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Providing Primary / Reproductive Health Services in Asian Urban Areas with Attention to Vulnerable Populations, Especially Women and Girls

Section One - The New Urban Challenge for Primary and Reproductive Health Care

3. Regional Findings


Table 1 on page 8 shows the nine cities ranked, from left to right, by their nation’s level of per capita GDP. Malaysia is the wealthiest of our nine countries; Bangladesh the poorest. This reflects our basic two-part perspective on RH conditions and services. First, a major determinant is the wealth of the city or country. Wealth promotes RH at both system and individual levels. The wealthier a country, the more resources it has to give to RH. This will mean a greater infrastructure of the hospitals, clinics and stations that provide services. It also implies a greater infrastructure for water and waste management, which is a major determinant of RH conditions. Thus we should expect more favorable RH conditions in more wealthy countries. The same is true at the individual level. The greater the wealth of a nation, the greater will be individual incomes, and thus the greater will be levels of nutrition and individual medical protection. 

Our second major assumption, however, is that something beyond mere wealth also affects RH conditions and services. This is something we have called the political-administrative system: a combination of the political power and will to provide good human services and an administrative capacity to implement the decisions to do that. It is in this area that we believe regional programs are most useful. They set standards for individual countries to emulate and help mobilize the political and administrative capacity to carry out more effective social service movements. 

We also see another common condition. Wealthier countries have made more progress through the demographic transition. That progress itself implies improvements in reproductive health. In traditional demographic regimes, fertility and mortality are both high. Under these conditions, women typically bear early, frequently and late in the reproductive periods. It is well known that all three of these conditions kill women and infants. Moving through the demographic transition to lower mortality and fertility means raising the age of first birth, increasing the birth interval and reducing the age at last birth. All three improve the health of mothers and infants. 

In the table national wealth is given in current US dollars of Purchasing Power Parity ($PPP), with data drawn from the World Bank World Development Indicators online data bank. Here we also show a number of indicators of reproductive health and services. First are objective indicators to assess the level of reproductive health: Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR), Total Fertility Rate (TFR) and contraceptive use. Before reviewing these movements, we should say something about the lack of TFR data in seven of the nine cities. In some cases, especially in Kuantan and Weihai, the basic data are available in the cities’ vital registration statistics; they are simply not calculated at the city level. This reflects an important weakness in local administration that AUICK has often observed and just as often commented upon as an obstacle to effective local administration. Central governments collect data from local governments, but seldom return locally relevant data to their sources so the local administrations can better assess their conditions and plan for progress. To improve local capacities to promote RH, UNFPA could consider the basic issue of improving local data collection and analysis. AUICK has worked with Chittagong, Khon Kaen, Surabaya, Olongapo City and Danang to develop better data systems as Management Information System (MIS) through City University Partnerships. The UNFPA Philippines Country Office has recently designated the Olongapo City MIS as a best practice model. This is a point to which we shall return in our discussions in the second part of the analysis. Now back to the indicators.  

Nine Cities' Comparative Reproductive HealthThe first two indicators show a general rise from left to right, as we would expect. There are, however, some interesting exceptions. IMR clearly increases from left to right, but note that China is slightly ahead of Thailand, which is slightly wealthier. More striking, however, is the exceptionally low IMR of Danang, third lowest city of the nine, which ranks a far eighth in national wealth. It also is lower than expected in maternal mortality. We have observed previously that revolutionary socialist governments tend to give higher priority to effective health and educational services, especially directed at the rural levels. China’s “barefoot doctors” program is an excellent example. It promoted the use of paramedics to reduce infectious diseases and was wildly successful, especially in reducing infant mortality. More important is the striking contrast with India, where the Indian Medical Association successfully resisted a similar program to use paramedics more extensively in the country’s health system, especially in the rural areas. China would not permit such resistance and India paid a large price in continued high infant mortality rates. 

