Mortality Rate in Pakistan - among Low and Middle-Income Countries

Abstract

Age-specific and sex-specific cause of death determination is becoming very important task particularly for low- and middle-income countries (LMICs). Therefore, consistent openly accessible information with reproducibility may have significant role in regulating the major causes of mortality both in premature child and adults. The United Nations (UN) reported that 86% deaths (48 million deaths) out of 56 million globally deaths occurred in the LMICs in 2010. The major dilemma is that most of the deaths do not have a diagnosis of COD in such countries. Despite of the allocation of a large portion of resources to decrease the devastating impacts of chronic illnesses, their prevalence as well as the health and economic consequences remains staggeringly high. There are multiple levels of interventions that can help in bringing about significant and promising improvements in the healthcare system. Currently, Pakistan is facing double burden of malnutrition with record high prevalence rates of chronic diseases. Pakistan spends only a marginal of its GDP (1.2%) versus the recommended 5% by World Health Organization. On average, there are eight hospitals per district, with people load per hospital being 165512.452 and poor data management in the country, and we lack a consistent local registry on all-cause of mortality. This article was planned to compile the data related to major causes and disease specific mortality rates for Pakistan and link these factors to the social-economic determinants of health.

1. Introduction

The healthcare system practiced in Pakistan is a composite of two major fields of practice, i.e., modern medicine and Unani medicine. The former one is based on practicing the evidence-based modern medicine (allopathic medicine) delivered through public sector as well as private sector healthcare facilities. The latter field of practice for therapy is traditional treatment known as Unani medicine (Unani Tibb). This system has rooted in Perso-Arabic traditional medicine or more, precisely the Greek/Greece medicine (Greek Urdu translation is Younan or Unan or Unani). The government of Pakistan formally recognized (through an Act passed in 1965) the Yunani medicine, along with modern medicine in 1965. Overall, Pakistan has 36,000 practitioners related to this branch of professionals. Another study shows around 52600 registered Unani medical practitioners in Pakistan [1]. According to WHO, about 70% or more of the population in developing countries uses traditional medicine and about 30% pharmaceutical preparations are derived from herbal medicines [2, 3].

The more vast healthcare system in Pakistan is the practice of modern medicine and hospitals, including both public and private sectors. Data from 2020 statistics show that there are almost 1282 public hospitals working throughout the country as general hospitals and specialized hospitals. Among the healthcare providers, the numbers of registered doctors, dentists, and nurses are 2,45,987; 27,360; and 1,16,659, respectively. Till the end of 2021, total numbers of districts in Pakistan are 160, which mean that there are approximately eight hospitals per district (1282/160). The total of Pakistani population as of 2020 is approximately 21,18,55,939 reported by United Nations report data that make about 2.83% of the total world population (Woldometers population report regarding Pakistan).

Table 1 represents people load per hospital calculated using the statistics tools on the basis of currently available data on the website of Pakistan Bureau of statistics, Government of Pakistan. Table 1 explores that province Punjab has the highest patient load per hospital versus as comparative to other provinces of Pakistan. The average life expectancy of the Pakistani population is reportedly increased to 67.3 years (2019 estimate), while the population growth rate showed a decline from 2% to 1.9%. Regarding the health expenditure in Pakistan, it is shown that Pakistan spends only a marginal of its GDP (1.2%) that is below the recommendation of the World Health Organization (5%) (https://www.geo.tv/latest/354581-pakistans-health-care-system-in-2020-hospitals-doctors-increase).

Provinces	Total people	Total districts	Approx. available hospitals	People load per hospital
Punjab	110,012,042	36	36 × 8 = 288	110012042/288 = 381,986.76
KPK	35,525,047	35	35 × 8 = 280	126,875.167
Sindh	47,886,051	30	30 × 8 = 240	199,525.212
Baluchistan	1,23,40000	26	26 × 8 = 208	59326.92
AJK	4045,000	10	10 × 8 = 80	50562.5
Gilgit Baltistan	883,799	14	14 × 8 = 112	7891.062
Islamabad Capital	1,164,000	1	1 × 8 = 8	145500
Total districts	211855939	160	160 × 8 = 1280	165512.452

Table 1.

