The need to focus on healthcare

A well-educated and healthier population grows more slowly than those that have high rates of mortality and illiteracy

Shahid Javed Burki April 12, 2021
The writer is a former caretaker finance minister and served as vice-president at the World Bank

In 2021, Pakistan’s population is estimated at about 221 million which makes the country the fifth largest in the world. China, India, the United States and Indonesia have larger populations. However, the rate of growth of Pakistan’s population now is estimated at 2.04% a year. It is much higher than that of the four largest countries. The Chinese population is growing at the rate of 0.71%; that of India at 1.09%; that of the Indonesia at 0.77%; and that of the US at 0.71%. If the Pakistani growth does not slow down, it is likely to overtake both Indonesia and the US and go on to become the world’s third largest country. A large population can be both an asset or it can also be a burden. Developing the human resource increases worker productivity which pushes up the rate of economic growth. Neglecting the development of the human resource works as a burden on the economy. The second of these two propositions is currently true for Pakistan.

What can be done to slow down the rate of population growth? The answer lies in both government action as well as people’s attitude towards family formation. China and Bangladesh offer two interesting examples of the demographic roles played by governments. During the time of Mao Zedong, China forced the “one child” policy on its people. The rate of growth of population slowed down dramatically and did not recover even when the policy was changed.

Bangladesh has also gone through a remarkable demographic transition. This happened because of the change in the status of women in society. After the country gained independence from Pakistan, the new country was given one-half of the textiles export quota that was prescribed for Islamabad under the Multifiber Agreement, the MFA. This agreement allowed duty-free access to various forms of cotton products, including finished garments. In order to take advantage of the access the country had to the markets in North America and Europe, private investment flowed in from East Asia. This led to the rapid development of the garment industry in the country which employed mostly women. Women’s employment took them out of their homes and protected them from frequent pregnancies. Consequently, the rate of growth of the Bangladeshi population declined to less than 1% a year. The current estimate is 0.97%.

For Pakistan to bring down the growth rate of its population, it must invest in developing its large human resource. A well-educated and healthier population grows more slowly than those that have high rates of mortality and illiteracy. The state of health in Pakistan has attracted a great deal of foreign attention. For instance, The New York Times Magazine of April 4, 2021, had a cover story on the health situation in Pakistan, focusing in particular on the outbreak of pediatric HIV in the country. The story written by Helen Ouyang took the breakout of the disease in Sindh’s city of Ratodero. “In 2020, about 2.8 million people worldwide under the age of 20 were living with HIV; over half of them were younger than 10, according to UNAIDS, the United Nations HIV programme,” wrote Ouyang. “In a vast majority of these cases, the infection was acquired through vertical transmission, meaning an HIV-positive mother passed the virus to her child during pregnancy or delivery or while breastfeeding.” However, during her visit to the Sindhi town, the author met two children who were HIV-positive while their parents were tested negative.

“Why has there been a resurgence of HIV in Pakistan even as it has declined elsewhere?” asks Ouyang. “Much of the reason is money — specifically, the lack of consistent and equitable government spending on health. Prime Minister Imran Khan seems to be aware of the problem his country faces in getting the right amount of resources into both education and health. In the heath sector he has called in two professionals to help him. Both Sania Nishtar and Faisal Sultan have come with very good reputations. A great deal needs to be done. According to the World Bank just over 3% of Pakistan’s gross domestic product goes in the health sector, one of the lowest such expenditures in the world. Even neighbouring Afghanistan spends more than three times as much — 10% of its GDP. At $45 per person, health expenditure in Pakistan is one of the lowest in the world and much of it is in the form of foreign aid. Life expectancy in Pakistan is 67 years, 10 years less than the average for developed countries.

Pakistan is one of the three countries that has still not eradicated polio. It also currently bears some of the heaviest burden from tuberculosis, partly because being positive increases the risk by 20-fold of developing the disease.” It is not surprising, therefore, that Pakistan is finding it hard to control the spread of Covid-19 by relying heavily on the use of vaccines to protect people. A multifaceted approach covering the entire health sector is needed.

According to The New York Times, “many poorer countries manage to have better health outcomes than Pakistan by focusing on primary care and strengthening their public health capacities. Allocating resources strategically and prioritising hard-to-reach areas and marginalised groups can help ensure that access to services is not determined by geography, or income. Active disease surveillance and prevention can blunt outbreaks, or at least stop health systems from becoming apathetic and dysfunctional when crises do occur. The vexing failure that can follow these steps is nowhere more visible than it is in Ratodero,” wrote the Times correspondent after visiting the city in Sindh to collect material for her article. “As of November 30, an astonishing 1,132 children in the city and its environs were HIV positive, most of them under age 13. To put this in perspective, the equivalent figure for the United States is less than 2,000; the American population, 330 million, is a thousand times that of Ratodero metropolitan area.”

To the list of efforts indicated by the Time’s correspondent, I would add special attention to women in particular those living in the countryside. As I have already indicated, Bangladesh has done well demographically by improving the status of women in society. The situation with respect to women remains poor in Pakistan. According to Zahid Hussain, a journalist and a book author, writing recently “around 14,850 kidnapping cases involving women had been reported in Punjab in one year. Figures for three years from 2014 to 2017 also showed that a number of women had been kidnapped with a vast majority being raped. Some were also killed. The countrywide numbers were similarly atrocious.” Research has shown that low status of women results in high population growth rates. Bangladesh and Pakistan have treated their women differently. At the time Pakistan was born and Bangladesh was the country’s eastern wing, its population at 40 million, was 25% more than West Pakistan’s 32 million. Now more than 70 years later, Pakistan at 221 million is 34% larger than Bangladesh’s 165 million.


Published in The Express Tribune, April 12th, 2021.

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