Selected correlates of morbidity in Pakistan.

Khan, Zubeda

INTRODUCTION

The study of morbidity from the point of view of demographic analysis refers to the incidence and prevalence of sickness in the population during a certain reference period. Morbidity being the state of condition from which people may return to normal health or, subject to the seriousness of illness, may in some cases die. Though from the point of view of medical discipline any deviation from normal health i.e. a state of complete physical, mental and social well-being, is of direct concern for research. The morbidity statistics for which data have become available for a national level statistical or demographic analysis, refers to inability to perform the usual daily routine, inability to take normal food and requiring bed rest for a specific period of time.

BACKGROUND

According to the 1981 census, the population of Pakistan was 84.25 million, with 44.23 million males and 40.02 million females. Among the four provinces of Pakistan, Punjab had 58.6 percent (Table 1) of the total population, followed by Sindh with 23.5 percent, N.W.F.P. with 12.5 percent, and Balochistan with 5.4 percent. A large proportion of the population is young, 44.5 percent under 15 years of age, (Table 2) statistics which are reflective of a high birth rate and is also at least particularly responsible for keeping the proportion of population in the age bracket of 60 and over to the 7 percent. The literacy ratio, one of the lowest among the developing nations of the Asian region, stands at 26.2 percent, the figure for males being 35 percent and for females 16 percent. There is, as expected, a higher level of literacy in urban as opposed to rural areas. The literacy figures for males and females in urban areas are 55 percent and 35 percent respectively, while in the rural areas only 26 percent of males and 7 percent of females are literate. Table 3 shows the figures for literacy ratio for persons 10 + years by sex, urban/rural residence of Provinces of Pakistan.

In July 1990, the population of Pakistan was estimated at 112 million with a high birth rate of 42.3, comparatively low mortality rate of 11.1, and an infant mortality rate of 80 per 1000 live births. Life expectancy stood at 61 years.

The number of hospitals in the country as of 1st January 1989 was 717, and the population covered per hospital was 156,206. However, only 18 percent (130) of the hospitals were in the rural areas which contain the bulk of Pakistan's population. The number of total primary health care facilities in the country was 8,503, the urban areas having 2,247 such facilities, and the rural areas having 6,556. The population covered by each primary facility is 12,722 persons.

Morbidity has not yet received the same amount of attention for research as mortality. In most developing countries, morbidity statistics are either not available or inadequate. Hospitalisation records often refer to Government hospitals only, and even for them causes of morbidity are recorded only for patients who died or were attended to during terminal illness by a physician. Urban people are more likely to seek hospital treatment due to relatively easier access to them, or because more people have the resources for hospitalisation.

A child whose life is saved is returned to the environment in which poverty, lack of adequate housing, sub-standard sanitation facilities, and absence of proper drinking water, may collectively or individually has chances of catching the infection again. Studies in Pakistan show higher infant mortality and crude death rates in the rural areas due to the above-mentioned problems. Other reasons for the afore-mentioned risks are congenital anomalies, birth injuries, and pre-natal causes. Children under five are extremely susceptible to catching various diseases and as such need proper health and medical services. Diarrhoea is the major cause of illness among young children. The WHO estimates that there are three-quarters of a billion cases of diarrhoea among children of developing nations each year, resulting in nearly five million fatalities [Synder and Merson (1982)].

CORRELATES OF MORBIDITY

Morbidity depends on a number of factors related to the surrounding environment, availability of basic facilities, the demographic and socio-economic characteristics of the people, and access to health, medical, and social facilities. Isolated and fragmented information can be obtained from hospitalisation records, but it is unrepresentative of the conditions of people.

To compensate for the lack of data, a National Health Survey was conducted in 1982-83. The survey provided information at National and Provincial levels and was classified on urban and rural basis. The survey provided information on all the correlates of morbidity, and was based on the prevalence of morbidity for a period of one month uptil the day of survey. The curative measures taken by sick persons and expenditures on hospitalisation and treatment were also recorded.

