OBJECTIVE:
Socioeconomic status is an important determinant of health outcome measures. This study examines and presents some of the important health outcomes amongst the higher and lower socioeconomic groups within the urban poor.  SETTING:
Data analysis is based on a Health and Demographic Survey conducted in urban squatter settlements of Karachi in 1996.  METHODS:
A structured questionnaire was administered to all households in the catchment area. The indicator used to assess economic status is ownership of assets.  RESULTS:
Comparison between the two economic levels shows that the lower socio-economic group was more likely to experience child mortality, (CI; 1.02-1.29, p = 0.02) have lower contraceptive usage (CI; 2.11-2.64; p \u3c 0.001) and childhood immunization rates (CI; 2.08-2.40, p \u3c 0.001). No significant association was observed between economic levels and prevalence of diarrhea. The housing, literacy and employment status was consistently better in the higher economic stratum who were more likely to be Pushto-Punjabi speaking as compared to the Sindhi speaking population.  CONCLUSION:
To have sustainable improvement in the health status of the poor, those who are most vulnerable need to be identified and programs aiming to improve health should also undertake broader development initiatives like raising family income

Merchant, Anwer T.

Rabbani, Fauziah

English

eCommons@AKU

eCommons@AKUCommunity Health Sciences Department of Community Health SciencesMay 1999Economic development and health status amongthe poor in squatter settlements of Karachi.Fauziah RabbaniAga Khan University, fauziah.rabbani@aku.eduAnwer T. MerchantAga Khan UniversityFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_chs_chsPart of the Family Medicine Commons, and the Public Health CommonsRecommended CitationRabbani, F., Merchant, A. T. (1999). Economic development and health status among the poor in squatter settlements of Karachi..JPMA: Journal of the Pakistan Medical Association, 49(5), 117-121.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_chs_chs/230Economic Development and Health Status among the Poor insquatter settlements of KarachiPages with reference to book, From 117 To 121 Fauziah Rabbani,Anwer T. Merchant ( Department of Community Health Sciences, The Aga Khan University, Karachi. ) Abstract Objective: Socioeconomic status is an important determinant of health outcome measures. This studyexamines and presents some of the important health outcomes amongst the higher and lowersocioeconomic grou PS within the urban poor.Setting: Data analysis is based on a Health and Demographic Survey conducted in urban squattersettlements of Karachi in 1996.Methods: A structured questionnaire was administered to all househoIds in the catchment area. Theindicator used to assess economic status is ownership of assets.Results: Comparison between the two economic levels shows that the lower socio-economic groupwas more likely to experience child mortality, (Cl; 1.02-1.29, p= 0.02) have lower contraceptive usage(CI;2.11-2.64; p<0.001) and childhood immunization rates (CI: 2.08-2.40, p< 0.001). No significantassociation was observed between economic levels and prevalence of diarrhea. The housing, literacyand employment status was consistently better in the higher economic stratum who were more likely tobe Pushto-Punjabi speaking as compared to the Sindhi speaking population.Conclusion: To have sustainable improvement in the health status of the poor, those who are mostvulnerable need to be identified and programs aiming to improve health should also undertake broaderdevelopment initiatives like raising family income (JPMA 49:117, 1999).Introduction Todaro, an economist defined development as raising people’s living standards, creating conditions toenhance self-esteem and increasing the freedom to choose from a variety of goods and services1. The1992 holistic model of Mahadevan outlines overall development indicators (ODI) as infant mortalityrate (IMR), literacy pet- capita domestic product and road length per 100 square km1.This gap in per capita income is widening, not only among the rich compared with the poorest, but alsobetween the rich compared with the middle income class and middle class compared with the poorestand then between the poor and the poorest2. Graphs comparing infant and general mortality ratesamong various Indian states with indicators of economic programs, economic development, healthexpenditures and fertility over most of the present century indicate that mortality decreased mostsignificantly when economic growth was at its maximum3. Socio-economic change is therefore viewedas the basis for any effective solution to population problems and economic and social development isnow being directed to elevate the quality of life4.Pakistan’s Poverty Assessment Survey5 carried out by the World Bank in 1995 has examined whetherhuman capital and physical assets are determinants of a household’s standard of living and whetherthese are associated with poor human development indicators. The assessment shows that adult literacyand school enrollment is much lower among households in the lowest quintile of per capita householdexpenditure. Also, IMR was much higher amongst those households in the lowest quintile of householdexpenditures and facing poor water and sanitation conditions. The incidence of disease especiallydiarrhea does not appear to be strongly correlated with household expenditures. Similar studies havebeen conducted in Canada, Kenya and Finland comparing mortality, disease pattern and contraceptiveusage amongst the lowest and highest quintiles of income level6-8.Intra- urban health differentials exist between the urban rich and those living in urban slums. TheDepartment