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Health And Poverty
Dr.Akmal Hussain
Newspaper: Daily Times
Dated: Thursday, May 15, 2003

My research for the National Human Development Report over the last three years has shown that ill health is so widespread in Pakistan that it should now be regarded as a major national issue in the context of poverty alleviation and economic development. The latest survey data show that as much as 65 per cent of the poor population in Pakistan is afflicted by ill health, with the poor on average being sick for three months of the year. A large proportion of the middle class is also suffering from ill health and gets locked into high cost sources of private medical health care. This results in not only lower productivity and incomes, but also a loss of already low income due to expensive medical care for repeated and sometimes chronic illness. In this article, we will briefly discuss some of the evidence on health particularly with respect to women and children.

Three factors account for 60% of the burden of disease in Pakistan, when measured in terms of life years lost: (i) Communicable infectious diseases. (ii) Reproductive health problems. (iii) Nutritional deficiencies. Inspite of the fact that all three of the factors are preventable as well as treatable, the incidence of disease and mortality remains high. This is indicative of high levels of poverty (causing poor nutrition, and unhygienic living conditions within the household). Equally important is the continued severe lack of preventive and curative health infrastructure. The seriously inadequate preventive measures include sanitation, safe drinking water, adequate reproductive health care facilities for women and food safety regulations with respect to both raw and cooked food available outside the household.

The curative health care system has expanded substantially during the last decade. For example, the population per doctor has fallen from 2082 in 1990 to 1529 in the year 2000, and the population per nurse has fallen from 6374 to 3732 over the same period. The fact that inspite of this expansion the incidence of disease remains high points to both inadequate coverage and poor quality. According to the National Health Survey of Pakistan there is a high prevalence of ill health particularly amongst women. For example in rural areas prevalence of fair plus poor health for females above 25 years is about 75%, while for males in the same age group it is about 45%. The high prevalence of disease is also indicated by the fact that visits to a health care provider per person aged 5 years and above, is as high as 6 per year. An increasing proportion of the health care is now being provided by the private sector.

Malnutrition is a major problem in Pakistan and is an important underlying factor in ill health and morbidity. For example for children, protein energy malnutrition is an underlying cause of death in about one third of all deaths below 5 years of age. For women inadequate intake of energy, protein and micronutrients, compounded by high fertility and unhygienic living conditions associated with poverty, are major factors in the high prevalence of disease. For children, women and men, malnutrition leads to impaired immunity and high susceptibility to infection.

The data from the survey conducted for the National Human Development Report, suggest that the high prevalence of disease amongst those who are slightly above the poverty line is a major factor in pushing them into poverty. Those who are already poor get pushed into deeper poverty as the result of loss of income and high medical costs resulting from illness. The data show that on average 65% of the extremely poor were ill at the time of the survey and they had on average suffered from their current illness for 95 days. The NHDR data show that the poor predominantly go to private allopathic medical practitioners. Many of them are poorly trained and have grossly inadequate diagnostic facilities. Consequently when the poor fall ill they suffer for a protracted period and get locked into a high cost source of medical treatment, which erodes whatever few assets they have, and pushes them into indebtedness and deeper poverty.

Infant mortality rates have declined over the decade of the 1990s although they are still high compared to other low-income countries. The infant mortality rate (IMR) in Pakistan declined from 122 per 1000 live births in 1991 to 89 per 1000 live births in 1999. The IMR for males was 93 per 1000 live births and for females 85 per 1000 live births. Health data suggest that infants born to the least educated mothers have twice the risk of dying within the first year after birth compared to more educated women. However it is noteworthy that since the percentage of uneducated women is much higher amongst poor households, infant mortality rates may be correlated not simply with the educational status of the mother but also with poverty and hence the inability of the mother to get adequate nutrition, pre natal and post natal care.

The critical determinant of an infant's survival and subsequent health is the nutrition status and health care received by the mother. In Pakistan where 40% of the women are anemic and almost 80% deliver at home without trained assistance, it is not surprising that both infant mortality and maternal morbidity associated with pregnancy are amongst the highest in Asia. (Maternal mortality rates are 300 to 400 per 100,000 live births).

Although the government has not been able to achieve its immunization target rate of 90%, there has been a significant improvement in the immunization rate over the decade 1991 to 1999. The percentage of children between 12 and 23 months who were fully immunized increased from 37% to 49%. The immunization rates in children improved for both genders as well as rural and urban areas. According to PIHS data there is a strong correlation between income levels of household and immunization rates. For example 75% of the children in the upper income quintile were fully immunized as against only 25% in the lowest income quintile

In view of the evidence, it is important that the government integrate its health policy with the strategy of poverty alleviation. Five broad initiatives are necessary in this context: (1) Improve the quality and coverage of preventive health facilities. (2) Improve the service delivery of basic health units where the frequent absence of doctors from duty and lack of medicines have made them largely ineffective at the moment. (3) Improve the hygiene standards, diagnostic facilities and professional quality of medical care at Tehsil level hospitals. (4) Establish at least one model hospital of international standards in each district. (5) Launch a national campaign for: (i) Provision of hygienic drinking water, (ii) Control of hazardous pesticides used on food grains and vegetables, (iii) Strict implementation of food adulteration laws and control of unhygienic food supplied by vendors, cafes and restaurants.

Improved health of Pakistan's population through preventive and curative measures will be an important factor in improving productivity, incomes and in alleviating poverty in the future.

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