1. © 2006 POPULATION REFERENCE BUREAU Presentation by Dr. Fariyal Fikree of the Population Reference Bureau, November 1, 2007 Pakistans Health Status: Past, Current and Future

2. © 2006 POPULATION REFERENCE BUREAU Burden of Disease Disease Conditions % total deaths % total DALYs Communicable, maternal, and perinatal conditions52.856.1 Diarrheal diseases8.58.7 Respiratory infections12.110.5 Maternal conditions1.73.4 Perinatal conditions8.29.8 Low birthweight5.96.6 Nutritional deficiencies1.53.1 Non-Communicable Diseases39.434.2 Cancers5.62.1 Diabetes mellitus1.20.8 Neuropsychiatry1.810.1 Cardio-vascular diseases20.720.2 Injuries7.89.7 Source: Mathers, Lopez & Murray, Burden of Disease Volume, 2006.

3. © 2006 POPULATION REFERENCE BUREAU Age Pyramid - 2000 35,093,285 Ages 15-49 33,127,740 Ages 15-49

4. © 2006 POPULATION REFERENCE BUREAU Age Pyramid – 2025 62,386,844 Ages 15-49 58,998,903 Ages 15-49

5. © 2006 POPULATION REFERENCE BUREAU Family Planning Trends: 1990 - 2007 Source:Pakistan Demographic & Health Survey (1990-91) Pakistan Demographic & Health Survey (2006-07 Family Planning1990-912006-07 Total Fertility Rate Urban Rural 5.4 4.9 5.6 4.1 3.3 4.5 Contraceptive Prevalence Rate (%) Ever Used Currently Using 20.7 11.8 48.7 29.6 Method Used (%) Female sterilization Condom Oral Pills Injectables Others 3.5 2.7 0.7 0.8 4.1 8.2 6.8 2.1 2.3 10.2

6. © 2006 POPULATION REFERENCE BUREAU Child Health Trends: 1990 - 2007 1.At 12 months (BCG, measles and three doses of DPT and polio) 2.Birth to 5 years to a health provider or facility Source:Pakistan Demographic & Health Survey (1990-91) Pakistan Demographic & Health Survey (2006-07) Child Health1990-912006-07 Neonatal Mortality Rate51.454 Infant Mortality Rate90.578 Immunization Status 1 21.847.3 Health Seeking Behavior 2 Acute Respiratory Infections66.469.3 Fever64.865.8 Diarrhea48.354.5

7. © 2006 POPULATION REFERENCE BUREAU Maternal Health Trends: 1990 - 2007 1.At least once by a health professional 2.Various sources (WHO, National Institute Population Studies) Source:Pakistan Demographic & Health Survey (1990-91) Pakistan Demographic & Health Survey (2006-07 Maternal Health1990-912006-07 Tetanus Toxoid Immunization23.358.3 Antenatal care visit 1 30.460.9 Delivery at a Health Facility13.434.2 Postnatal Care-21.7 Maternal Mortality Ratio 2 350320

8. © 2006 POPULATION REFERENCE BUREAU Age Pyramid - 2000 16,914,726 Ages 35-74 16,872,637 Ages 35-74

9. © 2006 POPULATION REFERENCE BUREAU Age Pyramid - 2025 38,481,889 Ages 35-74 37,383,943 Ages 35-74

10. © 2006 POPULATION REFERENCE BUREAU Imploding Health Care Needs: Non- Communicable Diseases and Injuries Very high mortality - a quarter of total deaths Rapidly rising morbidity: One in three adults over the age of 45 suffers from hypertension Prevalence of diabetes – 10% Tobacco Consumption – 40% of men; 12.5% women Cancers: Breast, lung and oral cavity Hospital visits: 25% are related to injuries

11. © 2006 POPULATION REFERENCE BUREAU Health Delivery System Integrated Rural Health Complex Basic Health Units Rural Health Centers District Headquarters Hospital Tertiary Hospitals Population Served Referral Centers 100,000 – 300,000 25,000 – 50, 000 5,000 – 10,000 Health Care Providers Specialists, Doctors, Nurses, Paramedical Staff Doctors, Nurses, Paramedical Staff Paramedical Staff

12. © 2006 POPULATION REFERENCE BUREAU Meeting United Nations Standards for Safe Motherhood ; Multan District, 2003. United Nations Process Indicator Recommended Level Multan District 1 Multan District 2 Availability of Emergency Obstetric Care Comprehensive Facility (One) 3 34 Basic Facility (Four) 3 80 Proportion of all births in Emergency Obstetric facilities> 15%5.50%10.30% Met need100%14.90%23.30% Cesarean deliveries as a proportion of all births5-15%0.08%2.40% Case fatality rate<1%50%13.50% 1.Excludes tertiary hospital 2.Includes tertiary hospital 3.Per 500,000 population Fikree FF, Mir AM and ul-Haq I. She may reach a facility but will still die! An analysis of quality of public sector maternal health services, District Multan, Pakistan. Journal of Pakistan Medical Association 2006; 56(4): 156-163

13. © 2006 POPULATION REFERENCE BUREAU Health Systems Constraints: Infrastructure and Resources Infrastructure: Physical buildings Water, electricity and disposal/incineration Human Resources: Skilled Health Care Providers Training institutions Retention Equipment & Supplies: At Basic Facilities Secondary Level Facilities

14. © 2006 POPULATION REFERENCE BUREAU Conclusions High and growing burden of disease Inadequate Health Care Services to meet current and future growing demands Broader Question: Where to focus attention/investment? Social Needs – education, health, employment, justice