of Community Health Sciences (CHS), Aga Khan University (AKU) is involved inapplication and delivery of primary health care services in the urban squatter settlements of Karachi.This paper examines and presents some of the important health outcomes that distinguish those who areeconomically better off with those who are worse off within these squatter settlements and alsodescribes common socio-economic characteristics of the two groups being compared.Methodology Setting of the StudyData analysis for this paper is based on the CHS Health and Demographic Baseline Survey conductedin six urban squatter settlements of Karachi from May-July 1996. These squatter settlements’ residentsbelong to different ethnic groups from all over Pakistan and are usually from the lower socioeconomicstrata. The squatter settlements include; Hijrat Colony, Sultanabad, Moinabad, Future Colony,Khuldabad (predominantly Pushto-Punjabi speaking) and Rehri Goth, lbrahim Hyderi and MohammadiColony (predominantly Sindhi speaking). CHS has mobilized the communities to form CommunityManagement Teams (CMTs) comprising of influential people, religious leaders, school teachers andrepresntatives of existing community-based organizations in the area. It is now working to develop thecapacity of CMTs for sustainable health and development approaches to improve the health status ofthese communities.Sampling Strategy, Sample Size and Interview CharachteristicsAll persons in the catchment areas were surveyed; this came to 18,569 households and 109,165 people.The refusal rate was 3%. Trained female interviewers collected the information on pretested, structuredquestionnaires.Study VariablesThe questionnaire gathered information on socio demographic characteristics, health seeking practicesand health status. Some of the socio-demographic variables utilized for this analysis were; totalhouseholds, language spoken, literacy level, employment status, household construction and watersupply. Amongst the socio-economic variables, information was also collected on ownership ofhousehold assets. The assets considered for this analysis were television (Rs.10,000), videocassetterecorder (Rs.8,000), semi-automatic washing machine (Rs.4,000), car (Rs.150,000), dish antenna(Rs.5,000), motorcycle (Rs. 40,000), refrigerator (Rs. 10,000) and radio (Rs.l,000). The numbers inparenthesis indicate the market value of each item in local currency at the time of data collection. Afterdetermining the market value of each asset, the total household assets were calculated by addingtogether the value of each asset the household possessed. This was our indicator for economic status.The lower economic group comprised of households that did not possess any asset; these wereapproximately 40% of the total population. The higher economic group comprised of households thatwere approximately amongst the top 40% of total household assets.Data Entry and AnalysisData entry and basic frequencies were generated on a computer software package (Epi Info, 6.04). Chisquare was used to detect significant differences between the two economic groups for various healthoutcomes studied and p values, odds ratios and confidence intervals were generated. We compared theassociation of economic status with immunization in children, contraceptive use, child deaths anddiarrhea in children less than five years of age. The socio-demographic variables listed above were alsocompared across the two economic levels.Results Approximately fifty three percent of the households did not have any assets. The heads of suc!:households were more likely to be daily wage earners, Sindhi speaking and illiterate as compared toheads of households with assets. Their houses were less likely to be “pucca” and have piped watersupply (Table 1)as compared to the households with assets.Households having no assets were 15% more likely to report a child death in the last five years thanthose in the higher economic group (17.7% vs 15.8%; OR 1.15; CI: 1.02-1.29; p=O.O2). On furtheranalysis, comparing households in the top 7% of households assets with the lower economic group thelikelihood of child mortality in the lower economic group increased further (OR 1.6; Cl: 1.34-2.04; pNo significant association was seen between the two socioeconomic groups under comparison withrespect to prevalence of diarrhea (period prevalence, two weeks recall at the time of survey).Discussion Findings from this study suggest that for the health outcome variables considered, there existdifferentials in terms of socio-economic status amongst the poor residing in squatter settlements thatcan possibly help identify households which are poorest of the poor and hence most vulnerable to anundesirable outcome. These households experience greater childhood mortality and under-utilizepreventive services like immunization and family planning.The profile of a vulnerable household (in terms of adverse health effects) within the urban squattersettlements of Karachi is that of a poor household with no assets, living in a poorly constructed housewith no piped water supply and having uneducated, unemployed, Sindhi speaking residents. The CHSHealth and Demographic Baseline Survey of 1996 has also observed that Sindhi families have highercrude birth rates, infant mortality rates, average family size, maternal anemia and childhoodmalnutrition as compared to Pushto speaking and other linguistic counterparts. In another analysis itwas shown that a household was more likely to experience a child death if it was poor or headed by aSindhi speaking member or an illiterate person or a person not permanently employed9. Householdswith similar characteristics have also been documented to be at risk in urban slums of India10.It is underscored that the poor are