Moreover, BISP also complements SBP's and the government's goal to increase financial inclusion in the country. Monthly stipends to over 90 percent of BISP beneficiaries are directly deposited into "BISP Cards," which function as debit cards; the beneficiaries can withdraw the funds through any ATM machine. The government, in partnership with private sector stakeholders, is currently working on incorporating a biometric verification system into this process, which will make it easier for the beneficiaries to withdraw funds.
Meanwhile, recognising the role played by lack of education in perpetuating the cycle of poverty, BISP launched a pilot programme, Waseela-e-Taleem, in 2012 to encourage BISP beneficiaries to send their children aged 5-12 years to schools. It involves the government paying a cash stipend of Rs 750 per child per quarter to BISP-eligible families; the family is responsible for enrolling their offspring in schools and then ensuring that the children maintain an attendance level of 75 percent during the school year. The program was subsequently extended, and currently around 1.1 million children are enrolled in primary schools under its umbrella. Many BISP beneficiaries have also availed other state-funded initiatives, like microfinance and interest-free loan schemes, technical education courses etc.
Microfinance: As a result of increasing outreach efforts of microfinance providers and an enabling policy framework provided by SBP, the microfinance industry's gross portfolio has been on a rising trajectory, as shown in (Table 7.5.1), supplementing other poverty alleviation measures.
========================================================
Table 7.5.1: Key Microfinance Indicators
========================================================
FY15 FY16
========================================================
Gross loan portfolio (Billion Rs) 45.6 72.9
Deposits (Billion Rs) 52.0 87.0
No of borrowers (in Million) 1.3 1.7
No of depositors (in Million) 11.6 12.8
Assets (Billion Rs) 82.8 133.3
========================================================
Source: State Bank of Pakistan
Philanthropy: The third reason could be the role played by the private sector's philanthropy efforts. Corporate philanthropy efforts have increased manifold during the past decade or so.33 Though most of these activities generally tend to be narrowly focused (both in terms of their target population and active duration), they are also a means of sustenance for the poor, instead of being a sustainable route away from poverty. The obvious exceptions to this phenomenon are full-time charity organisations like the Edhi Foundation, Chhipa Welfare Association, Saylani Welfare Trust and others, which operate round the clock and serve millions of people by providing free food, and operating free orphanages, clinics and dispensaries, and rehabilitation programs for drug addicts.
Income inequality: While the positive effects of these poverty alleviation programs are visible in terms of the reduction in headcount poverty, these have yet to reveal their full impact on income inequality in Pakistan. In fact, income inequality has risen in the country in overall terms. In 2004-05, the average monthly income earned by the richest 20 percent of households in the country was 2.9 times that earned by the poorest 20 percent; by 2013-14, this difference had increased to 3.2 times. Moreover, at the national level, the monthly income of the poorest 20 percent of households had risen the least (in CAGR terms) during the 10-year period, while the income of the highest 20 percent earners had risen the most (Figure 7.5).34
On the one hand, the absolute improvement in incomes across the bottom two quintiles complements other data that has shown an overall declining trend in poverty in the country. That said, the improvement in the livelihood of the poorest of the poor is occurring at a very slow pace as compared to the rest of the population (Figure 7.5). If this trend continues, it will further widen the income gap with potentially serious consequences for the social fabric of the country.
Official data also shows inequality to be higher in urban as opposed to rural areas; however, inequality is rising at a faster pace in rural areas as opposed to urban areas. In 2003-04, the top 20 percent households earned 3.1 times the average monthly income of the lowest 20 percent of households in urban areas; this ratio had risen to 3.3 times by 2014-15. For rural areas, the imbalance increased from 2.3 to 2.8 times during this period.
Using this income disparity on provincial data also presents some interesting results: income inequality increased in Punjab and Balochistan during 2004-05 and 2013-14, while it actually declined in Sindh and KP.35 In case of Sindh, the decline appeared to come entirely from urban areas, as inequality had risen in the province's rural areas. For KP, the reverse was true, as inequality in its rural areas had decreased by 24.9 percent in relative terms, and increased by 5.1 percent in its urban areas. In Punjab's case, income inequality rose in both urban and rural areas, with the level of inequality in its urban areas being the highest among all provinces as well as at the national level.36
More importantly, these differing provincial income-inequality patterns highlight four different growth stories and development levels within the country.
