Health financing in Malawi: Evidence from National Health Accounts

Trends in National Spending on HIV/AIDS Prevention and Control in Thailand from 2008 to 2013

Background and Objectives: The health system of China in 1970 was an exemplary model to the world but it began deteriorating after the economic reform in 1980. In order to address the deteriorating health system, government of China implemented the ambitious health reform program in 2009, with the aim to provide “safe, effective, convenient and affordable” health service to all people by 2020. In this study we try gain more insight about the health financing system of China prior to health system reform 2009. Methodology: Secondary data were collected from online data sets of World Health Organization (WHO), World Bank, Economic Co-operation and Development (OECD) and from publicly available reports and documents of related Ministries, and other published sources. Analysis was done with descriptive approach, focused on the three dimensions of health, namely the financing system: total health expenditure, financing source and financing scheme/agents. Results: China’s total health expenditure (THE) from 1995 to 2008 remained below 5% of GDP. From 1995 to 2001, the Government share on health expenditure decreased continuously and reached the lowest level of 36.4 % in 2001. Private financing was the primary funding mechanism and sources of revenue for private financing were private insurance and out-of-pocket payments. Household spending on health has increased with an average growth rate of 11.5 % from 2000 to 2008. Health financing scheme was social insurance type with fragmented risk pooling. Conclusions: Low level of public funding and heavy reliance on out-of-pocket payment were the major problem in the past decades. Hence the daunting problem of inadequate health financing ruled the last three decade of China health system. Janaki Medical College Journal of Medical Sciences (2013) Vol. 1 (2): 46-64 DOI: http://dx.doi.org/10.3126/jmcjms.v1i2.9270

The way a health system is financed affects the performance of its other functions of stewardship, input (or resource) creation and services provision, and ultimately, the achievement of health system goals of health improvement (or maintenance), responsiveness to people's non-medical expectations and fair financial contributions. To analyse the changes between 1998 and 2002,in health financing from various sources; and to propose ways of improving the performance of health financing function in the WHO African Region. A retrospective analysis of data obtained from the World Health Report, 2005. The analysis reported in this paper is based on the National Health Accounts (NHA) data for the 46 WHO Member States in the African Region. The data were obtained from the World Health Report 2005. It consisted of information on: levels of per capita expenditure on health; total expenditure on health as a percentage of gross domestic product (GDP); general government expenditure on health as a percentage of total expenditure on health; private expenditure on health as a percentage of total expenditure on health; general government expenditure on health as a percentage of total government expenditure; external expenditure as a percentage of total expenditure on health; social security expenditure on health as a percentage of general government expenditure on health; out-of-pocket expenditure as a percentage of private expenditure on health; and private prepaid plans as a percentage of private expenditure on health. The analysis was done using Lotus SmartSuite software. The analysis revealed that: fifteen countries spent less than 4.5% of their GDP on health; forty four countries spent less than 15% of their national annual budget on health; sixty three percent of the governments in the Region spent less than US$10 per person per year; fifty per cent of the total expenditure on health in 24 countries came from government sources; prepaid health financing mechanisms cover only a small proportion of populations in the Region; private spending constituted over 40% of the total expenditure on health in 31; direct out-of-pocket expenditures constituted over 50% of the private health expenditure in 38 countries. Every country needs to develop clear pro-poor health financing policy and a comprehensive health financing strategic plan with a clear roadmap of how it plans to transit from the current health financing state dominated by inequitable, catastrophic and impoverishing direct out-of-pocket payments to a visionary scenario of universal coverage. The strategic plan should strengthening of health sector advocacy and health financing capacities, health economics evidence generation and utilisation in decision-making, making better use of available and expected resources, monitoring of equity in financing, strengthening of the exemption mechanisms, managed removal of direct out-of-pocket payments (for countries that choose to), and improving country-led sectoral coordination mechanisms (e.g. Sector Wide Approaches).