Province-wise computed people load per tertiary care hospital in Pakistan.

KPK = Khyber Pakhtunkhwa; AJK = Azad Jammu & Kashmir.

2. Mortality

Identifying the gaps and evaluating factors related to mortality should be prioritized as the first step for dissecting the threshold of diseases, allocating appropriate human and monetary resources, and designing health policies. The mortality rate estimates the number of deaths in a particular time and population [4]. These rates are an indirect measure of nutritional status as well as healthcare facilities of a region. Death rates are expressed per 1000 individuals; for example, a mortality rate of 5.5 per 1000 persons means 5.5 deaths or 0.55% out of the studied population. Reports explored that in Pakistan, life expectancy in males aged 1–4 years is better (41% lower death rate), while the death rate of males aged 35–39 years is higher as compared with other low- and middle-income countries (LMICs). It was well reported that a wide range of factors might expedite the death rates, for example, natural disasters, health conditions, environmental pollution, conflicts, human-made disasters in case of deadly infections, which rapidly propagate in response to higher population density [5, 6].

2.1 Classification of mortality

Mortality is classified into various categories, such as mortality due to various chronic diseases, age, and gender, to name a few (Table 2). Collectively, irrespective of the cause, mortality is expressed as crude death rate (CDR). Eq. (1) is a generic formula for the determination of the crude death rate CDR.

Types	Characteristics
Under 5 mortality	Under-5 mortality is also referred to as child mortality. UNICEF defines child mortality as child death that occurs between birth and age 5, while the rate is measured per 103 live births in a specific region.
Infant mortality	Infant death rate refers to the death of those under the age of 1 year
Gender-specific mortality rate	The death rate in males or females. For example, the female mortality rate is expressed as the “total number of female death ratio total number of females in a particular year.” The same is the case with a male mortality rate
The mortality rate in a particular age group	Number of deaths in a particular age group ratio number of individuals living in that specific age group in a given time
Diseases specific death rate	Number of deaths allocated to a particular disease or cause ratio the total population in that area in a given time point
Maternal mortality rate	Loss of life of mothers due to the complications arising from pregnancy ratios total live births in a predefined time point.
Infant mortality rate	Loss of life among children ages less than 1-year ratio total live births in a predefined time point
Perinatal mortality rate	Also known as fetus or neonate deaths that occur intrauterine during pregnancy. Neonate deaths at 20 weeks or 28 weeks of gestation are also named stillbirths. Sometimes the stillbirths are measured in terms of fetus weight, i.e., 350 grams birth weight plus the sum of deaths among live babies who sustain life up to 7 completed days ratio total number of births in a year (C.D.C. definition)

Table 2.

Classification of the frequently used measures of mortality.

^*Mortality rate per 1,000 persons.

$$\begin{array}{l}CDR=\mathrm{Overall}\mathrm{number}\mathrm{of}\mathrm{death}\mathrm{in}\mathrm{a}\mathrm{time}\mathrm{point}/\\ \mathrm{Population}\mathrm{under}\mathrm{obsrvation}\times {\left({10}^3\right)}^{\ast }\end{array}$$E1

The global burden of CDR was plus seven deaths out of 1000 people per year (C.I.A., 2020). According to the World Health Organization report [7], major ten (10) global causes of death in the year 2019 were ischemic heart disease, stroke, pulmonary disease, respiratory infections, neonatal conditions, trachea, bronchus, lung cancers, neurological issues, diarrhea, hyperglycemia, and kidney diseases. Furthermore, World Health Organization (2016) showed around 56.9 million deaths globally due to various causes. Loss of life due to chronic disorders such as ischemic heart disease and stroke was the leading cause of 15.2 million deaths (2016) worldwide.