This has important implications for policy design and implementation, and calls for a multi-pronged approach to: increase employment opportunities for youth in rural areas; improve the targeting of poverty reduction initiatives; and develop a national vision, which recognises the regional differences in poverty patterns to lift masses out of poverty.
7.4 Social services
7.4.1 Healthcare
The trend in basic health indicators for Pakistan has been on a positive trajectory for the past couple of decades. However, the pace of improvement and the health outcomes leaves much to be desired, when compared with the progress made by regional peers. As shown in Table 7.3, Pakistan currently has one of the lowest life expectancy ratios, along with a relatively high level of maternal mortality ratio. Pakistan is one of three remaining countries with endemic polio, and is the sixth highest with the burden of tuberculosis. Occurrence of neonatal, infant and under-5 mortality rates is relatively high in the region due to malnutrition, diarrhoea, acute respiratory illness and other communicable and vaccine preventable diseases.
=============================================================
Table 7.3: Comparison of Key Health Indicators across Asian
Countries (2014)
=============================================================
Life Infant Maternal Health
Expectancy Mortality Mortality Expenditure
Rate Ratio as % of GDP
=============================================================
Bangladesh 72 32 188 0.8
China 76 10 28 3.1
India 68 39 181 1.4
Indonesia 69 24 133 1.1
Malaysia 75 6 41 2.3
Nepal 70 31 275 2.3
Pakistan 66 67 184 0.9
Philippines 68 23 117 1.6
Sri Lanka 75 9 31 2.6
Thailand 74 11 21 5.6
=============================================================
Source: World Development Indicators, World Bank
Importantly, Pakistan has fared quite poorly in terms of most health-related targets that it had set under the MDGs (Table 7.4). For instance, the under-5 mortality rate is still much higher than the target of 52 deaths per 1,000 live births set under the MDG. These slippages represent: (i) weaknesses in public health service delivery mechanisms, particularly in (but not limited to) rural areas; (ii) poverty, along with high out-of-pocket expenditure on healthcare; (iii) persistence of high risk factors, like lack of proper sanitation and clean water; (iv) dearth of skilled birth attendants; (v) cultural setbacks that limit women's access to proper healthcare; and (vi) limited private sector participation in rural areas, and in large-scale programs (like polio/malaria eradication campaigns).
=======================================================================
Table 7.4: Health-related MDGs
=======================================================================
Actual* Target
=======================================================================
Goal 4: Reduce child mortality
-----------------------------------------------------------------------
Under 5 mortality rate
(deaths per 1,000 live births)2 85.5 52
Infant mortality rate
(deaths per 1,000 live births)3 66 40
Proportion of fully immunized
children 12-23 months1 82 >90
Proportion of under 1 year children
immunized against measles1 83 >90
Proportion of children under 5 who
suffered from diarrhoea in
the last 30 days ( percent)1 9 <10
Lady health worker's coverage
(percent of target population)4 83 100
-----------------------------------------------------------------------
Goal 5: Improve maternal health
-----------------------------------------------------------------------
Maternal mortality ratio2 170 140
Proportion of births attended
by skilled birth attendants1 58 >90
Contraceptive prevalence rate2 35.4 55
Total fertility rate4 3.8 2.1
Proportion of women 15-49 who had given
birth during last 3 years and made at least one
antenatal consultation1 73 100
-----------------------------------------------------------------------
Goal 6: Combat HIV/AIDS, malaria and other diseases
-----------------------------------------------------------------------
Baseline
reduced by
-----------------------------------------------------------------------
HIV prevalence among 15-49 year old pregnant women4 0.041 50%
Proportion of population in malaria risk areas
using effective prevention and treatment measures4 40 75
Incidence of TB/100,0002 275 45
TB cases detected and cured under DOTS4 91 85
=======================================================================
Source: 1: PSLM 2014-15; 2: UN MDG Progress Snapshot 2015 (2013 data); 3:
Economic Survey of Pakistan 2015-16; 4:
Pakistan MDG Progress Report 2013, Ministry of Planning
*-- latest available data
That said, it must also be acknowledged that attempts to improve healthcare indicators over the past few years met with lower than expected success because of the direct increase in intensity of terrorist attacks on health teams; floods in many districts; and internal population displacement.37 This is the major reason why the performance of Khyber Pakhtunkhwa, FATA, Balochistan and rural areas of the country has been worse.
