Pakistan has one of the highest percentages of stunted children in South Asia. Nearly half of the country’s children are at a risk of dying before their fifth birthday! If they are lucky enough to survive, they are unable to live a healthy and active life. Alas, after 70 years of independence, a vast majority of Pakistan’s rural population still lacks access to basic human, social and economic services!
The World Bank’s report ‘When Water Becomes a Hazard: A Diagnostic Report on the Status of Water Supply, Sanitation and Poverty in Pakistan and its Impact on Child Stunting’ was released in the first week of November and is a timely contribution to the situation. The report provides a picture of the elite nature of social and economic services in the economy and its impact on the poor of the country.
One main focus of the report is on the widening rural-urban divide — in terms of the allocation of public resources and the provision of basic health and sanitation services. This leads to different levels of poverty persistence, poverty reduction and malnutrition in rural and urban areas of the country. The report analyses how the poor quality of water, toilets, sanitation and inadequate hygiene conditions causes child stunting and poverty, especially in rural areas.
The report, surprisingly, finds that head-count poverty has declined in the country by 35 percentage points between 2001/02 and 2013/14, from 64.3% to 29.6%. This decline in poverty is in line with the estimates presented in the Economic Survey of Pakistan (2015/16). However, it is less consistent with other studies on poverty and the economic performance of the country for the referred period. Haroon Jamal (2017) estimated that the incidence of poverty was 33% in 2001/02 and increased to 38% of the population in 2015/16. The macroeconomic performance of the economy, the real growth in GDP and the key economic indicators of the agriculture, manufacturing and service sectors did not perform well enough to provide a plausible explanation for any huge decline in poverty.
Despite variations in estimates, there is a general consensus that the incidence of poverty is high in rural areas. Over three quarters of the country’s poor live in rural areas of the country. This divide is starker in Sindh where the proportion of those living below the poverty line is 19% in urban areas and 50%, one in two, in the rural areas.
The World Bank report traces the rural-urban divide in the provision of access to water supply, sanitation, and hygiene (WASH) services. Despite a substantial improvement in access to water and sanitation, only a quarter of households had access to piped water in 2014/15. This access to government-provided piped drinking water was four times higher in urban areas, 48%, than in rural ones where it was 13%. Shockingly, the report finds that the provision of piped water in rural areas has declined over the past decade. In rural Sindh, piped drinking water declined from 19% in 2004/05 to 8% in 2014/15. Over two-thirds of households in the rural areas use hand-pumped water. The reliability of the piped water is another concern: in rural Sindh and Balochistan, households received only 5-7 hours a day of piped water.
The report finds that sanitation facilities improved substantially during the last decade. The rate of open defecation declined from 29% to 13%. However, the main progress is reported in the flush-to-septic-tank and flush-to-open-drain toilets. The number of toilets connected to a sewerage system increased only marginally in rural areas of the country. In urban areas 74% of households had access to improved toilets, whereas in rural areas it was only 46%. Worryingly, one in five rural households use open-defecation toilets.
Access to flush toilets connected to sewerage remains negligible in rural areas of the country. In rural Punjab and Khyber-Pakhtunkhwa, the sanitation infrastructure was more dominated by flush toilets connected to septic tanks, whereas in the rural areas of Sindh and Balochistan flush toilets were mostly connected to open drain and pit latrines. In all the rural areas of the four provinces, there was negligible connection of toilets with a covered drainage system.
The report reveals that half of children are stunted and one-third of children are underweight. It argues that poverty has an impact on stunting because poorer neighbourhoods have poorer quality of sanitation, and therefore higher levels of bacterial contamination of soil and water. Moreover, health vulnerability and poor wash, the report argues, are the product of the underlying economic and geographical inequalities in the country. Children in poorer households are four times more likely to be underweight than those in households in the richest districts. At the provincial level, the report reveals that the situation in Sindh has worsened during the last decade, as the number of stunted children is increasing.
Public spending, the report finds, is highly biased in favour of provincial capitals. These receive the lion’s share in provincial spending. The per capita share of expenses in Lahore is found to be 17 times higher than other districts in the province. The highest disparity in the allocation of public funds, however, is revealed in Sindh where the per-capita budget allocated to Karachi is 83% higher than the average to other districts in the province. The report is silent on the slums of Karachi where the situation is as bad as in most of the rural areas of the province.
The targeting of the spending is also found to be regressive, with poorer districts receiving a lower allocation of resources. There are no clear criteria for taking into account the social, economic and health deprivation of the population in the allocation of public resources. Even after the 18th constitutional amendment and the decentralisation of resources since 2011/12, the report finds little improvement in the allocation of resources and targeting of public spending, especially in Sindh and Punjab.
The report provides serious food for thought in relation to public policy for improving sanitation services and reducing poverty in the country. The PTI-led government, with the slogan of Naya Pakistan, needs to spend a higher share of GDP, at least 1.4% annually, on public health services to fulfil its promise of a healthy Pakistan, where its citizens will have access to safe water and basic sanitation services. Provincial governments, especially in Sindh, need to rationalise and prioritise their allocation of resources to increase spending on safe water and improved sanitation services and to target the poorest districts, particularly those in rural areas, where urgent attention is needed to reverse the trend of increasing stunting and poverty.
Published in The Express Tribune, November 30th, 2018.