Addressing the Population Explosion

Imaan Zainab, Mazari-Hazir

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

Steps Taken So Far: 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 centers 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.

Issues: 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 program. 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.

While resources are scant, those that have been allocated towards family planning have not been utilized appropriately. There has been ample research reflecting Pakistan’s dismal service delivery.

In 2019, Pakistan had a CPR of 34 percent, in contrast with India’s 56 percent and Bangladesh’s 62 percent. Many experts in the field have highlighted poor service delivery as the cause for low CPR in the country, due to which the poorest of women in Pakistan, mainly residing in rural areas, are adversely affected. In fact, research also indicates that only one third of married Pakistani women use some form of birth control.

So while abortion is illegal in Pakistan, our state’s inability to protect women led to around 890,000 induced abortions in 2002 (it must be noted that these are just the reported instances). The health complications unwanted pregnancies and induced, unsafe abortions cause for women in this country have been documented at length. In fact, in 2002, around 197,000 women were hospitalized in Pakistan as a result of complications culminating from unsafe abortions.

As per the National Institute of Population Studies, in 2018, the most commonly used contraceptive methods in Pakistan were condoms and female sterilization. The government of Pakistan is the largest provider of contraceptives in the country, so it is directly responsible for its failure to not only improve service delivery, but also its failure in making available more contraceptive methods.

While the Iranian family planning programme is light-years ahead of what we in Pakistan can emulate, one of its key reasons for success was because of its targeting of the most remote, rural locations. Its rural health houses and mobile clinics now cover over 90% of the population.

It is perhaps understandable why Pakistan’s political governments do not take the necessary measures to ensure effective family planning across the country, but this foolish populism has cost us and will cost us even more dearly in the future unless we reform. There is a clear discrepancy between our international commitments and the work actually carried out on-ground.

What is required urgently is a comprehensive and coordinated policy, with clearly identifiable principles and goals. All the way from the top, from the Prime Minister’s Office, to the grassroots level, of health centres, a concerted effort and commitment is required to emphasize the urgency of the situation. Innovative ideas and approaches are the need of the hour, as there are evidently loopholes in monitoring service delivery.

Involving the media, academics, NGOs and CSOs in awareness and advocacy on the issue is equally important. This is particularly crucial with respect to dissemination of information on contraceptive methods. At present, people are unable to make informed decisions regarding contraceptive methods due to a lack of information concerning use and side effects. Moreover, we must simultaneously improve our data collection, whether through the Pakistan Bureau of Statistics or through planning departments at the provincial level.

The lack of leadership commitment at the highest level would ordinarily indicate that perhaps there is little voter support for family planning. However, at present, we cannot draw any definitive conclusions on that front. What is required immediately and on a priority basis is a baseline survey on reproductive age groups, premarital concepts regarding family planning, post-marital approaches to family planning, etc. A knowledge, attitudes and practices (KAP) survey needs to be carried out across the country to assess what current behaviours and attitudes towards family planning are.

There has been input from experts in this area through several research articles and studies, including a 2015 KAP study of married men and women in rural Pakistan, which provides important insights into the issue. The 2015 study highlighted how around 28,000 women in Pakistan die annually as a result of pregnancy-related complications. Moreover, the study identified that only half of the deliveries in Pakistan occur in the presence of a skilled health provider, while rural and less educated women are less likely to receive skilled care.

In fact, the average distance to a reproductive health facility in Pakistan’s rural areas is greater than that to urban areas, which effectively renders these health facilities useless for rural women who do not have transportation or finances. Another important fact the 2015 study highlighted was that over 70 percent of our population tries to access private sector healthcare, thus reflecting an appalling lack of both availability of and confidence in public health facilities.

Our own demographic and health surveys reflect that neonatal mortality rate in Pakistan has remained largely unchanged in the last fifteen years, with such mortality most prevalent in Punjab, then Sindh, followed by Khyber Pakhtunkhwa and lastly Balochistan. There is also an unmet need for contraception (around 20 percent). Adding to these problems are the socio-cultural constraints on women in the country. There is a lack of communication between spouses with respect to family planning decisions, immense interference from in-laws and ultimately men in Pakistan have final decision-making authority with respect to women’s reproductive health rights (something that cannot possibly be condoned in the 21st century). None of this has been discussed by any government, let alone redressed.

In fact, each successive government’s messaging on family planning has fallen short. Perhaps that is partly also because our leadership does not understand the far-reaching implications of this population explosion on our resources, the law and order in the country and our international standing.

Our population is expected to swell beyond 300 million by the year 2050. We have the highest growth rate in the region. Then why is it that family planning is not at the top of any government’s agenda? That very reality reflects our inability, as a collective, to take this seriously or to understand the implications of failed family planning approaches on female literacy, maternal mortality, infant mortality and neonatal mortality.

As a result of Bangladesh’s family planning programme, the country has experienced a huge reduction in child mortality rates (barring some problems they are still struggling to address vis-à-vis the rate of under-five mortality). In fact, between 1990 and 2010, there was a reduction in maternal mortality in Bangladesh from 574 deaths per 100,000 to 194 deaths per 100,000. The decline in maternal mortality was attributed to a reduced total fertility rate, increased and improved service delivery, improved access to health services, improvements in female education and increases in per capita income.

Conclusion: Pakistan’s family planning strategy needs a jumpstart and revamp. At this stage, we cannot afford the Government’s messaging being poorly framed and targeted, as per routine. The government must involve communication experts in its messaging on family planning. Clearly, the “kam bachay, khushaal gharaana (fewer children, prosperous home)” is not helping with our family planning programme. Our unabated population growth is a time bomb waiting to explode and will affect us in ways we have not even begun to imagine due to the shortsightedness of our leadership.