consumption, and is expressed in kilocalories
the region as a whole over the past two decades, from (kcal). Measures of protein and fat are expressed

around 2 300 kcal in 1990 to the current value of 2 500 in grams. The content of each is derived by
(Figure 2.4.3). China’s sustained economic expansion applying appropriate food composition factors
has led to many gains for its population, including in to commodities.
food intake, which rose to almost 3 000 kcal in 2007. Undernourishment refers to the condition of
Bangladesh has achieved substantial increases in rice people whose intake of calories is continuously
production; however its self-sufficiency continues to below a minimum dietary energy requirement
be threatened by population growth, traditional needed for light activity and acceptable weight-
farming practices, limited available land and frequent for-attained height.
natural disasters (WHO, 2008a). More recent declines
in exports, remittances and income, coupled with the
global food crisis and a devastating cyclone led to

44 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 2.4, NUTRITION

2.4.1. Dietary energy consumption, 2 4 2 Prevalence of

. . . undernourishment
2005-2007 in total population, 2004-2006
OECD
3166 Australia

3151 New Zealand

3073 Korea, Rep.
3033 Fiji

2987 Brunei Darussalam

2974 China 10

2908 Malaysia
2806 Japan
2769 Vietnam 1 13
I

2535 Indonesia I 1<

I

2529 Thailand 1

Asia-19 ii

2518 Philippines
1

2439 Myanmar 1

2434 Solomon Islands 9

2392 Sri Lanka
2349 Nepal
2301 India

2254 Mongolia
2251 Pakistan
2250 Bangladesh
2245 Cambodia
2228 Lao PDR
2146 Korea. DPR

4000 3000 2000 1000 0 0 10 20 30 40 50

kcal/person/day Per cent

2 4 3 Dietary
. . . energy consumption, 2 4 4 Dietary protein
. . . and fat consumption,
selected countries, 1990-2007 OECD and Asian countries, 1990-2007

Bangladesh — — China — •
—Korea, DPR OECD
Protein. “ — Protein, Asia-19

Fat, OECD Fat. Asia-19

Asia-19 OECD
kcal/person/day grams/perpson/day

Source; FAOSTAT Database, faostat.fao.org.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 45

2.5. UNDERWEIGHT AND OVERWEIGHT

Poor nutrition, leading to either underweight or Mirroring underweight. New Zealand, Australia,
overweight, is closely associated with ill health. More Fiji and Malaysia have comparatively high rates of

than one- third of all deaths worldwide are due to ten overweight (Figure 2,5,2). Around 50% of the adult
main risk factors, and seven of these are related to population in OECD countries has a BMI greater than
nutrition (WHO, 2002). 25, which is in stark contrast to the average in Asian

Among developing countries, underweight is

countries (around 20%). In developing countries

the risk factor most closely associated with early obesity, which presents greater health risks, is more
death. Undernutrition in pregnant women often leads common among people with a higher socioeconomic
to low birthweight babies (see Indicator 2.2 “Low status, thoseliving in urban regions and among

More than half of all deaths of children

birthweight’’). middle-aged women. In developed countries however,
aged under five are attributed to being underweight obesity is increasing among all age groups, and is

(WHO, 2008a). Social determinants of health such as associated with lower socioeconomic status,

poverty, inadequate water and sanitation, and especially among women (Sassi, 2010).

inequitable access to education and health services

underlie malnutrition. For further reading

A significant proportion of adults in Southern WHO (2008), Health in Asia and the Pacific, World
Asia are underweight (Figure 2.5.1). In India, Pakistan Health Organization, Regional Office for Southeast
and Bangladesh, more than one-quarter of adults Asia, New Delhi.
have a body mass index less than 18.5. Across 14
Asian countries, 18% of females and 14% of males
Definition and measurement
were underweight in 2007, compared to an average of
4% and 1% in OECD countries. In Mongolia, Fiji, the The most used measure of
frequently

Republic of Korea and China, less than 10% of male underweight, overweight and obesity is the Body

and female populations are underweight. However, it Mass Index (BMI). This is a single number that
should be noted that some Asian populations may evaluates an individual’s weight in relation to
have different associations between BMI, percentage height, and is defined as weight in kilograms

of body fat and health risks than other populations divided by the square of height in metres

(WHO Expert Consultation, 2004). (kg/m=).

Around of all underweight children

half Based on the WHO classification, adults with a
worldwide are Southern Asia. Latest estimates
in BMI below 18.5 are considered to be
show that the prevalence of moderate or severe underweight, and 25 or over are overweight.
underweight ranges from 3% (Singapore) to 45% or Adults whose BMI is 30 or over are defined as
more (Nepal, Bangladesh and India) (Figure 2.5.4). A obese. This classification, however, may not be

majority of countries in the region have problems suitable for all Asian populations, some of whom
with wasting (low weight-for-height) and stunting may have equivalent levels of health risk at

(failure to grow to normal height) among children.

lower or higher BMI (WHO Expert Consultation,
Severe underweight in the region is decreasing, 2004).

although progress is uneven. China has shown rapid For children, moderate and severe
progress in reducing child undernutrition and underweight includes the proportion of under-
mortality. fives falling below minus two standard
As countries experience economic growth, they deviations from the median weight-for-age of

undergo demographic and epidemiological transition. the WHO reference population.

The prevalence of overweight and obesity tends to In many countries, self-reported estimates of
increase, accompanied by rises in non-communicable height and weight are collected through
diseases such as cardiovascular disease, diabetes and population-based health surveys. In a smaller
cancer. In the Asia/Pacific region, non-communicable number of countries, including Australia, Japan,
diseases already cause more than 60% of all mortality the Republic of Korea and New Zealand, health
(WHO, 2008a). The populations of a number of examinations measure actual height and weight.
countries currently undergoing health transition- These differences limit data comparability. BMI
such as Thailand, the Philippines, Singapore and estimates from health examinations are more
Malaysia-exhibit sizeable rates of both underweight reliable, and generally result in higher values
and overweight (Figure 2.5.3). These countries face a than from self-report surveys.
double burden of under- and overnutrition occurring
simultaneously among different population groups
(FAO, 2006).

46 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 2.5. UNDERWEIGHT AND OVERWEIGHT

2 5 1 Adults
. . . who are underweight (BMI<18.5), 2 5 2 Adults
. . . who are overweight (BMI>=25),
latest year available latest year available

India, 2005-06
Pakistan, 1990-94

Bangladesh
Vietnam, 2000

Nepal. 2006

Cambodia, 2005-06
Thailand, 2003-04

Asia-14
Philippines, 1993
Lao PDR, 2000
Singapore, 2004

Japan, 2007

Malaysia. 2005-06

China, 1997-2002

Korea, Rep.

Fiji, 2004
OECD
Mongolia, 2005

Australia, 2007-08
New Zealand, 2006-0/

Indonesia, 2001

40 30 20 10 0 0 20 40 60 80

Per cent Per cent

Source; WHO Global Database on Body Mass Index, OECD Health Data 2010.

2 5 3 Proportion of female population who are

. . . 2 5 4 Children
. . . under 5 years who are moderately or
underweight or overweight, latest year available severely underweight, latest year available

Percent
Overweight (%)
Singapore, 2000
Mongolia, 2005

China, 2005

Malaysia, 2005

Thailand, 2005-06

Vietnam, 2006
Solomon Islands, 1989
Sri Lanka. 2006-07

Korea, DPR. 2004

Papua New Guinea, 2005
Philippines, 2003
Indonesia, 2003

Myanmar, 2003
Cambodia, 2005
Lao PDR, 2006
Pakistan, 2001-02

Nepal, 2006

Bangladesh. 2007
India, 2005-06

0 10 20 30 40 50 60
Underweight (%)

Source; WHO Global Database on Body Mass Index, Source; UNICEF Childinfo.

OECD Health Data 2010.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 47

2.6. WATER AND SANITATION

Safe water and adequate sanitation are vital to rural dwellers has improved steadily since 1990, to
human health and well-being. Their want has serious reach 83% of persons in 2008 (Figure 2.6.3). Improving

repercussions for individual health, livelihood and sanitation in rural areasis more problematic. Across

quality of life. Diarrhoeal diseases alone kill almost the region, only 40% of rural dwellers have access,
two million people annually, mostly children under and in India, only around 20% (Figure 2.6.4). Most of
the age of five. Better access to water and sanitation the gain in improved sanitation since 1990 has
leads to great social and economic benefits, whether occurred in urban areas, although rapid population
through higher educational participation, improved growth in cities has worked against major progress.
living standards, lower health care costs or a more More financial resources are needed in
productive labour force. developing countries to achieve water and sanitation
The use of improved sources of drinking-water policy objectives and to realise the associated
is high in the Asia/Pacific region, at 86% of the economic, social and environmental benefits. Tax-
population (Figure 2.6.1). Between 1990 and 2008, 1.1 based public subsidies, well-designed water tariffs
billion additional people in the region-mostly in and strategic use of aid flows to the water sector can
India and China-gained access to improved sources, assist in ensuring that poor and vulnerable groups
often through piped connections to their homes. have access to sustainable and affordable water and
Despite this, around 460 million people in the region sanitation services (OECD, 2009b).
still do not have access to this basic necessity. Growth
in access has been slow in some developing countries For further reading
in the Pacific region, with less than 50% of the
WHO/UNICEF (2010), Progress on Sanitation and
population in Papua New Guinea and Fiji having
Drinking-Water: 2010 Update, WHO/UNICEF Joint
improved drinking-water sources. The countries with Monitoring Programme for Water Supply and
the lowest level of access such as Papua New Guinea,
Sanitation, Geneva.
the Lao PDR, Cambodia and Myanmar, also have high
rates of under-five mortality (see Indicator 1.3
“Under-5 mortality”). Definition and measurement
Nearly two billion people (35%) in Asia/Pacific An improved drinking-water source is

countries do not use improved sanitation (Figure constructed so that it is protected from outside
2.6.2), equivalent to three in every four persons contact, especially with faecal matter. Sources
worldwide. In India, Nepal, the Solomon Islands and include piped water, public taps, boreholes, and
Cambodia, less than one-third of the population have protected dug wells or springs. Improved
facilities for adequate excreta disposal, with open sanitation facilities hygienically separate excreta
defecation still common. The proportion of the from human contact, through use of flushing to
population using improved sanitary facilities has piped sewer systems, septic tanks or pit latrines,
grown rapidly in China (from 41% in 1990 to 55% in along with improved pit latrines or composting
2008) and India (18% to 31%). Even so, the WFIO goal toilets (WHO/UNICEF, 2010).
to halve the worldwide proportion of people without The WHO/UNICEF Joint Monitoring
access by 2015 is unlikely to be met (WHO/UNICEF,
Programme for Water Supply and Sanitation
2010 ). (JMP) database includes nationally
The vast majority of people without safe water representative household surveys and censuses
and adequate sanitation live in rural areas. Seven out that ask questions on water and sanitation,
of ten people without basic sanitation, and more than mostly conducted in developing countries.
eight out of ten people without improved drinking- Generally, developed countries supply
water sources live in rural areas. Safe water access for administrative data.

