Health Systems Profile- Pakistan Regional Health Systems Observatory- EMRO

3 H EALTH STATUS AND DEMOGRAPHICS

3.1 Health Status Indicators

Table 3-1 Indicators of Health status
Indicators 1990 1995 2000 2002
Life Expectancy at Birth: 59.10 60.88 62.96 65
HALE: - - 50.9 53.3
Infant Mortality Rate: 96 90 81 76
th
Probability of dying before 5
138 125 108 101
P P

birthday/1000:
Maternal Mortality Ratio: 550 - - 340-400
Percent Normal birth weight babies: 75 75 66-75 66-75
Prevalence of stunting/wasting: 51 (88) 23* - 61.9
Source: DG report 2002-3
State of world’s children 1990
World health report 2003- Background country papers
*National health survey of Pakistan 1990-96

Table 3-2 Indicators of Health status by Gender and by urban rural

Indicators Urban Rural Male Female
Life Expectancy at Birth: - - 64 66
HALE: - - 54.2 52.3
Infant Mortality Rate: 65 88 84 81
Probability of dying before 5th
- - 98 108
birthday/1000:
Maternal Mortality Ratio: 55-150 200-500 - -
Percent Normal birth weight babies: - - - -
Prevalence of stunting/wasting: - - - -
Source: PIHS 2001-2002
PDS 2001
WHO World Health report 2003

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Health Systems Profile- Pakistan Regional Health Systems Observatory- EMRO

Table 3-3 Top 10 causes of Mortality/Morbidity

Rank Mortality Morbidity/Disability
1. Diarrhea Hypertension
2. LTRI-Child Injuries
3. Tuberculosis Eye diseases
4. Rheumatic heart disease Malnutrition
5. Chronic liver disease Birth diseases
6. Congenital malformations Congenital malformations
7. Birth diseases Dental diseases
8. Ischemic heart disease Ischemic heart disease
9. Child septicemia Anemia (in females)
10. Other respiratory diseases Mental retardation
Source: 1. Adnan A. Hyder, Applying Burden of Disease Methods in Developing Countries: A Case
Study From Pakistan, American Journal of Public Health, August 2000, vol 90. N0. 80
2. Top 10 Causes (by Rank Order) of Premature Mortality and Disability in Pakistan, 1990,
www.worldbank.org/transport/forum2003/presentations/hyder.ppt

The current health status of the nation is characterized by a high population growth rate,
high incidence of low birth-weight babies and maternal mortality. While communicable,
infectious, and parasitic diseases remain a severe burden, malaria and tuberculosis (TB)
continue to be potential threats. People in Pakistan have grown healthier over the past
three decades: the rates of immunization of most groups of children have more than
doubled over the past decade, and knowledge of family planning has increased
remarkably and is almost universal. Pakistan’s per capita income is much higher than the
average for low-income countries. Yet, despite these positive aspects and government-
and donor-financed interventions, health indicators have been improving very slowly.
Communicable diseases such as diarrheal diseases, respiratory infections, tuberculosis,
and immunizable childhood disease still account for the major portion of sickness and
death in Pakistan. Maternal health problems are also widespread, complicated in part by
frequent births. In fact, Pakistan lags far behind most developing countries in women’s
health and gender equity: of every 38 women who give birth, 1 dies. The infant
mortality rate (76 per 1,000) and the mortality rate for children under age five (101 per
1,000 births) exceed the averages for low-income countries. Although use of
contraceptives has increased, fertility remains high, at 4.5 births per woman, and
population growth rates are much higher than elsewhere in South Asia. The underlying
problems that affect health—-poverty, illiteracy, women’s low status, inadequate water
supplies and sanitation—persist. Nevertheless, Pakistan is committed to the goal of
making its population healthier, as evidenced by the National Health Policy.
Although, consolidated public health expenditure rose during 1995-96 to 2000-01, it
represents 0.60 percent of the GDP. Additionally, a major share of these expenditures is
focused towards tertiary health care facility with the result that primary and secondary
tiers especially in rural areas have been neglected. In addition, serious institutional and
governance deficiencies mar the health sector. The other challenges facing the health
system are access (availability and affordability), unawareness, and inadequate
budgetary spending. Analysis of the burden of disease (BOD) conducted in 1996