Budgetary constraints Allocation of public funds for healthcare has remained low over the years. The government is spending only 0.7 percent of GDP on healthcare,38 which is strikingly low compared to the World Health Organization's recommendation of 5 percent, and also in view of how much other Asian economies are spending on health (Figure 7.6).
In the past, this low level of spending on healthcare represented stretched federal budgets: governments had been bogged down with unavoidable expenses like debt servicing, defence, and running of government, which left little room for social spending. With the promulgation of the 18th constitutional amendment, health has become a provincial subject. Responsibility now falls on provincial governments to formulate policy, mobilise resources, and streamline the delivery mechanism. As it turned out, the provinces have been unable to shore up healthcare spending.
Growing role of private sector and under-spending on healthcare The poor state of public facilities has contributed to an increase in the private sector's role in the provision of service delivery. Over 70 percent of Pakistan's population now consults private healthcare providers, with only 20 percent relying on public services.39,40 A low penetration of public healthcare facilities means that the bulk (61 percent) of expenditures on healthcare is being met via private funding. Since contributions from health insurance and social security are abysmally low, households are forced to use their own resources to pay for healthcare. These so-called out-of-pocket expenditures constitute 88 percent of private healthcare expenditures in Pakistan41 - quite typical for a South Asian country (Figure 7.7). Similar to other countries in the region, low income earners in Pakistan either tend to completely avoid proper healthcare services, or under spend. Furthermore, private facilities are available mostly in urban areas, with the rural population being largely been left out.
Poor sanitation Lack of access to safe drinking water and sanitation facilities and poor hygiene are associated with skin diseases, acute respiratory infections, and diarrheal diseases, which remain the leading causes of childhood deaths in Pakistan. The absence of a proper solid waste disposal system in the country and the huge amount of uncollected waste are immensely hazardous to public health because these become the breeding ground for mosquitoes and flies, which transmit malaria and cholera. In Pakistan, 21 percent of households have no toilet facility at all; this problem is more serious in rural areas where 31.5 percent households lack this access.42 Moreover, 30 percent of households use a non-improved toilet facility.43,44 The situation for solid waste management is also grim. Only 50 percent of garbage is lifted from the cities and is taken to informal dumping sites.45 The system for the disposal of hospital waste exists only partially in Karachi and Lahore. As for clean drinking water, only 20 percent of rural households have access to piped water; most of the households rely on tube-wells, boreholes or hand pumps. 46 Importantly, only 20 percent of the urban and 1.5 percent of the rural households use appropriate measures to clean drinking water.47
Inadequate public facilities in populous rural areas
The Eleventh Five Year Plan (2013-18) notes: "The present healthcare system is inadequate since basic medical facilities are non-existent, especially in the rural areas. All tiers lack a proper referral system. The first level is under-utilised, while the secondary and tertiary are over burdened. There are Mother and Child Health Centers (MCHC) and Civil Dispensaries (CDs)... These facilities are under staffed and improperly equipped." Health conditions are much worse in rural areas, where 61 percent of Pakistan's population resides.48 Not only are vulnerabilities and risks to health high in these areas (because of poor sanitation and lack of clean water), the delivery mechanism of primary and tertiary healthcare is also in dilapidated shape.49 The most important problem is geographical accessibility: the average distance of a village from a basic health unit (BHU) in Pakistan is 15 km, which is quite high. Importantly, for 12 percent of the population, a BHU is located at a distance of 26 km and above from the settlement; this ratio is highest for Balochistan, where there is no BHU at a distance of 26 km for 44 percent of the population.50
No wonder, this large distance is the most commonly cited reason by rural households for not visiting a public facility.51 Even where infrastructure exists, the availability of healthcare professionals is not ensured (especially females), and weak monitoring and absenteeism further disrupt service delivery in these areas. Furthermore, medical equipment and medicines are not replenished regularly. On top of this, lack of proper sanitization of medical equipment jeopardises the patients' well being. Therefore, it is not surprising that only 55 percent of the country's rural population is satisfied with public basic health facilities.52
Unskilled personnel The Punjab Healthcare Commission (PHC) has made startling revelations in the document containing strategy against unregistered practitioners in the province. Most of them are practicing without a formal degree in medicine, under the cover of either a drug store or using a fictitious doctor's name, and charging a nominal fee. Because of the high cost of formal private healthcare, households often consult these unskilled personnel for the treatment of minor ailments (anecdotal evidence suggests that formal private facilities are consulted only when these ailments are mishandled).