Literacy, especially that of mothers plays a vital role in controlling morbidity. There is a vast difference in the levels of morbidity between the urban and rural areas as shown in Table 4. Majority of the morbidity cases are reported among children upto four years old (Table 5). Morbidity further rises among babies under one, and is highest in the first six months. Male children have a higher risk of morbidity then female children, a pattern which occurs in most countries. This gender difference in morbidity rates reverses itself for people with ages between 20-54 years mainly due to this being the females reproductive cycle. In this period, female fatalities are higher in developing nations due to inadequate delivery systems.

Morbidity also varies by marital status (Table 6). Married people both male and female, have higher incidence of morbidity. Widowers have the highest morbidity rates, primarily because they do not have their spouses to take care of them. The above patterns hold true for three out of four provinces of Pakistan while there might be under reporting in Balochistan.

The biggest cause of morbidity in Pakistan is Malaria (41 percent) (Table 7) which includes other fevers also. This is true among both urban and rural areas, and also males and females. This is followed by the common cold and respiratory diseases with influenza also being quite common in Pakistan. Among children, the leading causes of morbidity were diarrhoea, dysentery, and other disorders of gastrointestinal system. Next in frequency were respiratory diseases followed by fever. In Balochistan, there are a high number of morbidity cases among children due to measles and polio, while in N.W.F.P. children suffer to a high degree from tetanus.

Analysis of morbidity in relation to occupation of the patient (Table 8) shows that people working in the agricultural sector have the highest rate of morbidity as they work in rural areas where health and sanitary conditions are the worst, and medical facilities least available. Incidentally this is the area in which the largest proportion of Pakistanis are working. The group with the next highest level of morbidity is that of people connected with the retail trade such as small shopkeepers and salesmen. Technical and other types of skilled workers also have a high morbidity rate. Professionals have the lowest morbidity rate by occupation. They are often highly educated, live in large cities, and have access to most of the requisite health and medical facilities.

In urban areas, 41 percent (Table 9) of sick people seek treatment at private clinics while in rural areas 21 percent do so. In rural areas, as access to doctors, as well as hospitals and clinics is not easy, around 17-18 percent people seek help with compounders (pharmacists) while only 7 percent people in urban areas utilise compounders. Similarly, in rural areas a sizeable number of people 14-15 percent get treatment from Hakims (Homeopathic doctors) while only 4 percent of urbanites go to Hakims. In Balochistan, the proportion of people being hopitalised is the highest inspite of the fact that it is the least developed province of Pakistan (Table 10). This is so because of the very low density of population which improves the doctor to patient and hospital to patient ratio.

As shown in Table 11, there are a few amenities, the availability of which ensures to a great extent the provision of good health. These are Pucca (Concrete) housing, piped water, gas for cooking, and flush toilets. People who lack any or all of these facilities are most prone to illness. Table 12 shows that migrants of the Medical Institution were at a for flung distance from the rural areas of Pakistan.

CONCLUSIONS

Although mortality levels declined in the past 40 to 50 years in Pakistan and in other developing countries, it is more due to the effectiveness of modern medicine for reducing the termination of life by death, and not primarily due to the control of the incidence of disease. The conditions of high fertility and declining mortality have contributed to a fast growth in population under the conditions of low literacy specially among women, inadequate health facilities and limited financial resources for the majority of the population. Such conditions along with unhealthy environmental factors are favourable to the chances of becoming ill.

Fever has been identified as a major cause of sickness (41 percent) which is followed by digestive disorder (8 percent) and respiratory disorders (6 percent). Maximum sickness was registered in rural areas having the poorest sanitary conditions.

Low educational levels, poor hygienic status of the families, poor environmental sanitation and low per capita income are important correlates of morbidity. Also a low level of health status is due to overcrowded houses, poor environmental sanitation, lack of education, and unemployment in youth.

