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Investing in Maternal Health. Learning from Malaysia and Sri Lanka

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Investing in Maternal Health. Learning from Malaysia and Sri Lanka 25901 Human Development Network Health, Nutrition, and Population Series Public Disclosure Authorized Investing in Public Disclosure Authorized Maternal Health Learning from Malaysia and Sri Lanka Indra Pathmanathan • Jerker Liljestrand Jo. M. Martins • Lalini C. Rajapaksa Craig Lissner • Amala de Silva Public Disclosure Authorized Swarna Selvaraju • Prabha Joginder Singh Public Disclosure Authorized Health, Nutrition, and Population Series This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank’s Human Development Network. It provides a vehicle for publishing polished material on the Bank’s work in the HNP Sector, for consolidating previous informal pub- lications, and for improving the standard for quality control, peer review, and dissemination of high-quality analytical work. The series focuses on publications that expand our knowledge of HNP policy and strategic issues that can improve outcomes for the poor and protect vulnerable populations against the impoverishing effects of illness. Best practice examples of both global and regional relevance are presented through thematic reviews, analytical work, and case studies. The Editor in Chief of the series is Alexander S. Preker. Other members of the Editorial Committee are Mukesh Chawla, Mariam Claeson, Shantayanan Devarajan, Gilles Dussault, A. Edward El- mendorf, Armin H. Fidler, Charles C. Griffi n, Jeffrey S. Hammer, Peter F. Heywood, Prabhat Jha, Gerard Martin La Forgia, Jack Langenbrunner, Ruth Levine, Maureen Lewis, Samuel S. Lieber- man, Benjamin Loevinsohn, Elizabeth Lule, Akiko Maeda, Judith Snavely McGuire, Milla McLachlan, Thomas W. Merrick, Philip Musgrove, Ok Pannenborg, Oscar Picazo, Mead Over, Juan Rovira, George Schieber, and Adam Wagstaff. Investing in Maternal Health Learning from Malaysia and Sri Lanka Human Development Network Health, Nutrition, and Population Series Investing in Maternal Health Learning from Malaysia and Sri Lanka Indra Pathmanathan Jerker Liljestrand Jo. M. Martins Lalini C. Rajapaksa Craig Lissner Amala de Silva Swarna Selvaraju Prabha Joginder Singh THE WORLD BANK Washington, D.C. © 2003 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 Telephone 202-473-1000 Internet www.worldbank.org E-mail [email protected] All rights reserved. 1 2 3 4 06 05 04 03 The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any ter- ritory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is copyrighted. Copying and/or transmitting portions or all of this work without permission may be a violation of applicable law. The World Bank encourages dissemination of its work and will normally grant permission promptly. For permission to photocopy or reprint any part of this work, please send a request with com- plete information to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA, telephone 978-750-8400, fax 978-750-4470, www.copyright.com. All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, World Bank, 1818 H Street NW, Washington, DC 20433, USA, fax 202-522-2422, e-mail [email protected]. ISBN 0-8213-5362-4 Library of Congress Cataloging-in-Publication Data has been applied for. Contents Foreword ix Acknowledgments xiii Executive Summary xvii Overview 1 Maternal Mortality Can Be Halved in Developing Countries Every 7 to 10 Years2 Maternal Mortality Reduction Is Affordable Regardless of Income Level and Growth Rate4 Maternal Mortality Declines Rapidly with the Provision of a Synergistic Package of Health and Social Services That Reach the Poor5 Governments Can Afford to Provide the Critical Elements of Maternity Care Free of Charge to the Client 10 Different Tactics Are Needed at Different Stages of Health Systems Development 12 Official Recognition of Professional Midwifery Is a Crucial Step toward Reducing Maternal Mortality 16 Raising the Importance of Maternal Death through Recording, Reporting, and Subsequent Advocacy Will Improve Program Performance 19 Conclusion 20 Note 21 v vi • Investing in Maternal Health 1 The Ingredients of Success 23 The Conceptual Basis 24 Aims of the Study 32 Study Approach 32 The Evidence 36 Maternal Mortality Transition: A Model for Action 47 Conclusion 58 Notes 59 2 Malaysia 61 Background: Malaysia Today 61 Political Context 62 Study Approach 64 Decline in Maternal Mortality 68 Key Policies and Program Interventions 73 Conclusion 102 Notes 103 3 Sri Lanka 105 Background: