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Editorial world
population day Productive
services comparison Foreign
resolve
Population as an impediment in economic development or population as a human resource? Different countries have followed varied examples and become models of development and prosperity, thus raising the living standard of their people. We, unfortunately, messed up pretty badly on the population front, too, and turned what could have been our best asset into our biggest disadvantage. Today, Pakistan is the sixth largest country of the world population wise but our social development indicators are the lowest. We cannot feed or clothe or educate our population. Any policy initiative faces a daunting challenge of massive number of people and becomes a non-starter. Like other areas, we sell this disadvantage to the world and get foreign aid in return. From the United Nations to USAID to DFID, the entire world is keen to help us get our priorities right and for decades now. But aside from the world of figures and slogans like "reproductive health", "birth spacing", "women empowerment" etc. the reality is stark. The drawing room discussions about the effectiveness of the message as well as the tools of reproductive health reaching the common people ring hollow the moment you step out into say a slum not far from your house and start hearing people's stories. In a slum, you get a chance to understand that in our country most women get married as little girls and then they produce children. They have not heard of any family planning measures and when they finally do, it's too late. The husbands do not figure anywhere in the discussion, nor does religious conservatism. Often, the message of the abortion clinic in the neighbourhood reaches them long before the LHV and her preventive solutions. Women die in child birth and at illegal abortion clinics and so do children. This is the real story of the Pakistan's overpopulation problem. This does not figure in any of the fancy conferences held in the country on the subject. Ironically, the Eastern part of the country which seceded from Pakistan on the issue of population (it was the majority province) has now controlled it and shows better social development indicators than us. If nothing else in the world can teach us, we should be willing to at least learn a few lessons from Bangladesh.
world
population day It is only two
years that Zohra, 42, has started using a contraceptive injection every
three months from “Green Star” but not before giving birth to nine
children and marrying off three of her daughters. She used to live in a
village near Kasur and had not heard anything about family planning or
contraceptives. “After coming to Lahore
some fifteen years back, when I started cleaning work in people’s houses,
I did get about four DNCs done,” she says referring to the abortion
facilities she availed. This is the story of
Katchi Abadi near Basti Saidan Shah in Lahore. On either side of the rail
track, are one room abodes of thousands of people. You could safely call it
a slum even if it’s less than a few hundred yards from a posh residential
area. The average number of children per family here are five to six. In the
morning, most women leave their kids at home and go to work. Some don’t.
They stay back with their children. Like a million such slums
in this country, this is a useful area. It is in places like these that any
kind of research on the effectiveness of the population policies and the
dissemination of the message must begin. And it is here that all analyses
and discussions on the issue of overpopulation have a chance of being
defeated before they even begin. Pakistan, world’s sixth
largest populated country, is still facing a high growth rate — 2.2 per
cent — and moving quite slow in controlling the increasing population. The
progress is described as ‘modest’. Among the top ten
contributors to world population growth during 1995–2000, Pakistan stood
third in absolute number, and was on the top in growth rate. According to global
projections, Pakistan was at number 13 with 40 million people in the 1950
while it reached at number seven in the world in 1996 with 140 million
people. United Nations’
Population Division projections show Pakistan as the third largest populated
country in the world by 2050 with 357 million people, leaving behind America
and following India and China. An effective population
policy must address reduction in the rate and incidence of unwanted
fertility; reduction in demand for big families, and large investment in
adolescents. Altaz Ezid Khan, Punjab
secretary for population welfare and planning department, highlights
multiple challenges to properly implement population policies and
strategies. “The biggest challenge is changing the mindset of people
through education and media, etc,” he says, adding, “Funding, training
and teaching adolescents at school and college level is a must.” Khan believes population
planning should not be taken as a clinical issue but as a social issue. The
current growth rate of Pakistan is 2.2 per cent, which ideally should be in
one digit. It was five per cent in the 1960s. He says population planning
programme remained neglected in Ziaul Haq’s regime. “We need to learn
from Bangladesh,” he urges. Here, in the slum near
Basti Saidan Shah, most women talk about one Kishwar who often comes and
administers vaccines to their children as part of government’s
immunization programme. She gives multi-vitamins to pregnant women and free
contraceptives, which many of them refuse. Zohra says her husband
