COMSATS Institute of Information Technology

Islamabad Campus
Synopsis

for the degree of

Name of
Student

SHABNAM ZULFIQAR

Department

ECONOMICS

M.S./M.Phil.

Ph.D.

Registration No. FA14-REC-002

Name of (i)
Research
Supervisor
Dr. SAIMA NAWAZ
(ii) Co Supervisor
Members of Supervisory Committee
1.
2.
3.
Major Field of
ECONOMICS
Study
Field of
HEALTH ECONOMICS
Specialization
Title of
EMPLOYMENT STATUS AND HEALTH-CARE UTILIZATION IN
Research
PAKISTAN :
Proposal
1. Introduction:
Someone has rightly stated that health is wealth. A good health is one of the basic requirements
and it is essential for the survival and general well-being of all human beings. That is why, access
to health-care services should be irrespective of caste, color, creed or sex. As it is a fundamental
human right. The provision of high-quality health services remains one of the top priorities of all
the governments around the world. The Health Ministry is a very important actor for the provision
of good health-care services equally for everyone. Better health makes an important contribution
to economic progress, as healthy population lives longer, saves more and is more productive.
Health plays a key role in determining human capital. Better health improves the efficiency and
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productivity of the labor and ultimately contributes to the economic growth that leads to human
welfare. To attain better, more skillful, efficient and productive human-capital resources,
Governments should subsidize the health-care facilities for its people. Any Governments strategy
should base on improvements in the supply of health services as well as on increasing or
decreasing the determinants which influence the level of utilization of health-care services
(H.C.S). Some other government departments, donor organizations (like NGOs), civil society
groups and communities themselves. For example, investments in infrastructure can improve
access to health services and it can also lead to decrease in transport cost that hurdles the
utilization of HCS. Inflation targets can constrain health spending whereas civil service reforms
can create opportunities. There is a tendency for governments to concentrate in the expansion of
the supply of health services and for this purpose, government should increase the employment
level in the economy.
However, in general people living in poor countries are deprived of this fundamental right. Many
individuals choose poor lifestyle habits and donot seek professional help in case of ailments with the
expectation that there will be no medicine available to treat their illness and that the expenditure will
be beyond their bearings. Health is their last priority for they have other issues of more severe nature
like food and shelter to tackle.
In LDCs mostly health indicators show very bad results. Some determinants for poor health
conditions in LDCs are socio-economic status, accessibility, lack of information, high growth in
population, less use of modern services like health insurance, shortage of drugs and medical
equipments, shortages of health care professionals, cost of transport, overcrowding in hospitals,
unequal distribution of wealth, remoteness of different areas, expensive treatment or cost/affordability,
lack of budget allocation in health sector, low wages, gender partialism, no female education, joint
families, size of family, more adults in a family, number of dependents, , more mobility of
professionals, poor technology usage and lack of data availability act as major barriers to access to
utilize the HCS equally in whole country. Also in LDCs the gender differential exists and it is also an
important reason which influence the level of utilization of health-care services differently in different
areas of same country.
Most important issue is low employment rate in developing countries. As utilization of HCS are
strongly associated with SES (social economic status) and employment status, particularly for highly
paid healthcare services; which may act as a barrier to their usage. In this context, the improvement in
employment status will lead to high purchasing power, individuals per-capita or disposable income
for more utilization of the healthcare services. Utilization of health care services may also be
dependent on work-related benefits such as health insurance, workplace or employment-related health
programs which are associated with the different employment statuses.
Like most developing countries, Pakistan too is facing severe health-care issues. Despite efforts and
consistent policies by the government, Pakistan still has magnanimous health-care problems. People of
low SES especially in the rural areas receives very limited health-care choices and almost entirely
depend on government based health-services in contrast to their relatively affluent counterparts.
Therefore, it is imperative for the concerned authorities to priorities countrys health-care sector.
Pakistan spends only 2.2% of its GDP for health expenditures (2009 census). Pakistans total
population was 154,794 in year 2006; life expectancy at the birth 62 years for both sexes, probability
of dying (per 1000) under age 5 years was 101 years for both sexes, population growth rate 1.9%
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(1994-2004), physicians per 100,000 people was roughly 74 only (1990-2004).What determines the
efficiency of a countrys development in health-care sector is based on qualified medical staff, local
production and export of surgical goods, number of medical colleges for students and hospitals
available but unfortunately, Pakistan lacks in both quality and quantity in these standards. Pakistan
faces both economical and political issues off and on. To make the situation worse, natural calamities
mainly flood and earthquake also affect the countrys health-care drastically.
The current indicators of health show that Pakistan demonstrates poor picture of expenditures on
health-care services. Pakistan is considered in the list of those countries that have lowest Human
Development Index (HDI) and other health parameter. The health-care system in Pakistan comprises