Sri Lanka Today 105 Political and Social Context 105 Study Approach 108 Decline in Maternal Mortality Ratio 112 Trends in Maternal Mortality Ratio and Female Death Rates 113 Development of Maternal and Child Health Services 125 Implementation of Critical Health Policies 140 Health System Expenditures, Affordability, and Sustainability 145 Conclusion 150 Notes 151 Appendixes 1 Data Availability and Quality in Malaysia 153 2 Data Availability and Quality in Sri Lanka 159 Contents • vii 3 Assessment of Affordability 163 4 Key Informants 165 References 171 Tables 1 Public Expenditures on Health Services and Maternal Health Care, Malaysia and Sri Lanka, 1950s–90s5 2 Per Capita Gross National Product for Selected Countries 26 3 Amount of Time to Halve Maternal Mortality Ratio, Malaysia and Sri Lanka, 1949–92 36 4 Key Health Features, Malaysia and Sri Lanka, 1940–61 44 5 Public Expenditures on Health Services and Maternal Health Care, Malaysia and Sri Lanka, 1950s–90s 56 6 Malaysia at a Glance 62 7 Amount of Time to Halve the Maternal Mortality Ratio, Peninsular Malaysia, 1933–97 68 8 Maternal Mortality Ratio, by Ethnic Group, Peninsular Malaysia, 1957–90 69 9 Overview of Health Service Capacity and Skilled Attendance during Childbirth, Peninsular Malaysia, 1949–95 72 10 Total Fertility Rates, by Ethnic Group, Peninsular Malaysia, 1957–97 78 11 Expenditures on Public Health, Malaysia, 1946–95 79 12 Estimated Public Sector Expenditures on Maternal Health Care, Malaysia, 1971–95 81 13 Trends in Expenditures for Maternal Health Care, Malaysia, 1946–95 87 14 Sri Lanka at a Glance 106 15 Trends in Adult Literacy, Sri Lanka, 1901–91 109 16 Time to Halve the Maternal Mortality Ratio, Sri Lanka, 1930–96 112 viii • Investing in Maternal Health 17 Deliveries with Skilled Attendance and Maternal Mortality Ratio, 1939–95 115 18 Deliveries in the Private Sector, Sri Lanka, 1981–93 117 19 Decline in Cause-Specific Maternal Mortality Ratio, Sri Lanka, 1942–52, 1955–70, and 1980–96 120 20 Development of Government-Employed Birth Attendants, Sri Lanka, 1930–95 120 21 Contraceptive Prevalence Rate, Sri Lanka, 1975–2000 122 22 Development of Maternal-Health-Care-Related Infrastructure, Sri Lanka, 1931–95 128 23 Categories of Institution, Sri Lanka 129 24 Place of Delivery by Monthly Family Income, Sri Lanka, 1982 142 25 Place of Delivery by Sector, Sri Lanka, 1982 143 26 Maternal Health Care Expenditures, Sri Lanka, 1950–99 147 27 Public and Private Health Services, Sri Lanka, 1953–96 148 Figures 1 Maternal Mortality Ratio, Sri Lanka, 1930–95 2 2 Maternal Mortality Ratio, Malaysia, 1950–993 3 Maternal Mortality Ratio and Expenditure on Health as a Percentage of Gross Domestic Product in Countries That Have Gross National Product Comparable Per Capita to Sri Lanka’s6 4 Maternal Mortality Ratio and Expenditure on Health as a Percentage of Gross Domestic Product in Countries That Have Gross National Product Comparable Per Capita to Malaysia’s7 5 Maternal Deaths as the Proportion of Deaths among Women of Reproductive Age, Sri Lanka and Malaysia, 1950–20008 6 Maternal Mortality Ratio in Less-Developed States Compared to Other States, Peninsular Malaysia, 1970–979 Contents • ix 7 Maternal Mortality Ratio and Skilled Attendance at Birth, 1995: Countries with Gross National Product Comparable to That of Malaysia in the Early 1960s 12 8 Maternal Mortality Ratio and Skilled Attendance at Birth, 1995: Countries with Gross National Product Comparable to That of Sri Lanka in the Early 1960s 13 9 Maternal Mortality Ratio, 1919–20, in Countries with Deliveries Predominantly Assisted by Midwives, Doctors, or Both 17 10 Determinants of Health-Sector Outcomes 27 11 Maternal Mortality Ratio, Malaysia and Sri Lanka, 1950–99 37 12 Critical Elements of Maternal Health Care 41 13 Maternal Mortality Ratio and Percentage of Live Births with Skilled Attendance, Malaysia, 1949–95 45 14 Maternal Mortality Ratio and Percentage of Live Births with Skilled Attendance, Sri Lanka, 1930–96 46 15 Maternal Mortality Transition: A Model for Action 48 16 Total Fertility Rate and Maternal Mortality Ratio, Malaysia, 1957–95 52 17 Total Fertility Rate and Maternal Mortality Ratio, Sri Lanka, 1952–95 53 18 Neonatal Mortality Rates, Malaysia and Sri Lanka, 1938–99 54 19 Place of Birth and Birth Attendance, Peninsular Malaysia, 1949–95 71 20 Phases of Health Systems Development for Maternal Health as Related to Reduction in Maternal Mortality Ratio, 1933–97 74 21 Admissions to Public Sector Hospitals for Complications of Pregnancy, Peninsular
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