Pro-People Policies are Possible in Poor Polities

By Anjum Altaf

How much of a useful story can be told with very few numbers?

Look at just one indicator of public welfare, the Under-5 Mortality Rate, in Pakistan, India, and Bangladesh: 86, 56, and 41, respectively in 2012.

The U5MR, which gives the number of children dying between birth and five years of age per 1,000 live births, is a very useful indicator because it captures the effect of many risks to life that occur during the crucial first five years of life – disease, poverty, malnutrition, etc.

What should jump out at the reader is that the 2012 U5MR in Bangladesh is less than half that in Pakistan? Asides from asking how that is possible, this striking statistic should trigger a whole host of related questions.

Let us examine a few obvious ones by way of example. Is it the case that this difference is related to geography, i.e., that the U5MR in Bangladesh was always less than that of Pakistan for climatic reasons. Here are the values in 1990 for the three countries in the same order: 138, 126, and 144. They are roughly in the same range with Bangladesh actually being worse than Pakistan.

Is it the case that Bangladesh is a much richer country compared to Pakistan and has been able to allocate its greater wealth to the improvement of the life chances of the majority? Here are the figures for the Gross National Income per capita in 2012 (in US $) for the three counties in the same order: 1260, 1530, 840. Bangladesh is roughly two-thirds as affluent as Pakistan and yet has a U5MR of less than half.

So what is the explanation for the rapid improvement in the survival rate of children in Bangladesh between 1990 and 2012? A scientifically acceptable answer to this question requires a statistical analysis that controls for all the possible factors that might be relevant. Notwithstanding that, it seems reasonable to assert that the difference does not stem from locational advantage or greater affluence. In all likelihood it is related to some variations of policy. That is the rationale for the claim that pro-people policies that make a difference to the lives of the impoverished majority are possible at low levels of income.

Let us look at one such policy without definitively claiming that it is the causative factor in the observed difference. By way of a speculative hypothesis I have selected the percentage of households forced to resort to open-air defecation, i.e., without access to any form of latrine: In 2015, the percentages for Pakistan, India, and Bangladesh were 21, 50, and 1, respectively. Even accounting for the imprecision of such numbers that is a stunning difference. And to ascribe it very clearly to policy it helps to refer to the fact that the corresponding percentage for Bangladesh in 2003 was 42, i.e., in the same league as the other two countries.

I have selected open-air defecation for a reason. It is well known that it leads to fecal transmission of preventable diseases like diarrhea. But diarrhea has other negative health impacts even when it does not kill directly. For example, chronic diarrhea undermines almost entirely the utility of nutrition programs like school meals. Addressing malnourishment requires meeting physiological needs with sufficient calories and nutritional needs with a balanced diet but it is usually forgotten that these work only when the diet is retained. Persistent diarrhea weakens the retention of food leading to death by other causes.

This observation alone should highlight the importance of a sound public health system. It is only when most people are healthy that a curative care system can function. If most people are exposed to systemic causes of disease the curative system would be overwhelmed as it is in Pakistan.

An analogy should make this clear. In a polluted river one would expect unhealthy fish. Taking all the fish out, nourishing them back to good health, and releasing them back in the same river would be an exercise in futility. Yet, that is the very thing we are doing with human beings.

The fact that public health does not seem to be in the news in developed countries is because they have long ago ensured a healthy base by eliminating systemic preventable diseases. What we see now are the incredible advances in curative care. But, as should be obvious, one cannot put the cart before the horse. The explosion in the number of hospitals and hospital-based physicians in Pakistan is yet another example of misplaced priorities.

The essential pillars of sound public health are safe drinking water and sanitation. If we really care for our people that is where we should be directing our attention and resources. Bangladesh has shown that it is possible to do so in a poor country.


This opinion was published in Dawn on 15 May, 2016 and is reproduced here with permission of the author.

For a remarkable piece written almost exclusively in words beginning with the letter ‘p’, see: PPP Prattle

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3 Responses to “Pro-People Policies are Possible in Poor Polities”

  1. Tehniyat Khan Says:

    Great article, sir! I wonder, though, if we have looked at what policies are made and which make it through to implementation. Every year we see a renewed committment (atleast in lip service and budgets on paper) to improve the lives of the poor, but few are actually put in place. How do you think we can get over this horrible bottleneck of lack of implementation, lack of drive from the policy makers to not just make good policies, but to make good policies work?

  2. Anjum Altaf Says:

    “Recently Bangladesh became the second South Asian country after Sri Lanka to effectively end open-air defecation… a stunning achievement for a country bedevilled by social, economic and political challenges since its establishment in 1971.”

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