Cultural constraints for women's healthcare The state of women's healthcare in Pakistan leaves much to be desired, with rural women at a more disadvantageous position than urban women. Low access of women to healthcare facilities is attributed primarily to their financial dependence on men, as well as cultural factors that restrict women's mobility. Even where the demand exists, the short supply of female healthcare facilities restricts the access. For instance, antenatal care must come from a skilled provider to monitor pregnancy and reduce the risk of morbidity for the mother during pregnancy and delivery. However, due to lack of female gynaecologists or women medical officers in health centres, this care is denied to many women.
Less than half of deliveries that took place between 2009 and 2013 were assisted by skilled providers (including doctor, nurse, midwife, and lady health visitor). The situation in rural areas is much concerning: of the 638 rural health centres surveyed in 2012, 276 (43 percent) were without a woman medical officer, whereas 222 centres had only one.53 Around 55 percent of deliveries in rural areas were attended by traditional birth attendants and relatives.54 Statistics for tehsil headquarters and civil hospitals are even more surprising: of the total 280 such hospitals surveyed, 206 were without a gynaecologist.
In overall terms, the most pressing concern in Pakistan's healthcare system is the insufficient availability of public services, which low-income earners cannot substitute with costly private facilities. Vulnerabilities to health problems are also high due to poor sanitation and hygiene practices in the country. The situation in rural areas is particularly challenging, and requires build-up of public infrastructure.
7.4.2 Education At an individual level, education is a fundamental human right enshrined under the UN Declaration of Human Rights as well as Article 25-A of Pakistan's constitution.55 At the macro level, it is a key ingredient in reducing entrenched poverty, cultivating a skilled labour force, and fostering the trend of innovation and entrepreneurship. The resultant increase in labour productivity will have positive spillover for the country's competitiveness and business environment, and help improve its perception as an attractive destination for long-term investment.
Box 7.6: Education and the Economy's Competitiveness An educated labour force is paramount for an economy to stay competitive in the current global environment. There are principally three channels through which education impacts labour force productivity.56 First, it enhances workers' collective ability to carry out tasks more rapidly. Second, workers are more likely to be well-versed with new technology and products (and thus use them efficiently in their jobs), if they have pursued secondary and tertiary education. They are also more likely to keep up with new information and trends emerging in their respective fields. And third, an educated work force is likely to be more creative in dealing with challenges; this will increase chances that the country as a whole will be able to generate new products and technologies.
The Global Competitiveness Index 2016-17 ranked Pakistan at 122 out of 138 countries, behind regional countries like Thailand (34), Philippines (57), India (39), and Vietnam (60). Its poor health and education indicators played a major role in this dismal performance; out of 138 economies, the country was ranked 134 in terms of ratio of female to male workers, and at 134 in trade protectionism (ie tariff duties). Granted that Pakistan's ranking has improved seven places over three years, its GCI score has remained almost static. A country's GCI score is based on 12 characteristics (or "pillars") that are divided across three main categories. Of these 12 pillars, two are directly related to education (primary education, and higher education and training), whereas others (like labour market efficiency, technological readiness and innovation) are indirectly related. Pakistan's rank (out of 138 countries) in key education pillars is shown in Table 7.6.1. These indicators basically relate to enrolment, access to educational facilities, and quality of education and school infrastructure.