3. The burden associated with chronic diseases

The burden associated with chronic diseases, particularly heart-related issues, on mortality and morbidity is overwhelming. Its gravity is, however, more momentous in lower and middle-income countries probably because of relatively unstable economy and inadequate allocation of national budget for healthcare sectors. It has been reported that approximately 50% of Pakistani people face at least one of the chronic disorder [8]. The prevalence of cardiovascular diseases (CVD) in Asian countries is reportedly high in Pakistan, India, Bangladesh, Sri Lanka, and Nepal versus Chinese and Canadian subjects [9]. As of 2020, the overall death rate in Pakistan was 6.8/1,000 people, and Afghanistan was 13.89 deaths/100,000 population [10], Bangladesh 5.526/1000 person (2019). As mentioned, a wide array of factors could expedite this death rate associated with the chronic illnesses. For example, disproportionately high intake of salt and lipid consumption showed a positive association with mortality. It is, therefore, crucial to make education programs as part of the curriculum aiming to mitigate consumption of salt and trans-fatty acids intake as they are highly associated with the high prevalence of CVDs and hypertension in Pakistan. WHO and Food and Agriculture Organization of the United Nations strongly recommend trans-fat content to be less than 4% in dietary fat. The consumption of vanaspati ghee (which contains 14.2–34.3% of trans fat) might be a leading factor the development of cardiovascular diseases in Pakistan and other Asian countries along with many other risk factors. A significantly appreciable work on trans-fat reduction in food items has been done by Denmark, where the mortality due to CVD is declined by 50% over two decades [11]. Such policies need to be kept as a gold standard and amended in local contexts too.

Tobacco consumption in Pakistan is very common. It was also reported that tobacco usage is significantly associated with various types of cancers, particularly with lung cancer. It increases the risk of mortality by almost 12 times, smokers are 2–4 times more prone to develop coronary heart disorder and two times at more risk to develop stroke [12, 13, 14]. Ahmed & Colleagues [15] during a survey conducted in Pakistan reported that tobacco usage is 36% and 9% among males and females, respectively. Moreover, it was also found that out of 36% almost 15% were young adult university students [16, 17]. Therefore, efforts are needed to reduce smoking tendency for reducing the overall burden of chronic diseases and mortality rates.

At the same time, appropriate measures should be taken to motivate the public for physical activity [18], which is reportedly linked with a decrease in health related issues and mortality rates in 17 countries (Asia and Western nations) [19]. Zhou and others [20] reported that regular workout is associated with reduced risk of mortality from all causes (46%), circulatory diseases (56%), and respiratory disorders (49%). It is noted that high workout is a relatively simple and highly recommended intervention strategy for the attenuation of mortality and CVDs across all age groups [18, 21].

Population growth rate determines the availability of health facilities to general public. If the medical facilities are not increased at rates to match the growing population, morbidity and mortality rates will ultimately rise. A recent meta-analysis recommended availability and access to hospitals and surgical care in developing countries [22]. It has been suggested in literature that changing the fertility and education rate and increasing human resources in medical care [23] should be one of the focus areas to address health-related issues.

The age-standardized cancer mortality rate in Pakistan is 48600 in male and 52500 in female reported by WHO cancer country profiles (2014), the death rate due to cancer in India was 0.44 million [24], Afghanistan (2015 data) 15,211, and the United States (2015 data) 667,333 cancer-related death [10].

Pakistan’s relatively high death rate (Global burden of diseases, 2010) is attributed to infections that affect the lower respiratory system, neonatal encephalopathy, and diarrheal diseases affecting all age groups and gender. However, after 1990, diarrheal diseases showed a declining trend in Pakistan; a 35% reduction was reported in 2010.

Air pollution in general and polluted in-house air from solid fuels affect the vulnerable segment of the Pakistani population. The rural–urban health disparities are also common in Pakistan. The majority of the population (60%) lives in a rural area where solid wood is burnt to generate energy. Further, poverty, accident, dietary insufficiency, sedentary lifestyle, higher carbohydrate have driven energy intake at the expense of the protein, negligible health insurance, and constrained access to hospitals are the major factors that accelerate the death rate. The actual mortality rate in Pakistan could be high as death records in the big city are maintained, but it is not usually reported in rural areas. It is, therefore, needed to consider more effective ways of registering death numbers.

Further, rural area where the majority of the population resides in Pakistan also faces a shortage of medical physicians. This scenario set the stage for an undiagnosed or unidentified cause of mortality. In conclusion, the death record, cause, and an appropriate number of medical physicians should be a national health policy priority.