48 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 . .

2.6, WATER AND SANITATION

2 6 1
. . Access to improved drinking water^ 2 6 2
. . Access to improved sanitation,
2008 2008

Australia

New Zealand
Japan
OECD
Malaysia

Korea. DPR
Korea. Rep.

Thailand W
Vietnam V5
Philippines

Pakistan
. .

China f5
Sri Lanka
India T3 31

Nepal HI 31

Asia*16
Indonesia S
Bangladesh ! 5$

Mongolia 50

Myanmar
Solomon Islands

Cambodia
Lao PDR 5:i

Fiji 71

Papua New Guinea 45

100 80 60 40 20 0

Percent Percent

2 6 3 Rural population
. . with access to improved 2 6 4 Rural population
. . with access to improved
water sources, selected countries, 1990-2008 sanitation, selected countries, 1990-2008

— —
China Indonesia
China — Indonesia
India Asia-18
• ^ India Asia-18
— • Papua New Guinea
•
“ * Papua New Guinea
•

Per cent Per cent

Source; WHO/UNICEF 2010.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 49

2.7. TOBACCO

Tobacco smoking is a common risk factor for a of females report that they currently smoke (Figure
large number of diseases that cause illness and death, 2.7.2), which will lead to negative health effects for
including cancer and cardiovascular disease. The many decades to come. Tobacco use is also greatest
global tobacco epidemic is directly responsible for among those who can least afford it (Figure 2.7.3).
around one-in-ten adult deaths tvorldwide, or some In Indonesia, the world’s third largest tobacco
six million deaths each year, most of which occur in consumer, smokers spent around 12% of their
low and middle income countries (Shafey et al., 2009). household income on cigarettes in 2005, which are
In the Asia/Pacific region, approximately 6 000 cheap at around USD 1 per packet, or a few cents for
people die prematurely from tobacco-related diseases individual sticks. Tobacco taxes are low in Indonesia,
every day, summing to 2.3 million deaths per year. but still 6% of government revenue was derived from
The economic and social costs are high, with families cigarette taxes in 2007. Increasing tobacco tax rates is
deprived of breadwinners, large public health costs an effective way to prevent deaths, through
for treatment, and lower workforce productivity discouraging youth from beginning cigarette smoking
(WHO, 2008a). and encouraging current smokers to quit. Higher
The proportion of daily smokers varies greatly taxes also generate additional government revenue
among countries (Figure 2.7.1). In 2006, rates among (Barber et al, 2008).

men were highest in the Lao PDR, the

China,
Democratic People’s Republic of Korea and Indonesia, For further reading
at over 50%. The smoking rate among Chinese men WHO (2009), WHO Report on the Global Tobacco
aged 30-60 is 70%. In Fiji and Australia, however, less Epidemic, 2009: Implementing Smoke-Free Environments,
than 20% of adult males smoked daily. The regional World Health Organization, Geneva.
average for men, at 40%, was significantly higher
than the 30% of males who smoked daily in OECD
countries. Definition and measurement
There are large male-female disparities in the Adults smoking daily is defined as the

Asia/Pacific region, with only 6% of women reporting percentage of the population aged 15 years and
smoking daily in 2006. Rates were highest in Nepal over who reported smoking every day.
International comparability limited, since data
(25%), where it is a common practice among rural
is

women, as well as in the developed countries of New were obtained from a broad range of surveys
Zealand (20%) and Australia (15%), with different survey instruments conducted in
different years. Results were age standardised to
Around one-third of the world’s smokers live in
the WHO Standard Population.
China. Within the next 15 years, unless habits change,
smoking will kill an estimated two million Chinese Current tobacco use among youth is derived
annually. Control policies face formidable opposition from the Global Youth Tobacco Survey which
from large tobacco companies, and low public was implemented between 1999 and 2008, It is
awareness, especially among the rural population, defined as the percentage of young people aged
adds to the challenges faced by China (Cui, 2010; Herd 13-15 years who consumed any tobacco product

et al., 2010). at least once during the last 30 days prior to the
survey.
In developing countries, there is a lack of public
awareness about risks and lax control measures.
Among youth aged 13-15 years, 17% of males and 8%

50 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 2.7. TOBACCO

2.7.1. Adults smoking daily, 2006

Males Females
CNn@
Lao PDR
Korea, DPR
Indonesia

Korea. Rep.

Mongolia

Philippines

Bangladesh

Cambodia
Malaysia

Japan
Asia-19

Myanmar
Thailand

Vietnam

Nepal

OECD
Pakistan

India

Singapore

Sn Lanka
New Zealand
Australia

Fiji

60 40 20 0
Per cent

2.7.2. Current tobacco use among youth 2.7.3. Cigarette smoking among men,
aged 13-15 years, 2007 by wealth quintile, selected countries and years
(or nearest year available)

Vietnam Lcwwdallh I2nd >Mddl& 4th

China (2005)
Note: High wealth = 1,0
CamtxxJia (2003)
Lao PDR Rate ratio

Bangladesh
2.0
Singapore (2000)
Fiji (2005)
Sri Lanka
Pakistan (2003)
1.8
Nepai
Korea, Rep. (2008)

Asia-17
India (2006)
1.5
New Zealand (2008)
Thailand (2005)

Myanmar
Indonesia (2006)
1.3
Mongolia
Philippines

Malaysia (2003)
Papua New Guinea 1.0

0 10 20 30 40 50 60 Bangladesh. 2007lndonesia, 2007 Nepal, 2006 Philippines, 2003

Per cent

Sources; WHO, 2009b; OECD Health Data 2010. Sources; DHS 2006-2009; Gawtkin et al., 2007.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 51

2.8. ALCOHOL

The health burden related to alcohol 2005, in conjunction with rapid economic
consumption, both in terms of morbidity and development.
mortality, is considerable in most parts of the world Changing patterns of drinking lead to more
(WHO, High alcohol intake increases the risk
2004). potential for harm through binging and heavy
for chronic disease and injury. Drunkenness and drinking occasions, especially among young people
alcohol dependence also have harmful social (Figure 2.8.4). In Japan, almost 40% of male drinkers
consequences. surveyed in 2001 reported regular heavy drinking. In
In the Southeast Asian region, 2.3% of all deaths Australia, around 10% of the adult population in 2007
in 2004 were attributed to alcohol consumption, and consumed alcohol at levels considered risky for
in the Western Pacific region, over 5%. The direct and health in the long-term (AIHW, 2008). A number of
indirect economic costs of alcohol (which include lost countries, including Australia, New Zealand, the
productivity, health-care costs, and road accident- Republic of Korea and Thailand are defining and
and crime-related costs) are substantial - in Thailand implementing policies to protect against alcohol’s
and the Republic of Korea these costs are about 2% of harmful effects (WHO, 2008a),
GDP (Rehm et al., 2004; Thavorncharoensap et al., The World Health Organization has endorsed a
2010 ). global strategy to combat the harmful use of alcohol,
Alcohol consumption across Asia/Pacific through direct measures such as medical services for
populations is highest among more developed alcohol-related health problems, and indirect ones,
countries (Figure 2.8.1). Adults aged 15 years and over such as the dissemination of information on alcohol-
in Australia, New Zealand, Japan and the Republic of related harm.
Korea consumed over eight litres of alcohol per capita
in 2005. In Thailand, the Lao PDR, China and the For further reading
Philippines, consumption was between four and eight WHO (2004), Global Status Report on Alcohol 2004,
litres, with all other Asia/Pacific countries listed here
WHO, Geneva.
consuming less than four. Because religious
traditions in a number of countries prohibit drinking
alcohol, consumption figures in these are minimal Definition and measurement
(Figure 2.8.4). In other countries, only certain people Alcohol intake is measured in terms of annual
groups consume alcohol; in Thailand, for example, consumption of litres of pure alcohol per person
around one-third of the population drink. The aged 15 years and over. Sources are based mostly
average consumption across 20 Asia/Pacific countries on FAO (Food and Agriculture Organization of
in 2005 was a modest 2.5 litres per capita, compared the United Nations) data, which consist of
to 9.5 in OECD countries. annual estimates of beverage production and
Average consumption across the whole region trade supplied by national Ministries of
exhibited little change between 1980 and 2005 Agriculture and Trade. The methodology to
(Figures 2.8.2 and 2.8.3), although variations exist convert alcoholic drinks to pure alcohol may
among countries. Among countries with significant differ across countries. Data are for recorded
intake, alcohol consumption declined in the Republic alcohol, and exclude homemade sources, cross-
of Korea, Australia and New Zealand. Consumption border shopping and other unrecorded sources.
increased in China, the Lao PDR, the Philippines, Information on drinking patterns are derived
Japan and Thailand, For China, alcohol consumption from surveys and academic studies (WHO, 2004).
increased from 1.7 litres per capita in 1980 to 4.4 in

52 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 —

2.8. ALCOHOL

2 8 1
. . . Alcohol consumption, population 2 8 2
. . Change consumption per capita,
in alcohol
aged 15 years and over, 2005 population aged 15 years and over, 1980-2005

Australia

OECD
New Zealand
Japan
Korea, Rep.
Thailand
LaoPDR
China
Philippines

Kcwea, DPR
. .