of public and private sector. The public sector provides fewer facilities and also faces administrative
crisis. Therefore, educated and well-off community prefers private sector which is very costly and is
almost inaccessible for the poor that are in majority. According to 2013 consensus the population of
Pakistan is estimated to be 182.1 million and the number of physicians are 1090 (consensus, 2015).
Pakistan ranks 7th in the category of most populous countries of the world, and by the year 2050 will
be one of the largest countries of the world with an estimated population of 285 million. Already the
existing population of Pakistan, with a growth per annum of 2.4% poses a challenge to the government
for provision of jobs, education and health services which roughly means 8 number of physician, 3
nurses for 10,000 numbers of people. The country operates health-care system, consisting of rural
hospitals, public and private health-care centers like district hospitals, provisional hospitals, military
hospitals, general hospitals and central hospitals located in major cities. Pakistans current health-care
situations are not satisfactory. Hundreds of people die due to dengue fever, a number suffers from
cholera and malaria and numerous suffer from hepatitis. Policies may not have completely eradicated
the diseases but has limited the spread to some extent.
The sanitation conditions are poor with 40% of population without sanitation facilities, 12% of which
has little to no access to clean water. According to a survey, waterborne diseases e.g. diarrhea and
typhoid cost the national exchequer 1.8 per cent of GDP, Rs120 billion, annually because of poor
access of almost all citizens to safe drinking water and better sanitation.
Pakistans health profile is characterized by public health threats and epidemics like tuberculosis in
which Pakistan is on sixth position. It is one of the only three countries in the world that still harbor
polio. Life expectancy is only 60 percent with the maternal mortality ratio as high as at 260 per
100,000 live births. Major reasons of high infant mortality rate are due to malnutrition, diarrhea, acute
respiratory illness and other diseases that can be prevented by vaccine and better health care.
According to a survey carried out by the express tribune (a daily news paper) 80% of diseases in the
country are waterborne. Jahangir shah, a senior scientific officer at PCSI, explained that a number of
diseases are caused by consumption of unhygienic water. Moreover, 80% of all illnesses and 40% of
deaths in Pakistan are caused illnesses that occur due to unhygienic water.
Pakistan has 14000 health institutions both in public sector hospitals. But 77% of people approach
private facilities. This means that people do not rely on public sector facilities which may indicate
flaws present in it that are of administration related. Hospitals are present in rural areas too so that
some health care is available even for people residing there. However, in some remote areas, people
still depend entirely on spiritual healers, traditional healers and sometimes even fall prey to quacks.
Pakistan spends 26% of its GDP on health.
Pakistan is in the middle of epidemiological transition where almost 40% of total burden of disease
(BOD) is accounted for by infectious/communicable diseases. These include diarrhoeal diseases, acute
respiratory infections, malaria, tuberculosis, hepatitis B&C, and immunizable childhood diseases.
Another 12% is due to reproductive health problems. Nutritional deficiencies particularly iron
deficiency causing anemia, Vitamin -A deficiency, iodine deficiency, disorders account for further 6%
of the total BOD. Some non -communicable diseases (NCD), caused by sedentary life styles,
unhealthy dietary habits, environmental pollution, smoking etc. Including cardio vascular diseases,
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cerebral-vascular accidents, diabetes and cancers account for almost 10% of the BOD in Pakistan
(MTDF, 2005-10)
There is positive relationship between HCU and employment. But besides this there is another channel
working in Developed Countries where population is fully employed they will mostly have better On
contrary, in LDCs like Pakistan, the health status of population is poor. The health care system in
Pakistan comprises the public as well as private health facilities. In Pakistan, the choice of health-care
provider is limited; also vast majority of doctors resides in urban area and attract the educated and well
off class to private sector. Utilization of public health care facility is not the main priority of the
educated class of the country. Government officials should pay attention to make it more convenient
for general public (Iram Manzoor, et al 2009).
In different provinces of Pakistan the employment status effects the utilization level of healthcare
services differently. The most prominent reason for this is that History shows that there may be
thousands of reasons in answering this type of questions few of them are listed here, i) the more
developed the province, region of residence (availability of facilities) the better the health facilities are
available people more likely to seek medical consultation. For example, it is found that over two times
more health facilities were availed of by sick children in the province of Punjab than in the other
provinces of Pakistan like province of Baluchistan. Also the province of Sindh does not lag behind
Punjab much. Some male-female differentials (gender difference) are found in the province of
Baluchistan, where only male rather than female children are more likely to be provided with health
care.. As it has been found out that difference in employment status alters the utilization of healthcare
services. Moreover it has also been found out that different employment statuses significantly affect
the utilization of healthcare services in LDCs and particularly in case study of Pakistan. There is need
to make some efforts for provision of better health-care facilities to every individual in the society,
subsidization of the health-care payment system, some policies to improve SES level, political
stability and also involvement of traditional providers.

