RAWALPINDI, Jan 11: The World Health Organisation (WHO) has estimated that the out-of-pocket health expenditure in Pakistan stands at 71 per cent — the highest in the Eastern Mediterranean region — and a burden for the poor.

The unregulated private sector delivers a high proportion of health services and there is a great discrepancy in the quality of services.

Those who can only afford to pay a little usually get the poorest quality of the services, says a World Health Organisation review on health inequalities in Pakistan.

In rural areas, the very poor women and men avail government services as they can afford only those.

They visit private doctors as a last resort, and sometimes because of a referral made by the government doctor, reveals the report.

With Pakistan experimenting with the outsourcing of public sector health facilities, there is little debate about whether such initiatives are likely to increase inequities.

The Rahim Yar Khan model in which the basic health units are handed over to a non-governmental organisation that has expertise in rural development has demonstrated that it can increase utilisation rates for health facilities, but correcting any inequities is not usually on the agenda of the NGOs, says the report.

Indicators of inequality in health and social status are only a starting point for assessing inequity. The link between women’s status in society and her condition explains why there is high mortality and morbidity in women in Pakistan.

It is associated with delay in access to health services, restrictions on women’s mobility, domestic violence, mental stress emanating from male unemployment, armed conflict and deaths due to armed conflict, and the high workload placed on women.

When customary practices place serious restrictions on women, and they live in a near perpetual state of insecurity, and when lawgivers have no sense of people’s rights, the challenge is to capture these deeply entrenched realities as determinants of the inequities that prevail.

With regard to rural-urban inequalities, rural areas where three-quarters of the people live are poorer and have far fewer health and educational facilities than urban areas. In rural areas, health indicators such as infant mortality and maternal mortality are higher, the report says.

A focus on urban-rural differences is not enough. It is important that inequities within the rural and urban sectors are also highlighted.

For example, nearly 50 per cent of population of Karachi lives in squatter settlements, the report reveals.

Literacy for women is a key to the health of her family, but the gap in gross primary school enrolment for girls (77 per cent) and for boys (94 per cent) is the largest such gender differential in the region. Dropout rates in public primary schools are much higher among girls and increasing compared to those of the boys.

The WHO report says a portrait of the “average” Pakistani woman indicates that she is illiterate and has five children, of whom those under three years old are malnourished. She works 15 hours a day and is anaemic and gives birth to low-weight babies.

Although its position has improved somewhat, the low rank of Pakistan on the gender-related development index (ranked 105 of 136 countries) and the gender empowerment measure (ranked 66 of 75 countries) indicates the extent of gender disparity in Pakistan.