knows nothing about contraception and can’t be bothered while she is happy
with the 50 rupee injection that prevents further pregnancies. Sharifan, 32, has five
children, four of whom are boys. She would rather have another daughter but
regrets she “cannot conceive now because my husband is old”. She, too,
meets Kishwar but has never used any contraceptive in her entire life. A 35-year old Najma has
five children. Her husband married another woman and left her and their five
children. She has remarried and would rather have more children because her
“new husband needs them”. Najma also availed abortion facilities in her
first marriage and not any preventive measures ever. The 40 years old Parveen
has no house to live on. She shows me her cot lying beside the rail track
where she lives with her one crippled daughter. She got married at the age
of twelve and gave birth to twelve children, without having a clue about
birth spacing or contraception. “How could I? I was also a child,” she
says. It’s been some time that her husband moved out with their ten
children to his mother’s house. Parveen, now left alone with one girl and
with no work in hand, lives with no roof over her head. Pakistan’s population
control framework started in 1965 with the creation of population welfare
department at the federal level. This is known as the best days of the
programme, from 1965 to 1969, during the era of Ayub Khan. Religious parties
protested against family planning, playing an important role in ending
Khan’s rule. Pakistan launched one of the first population control
programmes in the late 1950s, yet it has lagged far behind other countries
in effective implementation over the past five decades. It never had an
effective and comprehensive family planning policy till 2002. Based on fertility trends
of the 1990s, Population Policy 2002 projected to bring down fertility rates
by 2020. The National Population Policy 2010 draft, which is yet to be
approved by parliament, seeks population stabilisation goal through early
completion of fertility transition and facilitates realisation of
demographic dividend by linking fertility transition process with skill
promotion and employment generation policies. The policy repositions
family planning from health perspective and focuses on the attainment of
Millennium Development Goal of reducing maternal mortality by two-thirds by
2015. Pakistan started adapting
the contraceptives and related surgeries after 1994’s International
Conference on Population Development in Cairo. From 2002, the country
created provincial level secretariats and ministries for population welfare.
The federal population
ministry was devolved after the 18th Amendment in the Constitution, making
population a provincial subject. However, the federal government would
continue to financially support these departments and ministries by 2015. “Policies and strategies
are not very effective because people are not fully aware of the issue,”
says Kashif Mukhtar Abid, a district level population department officer
working in the Punjab. “Currently, our target is to bring the growth rate
at 1.3 per cent in the next few years and the focus is on one-mother,
one-daughter,” he says, adding, “Unwanted pregnancies for getting a male
child is a problem in our society. Policies need to be properly implemented
and funded as well.” Abid says the ratio of
contraceptive adoptability is 34 per cent at the moment. According to him,
low use of contraceptives, shyness to adopt family planning methods, want of
a male baby and religious factors are some of the challenges in achieving
the targets. “The subject of reproductive health and population should be
included in school and college level syllabus,” he suggests, adding, “In
Punjab, the population welfare department is running 1500 male and female
mobilisation centres providing training. Women of this slum in
Lahore seem to know nothing about population planning policies implemented
so far in the country. Their only brush with any policy endeavour is in the
shape of Kishwar and that too is half-hearted. They are obviously clueless
if population growth hampers economic development but they have no idea if
it affects their own or their children’s health. Yes, they do occasionally
see the mashoori (advertisement) on television but that’s about it. “Yes. There is an urge
in the society for population planning but there are no resources, proper
training and quality services,” says Dr Attiya Inayatullah, founder of
Family Planning Association Pakistan. She considers effective implementation
of policies and strategies as key to meet the challenge of population
planning. “Implementation of the policies is literally at zero level,”
she says, adding,” Political will, administrative priority, availability
of resources and quality services at the doorstep, employment for youth,
effectively inculcating family planning in health programmes and ownership
of policies and strategies at the provincial level are the main challenges
after 18th Amendment.” She says Pakistan obtained
“demographic dividend” in the 1998 census, which means people who earn
are more in number than the beneficiaries. Unfortunately, Pakistan has lost
the fruits of this dividend. Population is growing at the rate of 3.2
million every year, according to official statistics. Attiya says Pakistan is
losing this one-time opportunity. Eighty two mothers die in Pakistan every
day due to pregnancy complications. “Almost 60 per cent couples of
Pakistan want family planning while 30 per cent are able to meet this task.