==========================================================
Table 7.6.1: Global Competitiveness Report 2016-17
==========================================================
Education indicators Pakistan's rank*
==========================================================
Quality of primary education 115
Net primary school enrolment 133
Gross secondary school enrolment 124
Gross tertiary education enrolment 115
Quality of the education system 71
Quality of math and science education 98
Quality of management schools 84
Internet access in schools 105
Availability of specialized training services 97
Extent of staff training 120
==========================================================
*: Rank is out of 138 countries. Source: World Economic Forum
Despite the obvious importance of education for the country's progress, the sector remains neglected.
It was definitely unfortunate - though perhaps not surprising - that Pakistan failed to achieve the education-related MDG targets. These included: (i) achieving universal primary enrolment (67 percent, against the target of 100 percent); (ii) student retention rate; (iii) ensuring gender parity in primary and secondary education (ratio of girls to boys of 0.88, against the targeted 1.0); and (iv) increasing the adult literacy rate (60.7 percent by 2014-15,57 against the target of 88 percent).
A regional comparison also shows that Pakistan lags far behind other South Asian countries in terms of education indicators (Table 7.5). It has the second-lowest literacy rate, and the lowest primary school completion rate for females. Besides, as percentage of GDP, the country has also been devoting significantly less resources to education.
===================================================================================
Table 7.5: Regional Comparison of Education Indicators*
===================================================================================
Primary completion rate Public spending Pupil teacher
on education ratio (primary)
% of GDP
Adult literacy rate Male Female (2014) (2014)
===================================================================================
Bangladesh 59.7 (2013) 69 79 2.0 n.a
Bhutan 52.8 (2005) 91 103 6.0 27
India 69.3 (2011) 94 99 3.8 32
Maldives 98.4 (2006) n.a n.a 5.2 12
Nepal 59.6 (2011) 99 109 4.7 24
Pakistan1 57.0 (2015) 80 67 2.2 47
Sri Lanka 91.2 (2010) 99 97 1.7 24
===================================================================================
Source: World Development Indicators 1PSLM 2014-15 for adult literacy rate and Economic Survey of Pakistan ( 2015-16) for education spending.
n.a: Not available; * Figures for the latest available year (in WDI database) have been taken.
In relative terms, only Bangladesh and Sri Lanka spent lower than Pakistan on education as percentage of GDP in 2014; in Sri Lanka's case, the country has already achieved sufficient progress in the area (as seen by its near-perfect literacy and school completion rates, thus negating the need for it to spend as much on education as its neighbours).
Meanwhile, within Pakistan, a provincial comparison shows that not much has changed from FY10. Punjab leads the rest of the provinces in terms of literacy rate as well as public spending on education, with Balochistan faring the worst in these indicators (Figure 7.8).
Enrolment A comparison of provinces' primary school net enrolment ratios58 (NER) in 2004-05 and in 2014-15 yields some interesting results; the most striking of these is the tremendous amount of progress made by Khyber Pakhtunkhwa during the period. In 2004-05, KP had the third-lowest NER at the primary level (behind Punjab and Sindh); by 2014-15, its NER (at 71 percent) had risen to the highest among all provinces, and also beat the national average (Figure 7.9).
Having said that, it is critical to sustain the progress made in this area, as data also shows that NER scores drop drastically for all provinces when it comes to middle schools. In other words, after completing primary education, not nearly enough children are being enrolled in middle schools (ie classes 6-8). One major reason for this decline is the fact that there are simply not enough middle schools to cater to the children graduating from primary schools: for every three primary schools in the country (both public and private), there is barely one middle school.59
Moreover, 87 percent of all primary schools in the country are in the public sector, with the remaining 13 percent in the private sector. But this ratio reverses for middle schools, 38 percent of which are under public domain, with the majority (ie, 62 percent) coming under the private sector.
The above discussion basically shows that not only is there a dearth of middle schools in the country, but also that the gap left by the state in ensuring free and adequate middle school education for children is being filled by the private sector. Naturally, the private sector cannot be expected to deliver any service for free. Yet, the rate at which fees charged by private educational institutions has been rising in the country over the past few years, has been noticeable, and it might have resulted in many families simply being priced out of the system.
