MDG 4,5,6: How far do we fare? MDG 4,5,6: Are we there yet?

Lokman Hakim S, MScPH, PhD

17th Malaysian Family Medicine Scientific Conference 5 July 20123

Progress And Achievements Of The Malaysian Health System

Malaysia has won international recognition from WHO and other health-related agencies for its remarkable achievement
2

MDG 4 -Goals and Target

Goal 4: Reduced Child Mortality
Target 4A : To reduce by two third the mortality rate among children under five from 1990
No. 1. Indicators Infant mortality rate (per 1,000 livebirths) Under-five mortality rate (per 1,000 livebirths) Proportion of 1 year old children immunized against measles Baseline 1990 Target by 2015 Progress (2011p)

13.1 16.8 70.1%

4.4 5.6 > 95%

6.6 8.1 95.2%

2.

3.

Source: Department of Statistics Malaysia & Ministry of Health

Under-5 Mortality Rate, Infant Mortality Rate & Neonatal Mortality Rate (deaths per 1,000 live births) for Malaysia from 1990 2010
20 18 16.8

U5MR

IMR

NMR

16
Death per 1,000 live births

Stagnation of U5MR & IMR since 2000

13.2
10.3 12.5

14 12

13.1

10 8
6 4 8.4

9.3
6.8 5.5

8.9
6.5 5.7

8.5
6.6 3.9

8.4 6.7 4.3

2
0
1990 1995 1999 2000 2005 2010

Source: Population And Demographic Statistics Division, Department of Statistics Malaysia

Under-5 Mortality Rate, Infant Mortality Rate & Neonatal Mortality Rate (deaths per 1,000 live births) for Malaysia from 2000 2012
10.0
8.9 8.0
Death per 1,000 live births

U5MR
8.6

IMR
8.5

NMR
7.9 6.2
8.0 8.5 6.9 8.4 8.1 8.1 6.6

8.8

8.7

8.5

7.9
6.5 6.5 5.7 3.9

6.6

6.5

6.6

6.0

5.7

6.2

6.2

6.7

6.6

4.0

3.6

3.8
3.2

3.7

3.7

3.8

3.9

4.3

4.3

4.2

4.3

2.0

0.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Source: Population And Demographic Statistics Division, Department of Statistics Malaysia, 2000 -2011p preliminary data Family Health Development Division 2012p preliminary data

Number of Neonatal Deaths for Malaysia 2008 2012

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2008 2009 2010 2011 Early Neonatal Death Late Neonatal Death 2012
Early Neonatal Death at >75% from total Neonatal Death
n=2,023 n=1,984 n=1,944 n=2,092 n=2,173

476

414

397

476

462

1,547

1,570

1,547

1,616

1,711

Source: FHDD Family Health Development Division 2008 - 2012 - preliminary data PNM 1/1997 Pind.2000

Number of Neonatal Deaths for Malaysia 2008 2012

n=2,023 n=1,984 n=1,944 n=2,092 n=2,173

100% 80% 60%

35 144 249
236

28 172
279 200 573

43 160 254 182 533

38 153
274 199 616

77 206 238 197 685

556 40%
20% 0%
Immaturity

803

732

772

812

770

2008

LCM

2009

Infection

1. Cause of neonatal death: Immaturity (40%) & Lethal Congenital Malformations (25%) 2. Asphyxia (10%) are they preventable? 3.Still a significant numbers cause of death as unknown 2010 2011 2012

Asphyxia

Others

Unknown

Source: FHDD Family Health Development Division 2008 - 2012 - preliminary data PNM 1/1997 Pind.2000

Neonatal mortality, risk factors and causes: a prospective population-based cohort study in urban Pakistan: Jehan I et al, Bull WHO, 87: 130-138 Most common primary obstetric causes
Preterm delivery (34%) Intrapartum aspyxia (21%)

Final causes of neonatal death

Immaturity-related (26%) Birth aspyxia (26%) Infection (26%)

Antepartum haemorrhage (9%)

MDG 5 - Improve maternal health

Target 5A: Reduce by three quarters the maternal mortality ratio
i. ii.

Maternal mortality ratio Proportion of births attended by skilled health personnel

Target 5B : Achieve by 2015, universal access to reproductive health

i. ii. iii. iv.