Asia-20
Singapore
Fiji

Cambodia
Brunei Darussalam
P^ua New Guinea
Mongolia
Solomon Islands

India

Malaysia
Sri Lanka
Nepal
Myanmar
Vietnam
Indonesia
Pakistan
Bangladesh

Litres per capita Per cent

2 8 3
. . Trends in alcohol consumption, 2 8 4 Patterns of
. . consumption, 2003
selected countries, 1980-2006 (or nearest available year)

--- Australe OECD —China Asia-ZO India Heavy episodic drinking, males Lifetime abstainers

Per cent
Litres per capita

l-

1.
Mu jL.
Sources: WHO, 2010a; WHO Global Information System on Alcohol and Health (GISAH); OECD Health Data 2010.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 53

CopyngnteO t
 Health at a Glance; Asia/Pacific 2010
© OECD 2010

Chapter 3

Health Care Resources and Utilisation

3.1 Doctors and nurses

3.2 Consultations with doctors

3.3 Hospital beds and average length of stay

3.4 Hospital discharges

3.5 Pregnancy and birth

3.6 Childhood vaccination

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 55

3.1. DOCTORS AND NURSES

Access to high-quality services depends number of qualified nurses is the highest in high-
crucially on the size, skill mix, geographic income countries such as Australia, New Zealand and
distribution and productivity of the health workforce. Japan, with all of these countries having more than
Health workers, and in particular doctors and nurses, nine nurses per 1 000 population. The supply is much
are the cornerstone of health systems. lower in a number of low-income countries, including
The number of doctors per capita varies widely Bangladesh, Myanmar, Nepal, Pakistan and Papua
The Democratic People’s
across Asia/Pacific countries. New Guinea, where there is much less than one
Republic of Korea has the highest number of doctors nurse per 1 000 population. The number of nurses per
per capita, with 3.3 doctors per 1 000 population in capita is also relatively low in India and China, less

2003. This is an even higher number than the average than half the average across Asian countries of 2.4

among OECD countries (3.2 in 2008) (Figure 3.1.1). In nurses per 1 000 population (Figure 3.1.2).
the Democratic People’s Republic of Korea, the In many Asia/Pacific countries, there are
government has supported the training of health between two and five nurses per doctor, which is also
workers over the years, giving priority to training the case in many other OECD countries (Figure 3.1.3),

even in difficult conditions. There are about 100 While there are more than ten nurses per doctor in
training institutions for health personnel, including the Solomon Islands and New Guinea, this reflects
centraland provincial medical universities, as well as the fact that there are very few doctors in these two
nursing and midwifery schools (WHO, 2007b). countries. On the other hand, there is less than one

Australia and New Zealand also have a high nurse per doctor in Bangladesh, Myanmar and China.
number of doctors compared with other Asia/Pacific The fact that there are more doctors than nurses in
countries. Despite its relatively low health spending these countries raises questions about efficiency in
per capita, Mongolia also has a high number of the allocation of resources and tasks in health care
physicians per capita, much higher than the average delivery.

among Asian countries. Since 2000, the overall

number of doctors has increased a lot in specialist For further reading
hospitals and private hospitals in Mongolia, and there WHO (2008), Health in Asia and the Pacific, World
is evidence of oversupply of doctors, in particular of Health Organization, Regional Office for Southeast
medical specialists. Despite this large supply of Asia, New Delhi.
doctors in Mongolia, there is a shortage of
experienced doctors in rural areas (Asian
Development Bank, 2008).
Definition and measurement
Papua New Guinea, Indonesia and
In contrast, Doctors include physicians qualified in either
the Solomon Islands have the lowest number of allopathic medicine or other forms of medicine

physicians per capita. The low supply of doctors in such as Chinese traditional medicine, ayurveda
Indonesia is associated with a low level of health or homeopathy.

expenditure (see Figure 4.1.1 in the next chapter). Nurses are defined as persons who have
In China, the number of doctors has risen by completed a programme of basic nursing
about 2% annually over the past few years (OECD, education and are qualified to provide nursing
and the number of doctors now exceeds the care. Although midwives should normally be
2010),
average across Asian countries, although it remains excluded from nurses, some Asia/Pacific
less than half the average in OECD countries. countries report midwives together with nurses.

Nurses outnumber physicians most

in
Asia/Pacific countries, but with a few exceptions. The

56 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 3.1. DOCTORS AND NURSES
3.1.1. 3.1.2.
Doctors per 1,000 population, Nurses per 1,000 population,
latest year available latest year available
Korea. DPR {2003) Australia (2007)

OECD (2008) New Zealand (2008)

AusOalia (2007) Japan (2008)
MorgoHa (2006) OECD (2008)
New Zealand (2008) Hong Kong-China (2007)
Macao-China (2008) Brunei Darussalam (2008)

Japan (2008) Korea, Rep. (2008)

Korea, Rep. (2008) Philippines (2002)

Hong Kong-CMna (2009) Sii^apore (2008)

Singapore (2008) Korea, DPR (2003)

Oiina (2006) Mongolia (2005)
PhiKppines(2002) Macao<hina (2007)
A^-22 Asia-22

Brunei Darussalam (2008) Malaysia (2009)

Pakistan (2005) Fiji (2003)

Malaysia (2009) Thailand (2005)

Vietnam (2005) Solomon Islands (2003)

Sii Lanka (2008) Sri Lanka (2008)

India (2004) China (2006)

Fiji (2008) Lao PDR (2004)

Myanmar (2004) India (2004)

Lao PDR (2004)

Cambodia (2000)

Thailand (2005) Indonesia (2003)

Bangladesh (2005) Vietnam (2002)

Nepal (2004)
Papua New Guinea (2000)
Pakistan (2002)
Cambodia (2000)
Solomon Islands (2008) Nepal (2004)

Indonesia (2008)
Mvanmar(2004)
Bangladesh (2005)
Papua New Guinea (2000) 3.1.3.

0 112 2 3
Q 2 4

Per 1
6

000 population
8 10

Perl 000 popUaiion

Ratio of nurses to doctors, latest year available

12.0 I
10.5 10,3

Sources: OECD Health Data 2010; WHO Global Atlas of the Health Workforce (2003-2007); National Data Sources (see Annex 1).

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 57

CcpyngmM
3.2. CONSULTATIONS WITH DOCTORS

Consultations with doctors are an important in other households in most countries, and especially
measure of overall access to health services. In so in India and Indonesia. However, in other
general, consultation rates tend to be highest in the countries, people in poor households visit doctors
high and middle-income economies in the more often than the non-poor, particularly in Hong
Asia/Pacific region, and significantly lower in the low- Kong-China and the Republic of Korea, suggesting
income economies. that access is more based on needs than ability to pay.
The number of doctor consultations per person
per year ranges from over ten in Japan, the Republic For further reading
of Korea and Hong Kong-China, to fewer than two in Refer to Annex A.
Papua New Guinea, Solomon Islands and China
(Chart 3.2,1). Generally, doctor consultation rates in
the developing Asia/Pacific economies are lower than Definition and measurement
the OECD average. Consultations with doctors are defined as
Cultural factors might play a role in explaining contacts with physicians (both generalists and
some of the variations.example, Japan, the
For specialists). These may take place in doctors’
Republic of Korea, Hong Kong-China and Singapore offices or clinics, in hospital outpatient
have the highest rates, despite quite different health departments, and in some cases in the patient’s
financing and delivery systems. On the other hand, own homes. Doctors include physicians
payment of physicians by fee-for-service, which has qualified in either allopathic medicine or other
been suggested as explaining some of the variations forms of medicine such as Chinese traditional
across OECD countries, does not appear to be an medicine, ayurveda or homeopathy.
explanatory factor in the Asia/Pacific region. Two main data sources can be used to
Chart 3.2.3 shows a close relationship between estimate consultation rates: administrative data
doctor consultation rates and life expectancy, with and household health surveys. In general,
consultation rates highest in the countries with administrative data sources in the non-OECD
highest life expectancy. This does not necessarily economies of the Asia/Pacific region only cover
imply causality, since overall living standards may public sector physicians or publicly financed
influence both consultation rates and life expectancy. physicians. As physicians in the private sector
There are examples such as Mongolia where provide a large share of overall consultations in
relatively high consultation rates are associated with most of these countries, existing administrative
low life expectancy. data sources do not cover most physician
Information on consultations can be used to consultations. The alternative data source is

estimate annual numbers of consultations per doctor household health surveys, but as in OECD
in countries. This estimate should not be taken as a countries, these surveys in the Asia/Pacific

measure of doctors' productivity, partly because region tend to produce lower estimates of

consultations can vary in length and effectiveness, consultation rates, owing to incorrect recall and
and partly because it excludes the work doctors do non-response rates.

on inpatients, administration and research. It is also In those countries (such as Hong Kong-China,
subject to comparability limitations reported
the Singapore, Solomon Islands, Sri Lanka) where
below, and in particular variations across countries in administrative data only cover the public sector,
the extent to which a routine consultation is seen by household survey data have been used to obtain
a physician. Keeping these reservations in mind, this an estimate of private sector consultation rates,
estimate varies six-fold across Asia/Pacific countries to arrive at an overall estimate of consultations
(Chart 3.2.2). The range is comparable to that reported with doctors.
across the OECD countries, although on average there For many countries (such as China, Mongolia,
are many more consultations per doctor in the Asian Thailand, Vietnam), there was insufficient
economies covered (about 4 600) than the OECD information to fully assess the data sources, and
average (about 2 600), the comprehensiveness of coverage of private
Whilst there are large variations in consultation sector consultations could not be assessed. In
rates across countries, there are also substantial these cases, caution must be applied in using
variations in consultation rates between the poorest and interpreting the data.
and richest households within each country (Chart
3.2.4).Although the poorest quintiles might be
expected to have the greatest need for doctor
consultations, the consultation rates are lower than

58 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 3.2. CONSULTATIONS WITH DOCTORS
3.2.1. 3.2.2.
Doctor consultations per capita, Number of consultations per doctor,
latest year available latest year available

Japan (2007) Sri Lanka (2008)

Korea, Rep. (2008) Hong Kong-China (2009)
Hong Kong-China (2009) Korea. Rep. (2008)
Singapore (2008)
Thailand (2005)
OECD (2008)
Japan (2007)
Australia (2008)
Singapore (2008)
Macao-China (2008)
Malaysia (2009)
Mongolia (2005)

Asls-12 Fiji (2008)

Sri Lanka (2008) Asia-12

New Zealand (2007) Brunei Darussalam (2008)

Malaysia (2009) Vietnam (2005)
Brunei Darussalam (2008)
OECD (2008)
Fiji (2008)
Macao-China (2008)
Thailand (2005)
Mongolia (2005)
Vietnam (2005)
Australia (2008)
China (2006)

Solomon Islands (2006) New Zealand (2007)

Papua New Guinea (2008) China (2006)

0 5 10 15 0 1 000 2 000 3 000 4 000 5 000 6 000 7 000 3 000 9 000

Per capita Par doctor

3.2.3. 3.2.4.

Doctor consultations per capita and life Ratio of doctor consultation rates in poorest
expectancy atbirdi, latest year available and middle socioeconomic quintiles compared to
highest quintile
Life Expectancy at birth, years
Miadls quintile

Poorest quintile

India (1995/96)

Indonesia (2001)

Thailand (2002)

China (2003)

Bangladesh (1999/00)

Nepal (199S/96)

Hong Kong-China (2002)

Korea. Rep (1998)

Sn Lanka (2003/04)

0 1
oaorconsuRations per capita Ratio to highest gulntile

Sources: OECD Health Data 2010; National Data Sources (see Annex A).