Maternal mortality shows a more mixed picture, partly due to the relatively small numbers in our cases. As we shall see in Chapter IV, Kuantan’s high rate comes from only four maternal deaths in the last year. Officials recognize that the problem lies in the poorest of its citizens and is now taking new efforts to address the problem. Weihai had no maternal deaths last year, giving it the highly unusual 0 rate. Chennai’s exceptionally low rate can be attributed to its special status as a major health service center for India. Surabaya, Faisalabad and Chittagong show rates consistent with their levels of wealth. 

Next we turn to service indicators. Contraceptive use shows two distinctive conditions. One is the exceptionally high rate overall, regardless of wealth levels. With three exceptions, all the cities, and their countries, can be considered “contracepting societies.” For all, the CPR is roughly 70%, which indicates virtually all reproductive age couples who wish to are using modern contraceptives and directly choosing the number and spacing of their children. Even the poorest, Chittagong, has near achieved this status. Bangladesh, of course, is noted for its very effective national family planning program. 

Kuantan is the striking exception. Malaysia has almost completed the demographic transition; its TFR is near replacement level, indicating widespread use of modern contraceptives. Kuantan’s very low level is simply a reflection of the fact that contraceptive use is provided through an extensive private medical market system, where only a small proportion of people overall rely on the government program. Olongapo City is also lower than expected, though here it is obviously the Roman Catholic resistance that produces this low level. Faisalabad’s lower level is more understandable given its relative poverty. 

A further set of service indicators is the proportion of births that receive direct RH services: pregnancies, deliveries and vaccinations. Relatively poorer Faisalabad has the lowest reported figures. As in contraceptive use, however, the overall picture is one of considerable progress. AUICK noted this in its earliest surveys: Asia has advanced considerably in health and education since its countries gained independence in the wake of World War II. 

Next we turn to the level of financing, the fiscal resources given to health or reproductive health. Here we have first shown each country’s overall level of support for health. This is the World Bank reported current $PPP per capita spent on health. The overall movement is steadily from high and the left, declining to the right. The three exceptions are the slightly lower level of Olongapo and the higher level of Danang, and the exceptionally high level for Indonesia. Danang’s higher level obviously reflects higher government priority given to health, which is more specifically reflected in Danang’s overall status here. 

In addition, we attempted to obtain specific city level data on health and reproductive health services. We further attempted to turn these individual records into comparable data by translating them all from local currencies into current $PPP per capita. Note that the high levels for Weihai and Danang also reflect differences in administrative structure, which will confound any easy interpretation of results. China and Vietnam have the highest level of administrative decentralization of our nine cities. Thailand is at the other end of the scale, with the great proportion of expenditures under national units rather than local governments. The low figures for Kuantan and Khon Kaen thus reflect the large role that state, provincial and national programs and budgets play in local health services. Similarly, Weihai’s and Danang’s higher levels reflect Chinese and Vietnamese overall relatively high level of administrative decentralization, which was recently noted in a World Bank comparative study of local government in East and Southeast Asia. 

Next, we turn to the view of the local administrators, which we hoped would give us some insight into the administrative systems that affect RH and RH services. As will be seen in Chapter IV, we asked for administrators’ views and information on nine aspects of RH. For this summary we used a score of 1-5 to rate their views from low to high in priority, knowledge and specific programs. We then calculated a simple mean of all city scores. This, too, must be considered a not very enlightening exercise when we attempt, as here, to provide an overall assessment of administrators’ views. Weihai’s highest rating we believe reflects accurately the government’s priority, knowledge and programmatic activity in support of RH. Similarly, the lower levels of Faisalabad and Chittagong reflect Pakistan’s troubled war-torn conditions and Bangladesh’s low level of wealth. But we believe we will learn more of value to policy-makers when we consider the cities individually. 