4. Regional distribution of mortality rates

Figure 1 shows major causes of death in LMICs. Some of the middle-income countries work on continuously improving their healthcare services and provision. For example, Malta et al. [25] reported a significant decline in mortality (35.3%) in Brazil, demonstrating the remarkable achievement in health sector reforms in this country, particularly when deaths related to neoplasms and diabetes have been reduced. On the contrary, some economically emerging nations displayed record-high mortality rates; for instance, 6 years of data from Nigeria show 2,198 deaths in 49,287 participants who were admitted to the hospital [26] (Figure 2).

Figure 1.

Major 10 chronic disorders associated with causes of death in LMICs reported by WHO [7].

Figure 2.

Crude death rate (per 1,000 people) in lower-income countries in selected lower-income countries during the year 2019 [data generated from https://data.worldbank.org/] on 28-Nov 2021].

Abegunde et al. [27] published the burden of costs associated with chronic diseases in LMICs. The diseases burden due to chronic disorders in 23 LMICs was accountable for half (50%) of the total disease burden for the year 2005. Moreover, the death rates for men (54% higher) and women (86% higher) in 15 out of the 23 LMICs were higher versus the burden of the disease in men and women in high-income countries. Moreover, chronic diseases hardly hit women than men in the LMICs. Kassebaum et al. [28] documented that mother death ratios are 100 times more in LMICs than in developed nations, while the neonatal and fetal death rates are 10 times more than in high-income nations [29].

5. Adult mortality trend in LMICs and their comparison in Pakistan

Crude death rate/1,000 people for various middle-income countries is presented in Figure 3. Serbia and Bulgaria have the highest mortality rate for all age groups and genders, followed by Russian Federation and Romania. World Health Organization demographic data show a death rate of 15.4/1,000 people. Compared with neighboring nations in the European States, the death rate in Bulgaria is attributed to chronic noninfectious diseases such as cardiovascular disorders and cancer diseases. Other leading factors might be contagious diseases, malnutrition, inadequate healthcare, violence, poverty, and accidents. Other countries with undesirable ranking concerning their high death rate in the European sides were Montenegro, Kosovo, and Albania. Three countries in the Asian continent, such as Pakistan, India, and Bangladesh, occupy a similar position on the ranking. In contrast, small countries such as Malaysia, Nepal, and the Philippines where death rates were comparatively low show significant positive progress in their healthcare system.

Figure 3.

Crude death rate (per 1,000 people) in LMICs and their comparison in Pakistan.

6. Maternal mortality rate (MMR) in LMICs and their comparison in Pakistan

Bangladesh shows maternal mortality as 176/100,000 live births during 2015 [30]. Compared with other countries (India, Congo, Guatemala, Kenya, and Zambia have 456,276 births), Pakistan reported 91,076 births with MMR 319 per 100,000 live births versus the average 124/100,000 live births in the other five countries. Regarding per 1,000 live births death rate, Pakistan’s performance on the ranking is not satisfactory, 49.4 compared with the average 20.4 in the other five countries. [31]. Likewise, Afghanistan has reportedly recorded high MMR at 400/100,000 live births versus other countries on this side of the world [32]. Iran’s neighboring country has reduced MMR from 48/100,000 to 16/100,000 over 17 years, meaning an annual decrease of 6.3% in MMR [33]. Associated factors for high mortality may include the following: Challenges include prolonged conflicts, political instability, high blood pressure due to persistent stress, infection, bleeding, obstructed labor, unsafe abortion, dietary deficiency, low education, and poor maternal and birth in health facilities with a skilled birth attendant and newborn, postpartum care.