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 59

3.3. HOSPITAL BEDS AND AVERAGE LENGTH OF STAY

The number of hospital beds provides a partly substituting for outpatient care, with patients
measure of the resources available for delivering care being admitted for minor conditions, which in other
to inpatients in hospitals, and is related to overall countries are managed mostly on an outpatient basis.
access to hospital services. In most health systems, In Japan and the Republic of Korea, there may
hospitals account for the largest part of overall fixed be a problem of “social admission”, in that some
investment, so the supply of hospital beds is also a “acute care” beds may be devoted to long-term care,
reflection of past capital investment. partly explaining the long average length of stay
The number of hospital beds per capita varies (Hurst, 2007).
considerably across the Asia/Pacific region. It is

highest in Japan and the Democratic People’s For further reading

Republic of Korea, with over 13 beds per 1 000
Refer to Annex A.
population (Chart 3.3.1). These levels are more than
20 times higher than in countries such as Nepal,
Philippines, Indonesia and Myanmar, where the stock Definition and measurement
of beds does not exceed 0.6 per 1 000 population. All hospital beds should normally be counted,
These large disparities reflect substantial differences including those for acute care and for
in the resources invested in hospital infrastructure. chronic/long-term care, in both the public and
Hospitals in most countries account for the private sectors. The figures reported for ALOS
largest part of health expenditure. Consequently, the are for average length of stay for acute care only.
efficiency with which hospitals are used is of major This refers to the number of days (with an
interest. The average length of stay in hospitals (ALOS) overnight stay) that patients spend in an acute-
is one measure of the efficiency with which hospital care inpatient institution. It is generally
resources are used. All other things being equal, a measured by dividing the total number of days
shorter stay will reduce the cost per discharge, and stayed by all patients in acute-care inpatient
shift care from inpatient to less expensive outpatient institutions during a year by the number of
and ambulatory settings. However, shorter stays admissions or discharges. This definition
might be more service intensive and more costly per requires a consistent definition of acute care,
day. Too short a stay may also result in adverse health but there are considerable variations in how
outcomes. countries define acute care, and what they
In the Asia/Pacific region, there is a large include or disaggregate in reported statistics. For
variation in ALOS for acute care, although this the most part, reported ALOS data in the
variation is not as large as that in the overall supply developing economies of the Asia/Pacific region
of hospital beds. The longest lengths of stay are in cover only public sector institutions, and only a

Japan, the Republic of Korea, Mongolia and China, at few countries, such as China, Mongolia and
over nine days on average. These are two to three Thailand, comprehensively cover private sector

times longer than those in Sri Lanka, Bangladesh and institutions in their ALOS statistics.

Thailand (Chart 3.3.2). The shortest length of stay is Consequently, most of the statistics reported
in Sri Lanka, at 2.8 days. Thiscoupled with the high here relate to public hospitals only.
admission rates in that country (see Indicator 3.4)
suggests that inpatient services in Sri Lanka may be

60 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 3.3. HOSPITAL BEDS AND AVERAGE LENGTH OF STAY

3 3 1 Hospital
. . . beds per 1,000 population, 2008 (or nearest year available)
Beds per 1 ,000
population

Sources: OECD Health Data 2010; WHO. 2010d.

3 3 2
. . . Average length of stays for acute care in hospitals, 2008 (or nearest year available)

/ ^i ’
/^ j’ f ^ /
/ ^ ^
<1
/
'^ /
Sources; OECD Health Data 2010; National Data Sources (see Annex 1).

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 61

CcpyngmMr
3.4. HOSPITAL DISCHARGES

Hospital discharge rates are a measure of the For further reading

number of people who stay overnight in a hospital Refer to Annex A.
each year. Together with the average length of stay,
they are important indicators of the level and pattern
of hospital activities. The discharge rates presented Definition and measurement
here are not age-standardised, meaning that they do A discharge is defined as the release of a
not take into account differences in the age structure patient who has stayed at least one night in
of the population in different countries. hospital, including discharges following normal
Hospitalisation rates tend to be higher among elderly childbirth. It includes deaths in hospital
people than in younger persons. following inpatient care. Same-day separations
There is a large variation in hospital discharge are usually excluded, but insufficient
rates between countries in the Asia/Pacific region, information is available to assess the extent to
with the rate being seven-times higher in some which this definition is adhered to in the
countries than others (Chart 3.4.1), Hospital discharge available data for most countries in the region.
rates in the developing economies of the Asia/Pacific There are three potential data sources on
region tend to be significantly lower than in OECD discharge rates; administrative data, hospital
countries, but the rates in the high-income Asian surveys and household health surveys. As in
economies are comparable to those in the OECD (e.g., OECD countries, the estimates from
Hong Kong-China). Furthermore, the discharge rates administrative sources tend to be higher than
in some developing economies are also comparable those from household health surveys because of
to those in OECD countries (e.g., Mongolia, Thailand, incorrect recall and non-response rates. The
Sri Lanka). figures presented here come mostly from
Within the region, the highest rates are in Sri administrative sources.
Lanka, Hong Kong-China and Mongolia, with In several countries, administrative data are
hospitalisation rates significantly higher than the routinely collected and published for discharges
OECD average, although there are some OECD from both public sector and private sector
countries that have even higher rates (e.g., Austria, hospitals, but in Brunei Damssalam and Sri
France, Germany). Discharge rates are lowest in Papua Lanka these data are only collected from public
New Guinea, Bangladesh and China. In general, those sector institutions. In some countries, such as
countries that have more hospital beds tend to have Fiji or Solomon Islands, the number of private
higher discharge rates, and vice versa (see section 3.3 hospital discharges is nil or negligible, so lack of
- “Hospital beds”). This suggests that low hospital
coverage of private hospitals does not prevent
discharge rates in some countries are an outcome of estimation of overall discharge rates.
low availability of hospital beds, which may be driven
In those countries where administrative data
by low levels of public financing for inpatient care.
do not cover private hospital discharges and
As the disease conditions between
vary these are significant in number, other data
countries in the region, further comparison of sources have been used. In Sri Lanka, the rate of
hospital discharge rates would require examining private hospital discharges is derived from
rates by specific disease. This type of comparison is surveys of private hospitals. In Bangladesh, the
difficult however, since most of the countries in the rate of private hospital discharges has been
region do not publish hospital discharge statistics by estimated by using household survey data to
and 3.4.3 illustrate the value of
diagnosis. Charts 3.4.2 derive the ratio of private hospital discharges to
such a comparison for two diseases. Discharge rates public hospital discharges. In Brunei
for circulatory disease tend to vary in a similar Darussalam, the number of private hospital
manner to that of overall discharges. But there are discharges was estimated by assuming that the
some striking variations in discharge rates for bed-turnover rate in private hospitals was the
asthma, which can be considered an indicator of same as that in public hospitals.
“avoidable hospitalisation” and might reflect
In Singapore, the published data exclude
shortcomings of the primary care sector (OECD,
normal deliveries, and these have been
2009a). Discharge rates for asthma in Sri Lanka and
estimated and added to improve comparability.
Brunei Darussalam are substantially higher than in
For other economies, the exact scope of reported
other economies, indicating a high prevalence of
data is not always clear, and so other
under-treated asthma in the community requiring
inconsistencies may remain.
hospital admission.

62 HEALTH AT A GLANCE; ASIA/PACIFIC 2010 © OECD 2010

 3.4. HOSPITAL DISCHARGES

3 4 1 Hospital discharges per 1

. . . 000 population, 2008 (or nearest year available)

Sri Lanka
Hong Kong-China
Mongolia
Australia

Korea, Rep.
OECD
New Zealand
Thailand
Asia-13
Vietnam
Brunei Darussalam
Malaysia
Japan
Singapore
Fiji

Macao-China
Solomon Islands

China
Bangladesh
Papua New Guinea

0 50 100 150 200 250 300

Per 1 000 population

3 4 2 Hospital discharges for circulatory disease per

. . . 3 4 3 Hospital discharges for
. . . asthma per 1 000
1 000 population, 2008 (or nearest year available) population, 2008 (or nearest year available)

Sri Lanka

Brjnei Darussalam

Australia

New Zealand

Hong Kctfig-China

Japan

Kcjea, Rep.

0.6

0 2 4 6 B 10
Per 1 000 popjialion
Perl 000 populaLon

Sources: OECD Health Data 2010; National Data Sources (see Annex 1).

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 63

3.5. PREGNANCY AND BIRTH

The provision of medical care and counselling (Figure 3.5.3). One-third of deliveries in Pakistan take
during pregnancy and birth has an important effect place in a health facility, with the other two-thirds
on the survival of both the mother and the child. taking place at home. Delivery in a health facility is

Many health problems in pregnant women can more common among mothers giving birth for the

be prevented, detected or treated during antenatal first time, or thosewho have had at least four
care visits with trained health workers. The World antenatal visits, as well as among mothers living in
Health Organization recommends a minimum of four urban regions (NIPS & Macro International Inc., 2008).
antenatal visits comprising of pregnancy monitoring, In Australia, almost all deliveries take place in a

managing problems such as anaemia, counselling health facility.

and advice on preventive care and diet, and Poverty is the overarching reason why
encouragement to deliver in a health care facility developing countries in the region have poor
with skilled health personnel. During the period standards of maternal and newborn health. There is,
2000-2009, around three quarters of pregnant women for example, a strong association between household
in the Asia/Pacific region had at least one antenatal wealth and having a birth attended by skilled health
visit (Figure 3.5.1). In Nepal and the Lao PDR, however, personnel (Figure 3.5.4). In Bangladesh and Nepal,
less than half of all expectant mothers received less than 5% of the poorest mothers receive medical
antenatal care. Since the 1990s, the proportion of attention, and in a number of other countries well
pregnant women in developing countries who had at under half of mothers in the poorest wealth quintile
least one antenatal visit has increased from around receive medical care at birth.
64% to around 80% in 2008,
The major risk factor for maternal and neonatal For further reading
deaths is lack of access to skilled care at birth (WHO, DHS (Demographic and Health Surveys) (2006-2009),
2008a). In many countries in the region, almost all DHS Final Reports, http://www.measuredhs.com.
births are attended by skilled health professionals
such as doctors, nurses or midwives, but there are
several countries where the proportion is much lower Definition and measurement
(Figure 3.5.2). Less than 20% of births in Bangladesh The major source of information on care
are attended by a medically trained provider, with during pregnancy and birth are health interview
most deliveries (63%) assisted by dais, or untrained surveys. Demographic and Health Surveys (DHS),
birth attendants. In Pakistan, around 40% of births for example, are nationally-representative
are attended by medically trained persons, with household surveys that provide data for a wide
traditional birth attendants assisting with more than range of monitoring and impact evaluation
half of deliveries (52%). Traditional birth attendants and
indicators in the areas of population, health,
also maintain an important role in Indonesia, nutrition. Standard DHS Surveys have large
especially in rural settings. However, there has been sample sizes (usually between 5 000 and 30 000
an increase in the proportion of births assisted by households) and typically are conducted every
medical professionals in the last decade, reaching 73% five years, to allow comparisons over time.
in 2007. The Indonesian Ministry of Health has set Women who had a live birth in the five years
2010 as the target for 90% of births to be assisted by preceding the survey are asked questions about
skilled health professionals. that birth, including whether any antenatal care
The risk of birth complications and infections was received and what type, who provided
for both mothers and babies can be reduced by assistance during delivery, and where the
proper medical attention and hygienic conditions. In delivery took place.
Bangladesh, only 15% of births take place in a health
facility, with the majority taking place at home

64 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 3.5. PREGNANCY AND BIRTH

3.S.I. At least one antenatal visit during last 3.5.2. Births attended by skilled health personnel,
pregnancy, 2000-2009 2000-2008
Brunei Darussalam

Japan
Korea, Rep.
Malaysia
Singapore
Australia

Fiji

Mongolia
Sri Lanka
Thailand
OECD
China
Korea, DPR
New Zealand
Vietnam
Asla-16
Indonesia

Philippines

Myanmar
India

Cambodia
Solomon Islands

Pakistan
Papua New Guinea
Lao PDR
Nepal
Bangladesh

0 20 40 60 80 100
Per cent

Source; WHO, 2010d.