Pakistan’s drop-out ratio of couples for family planning is highest in the
Subcontinent due to poor services,” she maintains.
Productive
services This year’s
theme of World Population Day is universal access to reproductive health.
This was the theme last year as well. Staff members at the
Population Welfare Department centres in Punjab and elsewhere, keeping in
view the theme, assess the needs of the people who come to them for help and
provide them services accordingly. It is important to know
that some contraceptives at the Population Welfare Department (PWD) centres
cost as less as 50 paisas only. A family welfare assistant
at a PWD centre in Muhammad Nagar Lahore, Memoona Nausheen, says, “There
are solutions to everyone’s problems and people are becoming aware of the
need to safely keep the family small, so more people are seeking help in
planning family.” “We go for ligation —
a procedure for females that ends reproduction for good — when we see that
the family is complete and the youngest child is at least five year old. The
consent of both the partners is important here,” she says, adding, “Both
men and women can have ligation but the number of women actually going for
it is more as compared to men having vasectomy.” “With any complications
we suggest ligation because putting anything inside the body doesn’t
work,” she explains. Most commonly women
complain of unsafe sex and now they need help. “In that case, we give them
medicine which can be taken within 72 hours to prevent conception but we do
not give that medicine to a person more than three times in a year because
it has side-effects,” the health worker says, adding, “We are into
reproductive healthcare and receive ante-natal and post-natal cases as well
and give them medicines. Rarely, women come to us for delivery cases but if
they do we provide them this service as well.” Another health worker at a
Falahi Markaz in Islamabad advises women to go for ‘multi-load’ to
prevent conception as she considers it the best method for family planning
because it is safe. “It’s a round device made of plastic which is placed
inside women. You can safely prevent conception for ten years with this
device. I advise against Copper-T as it has many side-effects. It does not
suit at least 60 per cent of women as many women have reported discomfort or
infection later,” says the health worker who has over two years of
experience at a Falahi Markaz. After the device has been
placed inside a woman, she advises her not to crouch or lift a weight, nor
pull oneself up on feet for a week. “Do not lift a fan, a charpoy, a pail
of water — just anything heavy,” she says. She also warns against having
sex for 8 days after placement of this device. At a Sabz Sitara facility,
a multi-load is called ‘safe star’. “Only a trained doctor or nurse
can place this device right. Untrained hand results in wastage as the ring
comes out sometimes if not placed properly,” says the health worker at a
health centre in Islamabad. Health worker at the
centre says it is important not to place contraceptive if there is an
infection. “The infection has to be treated first,” she says, adding,
“People are more aware now.” There was a chart on
display at the Lahore centre. They were respected citizens: teachers, social
workers, dais and clients, their phone numbers written before their names.
It was heartening to know that people who have benefitted, are showing the
way to more people. While the worker at the
Lahore office said more people are coming and the service is given for free,
the health worker at the Islamabad office disagreed, “The services are not
for free everywhere.” “All welfare centres are
supposed to show that they have treated at least 30 cases in a monthly
meeting but if that is not the case the staff is supposed to go out and
communicate with the people to convince them for ligation,” says the
health worker requesting anonymity. “Since Falahi Markaz is
meant for poor sections of society, the services they offer are for free.
They are not supposed to charge but it is not so,” she says. The
25-year-old Islamabad-based health worker who is married, says the Markaz
receives at least 2-3 abortion cases every day. “While these centres are
not supposed to provide this service the society needs it,” she says. Overall, thousands of
Population Welfare Department centres in the country are under-utilised.