Box 7.7: Cost of Schooling Pakistan has been taking steps to improve the quality of education by encouraging the private sector to come up with quality education, strong curriculum, well-trained and qualified teachers, and improved facilities. However, perhaps because of this, the cost of schooling has almost doubled since 2008. Besides, from FY09 to April FY16, the YoY change in the education component of CPI has been greater than the change in overall CPI for almost the entire period (with the exception of FY10, when oil prices remained above US $100 per barrel), as shown in (Figure 7.7.1).60 Though the big divergence in the change in the education index and overall CPI from April 2014 onwards can partly be explained by falling global oil prices,61 the fact remains that education costs (as measured by the education component of CPI) have been increasing by over 10 percent YoY from April 2014 till June 2015.62
And while per capita income has also been rising in the country, it has not been increasing at the same pace as private schools' fees. This can be problematic for families who are unable to keep up with rising schooling costs, with parents forced to pull out their children from schools, in the most extreme cases.
Lower income groups also tend to be affected much more by inflation as compared to higher income groups; this is also true for educational expenses. As mentioned before, lack of adequate public educational facilities has led to increasing role of private sector in education. Yet, only a minority of the population of Pakistan can afford private schooling. A majority of students in Pakistan, ie 63 percent, are enrolled in public sector education.
It can also be argued that rising schooling costs can imply that the private sector is hiring additional teachers to cater to the rise in enrolment. However, this appears to be not the case: the student-teacher ratio at the primary level has actually risen from 37.5 in 2005 to 46.5 in 2015. Government college fees, on the other hand, have largely been stable throughout these years, with slight increases.
Other factors contributing to the rise in the education component of CPI are government medical college fees, coaching fees, school uniform prices and textbook prices (between 2008 and 2016, uniform prices have more than doubled). Even though prices have been increasing on a monthly basis, the demand for school uniform is mostly once a year only (before the start of school). Though this can be partially explained by higher demand for uniforms (in line with the increase in school enrolment) and a general rise in the cost of doing business in the country, these factors alone cannot justify the magnitude of the increase in uniform prices.
Another burdensome expense for families is textbook and stationery prices; prices for both of these have also more than doubled from July 2008 to April 2016. Publication houses have explained this increase by citing rising printing cost and paper prices, as well as a shortage of paper.
Female enrolment An unfortunate but expected result of these dynamics is that Pakistan has one of the largest number of out-of-school children in the world; moreover, this number has been increasing lately.63 And the problem appears more worrisome when looked through the prism of gender disparity. Female enrolment continues to lag behind that for males across all schooling levels, as shown in (Table 7.6). Cultural factors as well as an adverse law and order situation (which discourage parents from sending girls to schools) are both likely in play here. Militants have been known to target girls' schools, adversely affecting the morale of parents and students who desire to pursue education. In relative terms, Punjab and Sindh seem to do well in ensuring that girls, once they are through primary education, continue through to secondary education. This can be seen from the relatively similar enrolment rates for girls across multiple schooling levels. That said, there appears to be big drop in female enrolment in KP after the primary level, mainly owing to unstable law and order situation.
================================================================
Table 7.6: Female Enrolment (percent o total enrolment), 2014-15
================================================================
Primary Middle Upper
secondary
================================================================
Punjab 47 46 47
Sindh 42 44 41
KP 40 34 27
Balochistan 39 36 35
Overall 44 43 41
================================================================
Source: Pakistan Education Statistics 2014-15, National Education Management System.
Expenditure Despite some modest improvement over the past 15 years, Pakistan is among those regional countries that spend the lowest on education as percentage of GDP (Figure 7.10). While the government has officially targeted increasing public education spending to 4 percent of GDP by 2018, it looks unlikely that it will be able to meet this target, as it will involve the country having to virtually double its budgetary allocation for education, from this fiscal year's level of Rs 790 billion.
That said, we think it is also important to discuss if merely allocating more resources to the sector will improve Pakistan's education indicators. To put FY17's budgetary allocation for education of Rs 790 billion (around US $7.5 billion) into perspective, the amount is comparable with the entire foreign exchange assistance from official sources expected by the country in the year.64
Moreover, there is widespread variation in the amount of resources that are allocated to districts within each province. Even after checking for the size of the student population, tremendous variations can be seen. For instance, in Punjab, districts like Chakwal, Bahawalpur and Rawalpindi each spent over Rs 18,000 per student in 2014-15, against less than Rs 13,000 in districts like Chinniot and Bhakkar.65 Similarly, three of the top performing districts in KP received 23 percent of the total budget, while four of the poorest performing districts together received only 4.0 percent, according to a study.66 This misallocation of already meagre resources reflects the lack of capacity to conduct a detailed, technical assessment of the situation.