3.5.3. Place of delivery, 2007 3.5.4. Births attended by skilled health personnel,
or nearest year available by wealth quintile

Otner/Missing Private facility Public facility i Home r 2nd Middle 4th High wealth

Per cent Note: Low wealth = 1.0

Rate ratio

Sources; DHS 2006-2009; Laws & Sullivan, 2009. Sources; DHS 2006-2009; MICS 2006-2008.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 65

cccv'igtiiMr
3.6. CHILDHOOD VACCINATION

Childhood vaccination continues to be one of Underserved and hard-to-reach populations are

the safest and most cost-effective health policy especially at risk. Children born into poor households
interventions. Most countries in the Asia/Pacific in countries such as India, Indonesia, the Lao PDR
region have established vaccination programmes, and Pakistan are many times less likely to receive a
although schedules vary by country and depend full course of immunization than children in
primarily on the local epidemiology of the vaccine- wealthier households (Figure 3.6.3). Other countries
preventable disease and an ability to finance the in the region, including Bangladesh, Mongolia and
vaccine. The World Health Organization recommends Thailand, demonstrate greater equity.
that all countries immunize against diphtheria, Other challenges include ensuring vaccine
hepatitis B, measles, pertussis, poliomyelitis, and quality and
safety, enhancing disease surveillance
tetanus. Countries with a substantial disease burden and laboratorycapacity and improving vaccine
due to haemophilus influenzae type B (Hib),
security. Although national governments provide
tuberculosis (TB) or yellow fever are also encouraged much of the finance for childhood immunization,
to introduce appropriate vaccines into their schedule. many countries are also dependent on donors and
Many countries in the region maintain high external aid, and changes in donor priorities may
immunization coverage (Figure 3.6.1), but millions of jeopardise programmes (WHO, 2008a). Routine
infants remain unimmunized and large numbers of immunization in many countries throughout the
annual deaths from preventable diseases continue to region is being strengthened through the Global
occur. Challenges persist in increasing coverage in Alliance for Vaccines and Immunisation (GAVI), a
countries such as the Lao PDR, Papua New Guinea global health partnership representing stakeholders
and India, where coverage for diphtheria- tetanus- in immunization from both private and public sectors.
pertussis, measles and hepatitis B is estimated to be
below 70%. For further reading
Although measles deaths in the region declined WHO (2009), WHO Vaccine-Preventable Diseases:
by 46% between 2000 and 2008, this was well below Monitoring System. 2009 Global Summary, Geneva, WHO.
the global average of 78%. Three quarters of all
measles deaths in 2008 occurred in India. Since 1990,
diphtheria outbreaks have been reported in the Lao De&nition and measurement
PDR, Mongolia, Papua New Guinea and Thailand. Vaccination rates reflect the percentage of 1-

Hepatitis B is endemic in most countries in the year-old children who have received the
Asia/Pacific region, with an estimated 260 million respective vaccination in the recommended
chronic carriers (WHO, 2008a). timeframe. DTP =
three doses of diphtheria-

Immunization rates across the region continue tetanus-pertussis vaccine; Measles = measles-

to increase (Figure 3.6.2). Coverage for diphtheria- containing vaccine (MCV); Hepatitis B = three
tetanus-pertussis (DTP) and measles increased doses of hepatitis B vaccine.
throughout the 1980s as countries established Data are WHO/UNICEF estimates of national
national immunization programmes, and peaked in immunization coverage, derived from officially
1990 as a result of the WHO-led drive to achieve reported data by Member States to WHO, as well
universal childhood immunization. Hepatitis B as from published literature and ministry of
coverage has also increased steadily since 1990, as health surveys. Since childhood vaccination
more countries introduce the vaccine into their policies differ slightly across countries, the
schedules. Since then, average reported coverage for indicator is based on the actual policy in a given
DTP, measles and hepatitis B across the region has country.
risen steadily to approach 90%.

66 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 3,6. CHILDHOOD VACCINATION

3 6 1 Estimated infant vaccination rates for DTP,

. . . measles and hepatitis B, 2009
DTP Measles Hepatitis B
Per cent
100 - - -

Source; WHO, 2010c.

3 6 2 Estimated infant vaccination rates for DTP,

. . . 3 6 3 Children
. . . aged 1-2 who had received all basic
measles and hepatitis B, Asia-20 countries, vaccinations^"^, by wealth quintile
1980-2009

DTP — — Measles Hepatitis B

Per cent

Source; WHO, 2010c. (a) BCG, measles and 3 doses each o/DPT and polio vaccine.
Sources: DHS 2006-2009, MICS 2006-2008.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 67

CopyngnteO t
 Health at a Glance; Asia/Pacific 2010
© OECD 2010

Chapter 4

Health Expenditure and Financing

4.1 Health expenditure per capita

4.2 Health expenditure in relation to GDP

4.3 Financing of health care
4.4 Health expenditure by function
4.5 Health expenditure by provider

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 69

4.1. HEALTH EXPENDITURE PER CAPITA

Differences in health spending levels per capita for those countries towards a high income - high
reflect differences in overall income levels (GDP), as spending situation.
vrell as countries’ diverse financing and the
organisational structures of their health systems. For further reading
Much variation in health spending levels can be OECD (2000), A System of Health Accounts, version
observed among Asia/Pacific countries (Figure 4.1.1), 1.0, OECD, Paris.
ranging from Australia with a total health spending
WHO (2003), Guide to producing national health
per capita of USD 3
448 PPP to Myanmar with accounts: with special applications for low-income and
spending of only USD
24 PPP. The average OECD
middle income countries. World Health Organization,
spending per capita in 2008 was around six times Geneva.
that of the Asian economies (3 060 versus 526).
WHO (2010), National Health Accounts country data,
The share of public spending in total health World Health Organization, Geneva.
spending is much lower in Asia compared to OECD

countries: 59% versus 72% respectively. The lowest

share of public spending in Asia/Pacific countries was Definition and measurement
reported in Myanmar (10%), the highest in the Total health expenditure is defined as the sum
Solomon Islands (93%), followed by Brunei of expenditure on all core health care functions
Darussalam (81%) and Japan (80.3%), - that is, total health care services, medical
On between 1998-2008, the growth rate
average, goods dispensed to outpatients, prevention and
in per capita health spending in real terms was 4.9% public health services, and health
per year in Asia, higher than the 4.1% observed across administration and health insurance - plus
OECD countries (Figure 4.1.2). The growth rate for capital formation in the health care provider
Cambodia, China, the Republic of Korea, and Vietnam industry. Expenditure on these functions is
was even more rapid - almost twice the average rate included as long as it is borne for final use of
for the region. The 13.6% growth rate observed for resident units, i.e. as long as it is final
Myanmar - the highest among all countries- should consumption by nationals in the country or
be understood in the context of very low initial abroad.
spending per capita. The economy-wide (GDP) purchasing power
Three countries - Brunei Darussalam, Papua parities (PPPs) are used to compare spending
New Guinea, and Nepal - reported a decline in health across countries as they are the most available
spending per capita in real terms between 1998 and and reliable conversion rates. These PPPs are
2008. In particular, Brunei Darussalam reported a based on a broad basket of goods and services,
negative growth of 5.9% per year (on average) over the chosen to be representative of all economic
past decade, as compared to a positive growth of GDP activity. The use of economy-wide PPPs means

(0.2%). A strong pressure to reduce government that the resulting variations in health
spending (which accounted for 80% on average over expenditure across countries will reflect not
the decade), and a decline in household final only variations in the volume of health services,
consumption expenditure explains this trend. but also any variations in the prices of health
In general, health expenditure per capita services relative to prices in the rest of the

increases with per capita GDP. Figure 4.1.3 shows the economy.
relationship between per capita health expenditure To make useful comparisons of real growth
and per capita GDP in 2008 (on a logarithmic scale). rates over time, it is necessary to deflate (i.e.

This underlines the existence of a close relationship remove inflation from) nominal health
between income and health spending in the expenditure through the use of a suitable price
Asia/Pacific region, which parallels that seen among index, and also to divide by the population, to
OECD economies as a whole. On the top right of derive real spending per capita. Due to the
Figure 4.1.3 is a group that includes OECD countries, limited availability of reliable health price
Singapore, and Brunei Darussalam that have high indices, an economy-wide (GDP) price index is
income and high spending. China, Malaysia, and used in this publication, based on 2005 GDP
Thailand are three middle-income and middle- price levels.
spending countries. There is evidence of a transition

70 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 4.1. HEALTH EXPENDITURE PER CAPITA
4.1.1.
Total health expenditure per capita, public and private, 2008
USD PPP
• Public Private
^ 3.448

30 60

2,751

1 2,465
nr
L 1,820
1 757

1 194

526
1 259 201
1 _ 184
85 82 71 70 54 47 24
1 1

4.1.2. 4.1.3.

Annual average real growth in per capita Total health expenditure per capita and
health expenditure, 1998-2008 GDP per capita, 2008

Brunei Darussalam
Papua New Guinea
Nepal
Health spending per capita (USD PPP) {log scale)
Fiji

Pakistan
Japan
Singapore
Lao PDR
Solomon Islands
Indonesia
Mongolia
New Zealand
Philippines
Australia
OECD
India
Asia -19
Thailand
Sri Lanka
Malaysia
Bangladesh
Cambodia
China
Korea, Rep.
Vietnam
Myanmar

% growth
GDP per capita (USD PPP) (log scale)

Sources; WHO National Health Accounts database (2010); World Bank (for GDP deflator).