Many government hospitals are providing family planning services. So, if we
want the Centres to function to their optimum, the presence of a doctor is
imperative.
comparison At the time of
Bangladesh’s independence from then West Pakistan in 1971, its population
was approximately 69 million; compared to that Pakistan’s population stood
at approximately 61 million. A uniform family planning policy was in place
across both sections of the country and the fertility rate was almost
identical at 6.85 children per woman. Fast forward to 2011, and
in an ironic reversal of the situation Pakistan has far exceeded
Bangladesh’s population at 179 million and 152 million respectively. In 2010, Bangladesh’s
total fertility rate (TFR), i.e. the average fertility rate of the country,
was approximately 2.7 children per woman. In the same year, Pakistan’s TFR
was at 4.0 children per woman. Bangladesh’s success with lowering its TFR
is considered a successful model by population experts for other high TFR
countries to follow. How is it that two
countries that went down diverged paths from the same FTR standpoint have
had such different rate of success 42 years later? Ironically, Pakistan was
among the first countries in the region to develop a full population
planning programme back in the 1960s when Bangladesh was still a part of it.
But according to Dr Durre Nayab, director of Centre for Population, Health
and Social Policy at Pakistan Institute of Development Economics, we fell
short of the “planning” aspect of the programme. “Our stress has been
on the supply side of the issue (like provision and access to
contraceptives),” says Dr Nayab, “without giving any thought to the
demand side”. Contrarily, the Bangladesh
government, immediately after its independence, made it a priority to curb
population growth and implemented large-scale effective policies over the
next decade. A large part of its focus was helping couples change their
attitude towards using contraception. As a result, its TFR dipped down to
4.7 as early as 1989 while ours remained stagnated at about 6. A couple of steps the
Bangladesh policy makers took are considered fundamental in its reaping
long-term benefits. First, the government trained and deployed over 23,000
female field workers to go and talk to women in the privacy of their homes.
This “doorstep delivery system” helped women who, owing of limited
mobility due to societal constraints, could not visit family planning
centres. Additionally, financial rewards were given to couples for
sterilisation. Pakistan has developed a
similar network of lady health workers, but their effectiveness and
efficiency is not considered to be at the same level of those in Bangladesh. Second, the government
provided vast-scale maternal and child healthcare services (MCH services).
In the 1980s, it developed Programme on Immunisation (EPI) that is
considered one of the best in South Asia. Currently, the programme’s
coverage of children under two years is nearly universal. This has helped
with lowering the TFR as studies have found that the rate of under-five
childhood mortality can influence the parents’ decision to want to have
more children as an insurance that they will end up with the family size
they desire. While Bangladesh has been
able to bring its rate of under-five deaths down to 49 deaths per 1000 live
births, Pakistan’s is still stuck in the 70 plus range. Thus, high
mortality rate is also a contributing factor to parents wanting larger
families. Additionally, the
Bangladesh’s changing socioeconomic situation — increasing rate of
female education and female employment — is also quoted as reason for its
lower TFR. Dr Nayab believes women
empowerment is the key to changing attitudes towards family size and part of
the bigger picture that we have not yet been able to address. It is
important to ensure contraceptives methods are readily available, but it is
now more necessary to focus on creating a demand for these methods. “As we
[now see] in Bangladesh… females are economically more active and involved
in occupations where having children is a hindrance in their jobs,” she
says. Similar phenomenon can be
seen in Pakistan among the more educated and working women. There is a
demand for smaller families for such women and their spouses because larger
families interfere with the economic opportunities the women have. Once
women of lower socio-economic classes are similarly empowered, it will
automatically be in their interest to have smaller families.
