Unequal access to high-quality health care
A crucial impediment to further progress against anemia in Pakistan has been a lack of access to health care, particularly for rural and less-affluent communities.
Some of these barriers to health care access are similar to those mentioned earlier in reference to nutrition: Pakistan has lacked effective systems for implementing and monitoring programs; it has not provided for sufficient integration across various sectors and levels; and it has not invested enough in necessary resources.
The result, as with nutrition, has been a tangle of overlapping and underfunded programs. This has compromised everything from lady health worker coverage in rural areas to the provision of necessary medical supplies.
A major underlying problem is the persistence of profound inequalities in health outcomes and access to care, with significant variability among states, between the relatively affluent and the low-income populations, between the educated and the uneducated, and between urban and rural areas.
Pakistan showed reductions in anemia prevalence across all wealth and education categories, as the figure below indicates. However, the gap between the highest and lowest quintiles of wealth and education grew larger over this period. A similar phenomenon prevailed with regard to the nation's urban-rural split; there was some improvement across the board, but also a widening of previously existing inequalities.
Figure 14. Anemia prevalence among NPW in Pakistan, by wealth quintile, urban/rural residence, and women’s education level (2011–2018)

In some parts of the country, these inequalities come down to such basic matters as topography and road quality. In Balochistan—a relatively poor province and one in which progress against anemia has been especially hard to come by—a major barrier is the lack of access to facilities and trained personnel, which is complicated by the area's mountainous terrain.
These inequalities and implications on access to health care are also illustrated by the LHWP, despite the undeniable contributions of the program to health generally and anemia reduction specifically. In particular, the program struggles to achieve adequate coverage in precisely the areas where its services are most acutely needed—the poorest and most remote communities.
As the figure below illustrates, LHWs are almost as likely to visit households in the top two income quintiles, where their services usually are not urgently required, as they are to check in on the bottom two quintiles, where their attention could determine whether residents receive any meaningful health care at all.
In some of the nation's most disadvantaged jurisdictions (e.g., Khyber Pakhtunkhwa and Balochistan), they are almost twice as likely to visit relatively affluent homes as they are to enter the poorest.
Figure 15. Proportion of Pakistani population visited by lady health workers, by district and wealth quintile
The figure below offers some detail on the specific causes of bottlenecks in LHW coverage. Many of them are related to resource deprivations of some kind, particularly a lack of funding for staffing, training, and equipment.
Figure 16. Evaluation of bottlenecks in the Lady Health Worker Program
Additionally, not all barriers to health care access are physical. A lack of education or awareness of services can also hinder such access, as can long-standing social and cultural assumptions.
Given the close linkage between nutrition and health—especially with regard to anemia prevention—it is important to note that this inequality in health care access extends to the nutrition. Skilled workers are in short supply; and, if lady health workers cannot reach a community, people will commonly rely on family elders for guidance. Unfortunately, such authorities sometimes pass along unhelpful misconceptions about diet and nutrition.
Barriers to women's equality and empowerment
In assessing the challenges Pakistan faces in improving the health of women of reproductive age, it is important to consider the impact of long-standing cultural barriers to gender equality. These have limited women's ability to improve their own health outcomes and pose a range of practical obstacles to the reduction of anemia prevalence.
Across much of Pakistan, men are considered the leader of their family and household, whereas women are expected to focus on taking care of the family and performing household chores. These expectations commonly prevent girls and women from attending school or seeking employment. They also ensure that a high proportion of female labor in Pakistan—whether within the home or on a farm—is unpaid and unaccounted for.
"In our society, there is always a difference between males and females," said one Exemplars study interviewee. "Males are the main decision makers of the family. All rights are for men. More education and motivation is given to males."
Some of the ways in which that imbalance manifests itself in parts of Pakistan include gender-based food discrimination, in which women are given smaller portions or lower-quality food and often eat last.
In some regions, women are discouraged from visiting health facilities on their own. Exemplars respondents cite that the lack of female doctors in Pakistan perpetuates this dynamic, with lingering taboos preventing women and girls from visiting male practitioners.
One very tangible way in which these restrictions compromise female empowerment—and impede efforts to curb anemia among women of reproductive age—is the limitation of family planning coverage. Exemplars respondents from national agencies and nongovernmental organizations expressed disappointment at the continued lack of access to contraceptive measures, a situation that increases the risk of anemia for many Pakistani women.
Exemplars study interviewees noted the salience of Pakistan's urban-rural divide: urban women tend to be better educated and more likely to use contraception. In contrast, in many rural areas, family planning is discouraged and the desire to have male children can lead women to seek additional pregnancies.
Community-level interviewees said cultural stigmas continue to shape attitudes toward the safety and efficacy of contraception, the importance of birth spacing, and other topics related to family planning.
"Yes, when they visit the hospital, the official there guides them about family planning. But according to the norms of this community, people are usually displeased by this," said one Exemplars study respondent from Khyber Pakhtunkhwa. "According to the traditions and norms of our society, there is almost no concept of spacing between pregnancies."
Skepticism toward family planning is not restricted to rural areas. A certain stigma still extends into metropolitan settings as well, potentially limiting contraceptive usage and demand. "In urban areas, people are more aware of the elements of family planning," said one Exemplars study interviewee. "But the decision-making is influenced by a mother-in-law or husband. Many women have to take birth control measures [by] hiding it from their husbands."
Climate vulnerability and impact on healthcare access & food security
Another challenge to Pakistan's efforts to reduce anemia is its vulnerability to natural disasters and disruptions-a condition made substantially more dangerous by climate change, which has already subjected Pakistan to a series of extreme-heat events, droughts, and floods, and will very likely do so with even greater intensity over the years to come.
Several of the factors that have driven that reduction so far—notably increases in access to health infrastructure and improvements in food security—are directly impacted by natural disasters.
On healthcare access, a wide range of Exemplars study respondents cited the effect of extreme weather conditions on infrastructure and mobility. Roads blocked or clogged by excess precipitation can prevent entire communities from reaching health care facilities or performing income-generating work, especially across Pakistan's sizable stretches of mountainous terrain.
When increasingly common (and severe) floods and droughts damage crops, a vicious cycle of poverty and hunger can result as farmers are unable to bring crops to market and families are unable to provide food for their families. Floods and droughts further exacerbate malnutrition as communities are unable to access food for their children and families, both because crops are damaged but also because they are unable to purchase food due to their loss of income. Community-level respondents in the Exemplars study pointed out that this cycle tends to have its heaviest impact on rural and lower-income Pakistanis, making them more vulnerable to starvation and a range of illnesses-including anemia.