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 71

4.2. HEALTH EXPENDITURE IN RELATION TO GROSS DOMESTIC PRODUCT

Health expenditure as a percentage of gross increased between 1998 and 2008. In all economies
domestic product (GDP) in 2008 was 4.3% on average below that line, the increase in health spending - on
in the Asian region. This share varied from 2% in average - is lower that the increase in GDP. Hence the
Indonesia up to 9% in New Zealand (Figure 4.2.1). share of health spending in total spending has
Generally, the richer a country, the more it spends on declined.
health as a percentage of GDP. But there are In China, health spending has grown at almost
exceptions. Vietnam and Cambodia, for example, the same rate as overall economic growth over the
allocated a relatively high share of their GDP to past ten years, a growth rate of over 9% per year per
health, even though their GDP per capita is lower capita. In income elasticity was 0.8,
India, the
than in many other Asian countries. The percentage meaning that health spending growth has not kept
of GDP allocated to health in 2008 across OECD pace with economic growth.
countries is - on average - twice that of the Asian
The Republic of Korea and Japan have shown
countries and economies (9 versus 4.3).
the highest income elasticity over the last ten years
Between 1998-2008, the share of GDP allocated even if at a different level of real per capita
(1.9),
to health increased in Thailand, was generally stable growth (on average) in health spending (9.2% in the
in China and Indonesia, while the share slightly Republic of Korea and 2.2% in Japan).
declined in India (Figure 4.2.2). This share increased
rapidly in the Republic of Korea, while the increase For further reading
was more modest in Japan. Indonesia reported the
lowest figure among the countries studied, at less
WHO (2010), National Health Accounts country data.
World Health Organization, Geneva.
than 2%. The comparative analysis of the share of
health spending in GDP over time highlights the
different priority given to the health sector in Definition and measurement
different countries: from a similar situation in 1998
See indicator 4.1 for the definition of total
(around 4.3% of GDP spent on health), the Republic of
health expenditure.
Korea spent 50% more on health - in terms of share
in GDP compared
- to India in 2008. Gross Domestic Product (GDP) = final
consumption + gross capital formation + net
As in OECD countries, health spending growth
exports. Actual final consumption of households
in many Asia/Paciftc countries has exceeded
includes goods and services used by households
economic growth over the past ten years, resulting in
or the community to satisfy their individual
an increasing share of the economy devoted to health
needs. It includes final consumption
in most countries (Figure 4.2.3). The income elasticity
expenditure of households, general government
for health care during that 10-year period was 1.1 in
and non-profit institutions serving households.
Asia, ascompared to 1.6 in OECD countries. All
economies above the diagonal line report an income
elasticity above one. This means that the share of
health expenditure in total expenditure has

72 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 4.2. HEALTH EXPENDITURE IN RELATION TO GROSS DOMESTIC PRODUCT

4 2 1 Total health expenditure as a share of GDP, 2008

. . .

. .

4 2 2 Total health expenditure as a share of GDP,

. . 4 2 3 Health expenditure growth
. . and GDP growth,
1998-2008, selected countries 1998-2008

Average annual growth rate in health spending per capita

• China ——— India

Thailand •••••• Indonesia
Korea. Rep. Japan

% GDP

Sources: WHO National Health Accounts database (2010); World Bank (for GDP deflator).

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 73

4.3. FINANCING OF HEALTH CARE

Figure 4.3.1 shows that, on average, the public 43% and 50% in Sri Lanka and Tianjin (China)
share of health spending has slightly increased in respectively.
Asian countries, from 43% in 1998 to 45% in 2008. This In general, private household out-of-pocket
is about the same share as in the United States, but is
payments, comprising direct payments and cost-
much lower than the average in OECD countries, sharing payments, form the greater part of private
where the public sector accounted for 72% of funding sources (Figure 4.3.3). In India, Nepal,
financing in 2008, similar to 1998. In Thailand, Vietnam, Singapore, Bangladesh, Myanmar, China,
Mongolia, Papua New Guinea, Brunei Darussalam, and Brunei Darussalam, out-of-pocket health
and the Solomon Islands, public financing accounted spending represents 90% or more of private health
for more than 70% of all health expenditure, while it spending. Private health insurance plays a role in
accounted for less than 30% in Pakistan, India, Thailand, Malaysia, Fiji and the Philippines, in
Cambodia, and Lao PDR. Myanmar reported only 11% addition to OECD countries in the region. In all these
of public health spending in total health spending. countries, private health insurance covers at least 10%
The public share of health spending has of private health spending.
increased significantly over the past ten years in
Thailand and Indonesia (+ 20 points of share), while it For further reading
has decreased importantly in Singapore and the WHO (2010), National Health Accounts country data,
Philippines (- 10 points). World Health Organization, Geneva.
The split between the various financing agents
Jeong, H.-S, and Rannan-Eliya, R.P. (2010), SHA-
for selected shown in Figure 4.3.2.
countries is
Based Health Accounts in Uuelue Asia/Pacific Economies; A
General government accounts for 57% of total health
Comparatiue Analysis, SHA Technical Papers No. 10,
expenditure on average, being the main financing OECD/Korea Policy Centre, Seoul.
source in high-income
relatively economies.
Throughout the region, there is wide variation in the
public share (that is general government + social Definition and measurement
security funds), ranging from 28% in Bangladesh and The financing classification used in the
42% in Tianjin (China), up to 70% in Mongolia and 80% System of Health Accounts (OECD, 2000)
in Japan and New Zealand. In five economies - provides a complete breakdown of health
Bangladesh, Tianjin (China), Malaysia, Hong Kong- expenditure into public and private units
China and Sri Lanka - less than 50% of health incurring expenditure on health. Public
spending comes from public funds. financing includes general government revenues
There are various systems of public funding: and social security funds. Private sector
Australia, Bangladesh, Hong Kong-China, Malaysia, comprises private insurance, household out-of-
Mongolia, New Zealand, Sri Lanka and Thailand are pocket expenditure, non-profit institutions and
almost exclusively general government funded. Japan corporations. Private insurance covers both
and the Republic of Korea fund the public part of private social insurance and private insurance
health mainly through the social insurance schemes enterprises. Out-of-pocket payments are
paid by employer and employee contributions. In expenditures borne directly by the patient. They
Bangladesh, 63% of total health expenditures comes include cost-sharing and, in certain countries,
from households out-of-pocket payments. Of the estimations of informal payments to health care
other economies, the out-of-pocket share varies from providers.
lows of 14% and 15% in New Zealand and Japan up to

74 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 4.3. FINANCING OF HEALTH CARE

4 3 1 Public share of total expenditure on health, 1998 and 2008

. . .

% total expenditure on health 1998 2008

100

4 3 2 Share of total health expenditure by

. . . 4 3 3 Out-of-pocket and private health insurance
. . .

flnancing agent, around 2006 spending as a share of private expenditure, 2008^

General government ^excluding social security funds]
Social security funds
Out-of-pocket Private health insurance
Private insurance
Out-of-pocket payments
Non-profit organisations
Papua New Guinea
Corporations
Solomon Islands
Indonesia
LaoPDR
Australia
Pakistan
Mongolia
Cambodia
Korea, Rep.
Malaysia
Nepal
India
Thailand
Vietnam
Philippines
Fiji

Japan
New Zealand
Myanmar
Sri Lanka
Singapore
Bangladesh
China
Brunei Darussalam

Percentage
% of private expenditure

1. In China, the figures refer to the Tianjin municipality only, which may not be representative of the rest of the country.
2. The rest of private health expenditure comprises non-profit institution serving households and corporations (other than health
insurance)
Sources: Jeong & Rortnan-Eliya (2010); WHO National Health Accounts database (2010).

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 75

rcpyngntMr
4.4. HEALTH EXPENDITURE BY FUNCTION

The average percentage of total health spending out-patient care, and 20% for in-patient care (Figure
devoted to personal medical services and goods 4.4.3).Thailand reports only 15% of OOP spent on
equals 86% among a group of Asia/Pacific countries medical goods, and 54% on out-patient care, while for
for which breakdown of expenditure by
a detailed Bangladesh 69% of households out-of-pocket health
function of care is available. This ranges from a low of
4.4.1) expenditure is on medical goods and 9% on in-
78% in Bangladesh to a high of 93% in Japan (Figure patient care. In both cases, the comparability of the
. data with other countries may be low due to issues in
In terms of the split between personal medical the mapping of health spending categories.
services and goods, personal medical services
comprise 67% of the total health spending, with the For further reading
remaining 19% being spent on medical goods, mainly Jeong, H.-S. and Rannan-Eliya, R.P. (2010), SHA-
pharmaceutical goods. Bangladesh and the Tianjin Based Health Accounts in Uuelve Asia/Pacific Economies: A
(China) devote the highest proportion of expenditure Comparative Analysis, SHA Technical Papers No. 10,
on medical goods (44% and 39%), while Malaysia and OECD/Korea Policy Centre, Seoul.
Thailand the lowest (7% and 4% respectively).
Differences in the level of expenditure on
Definition and measurement
personal medical services partly reflect differences in
the dispensing goods and in
of pharmaceutical The functional approach of the System of

medical practice, as well as how expenditures are Health Accounts (OECD, 2000) defines the
currently classified. In many economies (e.g., Sri boundaries of the health system. Current health
Lanka, Thailand, Hong Kong-China), physicians expenditure comprises personal health care
dispense medicines as part of their overall delivery of (curative care, rehabilitative care, long-term care,

ambulatory care services, and the cost of the ancillary services and medical goods) and
dispensed medication is not explicitly charged to the collective services (public health services and
4.4.2)
patient, but instead is included as part of the cost of health administration).
the diagnostic or consultation fee. Curative, rehabilitative and long-term care can
Regarding the categorisation of current public also be classified by mode of production (in-

expenditure on health by mode of production (Figure patient, day care, out-patient and home care).

,
curative and rehabilitative in-patient care Day care comprises health care services

accounts for around 45% of current public health delivered to patients who are formally admitted

expenditure, ranging from 30% in Tianjin (China) to to hospitals, ambulatory premises or self

70% in Mongolia. Out-patient care accounts for standing centres but with the intention to
slightly more than a quarter (26%) of current public
discharge the patient on the same day. An out-

health expenditure on health - ranging from 13% in patient is not formally admitted to a facility
(physician’s private office, hospital out-patient
Tianjin (China) to over 42% in Thailand. Only three
countries reported expenditure on day care and centre or ambulatory-care centre) and does not

home care services, most

due to difficulties
likely in stay overnight.

recording separately those spending figures.

On average, 42% of household out-of-pocket
spending on health pays for medical goods, 37% for

76 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 4.4. HEALTH EXPENDITURE BY FUNCTION
4.4.1.
^
Medical goods and personal medical services as a share of total health expenditure, around 2006

% total health expenditure Personal medical services Medical goods

1, The4.4.2.
rest of total heath expenditure comprises prevention and health services, health administration
public 4.4.3. and health insurance, and
capital formation.

2 . In China, the figures refer to the Tianjin municipality only, which may not be representative of the rest of the country.

Share of current public health expenditure Share of household out-of-pocket expenditure

^ ^
by mode of production, around 2006 by mode of production, around 2006

In-patient care Day-care Out-patient care In-patient care Day-care Out-patient care

Home care Ancillary services Medical goods Home care Ancillary services Medical goods

Percentage
3, 4. The rest of current public health expenditure comprises prevention and public health services, and health adminsitration and
insurance.
Source; Jeong & Rannan-Eliya (2010).