Foreign
resolve Foreign aid for
family planning in Pakistan has played a vital role in achieving family
planning targets. The idea behind the support is to strengthen the
government infrastructure already in place and support government policies
on the issue. Organisations like the USAID and DFID have played their part
over the years, offering sufficient financial support in aid. International donors and
their local counterparts in Pakistan agree that the flow of aid for
government and non-government organisations largely depends on the
credibility of the organisation and the practicability of a project in terms
of achieving targets. Experts say while funding
has poured in for family planning in Pakistan over the years and there is
likelihood that it would continue coming in for the future, a lot will
depend on the willingness of the government to realise the importance of
family planning as INGOs and other funding organisations cannot replace but
only strengthen the government resolve and infrastructure. Funding organisations also
see family planning as a human rights issue. William A. Ryan, Regional
Communications Adviser for Asia and the Pacific, United Nations Population
Fund (UNFPA), replying to a question on email says, “International
agencies and donors that provide assistance for family planning activities
(in Pakistan or elsewhere) generally support the global consensus that being
able to determine the number and spacing of one’s children is a human
right, and that enabling couples and individuals to choose to have smaller
families can contribute to slower population growth and poverty
alleviation.” Ryan believes Pakistan has
to do a lot to catch up with other countries in the region as far as family
planning is concerned, “Pakistan lags behind most of its neighbours in
enabling people to access voluntary family planning services, and this is
reflected in higher fertility and population growth rates.” But he has not lost hope,
“However, Pakistan can make progress and catch up with greater political
commitment and policy coherence; increased resource allocation for family
planning and women’s health, education and women’s empowerment; and
provision of family planning information and services in all health
outlets.” Ryan talks about how
donors measure effectiveness of family planning measures, “Providing
access to contraceptive information and services contributes to increased
contraceptive prevalence and lower fertility rates, and these are two
outcome indicators used to measure the effectiveness of family planning
programmes. At the 1994 International Conference on Population and
Development, 179 countries agreed that family planning programmes should be
about choices, not targets.” He also points to a system
of transparency and accountability for local NGOs to qualify for foreign
funding, “All government agencies, NGOs and private sector agencies
receiving UNFPA assistance are required to account for their spending to
ensure that it is being used properly. UNFPA implementing partners are
regularly audited to ensure compliance with UNFPA policies and
procedures.” Government departments and
agencies have to fill in the critical slots for achieving the desired
results. Shahzad Ahmad Malik, Chief Population and Social Planning section,
Planning and Development Division, Government of Pakistan, tells how
government and international donor organisations have worked together to
achieve population planning targets. “For the government of Pakistan,
“healthy timing and spacing of pregnancy” as it is called, is a priority
issue. So, under the USAID Deliver Project, for instance, we have
contributed towards improving reproductive health, keeping in view women
empowerment. Since January 2010,
the USAID Pakistan’s project has helped sustained commodity
availability.” Malik gives some
statistics, “The project has provided commodities worth $52 million. USAID
has pledged for the assistance of $147m for the period 2010-2014 in the form
of soft and hardware support, supply chain, and health commodities and
contraceptive commodities. Its contraceptive support aims to avoid 7.7
million unintended pregnancies and saving the life of 200,000 infants and
8,300 mothers, during this period.” He says donors’ help is
mainly directed at building up the much-needed infrastructure where there is
none, “The project we are talking about focuses on extension and
improvement of warehouses, increasing storage capacity by 125 per cent at a
cost of PKR 300 million, automation of 143 districts of Pakistan on
Logistics Management Information System (LMIS), computerised contraceptive
reporting system, development of Contraceptive Procurement Manual and
establishment of “Procurement and Logistics Cell at the provincial
headquarters. Malik says the
accumulative impact of such a mechanism is timely availability of the
contraceptives to the clients, on which the success or failure of any health
programme depends. There are factors that may
affect flow of foreign funding in the family planning area. According to
Zulfiqar Ali, Documentalist, Information Resource Centre at the Family
Planning Association of Pakistan (FPAP), foreign funding in the family
planning has somewhat dwindled over the last five years or so due mainly to
the law and order situation in the Khyber Pakhtunkhwa and elsewhere. There are two main reasons
that affect foreign aid in family planning. “An NGO’s capacity and
credibility and the internal situation of a country, such as terrorism, etc.
“We have seen projects being called off on the request of donors because
the situation on the ground did not permit implementation as the staff’s
security was at stake,” says Ali. capiton Courtesy USAID.
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