Reproductive health essential to reduce poverty in South Asia, says new World Bank report

Contacts: 
In Delhi: Sudip Mozumder (91 11) 2461-7241
smozumder@worldbank.org
In Washington: Erik Nora (202) 458 4735
enora@worldbank.org

NEW DELHI, March 5, 2009:  A new World Bank report launched today says countries in South Asia need to do more if they want to make adequate progress toward the Millennium Development Goals (MDG) related to women’s reproductive health.

Amongst its several suggestions to improve reproductive health for the poor, the report has called for `a single window’ for reproductive health services including maternal care, family planning, nutrition and treatment of infections. It advocates tailoring services locally to the needs of poor women, promoting secondary education of women, addressing widespread shortages of staff, and financing reproductive health in innovative ways to reduce the burden on the poor.  At least these actions are needed to reduce the inequalities that exist widely. 

The report, Sparing Lives: Better Reproductive Health for Poor Women in South Asia, lead authored by Meera Chatterjee, Senior Social Development Specialist at the World Bank, analyzes the current state of reproductive health in five countries of South Asia – Bangladesh, India, Nepal, Pakistan and Sri Lanka and focuses on the major risks faced by poor women. It underlines the need for these countries to pay more attention to poor women’s reproductive health if the region and the world are to achieve the MDGs related to maternal and child health. An average South Asian woman faces a hundred times greater risk of dying during childbirth (1 in 43) than a woman in an industrialized country (1 in 4000).

While India has made some positive strides in the areas of fertility and infant mortality, its maternal mortality ratio, immunization coverage and malnutrition continue to remain causes of concern.  Other countries in the region have also succeeded in reducing fertility substantially (e.g., Bangladesh), raising the age of marriage (e.g., Pakistan), and reducing maternal mortality (Nepal and Sri Lanka).

“This report highlights that the countries in South Asia face similar challenges in addressing the reproductive health needs of poor women. At the same time, there are lessons which countries can learn from each other. In India, this challenge is even more significant, given its size and diversity. However, states like Tamil Nadu, Goa, and Kerala provide good examples of how these challenges can be overcome to achieve better reproductive health for the poor,” said Roberto Zagha, World Bank’s Country Director in India.

The report states that the Government of India’s National Rural Health Mission (NRHM), launched in April 2005 to provide better health care to rural people, is a good framework to address India’s concerns in the area of reproductive health.
 
The challenges ahead: The widening gap between the rich and the poor

The report advocates the need to reduce the wide disparities between rich and poor in access to health services. For example in India the number of poor women having access to antenatal care is half that of the rich.  In Bangladesh, Nepal and Pakistan it is about one-third.  Similarly, half as many of the poorest women in Nepal use contraceptives as better-off women. 

 “Women’s low education and poverty are consistently associated with low use of reproductive health services.  If we want to break the cycle of poverty we must improve reproductive health because poor reproductive health undermines the survival of individuals, well-being of families, and represents significant losses to the community, resulting in transmission of poverty from one generation to the next,” said Meera Chatterjee, lead author of the report.

Universalization of antenatal care and skilled birth attendance
Institutional delivery or the presence of a skilled birth attendant can make a critical difference to the survival of mothers and babies. Only in Sri Lanka do almost all births take place in institutions; in India and Pakistan it is around 40 percent.

Poor nutrition
Poor nutrition is another major challenge, according to the report. In fact two-fifths of all children under five in the region are malnourished. In Bangladesh, India and Nepal, 40-50 percent of all children are under-nourished, and even in Sri Lanka, which is otherwise the leader in reproductive health, it is 22 percent.

Contraceptive use
To help poor women achieve their desired fertility, the report calls for India to accelerate availability and use of temporary methods, in particular. “In 2005-06, while 48.5 percent of couples in India were using modern methods of contraception – only one-fifth of these were using temporary methods.  While the availability of spacing contraceptives has increased in the past decade, the continued predominance of terminal methods (i.e., sterilization) means that many couples continue to have more children than they really want,” said Ms Chatterjee.

Suggestions to improve RH in the region
The report suggests that improving reproductive health lies in the following:

• A ‘single window’ for the complete package of essential reproductive health services: Poor women often do not have the time, money or power to approach separate providers for health care, family planning, childbirth, etc. They, therefore, need to be provided a continuum of care through a ‘single window’.

• More and better human resources for health:  Most countries in the region need to increase the numbers of frontline female health workers and ensure that they are technically and socially well-equipped to carry out their difficult and critical work.

• Decentralized, action-oriented planning: This is working well in certain pockets of states such as Maharashtra in India and some districts of Sri Lanka. A focus on local-level action planning which involves poor women themselves, their institutions, local governments and health staff will increase relevance, ownership of programs, and accountability, the report suggests.

• Disseminating ‘know-how’: Good practices that have worked within each country, in other countries in the region and the world need to be shared. An important role can be played in this by central governments as well as non-governmental institutions.

• Innovative financing: The report calls for innovative financing in the reproductive health sub-sector to ensure improved access of the poor to services. Vouchers, reimbursements, insurance and social marketing are some feasible approaches that will reduce heavy out-of-pocket expenditures by the poor on reproductive health care. For example, Bangladesh has a good voucher system which is being used to increase the availability of services and improve equity.

• Efficient allocations: Increasing allocations to in-patient maternal and child health services over current low levels in most areas could substantially increase the availability of needed health care to the poor. |

For more information about the Report and the World Bank’s work in India, please visit http://www.worldbank.org.in