Finally, we can also say something about administrative structures, which vary immensely in our nine cities and countries. Side by side, Khon Kaen, Thailand and Weihai, China represent two extremes. Thailand has the most centralized administrative structure and China the most decentralized. A recent World Bank (2003) study found China making 69% of all government expenditures at the local level; for Thailand the figure was 10%. We have no comparable figures for Malaysia, but since it is a federation, national, state and city/district expenditures are substantial and we might estimate a local proportion of less than 50%. Vietnam shows 48%; Indonesia 32%; the Philippines 26%. India, Pakistan and Bangladesh were not included in the World Bank study. We do know that India’s highly federal structure has substantial local involvement in expenditure. We expect Pakistan and Bangladesh to show high levels of centralization. Still, all of our cities have their own budgets and can take real initiatives, as we have seen in the AUICK Workshops. With Kuantan, Khon Kaen, Weihai and Danang all showing the highest level of reproductive health conditions and services, it appears that the level of decentralization has little impact on the outcome. This can be rated a happy finding, at least for international assistance agencies. As we shall see in the individual city cases, all can initiate their own projects to improve reproductive health. AUICK’s focus has always been on assisting local urban administrators, who we feel are best suited to work out effective programs for their cities. We encourage other assistance agencies to listen to local administrators and provide them with as much help as possible to improve their cities’ quality of life. 

Conclusion

In these nine cities we have seen the broad impact of national wealth on both reproductive health and services. Wealthy societies can do more to promote reproductive health, and their more wealthy citizens can also do more to promote their own reproductive health. If that were all, however, the only prescription of assistance to reproductive health would be to promote economic development. The divergences from this overall impact do, however, provide more useful observations. Clearly the priority given not only to reproductive health writ broadly, but especially to innovative approaches to all health care issues, is a lesson China and Vietnam have to give to the world. 

In the AUICK Workshops we have also seen the utility of these regional programs, where city administrators can learn from and directly influence one another. Here we can give just a few pertinent examples. At a Workshop on HIV/AIDS, the participant from Danang saw the distinctive problem of the new and large migrant populations implied by Asia’s rapid urbanization. From this she devised the creation of storefront counseling centers, to find ways to reach the new young migrants, who are missed in the city’s well developed high school education and clinic-based MCH programs. This worked so well that it is now monitored by the national Association of Family Planning of Vietnam. At a Workshop on primary education, the representative from Khon Kaen developed an innovative local scholarship assistance program by which the city’s teachers flagged potential dropouts, and a new foundation provided financial support to the families to ensure that the children remained in school. Observers have also seen a mobile library program, putting books on “tuk tuks” to bring books to children. The Faisalabad and Kuantan representatives learned of this and developed similar programs for their own schools. These programs organized school teachers to have them identify poor children who were likely to drop out, and provide encouragement and assistant to their families. The impact on reproductive health has become especially clear in the past few decades. We know that the most powerful assistance to reproductive health comes from the education of women and girls, and when children are in danger of dropping out of school, it is usually the girls who drop out.

5. This is also a case where using Kobe as a major center of reference has been especially useful. Kobe does have all the data shown in Table 1. It collects and calculates a great deal of data so that it knows where its strengths and challenges lie and can more effectively meet those challenges. It has consistently held out this condition as one for the AUICK Associate Cities to emulate. 
6. Recall that this was enshrined as a basic human right in the Teheran Conference of 1968. 
7. We converted local currencies to current US$ and then to $PPP using the World Bank ratios, then divided by the population of each city. 
8. See World Bank, 2003, East Asia Decentralizes: Making Local Government Work, (Washington, DC: The World Bank) 267 pp.

CONTENTS

Top

Foreword

Section One

The New Urban Challenge for Primary and Reproductive Health Care

Executive Summary

1. Background: Urban Growth and Urban Primary / Reproductive Health (RH) Services

2. An AUICK Research Project Report

3. Regional Findings

4. Individual City Findings

5. Summary and Implications

Section Two

Providing Primary / Reproductive Health Services in Asian Urban Areas with Attention to Vulnerable Populations, Especially Women and Girls:

Nine AUICK Associate City (AAC) Reports

6. Kuantan, Malaysia

7. Khon Kaen, Thailand

8. Weihai, China

9. Surabaya, Indonesia

10. Olongapo, Philippines

11. Chennai, India

12. Faisalabad, Pakistan

13. Danang, Vietnam

14. Chittagong, Bangladesh

Annex I.
Research Instrument: AUICK Research Project Outline

Annex II.
AUICK Research Project Participants


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