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 77

4.5. HEALTH EXPENDITURE BY PROVIDER

In all of the countries and economies covered, of public funds on average, but it is more than 10% in
other than Malaysia, hospitals account for the the case of Bangladesh, Thailand, Malaysia and
highest proportion of current health expenditure Mongolia.
The percentage varies between 30% in
(Figure 4.5.1). The household expenditure on
largest shares of
Bangladesh up to 72% in Thailand, with an average health are directed towards providers of ambulatory
among the 11 Asia/Pacific economies of about 50%. care and medical goods - 32% and 35% respectively
Another 25% of current health expenditure is
on average (Figure 4.5.3). However, there is large
directed towards providers of ambulatory health care, variation across economies. In Thailand and Tianjin
ranging from 5%, only in Tianjin (China) up to 43% in (China), around 60% of households’ health
Malaysia. expenditure goes to hospitals, while in Australia,
Retail sale and other providers of medical goods Bangladesh and New Zealand the equivalent figure is
account for another 17% of current health less than 10%. The share of households’ total
expenditure, with a wide variation - between 4% in expenditure on health going to ambulatory care
Thailand to 47% in Bangladesh. In New Zealand, providers varies from as low as 6% and 11% in Tianjin
nursing and residential care facilities account for 9% (China) and Mongolia, to 48%, 50% and 56% in
of current expenditure. Other economies
health Australia, Malaysia and Hong Kong-China respectively.
no expenditures due to the small
report low or Finally, the share of households’ total expenditure
number of such establishments, though under- being paid for medical goods generally varies
estimation in the health accounts is a contributory between 25% and 50%. The exceptions are Malaysia
factor. and Thailand (14% and 16% respectively), while at the
Of the remaining health provider categories, other extreme is Bangladesh (70% of households’
provision and administration of public health expenditure).

programmes accounts for around 3% on average and

general administration of health around 5% of For further reading
current health expenditure. By comparison, in OECD Jeong, H.-S. and Rannan-Eliya, R.P. (2010), SHA-
countries spending by hospitals is lower (29% of Based Health Accounts in TUielue Asia/Paci/ic Economies: A
current health expenditure), while out-patient Comparative Analysis, SHA Technical Papers No. 10,
providers (31%), medical goods providers (21%), OECD/Korea Policy Centre, Seoul.
nursing and residential care facilities (12%) receive a
higher share of health spending.
Definition and measurement
Hospitals are the main recipients of general
government health financing - on average The provider classification of the System of

accounting for 65% of public health expenditure Health Accounts (OECD, 2000) comprises both
(Figure 4.5.2). The share varies from 42% in the primary producers of health care and secondary
Republic of Korea to 80% in Sri Lanka. The majority of producers. The principal activity performed by

the economies lie in a band between 70% and 80%.

primary producers is health care services.
On average, 16% of public health funds are directed to Examples are hospitals or doctors’ offices.
ambulatory health care providers - varying from 4% Secondary producers provide health care
in Tianjin (China) and 5% in Thailand up to 36% in services beside their principal activity as

Australia and 28% in Japan. In Japan, doctors’ clinics secondary Examples are residential care
activity.

play a considerable role in providing both inpatient which provide mainly social services
institutions

and outpatient care. The share of public financing such as sheltered houses but in combination
directed to providers of medical goods is relatively
with health care services, for example intensive
small (6% on average). The Republic of Korea has the long-term nursing care or psychiatric care.
highest proportion among the 11 economies (22%). Consequently, the SHA classifies both primary
and secondary producers of health care and
Public expenditures reported for nursing and
several classes in the provider classification may
residential care facilities accounted for less than 10%
comprise both of them. Examples are retail sales
of public spending on health in the case of New
of medical goods, administration, and nursing
Zealand, Hong Kong-China and Japan, and near zero
and residential care.
for the other economies. Of the other provider
categories, 5% is allocated to public health
programmes on average, reaching 11% in Malaysia.
General administration and insurance account for 6%

78 HEALTH AT A GLANCE: ASIA/PACIFIC 2010 ® OECD 2010

 4.5, HEALTH EXPENDITURE BY PROVIDER
4.5.1.
Share of current health expenditure by provider^ around 2006
Hospitals Nursing and residential facilities Providers of ambulatory care Retail of medical goods

Percentage

4.5.2. 4.5.3.

1. In China, the figures refer to the Tianjin municipality only, which may not be representative of the rest of the country.

Share of public expenditure on health by Share of households expenditure on health by

provider, around 2006 provider, around 2006

Hospitals Hospitals

Nursing and residential facilities Nursing and residential facilities

Providers of ambulatory care Providers of ambulatory care

Retail of medical goods Retail of medical goods

Provision and administration of pub. health prog Provision and administration of pub. health prog

General health administration and insurance General health administration and insurance

I I I

Mongolia

New Zealand
Sri Lanka

Malaysia

Korea, Rep.

Bangladesh

Australia

Japan

Thailand

Hong Kong-
China
China {Tianjin)
—I ^ 1-
20 40 60 80 100
Percentage Percentage
Source.- Jeong & Rannan-Eliya (2010).

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 79

CcpyngniMr
CopyngnteO t
 ANNEX A NATIONAL DATA SOURCES
:

ANNEX A: National Data Sources

Bangladesh
Data International (2010), lARS 2006-07, Data International for Ministry of Health and Family
Welfare, Dhaka.

Equitap Network, Health and Demographic Survey 2000.

Ministry of Health and Family Welfare (2009), Bangladesh Health Bulletin 2009, Directorate
General of Health Services, Dhaka.

Brunei Darussalam
Ministry of Health (2009), Health In/ormation Booklet 2008, Department of Policy and Planning,
Ministry of Health, Brunei Darussalam.

China
Equitap Network, National Health Household Interview Surveys 2003.
Ministry of Health of China (2007), China's Health Statistics Yearbook 2006, Peking Union Medical
College Press, Beijing.

National Bureau of Statistics of China (2008), China Statistical Yearbook 2008, China Statistics
Press, Beijing.

Hong Kong-China
Department of Health (2010), Health Facts of Hong Kong 2010, Department of Health and Census
and Statistics, Hong Kong.
Equitap Network, Thematic Household Survey 2002.
Hospital Authority (2010), Hospital Authority Statistical Report 2008-2009, Statistics and
Workforce Planning Department, Strategy & Planning Division, Hospital Authority, Hong Kong.
National Bureau of Statistics of China (2008), China Statistical Yearbook 2008, China Statistics
Press, Beijing.

India
Equitap Network, National Sample Survey 1995/96.

Indonesia
Equitap Network, SUSENAS 2001.

Korea, Rep
Equitap Network, National Health Survey 1998.

Macao-China
National Bureau of Statistics of China (2008), China Statistical Yearbook 2008, China Statistics
Press, Beijing.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 81

ANNEX A NATIONAL DATA SOURCES
:

Statistics and Census Service (2010), Yearbook 0/ Statistics 2009, Statistics and Census Service,
Macao.

Malaysia
Ministry of Health (2006), Annual Report 2006, Putrajaya: Ministry of Health, Malaysia.

Ministry of Health (2006), National Health and Morbidity Survey - III Report, Ministry of Health,
Kuala Lumpur.
Ministry of Health (2010), Health Facts 2009, Putrajaya: Ministry of Health, Malaysia.

Mongolia
National Center for Health Development (2006), Health Indicators 2005, National Center for
Health Development, Mongolia.

Nepal
Equitap Network, Nepal Living Standard Survey 1995/96.

Papua New Guinea

Government of Papua New Guinea (2010), National Health Plan 2011-2020, Government of Papua
New Guinea., Port Moresby.

Solomon Islands
Statistics Office, Solomon Islands (n.d.). Report of Solomon Islands Household Income and
Expenditure Survey Health Module 2005-2006, Statistics Office, Ministry of Finance & Treasury, Honiara.

Singapore
Ministry of Health (2010), Health Facts Singapore. Available for download from
http://www.moh. gov.sg/mohcorp/statistics.aspx?id=240.
Ministry of Health (2010), Healthcare Institution Statistics. Available for download from
http://www.moh. gov.sg/mohcorp/statistics.aspx?id=242.
Ministry of Health (2010), Healthcare Services. Available for download from
https://www.moh. gov.sg/mohcorp/hcservices.aspx?id=394.

Sri Lanka
Gentral Bank of Sri Lanka, Consumer Finances and Socio Economic Survey 2003/04. Available for
download from http://www.cbsl.lk/cbsl/cfs03_04.html.
Perera, C. et al. (2005), Public Hospital Inpatient Discharge Survey 2005, Institute for Health Policy,
Colombo.
Ministry of Health (2010), Annual Health Bulletin 2007, Ministry of Health, Colombo.

Ministry of Health (2010), Health Manpower Data. Available for download from
http://203.94.76.60/nihs/BEDS/Manpower-Summary2008.pdf.

Thailand
Bureau of Policy and Strategy, Ministry of Public Health (2008), Thailand Health Pro/ile 2005-2007,
Ministry of Public Health, Bangkok.
Equitap Network, Socio-Economic Survey 2002.