Contraceptive prevalence rate Adolescent birth rate Antenatal care coverage (at least one visit and at least four visits) Unmet need for family planning

Safe delivery and antenatal coverage :Malaysia 1990-2012

110 100

Percentage

90 80 70 60 50 1990 Safe Delivery 92.9 Antenatal coverage 77.9 40 1995 2000 2006 2008 2010 2011 2012 95.5 96.6 98.3 98.6 98.6 98.6 98.7 68.8 74.8 97.2 93.7 82.2 93.6 96.5

Source : Health Informatics Centre, MOH

Maternal mortality trend : MALAYSIA 1933 - 2010

MDG 5 : Improve Maternal Health

Targets MDG Indicators Baseline Target (2015) Latest achievement Remarks

TARGET 5.A : Reduce by threequarters between 1990 and 2015, the maternal mortality ratio TARGET 5.B : Achieve, by 2015, universal access to reproductive health

5.1 Maternal Mortality Ratio

44 per 100,000 LB (1991)

11 per 100,000 LB

26.1 per 100,000 LB (2010)

5.2 Proportion of birth attended by skilled health

5.3 Contraceptive prevalence rate 5.4 Adolescent birth rate

74.2% (1990)
54.6% (1994)

95%

98.6% (2011)

Increasing

51.8% ( 2004)

28 births per Decreasing 1000 adolescent

14 births per 1000 adolescent (2010)

5.5 Antenatal care 78% (1990) coverage (1st visit)

5.6 Unmet need for family planning 24.5 % (2004)

90%

94% (2011)

Decreasing

Cause of Death by Categorisation (Direct, Indirect and Fortuitous) Malaysia 2003 2012
350

300
No. of deaths

250 200 150 100

50
2003 Direct 123 Indirect 23 Fortuitous 90 Total 236

2004 120 27 111 258

2005 142 18 95 255

2006 121 32 94 247

2007 135 22 101 258

2008 137 23 107 267

2009 138 55 101 294

2010 124 46 103 273

2011 116 65 84 265

2012p 96 58 88 242

Source : 2003 -2008 : Reports on the Confidential Enquiries into Maternal Deaths in Malaysia 2009 2012 : BPKK, KKM

CAUSES of MATERNAL DEATH (3 yearly) : 1991 - 2011

Source : 2003 -2008 : Reports on the Confidential Enquiries into Maternal Deaths in Malaysia 2009 2012 : BPKK, KKM

Causes of maternal death (direct/indirect) : Malaysia 2011-2012

Obstetric embolism Hemorrhage Medical conditions HDP

Direct cause

Indirect cause

MDG 5a: Maternal Mortality Ratio (MMR) Achievement against Set Target MDG 5

MDG 5 by 2015 ~ 50 deaths

(no. of deaths)

(131) (137) (134) (128) (126) (110p)

Source: Department of Statistics Malaysia

Progress in Africa
MDG 4
6 countries on track
23 making progress but insufficient 16 no progress

MDG 5
MMR estimates for 2005 showed that the region

has made no progress towards achieving MDG target

Source: Towards reaching the health-related millennium development goals: Progress report and the way forward. Report of the Regional Director , WHO Regional Office for Africa, 2010.

Africa: The way forward

Countries and partners should:
Increase resources significantly Explore new and innovative ways

Allocate at least 15% of public expenditure on health

Strengthen existing structures and mechanisms. Implementing the 2008 Ouagadougou Declaration:

Better access to, and quality of health care Strong health workforce Effective health information system Access to essential medicine, vaccines and technolgies

Source: Towards reaching the health-related millennium development goals: Progress report and the way forward. Report of the Regional Director , WHO Regional Office for Africa, 2010.

Maternal mortality ratio (per 100,000 live birth)

450 400

350
300 250

200
150 100

50
0

Under 5 mortality per 1000 LB

70 60 50

40
30 20 10 0

Infant mortality per 1000 LB

60 50 40 30 20 10 0

Neonatal mortality per 1000 LB

35 30 25 20 15 10 5 0

Low birth weight (<2.5kg) per 1000 LB

30 25 20 15 10 5 0

% GDP (Total) on Health

20 18 16 14 12 10 8 6 4 2 0

Correlation between life expectancy and % GDP

14
12 10 % GDP 8 6 4 2

0
60 65 70 75 80 Maternal mortality 85 90

Correlation between maternal mortality and % GDP

14 12

10
% GDP 8 6 4 2 0 0 50 100 150 200 250 300 Maternal mortality 350 400 450

Health expenditure, international dollar converted using 2005 purchasing power parity
9000 8000

7000
6000 5000

4000
3000 2000

1000
0

Correlation between maternal mortality and health expenditure

Health expenditure (Int. dollar, PPP 2005)

9000

8000
7000 6000

5000
4000 3000 2000 1000 0 0 50 100 150 200 250 300 Maternal mortality 350 400 450

Number of nurses per 1000 population

12 10 8 6 4 2 0

Number of doctor per 1000 population

4 3.5 3

2.5
2 1.5 1 0.5 0

% birth attended by skilled health staff

120 100 80 60 40 20 0

Correlation between maternal mortality and % birth attended by skilled personnel

120 % skilled birth attendance 100 80 60 40 20 0 0 50 100 150 200 250 300 Maternal mortality 350 400 450