1. Statement of the Problem

Utilization of healthcare services is correlated with employment rate in the economy. There is need of
a study that will focuses on the main core question i.e. how different employment status will affect the
usage of health-care services in lower developing countries (LDCs) particularly in Pakistan. This
study is an extension of existing studies that will put light upon the impact of socio-economic status
(S.E.S) and employment status on the health-care utilization in Pakistan. It covers common diseases
along with the availability and utilization of HCS by people of different regions in the country under
consideration. To the best of our knowledge, the two fold objective of this research is ; (1) to
determine what are the different socioeconomic factors that affect utilization of healthcare services in
Pakistan, and (ii) to identify the pathway through which different employment status effects the
utilization of healthcare services in all provinces of Pakistan. This study will also contribute to
examining the socio-economic determinants that will be useful for some policy recommendations. It
also examine changes in predicted outcomes in utilization of healthcare services as well as the factors
that may be responsible for such changes in different provinces of Pakistan. It will assess the current
status of employed person in accordance with utilization of healthcare services as well as the change
in employment status in different provinces. Finally the findings of this study clearly point to the
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urgent need to develop innovative strategies for policy makers that will help upscale intervention
especially for improvement in the use of these services and it attempt to fill the research gap. In view
of these findings efforts should be made to minimize the effects that influence the utilization of
healthcare services badly. These findings will also be useful for further research to explore
beneficiaries of government healthcare programs in all provinces. Afterwards, predicted results will be
validated with already obtained real data from PSLM survey of Pakistan for the year 2013-2014. The
hypothesis is that in Pakistan the employment status plays a significant role and its a progressive for
utilization of HCS and there exist large inequalities in the different provinces of Pakistan while
considering same employment statuses of individuals.