82 HEALTH AT A GLANCE; ASIA/PACIFIC 2010 © OECD 2010

 ANNEX B: ADDITIONAL INFORMATION ON DEMOGRAPHIC AND ECONOMIC CONTEXT

ANNEX B: Additional Information on Demographic and

Economic Contexts

Tkble A.l. Total mid-year population, thousands, 1960 to 2008

1960 1970 1980 1990 2000 2008

Australia 10 276 12 728 14 695 17 091 19 171 21 074

Bangladesh 54 138 69 178 90 397 115 632 140 767 160 000

Brunei
82 130 193 257 333 392
Darussalam

Cambodia 5 433 6 938 6 748 9 690 12 760 14 562

China 645 927 815 951 980 929 1 142 090 1 266 954 1 337 411

Fiji 394 520 634 724 802 844

Hong Kong-China 3 075 3 942 5 039 5 704 6 667 6 982

India 448 314 552 964 692 637 862 162 1 042 590 1 181 412

Indonesia 93 058 116 921 146 582 177 385 205 280 227 345

Japan 93 189 104 448 116 794 123 191 126 706 127 293

Korea, DPR 10 946 14 247 17 239 20 143 22 859 23 819

Korea, Rep. 25 068 31 440 37 459 42 983 46 429 48 152

Lao PDR 2 124 2 692 3 238 4 207 5 403 6 205

Macao-China 173 254 252 372 441 526

Malaysia 8 140 10 853 13 763 18 103 23 274 27 014

Mongolia 959 1 256 1 663 2 216 2 389 2 641

Myanmar 21 075 26 403 33 561 40 844 46 610 49 563

Nepal 9 691 11 893 15 058 19 105 24 432 28 810

New Zealand 2 372 2 820 3 147 3 386 3 868 4 230

Pakistan 48 778 61 750 82 609 115 776 148 132 1 76 952

Papua New
2 080 2 554 3 199 4 131 5 388 6 577
Guinea

Philippines 27 057 36 567 48 112 62 427 77 689 90 348

Singapore 1 634 2 075 2 415 3016 4018 4615

Solomon Islands 118 161 229 314 416 511

Sri Lanka 10 018 12 520 15 060 17 290 18 767 20 061

Thailand 27 642 37 186 47 264 56 673 62 347 67 386

Vietnam 33 648 42 898 53 317 66 247 78 663 87 096

Asia-22 1 570 170 1 962 505 2 410 328 2 905 515 3 363 510 3 688 587

OECD 791 580 894 056 986 839 1 069 779 1 158 133 1 223 591

Source: UNDESA, 2009.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 83

ANNEX B: ADDITIONAL INFORMATION ON DEMOGRAPHIC AND ECONOMIC CONTEXT

Table A.2. Share of the population aged 65 and over, 1960 to 2008

1960 1970 1980 1990 2000 2008

Australia 8.5 8.3 9.6 11.2 12.5 13.4

Bangladesh 3.2 3,2 3.0 3.0 3.4 3.8

Brunei Darussalam 3.9 3.5 2.9 2.7 2.9 3.3

Cambodia 2.7 2,8 2.8 2,7 3.0 3.4

China 4.8 4.3 4.7 5.5 6.8 7.9

Fiji 2.5 2.4 2.8 3.1 3.5 4.6

Hong Kong-China 2.8 4.0 6.5 8.5 11.0 12.5

India 3.0 3.3 3.6 3.8 4.3 4,8

Indonesia 3.4 3.1 3.5 3.8 4.9 5.9

Japan 5.7 7.0 9.1 12.0 17.2 21.4

Korea, DPR 1.9 1.4 2.5 4.7 7.0 9.4

Korea, Rep. 3.7 3.3 3.9 5.0 7.3 10.4

Lao PDR 2.6 3.0 3.5 3.5 3.6 3.6

Macao-China 5.3 4.6 7.6 6.5 7.4 7.1

Malaysia 3.4 3.4 3.7 3.7 3.9 4.6

Mongolia 3.2 3.0 3.0 4.0 3.4 3.9

Myanmar 3.7 4.1 4.5 4.9 5.4 5.5

Nepal 2.6 2.9 3.1 3.2 3.5 4.0

New Zealand 8.6 8.5 9.8 11.1 11.8 12.5

Pakistan 6.0 5.3 4.5 3.7 3.7 4.0

Papua New Guinea 2.4 2.1 1.9 2.2 2.2 2.4

Philippines 3.0 2.9 3.2 3.2 3.5 4.1

Singapore 2.1 3.4 4.7 5.6 7.2 9.4

Solomon Islands 2.7 3.5 3.3 3.0 2.9 3.1

Sri Lanka 4.7 3.8 4.4 5,5 6.4 7.3

Thailand 3.2 3.4 3.9 4.6 6.3 7.4

Vietnam 4.5 4.9 4.8 4.7 5.6 6.3

Asia>22 3.6 3.7 4.2 4.8 5.8 6.8

OECD 8.6 9.9 11,4 12.1 13,5 14.7

Source; UNDESA, 2009.

84 HEALTH AT A GLANCE; ASIA/PACIFIC 2010 © OECD 2010

 ANNEX B: ADDITIONAL INFORMATION ON DEMOGRAPHIC AND ECONOMIC CONTEXT

Table A.3. Crude birth rate, per 1 000 population, 1960-65 to 2005-10

1960-65 1970-75 1980-85 1990-95 2000-05 2005-10

Australia 22 20 15 15 13 13

Bangladesh 47 47 43 32 25 22

Brunei Darussalam 43 35 30 28 22 20

Cambodia 45 40 52 41 26 25

China 38 29 22 19 14 14

Fiji 42 33 32 28 23 21

Hong Kong-China 33 20 16 12 8 8

India 40 37 34 31 25 23

Indonesia 44 39 32 24 21 19

Japan 17 19 13 10 9 8

Korea, DPR 33 30 22 21 15 14

Korea, Rep. 40 30 20 16 10 9

Lao PDR 43 43 42 40 29 28

Macao-China 32 20 25 17 7 8

Malaysia 43 35 33 28 23 21

Mongolia 43 41 38 29 18 19

Myanmar 42 39 33 25 22 21

Nepal 44 43 41 38 30 26

New Zealand 26 21 16 17 14 14

Pakistan 40 44 42 38 32 30

Papua New Guinea 42 42 38 37 34 32

Philippines 44 39 36 32 26 25

Singapore 34 21 17 18 10 8

Solomon Islands 44 47 40 39 34 31

Sri Lanka 35 29 26 20 19 18

Thailand 43 34 25 19 15 15

Vietnam 46 39 35 29 19 17

Asia-22 40 34 31 26 19 18

OECD 22 19 16 14 12 12

Source: UNDESA, 2009.

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 85

ANNEX B: ADDITIONAL INFORMATION ON DEMOGRAPHIC AND ECONOMIC CONTEXT

Table A.4. Fertility rate, number of children per women aged 15-49, 1960-65 to 2005-10

1960-65 1970-75 1980-85 1990-95 2000-05 2005-10

Australia 3.3 2.5 1.9 1.9 1.8 1.8

Bangladesh 6.9 6.9 5.9 4.0 2.8 2.4

Brunei Darussalam 6.7 5.4 3.8 3.1 2.3 2.1

Cambodia 6.3 5.5 6.6 5.6 3.4 3.0

China 5.6 4.8 2.6 2.0 1.8 1.8

Fiji 6.0 4.2 3.8 3.4 3.0 2.8

Hong Kong-China 5.3 2.9 1.8 1.3 1.0 1.0

India 5.8 5.3 4.5 3.9 3.1 2.8

Indonesia 5.6 5.3 4.1 2.9 2.4 2.2

Japan 2.0 2.1 1.8 1.5 1.3 1.3

Korea, DPR 3.4 3.7 2.9 2.4 1.9 1.9

Korea, Rep. 5.6 4.3 2.2 1.7 1.2 1.2

Lao PDR 6.0 6.0 6.3 5.8 3.9 3.5

Macao-China 5.1 3.2 2.5 1.6 0.8 1.0

Malaysia 6.7 5.2 4.2 3.5 2.9 2.6

Mongolia 6.0 7.3 5.7 3.5 2.1 2.0

Myanmar 6.1 5.9 4.6 3.1 2.5 2.3

Nepal 6.2 6.1 5.8 4.9 3.6 2.9

New Zealand 4.0 2.8 2.0 2.1 2.0 2.0

Pakistan 6.6 7.0 6.6 5.7 4.4 4.0

Papua New Guinea 6.3 6.1 5.5 4.7 4.4 4.1

Philippines 6.9 6.0 5.0 4.1 3.3 3.1

Singapore 4.9 2.6 1.7 1.8 1.4 1.3

Solomon Islands 6.4 7.2 6.4 5.5 4.4 3.9

Sri Lanka 5.2 4.0 3.2 2.5 2.3 2.3

Thailand 6.3 5.1 3.0 2.1 1.8 1.8

Vietnam 7.3 6.7 4.5 3.3 2.3 2.1

Asia-22 5.7 5.1 4.1 3.2 2.4 2.2

OECD 3.2 2.6 2.0 1.8 1.6 1.7

Source; UNDESA, 2009.

86 HEALTH AT A GLANCE; ASIA/PACIFIC 2010 © OECD 2010

 ANNEX B: ADDITIONAL INFORMATION ON DEMOGRAPHIC AND ECONOMIC CONTEXT

Table A5. GDP per capita in 2008 and average annual growth rates, 1980 to 2008

GDP per capita in

Average annual growth rate (in real terms)
USDatPPPs
2008 1980-90 1990-2000 2000-2008

Australia 37 701 1.7 2.3 1.5

Bangladesh 1 374 1.2 2.7 3.0

Brunei Darussalam 50 757 -0.4

Cambodia 1 942 2.8 5.9

China 5 870 7.6 9.3 7.4

Fiji 4 367 1.4 3.8 0.6

Hong Kong-China 44 299 4.5 2.3 3.3

India 2 886 3.7 3.5 4.6

Indonesia 3 979 3.4 2.6 3.0

Japan 34 743 3.4 1.0 1.2

Korea, DPR
Korea, Rep. 26 278 7.5 5.1 3.4

Lao PDR 2 225 2.8 3.7 3.7

Malaysia 14 023 3.1 4.3 2.5

Mongolia 3 505 -1.2 4.5

Myanmar 1 084 -0.7 4.9 6.8

Nepal 1 244 0.5 3.3 1.6

New Zealand 27 172 0.8 1.6 1.5

Pakistan 2 754 3.3 1.5 2.8

Papua New Guinea 2 079 -0.9 1.4 0.3

Philippines 3 575 -0.7 0.8 2.3

Singapore 51 829 4.9 4.6 2.5

Solomon islands 1 927 -2.0 -0.2 0.1

Sri Lanka 4 393 3.2 3.9 3.1

Thailand 8 401 5.8 3.4 3.4

Vietnam 2 792 3.8 5.8 4.9

Source; International Monetary Fund, World Economic Outlook Database, April 2010

HEALTH AT A GLANCE: ASIA/PACIFIC 2010 © OECD 2010 87

 Health at a Glance: Asia/Pacific 2010
© OECD 2010

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(81 2010 24 1 P) ISBN 978-92-64-09618-9 - No. 57799 2010

Health at a Glance
Asia/Pacific 2010
This first edition of Health at a Glance: Asia/Pacific presents a set of key indicators of heaith status,
the determinants of heaith, heaith care resources and utiiisation, and heaith care expenditure and
financing across 27 Asia/Pacific countries and economies in the Asia/Pacific region.

Drawing on a wide range of data sources, it buiids on the format used in previous editions of Health
at a Glance: OECD Indicators, and gives readers a better understanding of the factors that affect the
heaith of popuiations and the performance of heaith systems.

Each of the 32 indicators in the book is presented in a user-friendiy format, consisting of charts

iiiustrating variations across countries and over time, brief descriptive anaiyses highiighting the major
findings conveyed by the data, and a methodoiogicai box on the definition of the indicator and any
limitations in data comparability. An annex provides additional information on the demographic
contexts in which health systems operate.

Related reading

OECD Health Data 2010

Health at a Glance: Europe 2010
Health at a Glance: OECD Indicators 2009

ww.oecd.org/health
www.oecdkorea.org

Please cite this publication as:

OECD (2011), Health at a Glance: Asia/Pacific 2010, OECD Publishing.
http://dx.doi.org/10.1787/9789264096202-en
This work is published on the OECD ILibrary, which gathers all OECD books, periodicals and statistical
databases. Visit www.oecd-ilibrary.org, and do not hesitate to contact us for more information.

isbn 978-92-64-09618-9
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