The improvement in socio-economic conditions, education and awareness among the people, provision of health and sanitary facilities, both in rural and urban areas will help to limit the incidence of morbidity, which will contribute not only to further lowering of the mortality but also improve the productivity of the available manpower. It is also suggested that health surveys on morbidity and other related factors should be a regular feature of the statistical activity in Pakistan. Also the available data need further in-depth analysis to look at various aspects of morbidity.

Comments on "Selected Correlates of Morbidity in Pakistan"

Since the initiation of Pakistan's Family Planning Programme all efforts of research have been directed towards on examination of fertility levels and their determinants. As mortality has declined countinuously, little attention has focussed on mortality research in the country. This was due to the fact that no specialised mortality surveys had been undertaken in the country and as such all the research in this direction has been based on questions on deaths asked in demographic and fertility surveys. Similarly, as pointed out by the author there is a dearth of morbidity data from hospital records and no attempt has been made from the concerned departments to collect data on morbidity at national or regional level.

It has been only in the recent past that the Federal Bureau of Statistics, Government of Pakistan has undertaken a National Health Survey and has also asked questions on causes of death in the 1984-88 Pakistan Demographic Surveys. The author needs to be congratulated on initiating research on morbidity in Pakistan and it is expected that similar efforts will be continued in the future.

Although the author has analysed the morbidity data in detail yet the purpose of this presentation is to throw some more light on the available data. For instance, the morbidity rates are higher for females in the urban areas of the four provinces with the reverse phenomenon being observed in the rural areas. This is probably due to the fact that most of the urban women remain confined in their homes which are mostly located in congested areas and Katchi Abadis whereas rural women work both inside and outside the household and remain physically fit. It is worth noting that the curve of the morbidity rate is an inverted U-shape like the mortality curve, tending to indicate that morbidity and mortality are closely related with age. Further, another interesting aspect of the age curve of morbidity is that morbidity is higher for males in the age range 0-10 years, lower for males in the age range 15-55 years and higher for males beyond age 55. Although the morbidity rates for male children are higher yet female children still experience excessive mortality over male children. Is it because parents incur more expenses on the care of sons and if is so then Zeba Sathar's hypothesis of the neglect of female children gains recognition in the present case. Further, higher female morbidity in the reproductive ages is indicative of high maternal mortality in Pakistan. Higher male morbidity beyond age 55-59 is indicative of the fact that male mortality at advanced ages tends to remain higher as compared to female mortality.

Furthermore the data shows that morbidity rates for married males and females are higher than that of never married males and females. In fact the reverse should be the case here. It is suggested that morbidity rates for never married persons should be split up among children adults and aged persons.

Another interesting feature of the results are that only about 16 percent (18 Million) of the population of Pakistan is provided health care facilities by the Ministry of Health. On the other hand, only 15 to 20 percent of the population of Pakistan is covered by the family planning programme facilities which also provide maternal and child health care. Only about 13 percent of the urban population and 16 percent of rural population has access to government health facilities. The rural population as compared to the urban population utilises private health facilities to a much lesser extent probably because these services are quite expensive and as such the rural population tend to utilise less expensive treatment of Hakims, Homeopaths and Compounders.

As the National Health Survey is based on a national probability sample and since Balochistan represents only 5 percent of the total population, care should be taken to interpret the Balochistan figures.

In the end it is worthwhile to note that the rural sample population in the survey indicates the extent of accessibility of health facilities. For instance about 88 percent of the population has to travel 5 or more kilometres to reach the hospital, 33 percent of the population has to cover 5 or more kilometres to reach a dispensary, 28 percent has to cover 5 or more kilometres to reach M.C.H. Centres. In addition, 63 percent of the population has to travel 5 or more kilometres to reach a rural health center, 47 percent to reach a rural health sub-centre and 46 percent to reach a private clinic.

M. Naseem Iqbal Farooqui

National Institute of Population Studies, Islamabad.