2. Literature Review
A comprehensive review of literature, research materials, articles and evaluation is done to analyze the
existing situation and policy debate of a country under-consideration. A paper investigates differences
in health-care use according to employment status at the pick of the recent economic recession. The
study used data from a cross-sectional survey to assess differences in health-care seeking behavior by
employment status. Results show that employment status was statistically significantly associated with
health-care. Further, this study found that at the pick of the most recent economic recession, people
who were out of work used more often health services as compared with their employed counterparts.
The observed differences in health-care use were explained by demographic, socio-economic and
health-related variables.
A study by Shandana Shahid Dar explains that utilization of maternal health services is a complex
behavioral phenomenon. Empirical studies have established that the use of maternal health services is
related to social and cultural structures, household factors and personal characteristics of women such
as education and health knowledge. Yet the causal mechanism through which education of women in
Pakistan affects their health seeking behavior is poorly understood. This study found socioeconomic
factors affect maternal health care utilization behavior of women, and also identify the pathway
through which effect of womens education is transmitted to their maternal health seeking behavior.
The results of empirical analysis indicate that womens predisposing factors such as educational
attainment, childs birth order, spouses educational attainment and type of occupation, along with
female empowerment are important determinants of maternal health seeking behavior of women in
Pakistan. Results of this study also confirm an important role played by womens health knowledge,
independent of educational attainment, on their maternal health care utilization. Another study which
explains that Gender differentials in health care utilization are also very important in that study the
reason mention is education of mothers. The paper suggesting that ones with primary or less education
these mothers cares more for boys when they are sick. A mothers education is also positively related
to the immunization status of children. A study identified age, education, access to health facilities,
household wealth, residence, ethnicity, geography, and religion as important socio-economic factors
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influencing particularly the utilization of maternal health services. It is well established that higher
levels of family income is associated with increased utilization of modern health care services (Elo,
1992; Fosu, 1994). Husbands occupation can be considered a proxy of family income, as well as
social status. It has been shown that women whose husbands worked in businesses or services were
most likely to be users of modern health care services to treat complications during pregnancy. This
study shows positive relationship b/w profession of head of the family with the level of utilization of
health-care services. (Chakraborty et al, 2003). Womens involvement in gainful employment is also
an important factor positively affecting the use of quality medical care to treat complications. This also
empowers women to take part in decision-making processes about health care in the family. Women
who are involved in gainful employment are more likely to use modern health care services to treat
complications during their pregnancy (Chakraborty et al, 2003). Celik and Hotchkiss (2000) showed
that household wealth is positively and significantly associated with choosing health facility for
delivery. Gage (2007). The mothers level of education has an important impact on the use of maternal
health services. Therefore improving educational opportunity for women may have a large impact on
improving the use of such services (Elo, 1992). Education is said to enhance female autonomy so that
women develop greater confidence and capabilities to make decisions regarding their own health
(Raghupathy, 1996). It is also likely that educated women seek out higher-quality services and have
greater ability to use healthcare inputs to produce better care. It is argued that better educated women
are more aware of health problems, know more about the availability of health care services, and use
this information more effectively to maintain or achieve good health status. A number of studies have
shown a positive relationship between womens level of education and utilization of maternal health
care services (Becker et al., 1993; Celik and Hotchkiss, 2000; Addai, 2000; Mekonnen and Mekonnen,
2003; Chakraborty et al, 2003). Mothers education may also act as a proxy variable of a number of
background variables representing womens higher socioeconomic status, thus enabling her to seek
proper medical care whenever she perceives it as necessary (Becker et al., 1993). According to Gage
(2007), in high education areas, social networks may provide women with access to contacts and
information on safe motherhood and reduce uncertainty about formal health systems. These processes,
in combination with social influence, may also explain the relationship between area uptake of
prenatal care and the health outcomes examined. At the individual level, low maternal education, the
low status of women, and personal barriers remained important impediments to improved maternal
health care seeking. In studies done by Jnajua et al it was noted that in Pakistan, more than 80% of the
health care is provided at general practitioners clinics. Most of these clinics consist of a small, single
room structure where consultation, injection administration and drug dispensing is performed. Cost
has also been undoubtedly been a major barrier in seeking appropriate health care in Pakistan.
Consequently, household economics limit the choice and opportunity of health seeking. A research
based on finding the determinants and pattern of health care services and utilization shows that the
health care utilization of a population is dependent on their health seeking behavior which is
determined by their physical, political, socio-economic and socio-cultural aspects. That was conducted
to identify the determinants and the patterns of health services utilization by the postgraduate students
of Allama Iqbal Open University in Pakistan and it was a cross-sectional study and conducted from
December 2008 to April 2009 in Allama Iqbal Open University Islamabad. Chi-square test is applied
as a test of significance with fixing the p value at 0.05 as significant. Only 129 students 32 males, 97
females) out of 250 responded to the questionnaire with the response rate of only 51.6%. The
sociodemographic profile of the participants shows that 71 (55%) belong to age group 2029 years,
followed by 43 (33.3%) in age group 3039 years. The marital status of the participants had a
significant association with selection of health care services (p=0.04). Twenty-four (75%) of the males
and 67 (65%) of the females were using private sector facilities. Age, marital status and income of the
study subjects had significant association with selection of the provider with values of 0.000, 0.047
and 0.051 respectively. This study is undertaken to test whether or not there exists gender biasness in
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health care utilization of sick children in Pakistan. Overall, the results are encouraging, as medical
consultation has been sought for by a very high proportion (79 percent) of sick children. Moreover,
there do not appear to be significant differences by gender in health care utilization, be it curative or
preventive. This is so in spite of the fact that many studies on various gender-related issues in Pakistan
have generally shown significant gender biasness that favors male children. Thus, one may conclude
that parental altruism prevails at least in the provision of health care to sick children. However, the
extent and magnitude of effect varies by geographical, socio-economic, and demographic
characteristics of the mother . In view of these findings, efforts should be made to minimize gender
differentials among various categories of people so that children living in any circumstances may have
equal opportunity of health care utilization. This will be possible when health care facilities are easily
accessible to all. The Lady Health Workers Programmed of the Government of Pakistan is a major
positive step in this regard. Under this programmed, health care facilities are provided at peoples
door-step. The expansion of this programmed will be extremely beneficial in helping parents to
provide health care facilities to sick children, both male and female. An analysis confirms earlier
findings that economic status and number of old aged members are significant positive predictors of
OOP payments. This association can direct government to enhance allocations to healthcare and to
include program focusing on non-communicable diseases. The findings on literacy of the head of
household as positive predictor of OOP (Out Of Pocket) payments was similar to Tin- Su and Pakhrel
et al. (2006) and Okunade and Suraraetdecha et al. (2009) Rous and Hotchkiss (2003) found it to be a
negative predictor of OOP payments. The findings show that urban households made higher OOP
expenditures on healthcare than rural households. This contradicted Rous and Hotchkisss (2003)
findings. White collar households are a negative predictor of OOP payments in our analysis. It is
contradictory to the income and health expenditure relationship discussed above. We could not find
any research article that has included profession of the head of household in the analysis of
determinant of OOP payments. Fair access to free healthcare at government facilities and healthy life
style could be possible explanations. Earlier research found that government subsidies in health sector
in some developing countries for instance Nepal, China, Indonesia and India, benefited the rich more
than the poor. However this conclusion is based on income/ expenditure of the household rather the
profession or lifestyle. The regression analysis indicated that a household in KPK province was higher
predictor of OOP payment than for households in Punjab. Khyber Pukhtonkhwa province is generally
considered to be a more conservative society with a predominance of population of Pushtoon ethnicity.
It has a greater rural population, lower literacy, lower level of sewerage systems and larger household
size than the other provinces. In KPK province more female heads of household than other provinces.
In the regression model male head predicted negative influence on log of OOP than female heads. This
finding is contrary to Rous and Hotchkiss (2003) findings regarding influence of male head of
households on OOP payments. Besides other determinants we can associate higher OOP payments in
KPK to the more households headed by a female than other province.