7.5 The way forward The agenda for social development is large and the discussion here unpacks some deeper transformation channels, as we move forward:
* First, there is a need for a common vision on the existence of weaknesses in, and solutions for social and economic development. Such a national vision exists in the form of Pakistan Vision 2025, which puts developing human and social capital as the first pillar. It seeks a society based on fairness and equity, and inclusive growth by focusing on reducing the incidence of poverty and income distribution gaps. The main hurdle in implementing such a vision is that it has to be a shared one; creating such a shared-vision is a major task for a nation with institutional weaknesses.
-- Second, the road from envisioning to implementation is a long one. Indeed, whether it is education and health or the monitoring of large projects, the capability of the state to implement policies for social and economic change is an important challenge. Typically, decision-making involves multiple layers leading into several potential sources of failure within an organization. This means that in order to improve public decision-making, the institutional design where these decisions are made - be it federal, provincial or district levels, or at the state-run enterprise level - needs redesigning and modernization.
-- Finally, regional comparisons of various indices show that social development requirements across the provinces are neither equal, nor do the regions have similar income distributions. This means that our shared vision for social change has the difficult task of: (i) recognizing the varied pace of regional development; (ii) coming out with multiple policies required to tackle multi- dimensional poverty; (iii) developing tools to close regional income gaps; and (iv) designing channels for state delivery of public services crafted for regional needs. This level of precision policymaking would be a tall order for any government in the midst of a war on terror.
A major feature of social challenges that Pakistan faces is the disproportionate effect of compromised public services on low-income groups. This segment is at a disadvantaged position because it is bound to depend on public services; private facilities are not affordable for this segment. From this perspective, some measures become predominantly important for human development going forward: continue, and increase, the targeted programs for poverty alleviation (like BISP); build infrastructure for public service delivery all across the country; seriously work on HR planning and career management of healthcare and education practitioners; and improve monitoring of public spending and programmes. However, at its core, the prime objective should be to lift incomes of the poorest and reduce the gap between the rich and the poor. Inclusive growth provides a sustainable way of achieving this.
In overall terms, the task of social uplift remains challenging, given the existing gaps in the services and key challenges that the government confronted over the past few years that have adversely affected social indicators (including the burgeoning cost of war on terror, high inflation, infrastructure issues, and slowdown of economic growth). However, now, with the improved security situation and broad-based economic recovery, a strong commitment on the part of the government and renewed focus on development can improve the social indicators of the country.
(Concluded)
33. Donations by public listed companies amounted to Rs 4.8 billion in the year 2013, against Rs 228 million in 2000 (source: Corporate Philanthropy in Pakistan 2013, Pakistan Center for Philanthropy).
34. The first quintile refers to the poorest 20 percent of earning households, whereas the fifth quintile refers to the highest 20 percent.
35. In relative terms, the ratio of monthly incomes of top 20 percent earners to that of lowest 20 percent earners declined 12.8 percent in Sindh and 20.7 percent in KP during 2004-05 to 2014-15. In the same period, the ratio increased by 22.0 percent for Punjab and 36.2 percent for Balochistan (source: Household Integrated Economic Surveys 2004-05, 2013-14).
36. The richest 20 percent households in urban areas of Punjab were earning 4.1 times what the lowest 20 percent households were earning in 2013-14.
37. Source: Pakistan Millennium Development Goals 2013, Planning Commission of Pakistan.
38. In 2014-15 (source: Economic Survey of Pakistan 2015-16).
39. Source: Pakistan Standard of Living Standards Measurement Survey 2014-15.
40. Certainly, households in areas where private sector has not set its foot yet, are still relying on public facilities. In Punjab and Sindh, consultation with public hospitals and dispensaries accounted for only 17 and 20 percent respectively, whereas in KP and Balochistan, this ratio stood at 28 percent.