REFERENCE

Snyder, John D., and Michael H. Merson (1982). The Magnitude of the Global Problem of Acute Diarrhoeal Disease: A Review of Active Surveillance Data. Bulletin of the World Health Organization 60: 605-613.

Zubeda Khan is Senior Research Demographer at the Pakistan Institute of Development Economics, Islamabad.

Table 1
Percentage Distribution of Population by Urban-Rural
Residence-Provinces-Census, National Health
Survey And Pakistan Demographic Survey

Census/Survey Punjab Sindh NWFP Balochistan

1981 Census
 All Areas 58.6 23.5 12.5 5.4
 Urban 55.4 34.8 6.9 2.9
 Rural 59.9 18.9 14.8 6.4

National Health
Survey 1982-83
 All Areas 64.2 21.0 10.8 4.1
 Urban 56.2 34.9 6.2 2.7
 Rural 67.3 15.6 12.6 4.6

Pakistan Demographic
Survey 1988
 All Areas 60.2 23.4 12.9 3.5
 Urban 55.6 36.1 6.6 1.6
 Rural 62.3 17.4 15.8 4.4

Table 2
Percentage Distribution: by Age and Sex
Census, NHS and DHS, Pakistan

 Census 1981 NHS 1982-83 DHS 1988
Age
Group Male Female Male Female Male Female

0-4 14.3 14.6 16.1 16.5 15.8 16.8
5-9 15.8 17.0 17.0 16.2 16.5 16.6
10-14 13.7 13.3 13.4 12.6 12.6 12.7
15-24 17.4 17.5 17.8 17.0 17.0 17.8
25-34 12.3 10.4 11.5 12.3 12.4 12.6
35-44 9.4 9.3 8.5 10.2 9.9 9.0
45-59 9.5 10.3 11.1 9.0 9.8 8.9
60+ 7.6 7.6 6.8 6.1 5.9 5.6
Total 100.00 100.00 100.00 100.00 100.00 100.00

Table 3
Literacy Ratios for Persons of 10+ Years By Sex, Urban/Rural
Residence--Pakistan and Province--NHS

Locality Both Sexes Male Female

Pakistan
 All Areas 31.8 44.9 17.6
 Urban 52.8 64.5 39.9
 Rural 23.4 36.9 8.7
Punjab
 All Areas 31.5 44.2 18.1
 Urban 52.3 63.1 40.4
 Rural 24.6 37.7 10.8
Sindh
 All Areas 37.4 50.0 22.7
 Urban 55.9 67.8 42.3
 Rural 20.5 34.1 4.3
N.W.F.P.
 All Areas 26.7 43.5 8.7
 Urban 44.5 59.3 28.7
 Rural 23.1 40.4 4.7
Balochistan
 All Areas 20.5 32.6 6.5
 Urban 43.8 60.6 23.6
 Rural 14.9 25.7 2.6

Excludes FATA from N.W.F.P.

Table 4
Morbidity Rates for Pakistan and Provinces, by Sex and
Urban/Rural Residence--NHS

Locality All Areas Urban Rural

Pakistan
 Both Sexes 171.2 143.1 182.3
 Male 171.9 138.2 185.2
 Female 170.5 148.4 179.1
Punjab
 Both Sexes 177.3 144.5 188.0
 Male 180.5 137.9 194.6
 Female 173.8 151.6 180.9
Sindh
 Both Sexes 150.0 136.1 162.1
 Male 147.5 134.9 158.4
 Female 152.7 137.5 166.3
N.W.F.P.
 Both Sexes 204.4 195.5 206.1
 Male 199.6 186.4 202.0
 Female 209.6 205.2 210.4
Balochistan
 Both Sexes 98.7 85.0 101.9
 Male 91.5 78.3 94.6
 Female 106.5 92.7 109.6

Table 5
Age-specific Morbidity Rate by Sex

 Age-specific Morbidity Rates
 (Per 1000 Persons)