BackgroundEven though Africa has the highest disease burden compared with other regions, it has the lowest per capita spending on health. In 2007, 27 (51%) out the 53 countries spent less than US$50 per person on health. Almost 30% of the total health expenditure came from governments, 50% from private sources (of which 71% was from out-of-pocket payments by households) and 20% from donors. The purpose of this article is to reflect on the proceedings of the African Union Side Event on Health Financing in the African continent.MethodsMethods employed in the session included presentations, panel discussion and open public discussion with ministers of health and finance from the African continent.DiscussionThe current unsatisfactory state of health financing was attributed to lack of clear vision and plan for health financing; lack of national health accounts and other evidence to guide development and implementation of national health financing policies and strategies; low investments in sectors that address social determinants of health; predominance of out-of-pocket spending; underdeveloped prepaid health financing mechanisms; large informal sectors vis-à-vis small formal sectors; and unpredictability and non-alignment of majority of donor funds with national health priorities.Countries need to develop and adopt a comprehensive national health policy and a costed strategic plan; a comprehensive evidence-based health financing strategy; allocate at least 15% of the national budget to health development; use GFATM and PEPFAR funds for health systems strengthening; strengthen intersectoral collaboration to address health determinants; advocate among donors to implement the Paris Declaration on Aid Effectiveness and its Accra Agenda for Action; ensure universal access to health services for pregnant women, lactating mothers and children aged under five years; strengthen financial management capacities; and develop prepaid health financing systems, especially health insurance to complement tax funding.In addition, countries need to institutionalize national health accounts; undertake feasibility studies of various health financing mechanisms; and document and share best practices in health financing.ConclusionThere was consensus that every country ought to have an evidence-based comprehensive health financing strategy with a road map for attaining universal health service coverage vision; and increase physical and financial access by pregnant women, lactating mothers and by children under five years to quality health services.

One of the challenges to maintain an agenda for universal coverage and equitable health system is to develop effective structuring and management of health financing. Global experiences with different systems of health financing suggests that a strong public role in health financing is essential for health systems to protect the poor and health systems with the strongest state role are likely the more equitable and achieve better aggregate health outcomes. Using Malaysia as a case study, this paper seeks to evaluate the progress and capacity of a middle income country in terms of health financing for universal coverage, and also to highlight some of the key underlying health systems challenges.The WHO Health Financing Strategy for the Asia Pacific Region (2010-2015) was used as the framework to evaluate the Malaysian healthcare financing system in terms of the provision of universal coverage for the population, and the Malaysian National Health Accounts (2008) provided the latest Malaysian data on health spending. Measuring against the four target indicators outlined, Malaysia fared credibly with total health expenditure close to 5% of its GDP (4.75%), out-of-pocket payment below 40% of total health expenditure (30.7%), comprehensive social safety nets for vulnerable populations, and a tax-based financing system that fundamentally poses as a national risk-pooled scheme for the population.Nonetheless, within a holistic systems framework, the financing component interacts synergistically with other health system spheres. In Malaysia, outmigration of public health workers particularly specialist doctors remains an issue and financing strategies critically needs to incorporate a comprehensive workforce compensation strategy to improve the health workforce skill mix. Health expenditure information is systematically collated, but feedback from the private sector remains a challenge. Service delivery-wise, there is a need to enhance financing capacity to expand preventive care, in better managing escalating healthcare costs associated with the increasing trend of non-communicable diseases. In tandem, health financing policies need to infuse the element of cost-effectiveness to better manage the purchasing of new medical supplies and equipment. Ultimately, good governance and leadership are needed to ensure adequate public spending on health and maintain the focus on the attainment of universal coverage, as well as making healthcare financing more accountable to the public, particularly in regards to inefficiencies and better utilisation of public funds and resources.

Introduction: One of the challenges to maintain an agenda for universal coverage and equitable health system is to develop effective structuring and management of health financing. Global experiences with different systems of health financing suggest that a strong public role in health financing is essential for health systems to protect the poor. Health systems with the strongest state role are likely to be more equitable and achieve better aggregate health outcomes. Using Kenya as a case study, this paper seeks to evaluate the progress and capacity of a middle income country in terms of health financing for universal coverage, and also to highlight some of the key underlying health systems challenges.Methodology: The World Health Report 2010: Health Systems Financing: The Path to Universal Coverage was used as the framework to evaluate the Kenyan healthcare financing system in terms of the provision of universal coverage for the population, and the Kenyan National Health Sector Services Fund Accounts (2011) provided the latest Kenyan data on health spending. Measuring against the four target indicators outlined, Kenya fared modestly with total health expenditure close to 4.5% of its GDP (3.75%), out-of-pocket payment below 40% of total health expenditure (30.7%), comprehensive social safety nets for vulnerable populations, and a tax-based financing system that fundamentally poses as a national risk-pooled scheme for the population.Results: Nonetheless, within a holistic systems framework, the financing component interacts synergistically with other health system spheres. In Kenya, out-migration from public to private of public health workers particularly specialist doctors remains an issue and financing strategies needs to incorporate a comprehensive workforce compensation strategy to improve the health workforce skill mix. Health expenditure information is systematically collated, but feedback from the private sector remains a challenge.Conclusion: As far as Service delivery is concerned, there is a need to enhance financing capacity to expand preventive care, in better managing escalating healthcare costs associated with the increasing trend of non-communicable diseases. Additionally, health financing policies need to instill the element of cost-effectiveness to better manage the purchasing of new medical supplies and equipment. Good governance and leadership are needed to ensure adequate public spending on health and maintain the focus on the attainment of universal coverage, as well as making healthcare financing more accountable to the public, particularly in regards to inefficiencies and better utilization of public funds and resources.