41. Source: Pakistan National Health Accounts 2011-12, Pakistan Bureau of Statistics.
42. Source: Pakistan Demographic and Health Survey 2012-13, National Institute of Policy Studies, Islamabad, and USAID.
43. WHO and UNICEF define improved toilet as the one used only by household members (not shared with another household), and one that separates waste from human contact.
44. Of these, only 6 percent use a flush toilet that is not drained to a sewer or septic tank/pit latrine, and 2 percent use pit latrines without slabs or have open pits.
45. Source: National Sanitation Policy, Government of Pakistan.
46. Source: Pakistan Demographic and Health Survey 2012-13, National Institute of Policy Studies, Islamabad, and USAID.
47. Appropriate water treatment methods include boiling, filtering, and solar disinfecting.
48. For instance, the infant mortality rate in urban areas is 63 per 1,000 live births, whereas the same in rural areas is 88. Similarly, the under-5 mortality rate is 74 deaths per 1,000 live births in urban areas, while the same in rural areas is 106.
49. Pakistan's public healthcare delivery system has three tiers: (i) First level care facilities include Basic Health Units and Rural health Centres; (ii) Tehsil or Taluka Headquarter Hospitals and District Headquarters Hospitals, and (iii) Teaching Hospitals (attached to medical colleges) which are equipped with all kinds of health services.
50. Source: Pakistan Mouza Statistics, 2008.
51. When asked for the reason for not visiting a government facility first for diarrhea treatment, 26 percent of rural households responded 'too far away'; 19 percent responded 'no government facility'; 13 percent responded 'not enough medicines'; and 10 percent responded 'doctor never available' (source: Pakistan Social and Living Standards Measurement Survey 2014-15). Similarly, 47 percent women in rural areas, who reported that they had serious problems in accessing health care for themselves when they got sick, cited distance to health facility as a major constraint. Half of these women also mentioned management of transport for not accessing health care facilities (source: Pakistan Demographic and Health Survey, 2012-13).
52. Source: Pakistan Social and Living Standards Measurement Survey 2014-15. Satisfaction level is the highest in rural areas of Punjab (65 percent) and lowest in rural areas of Balochistan (41 percent).
53. Source: Health Facility Assessment - Pakistan National Report, prepared by Technical Resource Facility, as part of the implementation of the monitoring and evaluation framework of the National Maternal Newborn and Child Health Program (NMCHP).
54. Source: Pakistan Demographic and Health Survey 2012-13, National Institute of Policy Studies, Islamabad and USAID.
55. Article 25-A of the Pakistan constitution states that "the State shall provide free and compulsory education to all children of the age of five to sixteen years in such manner as may be determined by law".
56. Source: World Economic Forum.
57. Source: Pakistan Labor Force Survey 2014-15, National Education Management Information System.
58. UNESCO defines net enrolment ratio as the "enrolment of the official age-group for a given level of education expressed as a percentage of the corresponding population". Basically, it expresses the number of pupils enrolled who are of the official age-group for a given level of education, as a percentage of the population for the same age-group (source: http://unesco.org.pk/education/life/nfer_library/Reports/3-32.pdf).
59. Source: Pakistan Education Statistics 2014-15, National Education Management System.
60. The average price of Saudi Arabia Light crude was US $111.2 per barrel in FY11 (source: Bloomberg).
61. Fuel prices (along with those of housing, water, electricity and gas) have the second-highest weightage in the CPI basket (29.41 percent). This is much higher than education's weightage of 3.94 percent.
62. Representatives of private schools associations have often explained the hefty fee increases (over the past year) by referring to additional security arrangements that schools have had to put in place following the APS Peshawar attack in December 2014.
63. From 2009 to 2014, the number of out-of-school children at the primary level actually increased 7.0 percent to over 5.6 million (source: World Development Indicators/Haver Analytics).
64. Source: FY17 budget documents. Official FX assistance is in the form of loans and grants by individual countries and multilateral agencies like the World Bank and ADB.
65. Source: Public Financing of Education in Pakistan 2010-11 to 2015-16, Institute of Social and Policy Sciences.
66. Malik, Rabea (IDEAS Pakistan) & Rose, Pauline (University of Cambridge), "Financing Education in Pakistan: Opportunities for Action" 2015.
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