Age Group Both Sexes Male Female

All Ages 171.2 171.9 170.5
 0-4 Years 230.5 258.8 208.3
 5-9 Years 144.8 153.9 134.7
 10-14 Years 104.2 112.3 95.0
 15-19 Years 105.0 102.8 107.6
 20-4 Years 112.0 102.0 122.2
 25-29 Years 135.4 120.5 149.5
 30-34 Years 154.5 141.9 165.4
 35-39 Years 166.9 138.3 196.3
 40-44 Years 190.5 157.3 223.8
 45-49 Years 217.8 191.1 247.3
 50-54 Years 232.2 213.9 253.7
 55-59 Years 245.4 250.7 239.7
 60-64 Years 296.3 291.3 303.6
 65 and Above 372.6 391.8 346.6

Table 6
Morbidity Rates by Marital Status; Sex and Provinces
Morbidity Rates (Per 1000 Persons)

 Pakistan Punjab
Marital
Status Male Female Male Female

All Areas 171.9 170.5 180.5 173.8
 Never Married 152.2 145.2 162.9 147.9
 Married 189.3 183.3 200.0 189.4
 Widowed 333.1 350.6 334.6 342.9
Urban Areas 138.2 78.3 137.9 151.6
 Never Married 123.8 123.1 123.7 124.4
 Married 156.8 170.4 158.4 180.0
 Widowed 261.2 277.5 227.2 266.3
Rural Areas 185.2 179.1 194.6 180.9
 Never Married 168.0 154.6 176.5 156.1
 Married 201.5 187.8 212.2 192.2
 Widowed 356.6 382.3 364.6 370.2

 Sindh N.W.F.P.
Marital
Status Male Female Male Female

All Areas 147.5 152.7 199.5 209.6
 Never Married 132.8 133.6 174.8 166.0
 Married 158.7 157.8 233.9 234.0
 Widowed 317.6 307.3 418.7 500.0
Urban Areas 134.9 137.5 186.4 205.2
 Never Married 122.2 117.0 162.9 167.6
 Married 148.2 150.8 218.6 227.2
 Widowed 303.2 254.2 334.9 518.7
Rural Areas 158.4 166.3 202.0 210.4
 Never Married 142.9 150.7 176.9 165.6
 Married 166.8 162.8 237.0 235.2
 Widowed 326.8 361.3 436.6 496.6

 Balochistan
Marital
Status Male Female

All Areas 91.5 106.5
 Never Married 88.7 104.2
 Married 92.8 90.7
 Widowed 151.6 291.3
Urban Areas 148.4 92.7
 Never Married 58.9 65.9
 Married 100.9 96.5
 Widowed 348.1 326.4
Rural Areas 94.6 109.5
 Never Married 96.3 113.1
 Married 91.1 89.5
 Widowed 114.4 279.9

Table 7
Percentage Distribution of Sick Persons by Sex Selected
Diseases and Urban/Rural Residence

 Both Areas Urban

 Disease Male Female Male Female

Code
01-02 Tuberculoses 2.54 2.26 2.27 2.23
 05 Dysentery 2.62 1.99 2.96 1.67
 06 Other Infective Diseases
 Commonly Arising in
 Intestinal Tract 3.78 3.13 3.81 2.90
 07 Certain Diseases Common
 Among Children 3.22 2.97 3.25 3.17
 09 Malaria (Includes all
 other Fevers) 41.08 39.55 32.72 30.64
 14 Allergic Disorders 4.03 2.70 3.69 2.37
 16 Diabetes Mellitus 0.80 0.53 0.84 1.07
 21 Diseases of Eyes 1.10 1.21 1.43 1.00
24-26 Chronic Rheumatic Hear
 Disease, Arteriosclerotic
 and Degenerative Heart 1.27 2.75 2.46 4.67
 Disease and Hypertensive
 Disease
 28 Acute Nasopharyngitis 6.76 6.16 9.56 6.71
 (Common Cold)
 30 Influenza 4.25 3.55 4.42 4.52
 31 Pneumonia 1.15 1.42 0.88 1.14
 34 All other Respiratory 5.51 4.71 6.68 5.22
 Disease
 35 Diseases of Stomach and 3.59 4.84 3.75 6.86
 Duodenum Except Cancer
 40 Other Diseases of 2.25 1.69 1.55 2.03
 Digestive System
 46 Arthritis and Rheumatism 2.63 3.90 2.50 4.58
 Except Rheumatic Fever
 50 Accidents, Poisoning, and 1.69 1.07 2.61 0.90
 Violence (External Cause)
 All other Diseases 11.73 15.57 14.62 19.22
 Total 100.00 100.00 100.00 100.00