National Health Accounts (NHA) are an important tool to demonstrate how a country's health resources are spent, on what services, and who pays for them. NHA are used by policy-makers for monitoring health expenditure patterns; policy instruments to re-orientate the pattern can then be further introduced. The National Economic and Social Development Board (NESDB) of Thailand produces aggregate health expenditure data but its estimation methods have several limitations. This has led to the research and development of an NHA prototype in 1994, through an agreed definition of health expenditure and methodology, in consultation with peer and other stakeholders. This is an initiative by local researchers without external support, with an emphasis on putting the system into place. It involves two steps: firstly, the flow of funds from ultimate sources of finance to financing agencies; and secondly, the use of funds by financing agencies. Five ultimate sources and 12 financing agencies (seven public and five private) were identified. Use of consumption expenditures was listed under four main categories and 32 sub-categories. Using 1994 figures, we estimated a total health expenditure of 128,305.11 million Baht; 84.07% consumption and 15.93% capital formation. Of total consumption expenditure, 36.14% was spent on purchasing care from public providers, with 32.35% on private providers, 5.93% on administration and 9.65% on all other public health programmes. Public sources of finance were responsible for 48.79% and private 51.21% of the total 1994 health expenditure. Total health expenditure accounted for 3.56% of GDP (consumption expenditure at 3.00% of GDP and capital formation at 0.57% of GDP). The NESDB consumption expenditure estimate in 1994 was 180,516 million Baht or 5.01% of GDP, of which private sources were dominant (82.17%) and public sources played a minor role (17.83%). The discrepancy of consumption expenditure between the two estimates is 2.01% of GDP. There is also a large difference in the public and private proportion of consumption expenses, at 46:54 in NHA and 18:82 in NESDB. Future NHA sustainable development is proposed. Firstly, we need more accurate aggregate and disaggregated data, especially from households, who take the lion's share of total expenditure, based on amended questionnaires in the National Statistical Office Household Socio-Economic Survey. Secondly, partnership building with NESDB and other financing agencies is needed in the further development of the financial information system to suit the biennial NHA report. Thirdly, expenditures need breaking down into ambulatory and inpatient care for monitoring and the proper introduction of policy instruments. We also suggest that in a pluralistic health care system, the breakdown of spending on public and private providers is important. Finally, a sustainable NHA development and utilization of NHA for planning and policy development is the prime objective. International comparisons through collaborative efforts in standardizing definition and methodology will be a useful by-product when developing countries are able to sustain their NHA reports.

The Millennium Development Goals call for a 75% reduction in maternal mortality between 1990 and 2015. Skilled birth attendance and emergency obstetric care, including Caesarean section, are two of the most important interventions to reduce maternal mortality. Although international pressure is rising to increase donor assistance for essential health services in developing countries, we know less about whether government or the private sector is more effective at financing these essential services in developing countries. We conducted a cross-national analysis to determine the association between government versus private financing of health services and utilization of antenatal care, skilled birth attendants and Caesarean section in 42 low-income and lower-middle-income countries. We controlled for possible confounding effects of total per capita health spending and female literacy. In multivariable analysis, adjusting for confounders, government health expenditure as a percentage of total health expenditure is significantly associated with utilization of skilled birth attendants (P = 0.05) and Caesarean section (P = 0.01) but not antenatal care. Total health expenditure is also significantly associated with utilization of skilled birth attendants (P < 0.01) and Caesarean section (P < 0.01). Greater government participation in health financing and higher levels of health spending are associated with increased utilization of two maternal health services: skilled birth attendants and Caesarean section. While government financing is associated with better access to some essential maternal health services, greater absolute levels of health spending will be required if developing countries are to achieve the Millennium Development Goal on maternal mortality.