3. Research Methodology
The evidences gathered from studied literature supports the existence of difference in employment
status that leads to differences in individual's demand for health-care services. Mostly this type of
study can be generally categorized into; (i) studies that identify supply side factors that determine
health seeking behavior such as infrastructure quality, availability of health-care facilities in a region,
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and (ii) studies that examine demand side determinants of health care utilization, such as education,
age and employment etc. Empirical studies regarding socioeconomic determinants of healthcare
utilization behavior in Pakistan remain limited. This study aims to fill this gap and it will be an
extension of the second category.
The following tasks are the main concern of this project.
1. Finding determinants that influence the utilization of HCS.
2. Understanding the theory behind impact of ES on HCU.
3. Analysis of the time series data of Pakistan from 2013 to 2014.
4. Indexes will be calculated of the considered data.
5. I will use Households data rather individual behavior.
6. Considering the current income of individuals rather permanent.
7. Results will be discussed in terms of statistical measures such as, ------8. On the basis of results, the prediction will be made for the next years.
9. Finally, predicted results will be compared with the already obtained statistical data.
10. Software will be used to simulate the proposed work.

5. Data
Data was collected from PSLM household survey conducted in Pakistan for 2013-2014. We
selected variables that described the economic status of the respondent, including: employment
status and income, and SES by assets. Considering the respondents where they most often
utilize health-care services when they or their family suffers ailments.

6. Bibliography

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