 Rural

 Disease Male Female

Code
01-02 Tuberculoses 2.62 2.27
 05 Dysentery 2.52 2.09
 06 Other Infective Diseases
 Commonly Arising in
 Intestinal Tract 3.77 3.49
 07 Certain Diseases Common
 Among Children 3.21 2.90
 09 Malaria (Includes all
 other Fevers) 43.53 42.42
 14 Allergic Disorders 4.12 2.80
 16 Diabetes Mellitus 0.79 0.35
 21 Diseases of Eyes 1.00 1.28
24-26 Chronic Rheumatic Hear
 Disease, Arteriosclerotic
 and Degenerative Heart 0.91 2.14
 Disease and Hypertensive
 Disease
 28 Acute Nasopharyngitis 5.94 5.98
 (Common Cold)
 30 Influenza 4.20 3.23
 31 Pneumonia 1.23 1.51
 34 All other Respiratory 5.16 4.55
 Disease
 35 Diseases of Stomach and 3.55 4.19
 Duodenum Except Cancer
 40 Other Diseases of 2.46 1.58
 Digestive System
 46 Arthritis and Rheumatism 2.66 3.68
 Except Rheumatic Fever
 50 Accidents, Poisoning, and 1.42 1.12
 Violence (External Cause)
 All other Diseases 10.91 14.42
 Total 100.00 100.00

Table 8
Morbidity Rates by Major Occupation Groups, Pakistan

 Morbidity Rates (per 1000
Major Occupation Group Employed Persons)

Total 157.8
 Professional, Technical and Related
 Workers 151.3
 Administrative and Managerial Workers 111.9
 Clerical and Related Workers 94.8
 Sales Workers 162.9
 Service Workers 155.5
 Agricultural, Animal Husbandry and
 Forestry Workers, Fishermen and Hunters 173.1
 Production and Related Workers, Transport
 Equipment Operators and Labourers 137.6
 Workers not Classifiable by Occupation 151.6

Table 9
Percentage Distribution of Sick Persons by Source of
Treatment Received Urban/Rural Residence for Pakistan

 Both Areas

 Source of Both
 Treatment Sexes Male Female

 1. Government Hospital/
 Dispensary/Rural Health
 Centre/Sub-Centre 15.66 14.80 16.41
 2. Private Hospital/ 17.73 18.13 17.70
 Dispensary
 3. Private Clinic 24.92 25.14 25.97
 4. Hakim 12.34 12.85 11.13
 5. Homeopath 1.23 1.21 1.29
 6. Compounder 15.29 14.44 15.55
 7. Self Treatment 5.54 5.81 5.14
 8. No Treatment 3.11 3.33 2.80
 9. Other 1.31 1.44 1.11
10. More than one Source 2.86 2.85 2.88
 Total 100.00 100.00 100.00

 Urban Areas

 Source of Both
 Treatment Sexes Male Female

 1. Government Hospital/
 Dispensary/Rural Health
 Centre/Sub-Centre 13.45 12.55 14.36
 2. Private Hospital/ 22.55 23.99 21.09
 Dispensary
 3. Private Clinic 40.66 39.81 41.52
 4. Hakim 4.29 4.68 3.89
 5. Homeopath 1.66 1.34 1.99
 6. Compounder 7.01 6.46 7.56
 7. Self Treatment 4.22 4.83 3.62
 8. No Treatment 2.20 2.46 1.94
 9. Other 0.75 0.83 0.67
10. More than one Source 3.21 3.05 3.38
 Total 100.00 100.00 100.00