ObjectiveThe analysis of health expenditure and its structure takes on a critical significance in national health policy research, and the public welfare of national health undertakings can be manifested by the government’s investment in health. In this study, the aim was to analyze total health care costs, the structure of health financing, and the government’s investment in health, so as to provide a reference for China’s health policy adjustment.MethodsDescription and cluster analysis were conducted using R language to analyze total health care costs and the structure of health financing of 31 regions in China between 1990 and 2020 to gain insights into the temporal and spatial changes total health care costs and the structure of health financing in China. The government’s investment in health was analyzed using description and abundance heatmap to know the temporal and spatial changes of the government’s health investment.ResultsThe total health expenditure per capita reached 5112.3 yuan in 2020, and the total health expenditure accounted for 7.10% of GDP. The government health expenditure took up a significantly lower share of the total health expenditure in 1993–2006 (17.09% [16.30,17.88]), whereas it has been nearly 30% (29.56% [28.73,30.3]) over the past few years. As to 31 regions in China, the government health expenditure per total health expenditure reached 67.94% in Tibet, whereas a level of 27.866% (25.629–30.103) were maintained in other regions. Beijing and Shanghai have achieved over 50.00% of social health expenditure per total health expenditure in recent five years, it was significantly higher than other regions. The per capita government expenditure as a fraction of GDP of Tibet (6.842%) was the highest region in 2011–2019, while Jiangsu (only 0.937%) was the lowest region.ConclusionsSustainable increases in total health expenditure as a percent of GDP take on a critical significance to adequate health financing. Equity in health financing has been insufficient in China, and spatial and temporal differences of China’s health financing structure are significant. The region’ governments should adjust policy based on typical regions to weaken the differences.

Health Expenditures in Pakistan: Cross-Checking Household Expenditure Data on Health for NHA and Adjustment with National Accounts

Objective: The role of the service sector in general and healthcare services in particular have been promoting in Iran’s economy. The implementation of the Health System Transformation Plan and the injection of new financial resources into this sector have raised concerns about the health system function. Thus, this is the first attempt to estimate and evaluate the share of rehabilitation services in the Iranian economic and health systems. Materials &amp; Methods: The study utilized longitudinal trend analysis using the National Health Accounts data during 2002-2015. National Health Accounts, through input-output tables, breaks down the share of different sources of financing for different functions of the health system. According to this method, both the share of rehabilitation services in Iran’s economy and the financing sources of these activities have been calculated and compared to other countries. Data on Iran's National Health Accounts has been collected from the Statistical Center of Iran. International data is collected from the World Health Organization's National Health Accounts and the databases of the Organization for Economic Cooperation and Development member countries. Results: Expenditures related to rehabilitation services in Iran increased from 884 billion rials in 2002 to more than 2967 billion rials in 1396, equivalent to 0.02% of Iran's GDP in that year. The share of rehabilitation expenditures in total health expenditures in 2007 was at its highest level (0.3%). In the following years, it has always had a decreasing trend. In 1396 it reached about 22.0%, the lowest amount during 16 Last year. Comparing the economic share of rehabilitation of the country's economic activities with different countries shows that the position of this sector is in no way comparable to developed countries and is even lower than many developing countries. Tunisia, Tonga, and Moldova have a similar situation to Iran's economy, with rehabilitation services accounting for about 0.05 to 0.1 percent of their total economic activity. Comparison of the prevalence of disability in these countries with Iran shows that these countries had a lower prevalence than Iran. Examination of the share of various sources shows that out-of-pocket payments with households with 6.37 percent, the most, and the government with 7.18 percent had the least role in financing rehabilitation services. It is noteworthy that this figure was about 65% before implementing the health system transformation plan. Social insurance in 2017 also covered only 6.24% of rehabilitation costs. Conclusion: Inaccessibility of people with disabilities to healthcare services is a very serious issue in the world. The rehabilitation services expenditures have always been mentioned as one of the most important barriers of accessing to these services. Following the implementation of the Health Transformation Plan, the share of rehabilitation activities in Iran’s health market has been shrunk.