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indicated that around 60% of BOD is because of poverty related communicable diseases,
childhood illnesses, reproductive health problems and malnutrition. Major impact of
these diseases is borne by poor segments of society and vulnerable groups. The major
challenges facing the health sector are slow progress in improving the indicators related
to maternal health, child health, and morbidity and mortality caused by communicable
diseases. Although, the coverage has improved over recent years, however, providing
quality health care to vast majority of population is a formidable task. The government is
well aware of the magnitude and depth of the problem. It has endeavored recently to
address the broader issues in social sector delivery through major reforms while IPRSP
reflected the government’s commitment to improving public service delivery as central to
achieving the goals of reviving growth and reducing poverty. The medium term health
strategy is focused towards raising public sector health expenditures through a focus on
prevention and control of diseases, reproductive health, child health, and nutrient
deficiencies. The thrust of public expenditures is geared towards primary and secondary
tiers. This approach provides a clear shift from curative to preventive health care and
focuses on disadvantaged, weaker sections of society especially those belonging to rural
areas. It aims at promoting gender equity through targeted interventions like increase of
Lady Health Workers (LHW) and improvements in maternal health care4. TP PT

As per BOD study 1998, Pakistan is also facing significant burden of non-communicable
diseases, unlike other developing countries. The major non-communicable health issues
are injuries, cardiovascular diseases, Diabetes, Hypertension, psychological disorders,
geriatric problems etc. The burden of non-communicable group of diseases is 44%,
indicating that Pakistan is facing double burden of diseases, where communicable
diseases are not fully controlled, while non-communicable diseases are emerging as a
major problem.

3.2 Demography
Demographic patterns and trends
The Islamic Republic of Pakistan, with a population of about 153 million (2005), has an
area of 307,374 square miles (796, 095 square km) and an overall population density of
182 persons per square km. There are four provinces and two regions. Provinces are
Punjab (the most populous), Sindh, North Western Frontier Province (NWFP) and
Balochistan (largest by area), and regions are Azad Jammu Kashmir (AJK) and Federally
Administered Northern Area (FANA). Afghan refuges and religious minorities reside in
certain areas of the country in significant numbers.
Geographic Distribution
The majority of southern Pakistan's population lives along the Indus River. In the
northern half, most of the population lives about an arc formed by the cities of
Faisalabad, Lahore, Rawalpindi/Islamabad, and Peshawar.
H

Ethnic groups: Pakistan's ethnic diversity is obvious and yet accurate numbers have been
elusive. Rough estimates vary, but the consensus is that the Punjabis are by far the
largest group, and that Pukhtuns and Sindhis are the next two largest groups. The main
ethnic groups include the following: the Punjabi, Pashtun, Sindhi, Baloch, Muhajir
(immigrants from India at the time of partition and their descendants), Seraiki, Brahui,
Kashmiri, and the various peoples of the Northern Areas. In addition, a large number of
Afghan refugees came to Pakistan during the Soviet invasion of Afghanistan, and it is
H H

estimated that over three million remain, with a large proportion settling in the country.

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Health Systems Profile- Pakistan Regional Health Systems Observatory- EMRO

Religions: Muslim 97% (Sunni 77%, Shiite 20%), Buddhist, Christian, Hindu, and other
H H H H H H H H H H H H

3%
Languages: As a first language, Pakistanis speak: Punjabi 48%, Pashtu 15%, Sindhi
12%, Siraiki (a Punjabi variant) 10%, Urdu (official) 8%, Balochi 3%, Hindko 2%, Brahui
HTU UTH

1%, English (official and lingua franca of Pakistani elite and most government
ministries), Burushaski, and others 1%. The majority of Pakistanis can speak or
understand two or more languages.5 TP PT

The health and population characteristics of Pakistan are high fertility, low life
expectancy, a young age structure, high maternal and child mortality, high incidence of
infectious and communicable diseases, and wide prevalence of malnutrition among
children and women. The country is going under a demographic transition, characterized
by a change from high mortality and high fertility to lower mortality but still relatively
high fertility.6 TP PT

