Addressing the population explosion - Part I

Pakistan has a population of 220 million people but nowhere close to the amount of resources required to house, feed, employ or in any way provide for these people.

We had committed, during the London Family Planning Summit 2012, that we would increase national contraceptive rates to 55 percent by 2020. Unfortunately, we have been unable to follow through on this commitment, not because we tried and failed but because we never even bothered to try. Like with all issues that require ‘uncomfortable’ conversations, Pakistan effectively keeps sweeping family planning under the carpet too.

As one of the first countries to commit to the FP2020 partnership in 2012, we have taken some steps in the right direction, which merit mention. Health centres have been established across Punjab, Sindh and Khyber Pakhtunkhwa. Provincial governments are developing plans to procure contraceptives. Some policies have been formulated and announced. However, the government’s messaging has been inconsistent and half-hearted, resulting in inadequate awareness campaigns and a population caught between fear and religious conservatism.

The first issue that must be noted is that of budgetary misallocations. In 2016, Pakistan’s health expenditure was around a mere 2.75 percent of the GDP. Budgetary misallocations clearly must be discussed and rectified but it is also important to understand the other important reasons why Pakistan has failed when it comes to family planning. The adverse impact of this failure will be especially difficult to deal with as a result of the current pandemic.

There are three major reasons, in addition to the budgetary misallocations discussed above, why Pakistan has been unable to institute and implement an effective national family planning programme. First, religious and socio-cultural attitudes have discouraged the use of contraceptives and deemed the concept of family planning ‘un-Islamic’. This is an area where we have much to learn from our Muslim neighbour, Iran, which not only revived its family planning programme in 1989, but experienced the positive impact of its efforts in the form of rising literacy rates, addressing water shortages, securing access to healthcare and providing improved quality of health services.

Unlike Pakistan, Iran maintained strong government determination to ensure its family planning programme succeeded. Religious leaders and mosques were actively engaged; the government itself set up a condom factory; a huge number of rural health centres were established; and compulsory premarital contraceptive counseling was instituted. Unfortunately, in our country, right-wing fanatics dictate policy to the government and not the other way around. This brings us to the second major reason for our family planning failure.

In place of attempts to alter the misinformed and hostile attitude towards family planning, there has been a clear lack of political will to engage on this issue. The onus for this falls on each successive government that has neglected this crucial area, whether it was in November 2015, when former prime minister Nawaz Sharif and the chief ministers of the four provinces decided not to turn up at the Population Summit in Islamabad, or the lack of implementation of the National Population Policy in 2010.

In contrast, our neighbours have taken a different path and serve as examples of successful family planning policies. In 1976, not long after East Pakistan became Bangladesh (and found itself in conditions far more dismal than ours at the time), the government of Bangladesh instituted a national policy for population control and family planning. Through this, it focused inter alia on the improvement of the status of women through education and participation in social, economic and political life.

Bangladesh provided economic opportunities to women in rural areas and empowered them, resulting in an increased contraceptive prevalence rate (CPR). Recognizing the limited mobility of rural women, Bangladesh recruited and trained Family Welfare Assistants (FWAs) and male outreach workers to carry out home visits, offering multiple methods of contraceptives, sharing information regarding their use, and maintaining comprehensive records and data. These FWAs have been described as “agents of change in the remote villages as they were the only contacts for family planning for many women” (Ghafur, 2017).

The distribution system in Bangladesh was modernized because the government of Bangladesh recognized the adverse impact of uncontrolled population growth and of gender inequality shortly after the country came into existence. In Pakistan, political commitment on these two issues is severely lacking: we have been unable and unwilling to change attitudes towards family planning or the perception of women in society.

So while Bangladesh in 1990 had 29,0000 female family planning workers actively engaged in service delivery, Pakistan’s family planning initiatives were already suffering as a result of lack of communication and coordination between the Ministry of Health and the Ministry of Population Welfare during this time.

In 1975, Bangladesh had a total fertility rate of 6.3 percent, which was reduced to 3.3 percent by 2000 and further reduced to 2.3 percent by 2011 (as per the Bangladesh Demographic Health Survey). Similarly, between 1993 and 1994, the CPR rate in Bangladesh was around 44.6 percent, which was increased to 53.8 percent between 1999 and 2000, and further increased to 58.1 percent by 2005.

Many studies conducted on Bangladesh’s family planning programme demonstrate that even though there have been fluctuations in CPR, a combination of other measures have led to decreased fertility rates. This serves as an example of how family planning involves not just increased provision of contraceptives and information on the same, but also improvements in access to education, economic opportunities and maternal health services.

The United Nations Population Fund has highlighted that Pakistan has one of the highest maternal mortality ratios in South Asia. In 2015, Unicef issued a report highlighting Pakistan’s maternal mortality ratio (per 100,000 live births) as 178 deaths, while the neonatal mortality rate (per 1,000 live births) was 46 deaths. In 2015, around 5,500,000 babies were born in Pakistan – an average of around 14,900 babies per day. Major causes of neonatal deaths include prematurity, birth asphyxia and trauma, and sepsis.

Several reports have highlighted the key reasons for Pakistan’s extremely high rate of maternal mortality, which include inter alia poor and inadequate access to medical/health care services, child marriages and lack of family planning. In contrast, between 1975 and 2014, Bangladesh saw a sevenfold increase in its CPR from 8 percent to 62 percent.

This, of course, underscores the need for coordinated cross-sector efforts in education, general health services and employment generation, which brings us to the third major reason for Pakistan’s failure with respect to family planning, which will form the subject-matter of the second/final part of this series.

To be continued

The writers are lawyers.