This article deals with the accuracy of statistical records used for political decision making and international comparative analysis. In developing countries, even major macroeconomic indicators can include data inadequacies and methodological differences in data generation between statistical agencies. Existing data show that total health expenditure as a percentage of GDP is about 50% lower in Pakistan than in other low-income countries (LIC). To determine whether these results reflect the actual situation in Pakistan or whether they are due to statistical error, Pakistan produced National Health Accounts (NHA) for the first time in 2009 to assess health spending in 2005-6. Improved NHA estimates are also being made for 2007-8, which will be based on the following: public expenditure data published with time lags; survey results for 2007-8; and multivariate analyses of data from 2010 and 2011 surveys on health-specific out-of-pocket (OOP) expenditure, healthcare providers, non-profit institutions and census data on autonomous bodies and large hospitals. Since these data are not yet available, a best estimate of health expenditure has to be made to support policy decision making and to provide a point of comparison for future NHA results. Health expenditure data are available from different data sources and estimates have been made by applying different methods, leading to a range of health spending estimates. As a result of this diversity of estimates and data, each with its own inaccuracies or gaps, there was a clear need to triangulate the available information and to identify a best possible estimate. This article compares estimates of household health expenditure from different sources, such as the Household Integrated Economic Survey, the Family Budget Survey and National Accounts (NA). The analysis shows that health expenditure figures for Pakistan have been underestimated by both WHO and the NHA. An adjusted estimate shows OOP spending to be twice as high as previously thought. Previous per capita total health expenditure estimates ranged from $US16 to $US19. The revised estimate showed per capita total health expenditure to be $US33, based on NA data. This puts Pakistan in a different position in international comparisons, with health expenditure exceeding the level of India ($US32.5) and the average of all LIC ($US24.5). Methodological differences in estimating expenditure and the multiple and conflicting estimates might cause stakeholders to make potentially adverse or even erroneous policy decisions on the allocation of resources. Because policy makers make decisions based on the estimates provided, the provision of a best estimate, made following a review of the advantages and limitations of existing sources and methods, is key.

Background Nepal has been undergoing demographic and epidemiological transitions, marked by an increasing burden of non-communicable diseases (NCDs) and injuries. These transitions have led to financial implications, including rising out-of-pocket (OOP) expenses. This study reviews and synthesizes evidence on the status, issues and challenges in health financing system, policies, and programs to achieve universal health coverage (UHC) in Nepal. Methods We conducted a scoping review of literature on Nepal’s health financing system, policies, and programs. A search strategy was developed using keywords related to two core concepts: health financing and universal health coverage. Grey literature was identified from the web pages of relevant ministries and organizations. A total of 148 studies/policy documents published in Nepali and English up to 31 December 2024 were included. Policies and content related to the health financing system were reviewed to understand the status, issues and challenges of health financing functions, and UHC . A framework-guided deductive content analysis approach was employed, and findings were interpreted using the three UHC components: service coverage, population coverage, and financial coverage. Results Nepal’s health policy documents prioritize financial protection for low-income people and target groups through social health protection programs/schemes. However, multiple social health protection schemes coexist with fragmented risk pooling and low efficiency in health financing. OOP expenditure is high at 54.2%, with 10% of the population facing catastrophic health expenditures. Injuries and chronic morbidities contribute significantly to this burden, with 70% of injury-related and 62% of NCD-related expenses borne through OOP payments. Despite efforts to improve financial risk protection, the National Health Insurance Program (NHIP) suffers from low population coverage (28%), low renewal rate (54%), and financial sustainability issues (as provider payments exceed revenue collection). The UHC service coverage index, though improving, was only 54 out of 100 in 2021 reflecting limited health system capacity and insufficient readiness to address health challenges, including those posed by shifting demographics and the growing burden of NCDs. Nepal’s total health expenditure remains around 2% of GDP, with persistent inefficiencies in resource allocation, fiscal decentralization, and budget absorption. Conclusions Nepal’s health financing policies align with UHC goals, yet critical gaps remain in multiple dimensions . Issues such as inefficiencies, underfunding, and fragmented social health protection schemes limit equitable access to quality health care. Therefore, comprehensive structural reforms-spanning legal, institutional, and policy frameworks-are urgently needed. Key reforms include: (1) merging or harmonizing existing social health protection schemes for efficient pooling and purchasing; (2) enhancing domestic health financing through increased health funding (≥5% of GDP) via payroll contributions, progressive taxation, and earmarked sin taxes; (3) reforming NHIP to mandatory enrollment starting from formal sector, subsidizing premium for informal sector and free coverage for disadvantaged groups, alongside strengthening policy implementation including accrediting of health facilities, ensuring service quality, prioritising and expanding coverage packages with strategic purchasing from all public and private health facilities; and (4) equitable public financing to ensure needs-based allocation across government levels that respond to demographic and epidemiological patterns. Further research is needed to assess hybrid tax and premium based insurance models, strategic purchasing optimization, and digital health innovations for financial sustainability.