 Rural Areas

 Source of Both
 Treatment Sexes Male Female

 1. Government Hospital/
 Dispensary/Rural Health
 Centre/Sub-Centre 16.23 15.47 17.08
 2. Private Hospital/ 16.50 16.41 16.60
 Dispensary
 3. Private Clinic 20.88 20.88 20.95
 4. Hakim 14.41 15.25 13.47
 5. Homeopath 1.12 1.18 1.06
 6. Compounder 17.42 16.78 18.12
 7. Self Treatment 5.88 6.10 5.64
 8. No Treatment 3.35 3.59 3.08
 9. Other 1.45 1.63 1.26
10. More than one Source 2.76 2.76 2.74
 Total 100.00 100.00 100.00

Table 10
Percentage of Sick Persons Hospitalised (1st Sickness) by Sex
and Urban/Rural Residence Pakistan and Provinces-NHS 1982-83

 All Areas

 Both
Area Sexes Male Female

Pakistan 3.69 3.57 3.83
Punjab 2.77 2.75 2.79
Sindh 5.97 5.46 6.52
N.W.F.P. 4.96 4.93 4.99
Balochistan 5.06 5.33 4.82

 Urban

 Both
Area Sexes Male Female

Pakistan 3.89 3.53 4.25
Punjab 2.76 2.68 2.84
Sindh 5.25 4.20 6.37
N.W.F.P. 4.79 5.38 4.21
Balochistan 10.91 9.52 12.24

 Rural

 Both
Area Sexes Male Female

Pakistan 3.63 3.58 3.69
Punjab 2.77 2.76 2.78
Sindh 6.50 6.38 6.62
N.W.F.P. 5.00 4.86 5.14
Balochistan 3.94 4.51 3.43

Table 11
Morbidity Rates by Type of Construction and Housing
Facilities by Urban/Rural Residence

 Morbidity Rates (Per
 1000 Persons)
Type of Construction/
Housing Facilities All Areas Urban Rural

A. Type of Construction
 1. Pucca 155.4 133.8 186.9
 2. Others 177.7 157.8 181.4

B. Source of Main Drinking Water
 1. Piped Water 155.6 147.6 178.7
 2. Well/Hand Pump 178.3 139.7 186.8
 3. Others 161.4 121.2 165.3

C. Type of Cooking Fuel
 1. Gas/Biogas/Electricity 135.8 135.8 135.9
 2. Cow-dung and Wood/Other 161.3 147.2 226.3
 3. Kerosene Oil 176.5 147.5 182.2

D. Type of Toilet
 1. Flush 142.0 136.7 216.3
 2. Without Flush 146.6 141.4 155.7
 3. Closed Pit/Open Space 183.0 159.1 185.0

Table 12
Distribution of Rural Sample Areas by Distance from Different
Categories of Medical Institutions, Pakistan

 Less than
 one
 Kilometer
 or within
Medical the Sample 1-2 3-5
Institution Area Kilometer Kilometer

Hospital 1.4 3.6 6.6
Dispensary 14.8 8.2 19.2
Maternity and Child 6.5 4.9 11.0
 Health Centre
Rural Health Centre 11.6 7.8 17.7
Rural Health Sub-Centre 21.7 9.8 21.3
Private Clinic 28.2 8.7 17.3

 More
Medical 6-10 than 10
Institution Kilometer Kilometer

Hospital 18.9 69.5
Dispensary 26.1 31.7
Maternity and Child 21.2 56.4
 Health Centre
Rural Health Centre 27.1 35.9
Rural Health Sub-Centre 22.9 24.2
Private Clinic 20.8 25.1