Fertility Transition: Unlike its neighbors- Sri Lanka, India, and Bangladesh- Pakistan
has confounded demographers by maintaining a high rate of fertility. However, the
transition to lower fertility in Pakistan, which had been expected as early as the 1960s,
has begun in the 1990s, according to Population Council researchers. The decline,
though moderate, is definitive. Several studies confirm that between the 1960s and the
1980s, the total fertility rate (TFR) in Pakistan remained above six births per woman.
“Pakistan has been a puzzle, a stalwart resister to fertility transition,” comments
Casterline. Beginning in the 1990s, however, the fertility rate dipped below six births per
woman for the first time. Among other surveys, the Pakistan Fertility and Family
Planning Survey (1996–97) found a TFR of 5.3 for the period 1992–96. The researchers
note that all the demographic analyses they examined point to a fertility decline in the
1990s. Some of the most persuasive evidence for a fertility decline comes from trends in
contraceptive use. During the 1980s, fewer than 10 percent of married women in
Pakistan practiced contraception. By 1991 that figure had risen to 12 percent, and by
1995 to 18 percent. As of the most recent survey, conducted in 1996 and 1997, about
24 percent of married women were using contraception. Women in urban areas were
about twice as likely as women in rural areas to use contraception. Demographic trends
throughout the world show that when mortality declines and social and economic
conditions improve, fertility decline follows, often with only a short lag. This has not
been true in Pakistan, where improvements in these conditions first appeared in the
1950s. Several other factors conspired to thwart any reduction in fertility. Women's
status remains unusually low in Pakistan, and men make many of the decisions about
reproduction. A strong economy in the 1960s through the 1980s gave families little
motivation to restrict fertility. Until the end of the 1980s, people viewed the social,
psychological, and cultural costs of contraceptive use as higher than the cost of
additional births.
Pakistan’s economy has turned sharply downward in the 1990s, while the spread of
mass media has helped to raise the aspirations of parents for the lives of their children.
Together these trends have led to a growing conviction that children are costly. At the
same time, there has been a cultural shift during the 1990s from the bonds of extended
family to the autonomy of the couple. In the past, kin had a voice in fertility decisions.
But many couples have migrated from rural to urban areas, weakening these family ties.
Reflecting these societal changes, the ideal family size has shrunk during the 1990s,
from 4.1 children in 1991 to 3.6 children in 1995.
“The most important reason that the transition is happening now rather than earlier is a
sense of economic stress that did not exist before. Sathar and Casterline believe that

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Health Systems Profile- Pakistan Regional Health Systems Observatory- EMRO

public and private family planning services have not played a large role in stimulating the
fertility changes in the 1990s. Family planning services in Pakistan remain seriously
deficient, with one study finding that only 10 percent of the population had easy access
to the services. To sustain the fertility transition in Pakistan, family planning services—
especially those in rural areas—should be expanded and improved as rapidly as possible.
Unmet need for contraception remains relatively high, and many couples desire
appropriately designed services. “The potential payoff of investing in and improving
family planning services is greater now than ever before,” stresses Sathar. “Without
expanded and improved services, we do not believe the transition will go far or proceed
rapidly.” Over the long run, however, the demand for children must fall further for
population growth to wane significantly in Pakistan. Ideal family size, while lower than in
past decades, remains well above replacement levels.7 TP PT

Table 3-4 Demographic indicators

Indicators 1990 1995 2000 2002
Birth Rate per 1,000 Population: 41 37 34 27.8

Death Rate per 1,000 Population: 13 10 8 7.2

Population Growth Rate: 2.54 2.46 2.2 2.01

Dependency Ratio %: 0.85 0.87 0.82 0.78

% Population <15 years 41.99 42.62 41.70 40.61
Total Fertility Rate: 5.84 5.20 4.68 4.01
Source: Pakistan demographic survey 2001, Federal Bureau of Statistics
Stat-Pocket-Book 2003, Federal Bureau of Statistics
NIPS

Table 3-5 Demographic indicators by Gender and Urban rural

Indicators Urban Rural Male Female
Crude Birth Rate: - - - -
Crude Death Rate: 6.3 7.6 7.4 6.9
Population Growth Rate: - - - -
Dependency Ratio: - - 31.84 30.26
% Population <15 years - - 29.2 27.5
Total Fertility Rate: - - - -
Source: Pakistan Demographic Survey 2001
World health report 2003

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