Hospital bed per 1000 population

16 14 12

10
8 6 4 2 0

Correlation between maternal mortality and number of hospital bed per 1000 population
16 14 Hosp bed per 1000 pop 12 10 8 6

4
2 0 0 50 100 150 200 250 300 Maternal mortality 350 400 450

Number of Cases and Notification Rate of TB, 1960-2011

No. of Cases 35000
Notification Rate (NR)/100,000, 2005-2011 80
62.3 63.1 63.9 68.4 72.4 61.6

NR/100,000 400 350

2011

30000

estimated

70 60 50

60.8

2005

2006

2007

2008

2009

2010

300 250

25000

20000 200 15000

150
10000 100 5000 50 0

Number of cases

Notification Rate (NR)/100,000

Rate/100,000 140 127 120 100 80 60 61 40 20 0

WHO Incidence Rate (Estimated) and Malaysia Notification Rate 1990-2015

108 95 86 82 78 72

MDG

58

65

68 61

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Year WHO Malaysia

HIV TREND AND ESTIMATION IN MALAYSIA

Cumulatifve HIV = 98,279 Cumulative deaths = 15,688 PLHIV (end of 2012) = 82,591

NEW HIV CASE: TARGET FOR 2015

YEAR 2008 TARGET 16.0 2009 15.3 2010 14.6 2011 13.9 2012 13.2 2013 12.5 2014 11.7 2015 11.0

ACHIEVE D

13.3

10.8

12.8

12.2

11.7

Target : To reduce new HIV from 21.7 per 100.000 pop (year 2000) to 11 per 100,000 pop by year 2015

SCREENING AND CASE DETECTION RATE

1,500,000

No. screening

Detection Rate
1.5

No. screening

1,000,000

1
500,000

0.5

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Year

Detection rate (%)

MALAYSIA HIV SITUATION

100 90
80

Percentage of HIV cases

70 60
50

40 30
20

10 0 1990 1992 1994 1996 1998 2000 IDU 2002 Sexual 2004 2006 2008 2010 2012

Current Responses : GARPS 2012

302.3

350.0 300.0 250.0 200.0 150.0

289.5

296.7

Incidence of Malaria (per 100,000 population) in Malaysia, 1990 2011

215.3 197.9 209.3 245.3 123.0 60.8

54.6

48.9

53.7

33.3

26.7

24.1

24.8

21.3

19.9

20.1

23.5
2010

50.0 0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

2003

2004

2005

2006

2007

2008

2009

2011

Incidence per 100,000 pop

Total Malaria Deaths and Case Fatality Rate (%) in Malaysia, 1990 - 2011
50 45 40 35 30 25 20 15 10 5 0

0.58 0.59 0.50 0.36 0.35 0.28 0.09 43

1990

0.40 0.25

0.41

0.33

0.37

0.34

0.12 47
1991

0.20 0.19
0.07 0.06 0.05 0.06 0.08 0.09 25 23 27 35 40 25
1992 1993 1994 1995 1996 1997

27
1998

21
1999

35
2000

46
2001

39
2002

21
2003

36
2004

33
2005

21
2006

18
2007

30
2008

26
2009

33
2010

18
2011

Total Malaria Deaths

Case Fatality Rate (%)

18.6
0.70 0.60 0.50

100.0

44.9

0.40
0.30 0.20 0.10 0.00

MALAYSIA IS VULNERABLE

MDR-TB MDR-Mal MDR-TB MDR-Mal

MDR-TB MDR-Mal
MDR-TB MDR-Mal

MDR-TB MDR-Mal

In conclusion
With only 2 more years left, if we continue at the

current rate: MDG 4 and 5 unlikely to be achieved MDG 6 TB unlikely to be achieved

MDG 6 HIV on track

MDG 6 Malaria exceeded target

Reorientation of health care delivery The need to really understand the contributing factors and specifically addressing them The need to focus on quality of care and public health intervention

Without improved quality, increased health care

coverage is unlikely to substantially improve perinatal, neonatal and maternal outcomes

Jehan et al., (2009). Neonatal mortality, risk factors and causes: a prospective population-based cohort study in Urban Pakistan. Bull WHO, 87: 130-138 Lawn JE et al., (2005). 4 million neonatal deaths: When? Where? Why? Lancet, 365: 891-900 Martines J et al., (2005). Neonatal survival: a call for action. Lancet, 365: 1189-1197

Thank you

I hereby declare the 17th Malaysian

Family Medicine Scientific Conference OPEN