poor, not only because they do not earn sufficiently, but mainlybecause they do not own much. The ownership of farmland is well known to be highly concentrated inthe hands of fortunate few in various countries of Latin America”. In the absence of valid and practicalsocioeconomic indicators available for assessing the economic status at community level we feel thatownership of assets is a useful measure of socioeconomic status in our population. Ownership of assets,however, did not have a significant effect on prevalnce of diarrhea. This is consistent with the earlierreported World Bank Poverty Assessment data5. Diarrhoea has probably to do more with generalenvironmental sanitation and provision of safe water supply which tend to be uniformly poorirrespective of economic level of households in Karachi.Studies in China, Costa Rica, Kerala and Sri Lanka recommend linkage between social and economicdevelopment and intersectoral policies for economic gains for sustained improvement in health12.World Bank in its Poverty Assessment Report outlines poverty alleviation strategies. One of them isdeveloping long term strategies for financing of basic social services with the involvement of non-govermental organizations (NGOs) and community organizations. The Aga Khan Rural SupportProgram’s (AKRSP) participatory approach is very applicable to communities where CHS is working.In this scheme village or community organizations receive grants for income-generating infra structureprojects that are selected, implemented and maintained by the organization themselves. In the processof completing the project communities develop the capacity to manage issues collectively. Thisinitiative is being tried and tested in the CHS field sites with the CMTS. CMT are being linked with theNGOs working in the field of development. The Orangi Pilot Project (OPP) with whom UHP andCMTs are in close collaboration is one such example. The OPP offers microentrenepuer credit schemesfor home schools and provides management skills to women for organizing work centers forembroidery and garment stitching.In order to reduce morbidity and mortality from different causes it is essential that risk factors anddeterminants be identified to initiate appropriate interventions. Based on our analysis we feel thathealth promotion efforts have to be combined with socio-econornic measures in order to have greaterimprovement in the health status of communities directed towards the most vulnerable or those greatestat risk.Aknowledgments We gratefully acknowledge the support USAID and CIDA who provided bilateral funding through theAga Khan Foundation for the support of the Urban Health Project (UHP) of CHS. The contribution ofall staff and faculty associated with UHP is acknowledged. We acknowledge the earlier work done byAmanullah Khan, Fozia Qureshi, Bilquis Sana Khan and Fauziah Rabbani in “inequities in UrbanHealth: Differential need among the poor in Karachi slums” -paper presented in the W.H.O. Workshopon Determinants and Indicators of Urban Health, Kobe, Japan, August, 1997.We acknowledge the support of Dr. Bryant, Professor Emeritus in providing us with the latest workdone by the World Bank on poverty assessment and reviewing the drafts of this paper. We thank Ms.Bilquis Sana Khan for her contribution in statistical analysis of this data.References 1. Mahadevan K, Tuan CH, Nair VB, et at. The differential development and dilemma in populationgrowth: perspectives from India. Demography India, 1991 ;20: 15-28.2. Bergstrom S. The Pathology of Poverty. In: Lankinens KS, Begstrom S, Makela PH and PeltommaM,eds. Health and disease in developing countries. London, The Macmillan Press Limited, 1994, pp. 3-12.3. Rosero-L: Determinants of the decline of infant mortality in Costa Rica. Association DemograficaCostaricensee, 1985:9-36.4. Bueno Sanchez E. Demographic effects of development projects. Approach to the problem. CentreLatinoamericano de Dernografia, 1990 Series No 11 005:LC/DEMJCRJG.23.5. Pakistan Poverty Assessment. World Bank Report No. 14397. Country Operations Division,.Country Department I, South Asia Region, 1995.6. Wilkins R, Adamso, Brancker A. Changes in mortality by income in urban Canada from 1971 to1986. Health Reports/Rapport’s Sur La Sante, 1989; I: 137-74.7. Stewart KJ. Factors predicting marriage and contraceptive use among adolescents in Kenya.Presented at the Annual Meeting of the Population Association of America, New Orleans, Louisiana,1996.8. Kaplan GA, Salonen JT. Cohen RD et al. Social connections and mortality from all causes and fromcardiovascular disease: prospective evidence from Eastern Finland. Am, J. Epidemiol.,1988;128(2):370-80.9. Khan A. Qureshi AF, Khan SB, et al. Inequities in Urban Health: Differential needs among the urbanpoor in Karachi slums. W.H.O Centre For Health Development, Presented in workshop onDeterminants and Indicators of Urban Health, Kobe, Japan, 1997.10. Basu S. Health and culture among the underpreviliged groups. Health for the Millions. 1992;18:23-4.11. Bergstrom S, Syed SS. Population Control: controlling the poor or the poverty? In: Lankinens KS,Bergstrom S, Makela PH and Peltomma M,eds. Health and Disease in Developing Countries. London,The Macmillian Press Limited, 1994, pp.25-36.12. Rosenfield PL. The contribution of social and political factors to good health. In: good health at lowcost, eds. Scott B. H alstead, Walsh AJ, Kenneth SW. New York. The Rockefellar Foundation, 1985,pp.173-80.

Economic development and health status among the poor in squatter settlements of Karachi.

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Economic development and health status among the poor in squatter settlements of Karachi.

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