7. Under-5 mortality rate in LMICs and their comparison in Pakistan

The Sustainable Development Goals (SDGs) of the United Nations aim to attenuate neonatal mortality to 12 deaths/1,000 live births and under-5 mortality rates to 25 deaths/1,000 live births by 2030 [34]. African countries show a negative ranking regarding under-5 mortality 77.5 per 1000 live births and neonatal mortality 27.7 deaths/1000 live births compared with their Asian counterparts. South Asian nations present under-5 mortality as 42.1 per 1000 live births and neonatal mortality as 25.8 deaths per 1000 live births [35]. The under-5 death rate for Bangladesh was 133 in 1990, which reduced significantly to 30.2 deaths/1000 live births [36, 37], while that of Pakistan was 69.3/ 1000 live births and India 36.6 per 1000 live births [38, 39]. Baqui et al. [40] documented a comprehensive 7 years’ (2007–2013) work on neonatal mortality that involved 149570 live births. The data collection was carried out from six countries, such as rural areas of Bangladesh, Ghana, India, Pakistan, the United Republic of Tanzania, and Zambia. The overall neonatal mortality in the studied countries was 30.5 /1000 live births. Overall, neonatal mortality in Pakistan from the selected population was 47.4 versus Zambia 13.6. Regarding the total mortality rate within 24 hours for the selected nation, it was 14.1 /1000 live births. The country-wise trend showed 5.1 in Zambia versus 20.1 in India. Likewise, the first 24 hours were crucial as 46.3% of all neonatal deaths followed within this time (36.2% in Pakistan compared with 65.5% in Tanzania). In parallel, in the first 6 hours mortality was less, i.e., 8.3 deaths/1000 live births for the selected countries (31.9%). Another study reported the stillbirth rate in Pakistan as 53.5/1000 births compared with the average 23.2 in India, Pakistan, the Democratic Republic of Congo, Guatemala, Kenya, Zambia [31].

Based on the data presented, it is desirable to lower neonatal mortality within the first 24 hours by adopting high standard medical care for mothers and babies before pregnancy, during, and after birth. A study from Brazil conducted (Foz do Iguassu city, from 2012 to 2016) demonstrates the high rate of neonatal mortality under the age of 5 (61%) versus average neonatal mortality in Brazil. Some of the countries showed exceptional performance in reducing neonatal mortality. For example, Bangladesh has shown remarkable improvement in attenuating the national neonatal mortality rate (1993) as 52 per 1000 live births versus 28 per 1000 live births in 2014, reflecting a 46% reduction [30]. The associated factors were a congenital fetal anomaly and low birth weight [41]. Overall, it is documented that 27.8 million neonates could lose their lives across the nation (2018–2030) due to poor neonatal and maternal care [42]. Moreover, this study associated neonatal mortality with respiratory and cardiovascular disorders (43%) and low birth weight and preterm (33%); other key factors that could accelerate neonatal deaths were placenta, cord, and pregnancy complications. Likewise, poor-quality medical and surgical conditions were lead factors. Low birth weight and preterm (42%) were the factors leading to neonatal death after discharge [42]. Kruk et al. [43] recommend universal health coverage, bringing innovation to quality healthcare that could prevent 8·6 million deaths per year. Nutrition policies such as taking care of maternal nutrition, antenatal care, and promotion of breastfeeding can prevent many of the cases of neonatal mortality.

8. Conclusion

Age-specific and sex-specific cause of death (COD) determination is becoming very important task particularly for low- and middle-income countries (LMICs). It was reported that such countries lack the proper system to record COD in such countries. Therefore, a valid policy must be adopted for assessment and reporting of up-to-date health-related data so that mitigation policies may be implemented. Currently, Pakistan is facing double burden of malnutrition in addition to the high prevalence rates of chronic diseases. There is a lack of data management in the country, and we lack a consistent local registry on all-cause of mortality. However, on reviewing the mortality rate in LMICs, it could be suggested that 1) cheap, easily accessible healthcare system should be available to all levels of the population; 2) integrating human resources for the health promotion should work together for the common goal, i.e., uplift public health; 3) most of the hospitals in rural area face huge shortage of financial resources. Timely allocation and management of resources could bring positive changes in healthcare. 4) Openly accessible data for local population should be available and 5) healthcare facilities should be centralized using modern means to update the COD nationwide.

Acknowledgments

We really appreciate the School of Health Sciences, University of Management and Technology, Lahore, Pakistan administration to give free access for downloading and compiling the reference data for the write-up of this article.

Conflict of interest

Authors have not any type of conflict of interest regarding the publication of data.