Catastrophic Expenditure for Health in the Philippines

In their Policy Forum “Global HIV/AIDS policy in transition” (11 June, p. [1359][1]), J. Bongaarts and M. Over conclude that antiretroviral therapy for AIDS is not a cost-effective use of donor funding for global health. We believe that Bongaarts and Over omitted key aspects of a complete cost-effectiveness assessment: numerous positive spinoffs to other services, the effect on increased attention on global health, and the ability to mobilize resources that would not otherwise have been available for global health. The situation in Rwanda serves as an example. Rwanda's total health expenditure declined from 1998 through 2002, but because of advocacy for HIV resources, total health expenditure doubled between 2002 and 2003 ([ 1 ][2]). HIV funding, even before the current focus on integration, provided resources for the renovation of health facilities, equipment, training, and management, as well as a culture of openness for best practices. With integration of HIV services into other health services, resources have had an even wider benefit, especially for maternal health services. Integration is still in progress, but successful steps have been made ([ 2 ][3], [ 3 ][4]). Rwanda's 2006 National Health Accounts reported that although reproductive health spending did not grow as rapidly as overall spending, it increased by 15% between 2002 and 2006 ([ 4 ][5]), and maternal mortality rate decreased from 1071 (in 2000) to 750 per 100,000 births (in 2005) and is expected to fall to about 350 in 2010. Rates of assisted deliveries, use of family planning, and receipt of four standard prenatal care services have seen a marked increase ([ 4 ][5]–[ 6 ][6]). Consistent with the results in Rwanda, a recent Lancet article correlated maternal mortality with HIV mortality in women ([ 7 ][7]). These improvements cannot be attributed to reproductive health spending alone; major health initiatives made possible by HIV funding are largely responsible. HIV resources also paid for the community-based health insurance premiums of many of the poorest segments of the population; the funding thus contributed to the increase in community-based health insurance enrollment rate from 7% in 2003 to 85% in 2008. The literature cited by Bongaarts and Over failed to consider all benefits gained beyond direct HIV services, including the value of saving a mother and its contribution to quality of life for her children and family and societal productivity. In doing so, Bongaarts and Over have greatly underestimated the impact of HIV funding on both HIV and non-HIV health results. 1. [↵][8] Rwanda Ministry of Health, “National health accounts 2006” (2008). 2. [↵][9] National AIDS Commission, “National strategic plan 2009–2012” (2009). 3. [↵][10] UNAIDS, “Rwanda country progress report 2008–2009” (UNAIDS, Geneva, 2010). 4. [↵][11] Rwanda Ministry of Health, “Rwanda demographic and health survey 2000” (2001). 5. Rwanda Ministry of Health, “Rwanda demographic and health survey 2005” (2006). 6. [↵][12] Rwanda Ministry of Health, “Rwanda demographic and health survey 2007–2008” (2009). 7. [↵][13] 1. M. C. Hogan 2. et al ., Lancet 375, 1967 (2010). [OpenUrl][14][CrossRef][15][PubMed][16][Web of Science][17] [1]: /lookup/doi/10.1126/science.1191804 [2]: #ref-1 [3]: #ref-2 [4]: #ref-3 [5]: #ref-4 [6]: #ref-6 [7]: #ref-7 [8]: #xref-ref-1-1 View reference 1 in text [9]: #xref-ref-2-1 View reference 2 in text [10]: #xref-ref-3-1 View reference 3 in text [11]: #xref-ref-4-1 View reference 4 in text [12]: #xref-ref-6-1 View reference 6 in text [13]: #xref-ref-7-1 View reference 7 in text [14]: {openurl}?query=rft.jtitle%253DLancet%26rft.stitle%253DLancet%26rft.aulast%253DMcCaw-Binns%26rft.auinit1%253DA.%26rft.volume%253D375%26rft.issue%253D9730%26rft.spage%253D1967%26rft.epage%253D1968%26rft.atitle%253DNew%2Bmodelled%2Bestimates%2Bof%2Bmaternal%2Bmortality.%26rft_id%253Dinfo%253Adoi%252F10.1016%252FS0140-6736%252810%252960924-5%26rft_id%253Dinfo%253Apmid%252F20569839%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [15]: /lookup/external-ref?access_num=10.1016/S0140-6736(10)60924-5&link_type=DOI [16]: /lookup/external-ref?access_num=20569839&link_type=MED&atom=%2Fsci%2F330%2F6001%2F176.1.atom [17]: /lookup/external-ref?access_num=000278689600024&link_type=ISI