Context

Geography and population

Pakistan is a country in southern Asia, bordered by India to the east, Afghanistan and Iran to the west, and China to the north. For thousands of years, its culture has been shaped by the 2,500 kilometer flow of the Indus River. This waterway links two of the nation’s other prominent geographic features: the Himalayan and Karakoram mountain ranges to the north (including the world’s second-highest peak, K2) and, to the south, over a thousand kilometers of coastline along the Arabian Sea.¹

Within this landmass live about 238 million people, making Pakistan the fifth most populous nation on Earth. Even though the country added almost 70 million people to its population between 2000 and 2018, the annual population growth rate decreased from 2.6% to 2.1%.²

Pakistan comprises four major provinces (Balochistan, Khyber Pakhtunkhwa, Punjab, and Sindh), two autonomous territories (Gilgit-Baltistan and Azad Jammu and Kashmir), and one federally administered capital territory (Islamabad Capital Territory) (see Figure 5 below).² Balochistan is situated in the southwestern part of the country, encompassing 43% of Pakistan’s land area, while only comprising about 6% of the population. The most densely populated province is Punjab, which by itself contains just over half (about 53%) of the nation’s entire population.¹

Pakistan has the highest rate of urbanization in South Asia, with over 36% of its population residing in urban areas, up from 22% in 1960.³

Economy

Over the past several decades, Pakistan has experienced steady economic growth. Per capita gross domestic product (GDP) has increased 62% since 1990, increasing from $2,017 to $5,236 (current international $) in 2018.⁶ This growth is all the more impressive in the context of steep population growth, catastrophic natural disasters, and chronic insecurity.

With fertile agricultural lands, natural gas reserves, and rich mineral deposits, Pakistan is endowed with abundant natural resources. The farming sector still accounts for the largest share of the national labor force—42% of the population.¹ Its major agricultural products include sugar cane, wheat, rice, cotton, and fruit.

Services and manufacturing are clustered around densely populated cities and districts, whereas rural and remote regions—such as Balochistan and Khyber Pakhtunkhwa, as well as parts of Sindh and Punjab—have lagged in economic development.

Health care sector

In 2001, the Local Government Ordinance divided sub-provincial government into three levels: districts, tehsils (towns), and unions (villages and neighborhoods).⁴ Health care delivery in Pakistan is organized into a three-tiered system. The following section will look at the roles these levels play in the delivery of health care. The first of these, providing primary care, focuses on curative and preventive services. For this most localized and basic level of medical attention, people visit facilities at the union level of local governance: basic health units and rural health centers.

For maternal and child health, mothers and children may either visit one of these facilities or go to a specialized maternal and child health center. In addition, a network of community lady health workers is also available for various nonemergency maternal and pediatric needs.

The next level is secondary health care, which focuses on providing technical, therapeutic, and diagnostic services, including specialist consultations and much of the nation’s hospital care. This category of service is provided through tehsil hospitals (typically serving catchment areas of approximately 500,000 to 1 million people) and district hospitals (serving somewhat larger areas of about 1 million to 3 million people). Finally, the tertiary level provides specialized inpatient care at major hospitals and relies on referrals from primary and secondary facilities.

This system—diverse and decentralized, and in some ways still under-resourced—has generated some impressive outcomes across a span of indicators related to the health of women of reproductive age. For example, the maternal mortality rate was cut by more than half between 2000 and 2017, with the proportion of mothers’ deaths per 100,000 live births reducing from 387 to 177 over that period.⁷

This achievement reflected improvements in a range of areas. The number of women receiving the internationally prescribed protocol of four or more antenatal care visits increased from 28% in 2011 to 35% in 2018,^8,9 whereas the fertility rate (births per woman) decreased from 4.1 in 2011 to 3.4 in 2018.^8,9

Natural disasters and climate change

Any review of Pakistan’s efforts to address anemia—or virtually any other major health challenge—must take into account the nation’s high level of vulnerability to natural disasters and climate change, which increasingly threaten the communities and infrastructure upon which Pakistanis depend for their health and well-being.

Pakistan experiences frequent earthquakes, especially in its mountainous northern and western regions. A 2005 quake in Azad Jammu and Kashmir and Khyber Pakhtunkhwa left an estimated 75,000 dead and 3.5 million homeless, with almost 600 health facilities destroyed or damaged.⁵

Increasingly, however, the most urgent environmental challenge to public health in Pakistan is the nation’s vulnerability to climate change, resulting in increased floods, droughts, storms, and extreme heat.

The climate across much of Pakistan is shaped by the monsoons that take place from late spring to autumn. In recent years, monsoon rains have become increasingly heavy, a phenomenon directly traced to climate change. Floods—rendered more severe by the rapid deforestation and glacial melting that have occurred in recent decades—affect an estimated 714,000 people each year. A 2010 monsoon flooded one-fifth of the country, killing over 2,000. In 2022, another series of floods took the lives of more than 1,700.⁵

At other times, climate disruptions have resulted not in too much water but too little—as in the droughts of 1999 and 2000, which resulted in crop failure and starvation. Extreme heat, made more urgent by the nation’s southerly latitude poses another major challenge.

Between 1961 and 2007, elevated temperatures from November through February have become more frequent, with the average temperature increase estimated at 0.47 degrees Celsius over this period.⁵ Warming has been more prevalent in the southern regions, which include the megalopolis of Karachi and some of the nation’s other highly populated areas. Punjab, Sindh, and Balochistan each experienced an increase in temperature from 0.91 degrees Celsius to 1.12 degrees Celsius during the winter seasons from 1961 to 2007.⁵

Between 1997 and 2015, Pakistan experienced approximately 7 heat waves per year, totaling 126 heat waves within that time. A 2015 heat wave in Sindh (where Karachi is located), resulted in more than 65,000 people being hospitalized for heat stroke and 1,200 heat-related deaths.⁵