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PAKISTAN: More Action, Less Words, Needed to Ease Population Bulge

Zofeen Ebrahim

KARACHI, Pakistan, Jul 6 2010 (IPS) - While militancy, power outages and skyrocketing food prices hog the limelight in parliamentary and media discussions in Pakistan, health experts warn that it is a neglected issue – the population bulge – that will prove to be a more insidious problem.

Population is the “denominator for everything”, says Sania Nishtar, president of Heartfile, a think tank considered a powerful voice for health policy in this South Asian country.

According to the latest Pakistan Demographic and Health Survey 2006-07, Pakistani women have four children on average. This trend will see Pakistan’s current population of 180 million balloon to more than 450 million by 2050.

Pakistan’s population growth rate needs slow down further from the current 1.56 percent increase each year, to match the country’s existing resource base and maintain its development path, says the Pakistani Ministry of Population Welfare.

To this end, the National Population Policy 2010 includes the reduction of the total fertility rate to three births per woman by 2015 as one of its objectives.

With proper reproductive health policies and support for women’s needs, Pakistan’s population could be kept to a more manageable 335 million by 2050, predicts the United Nations in its latest mid-range demographic projections.

But with 84 percent of Pakistani women not using any modern family planning methods, it is an uphill battle to achieve lower population growth rates.

Kuslum Bibi, 38, desired only two children, but did not take any preventive measures after the birth of her second child. A domestic worker, she got pregnant a third time while still nursing her second baby. “I was told by my sister-in-law that I was quite safe during the nursing period,” she explains.

Bibi believed that both oral pills and injectible contraceptives cause weight gain. “I’ve also heard that the coil (intrauterine contraceptive device) causes heavy period flow,” she says.

“Many Pakistani women and men regard continuing contraceptive practices more threatening to their health than an occasional induced abortion,” states the government’s report.

Apart from having perceived side effects, the use of contraceptives is not quite endorsed by many say religious and social norms. Experts say these fallacies surrounding contraception need to be cleared before more women will visit family planning clinics.

This also points to a gap in the country’s previous approaches to population policy: paying attention to women’s needs so that they feel comfortable about seeking advice about family planning choices and discussing their reproductive health.

“Non-availability of staff”, “lack of supplies”, and a “lack of trust in family welfare workers who are not well-trained and cannot provide women the support they need” create bad experiences that inhibit Pakistani women from visiting government family planning clinics, even though they might want to limit their family size, explains Farid Midhet, a Pakistani who heads medical research at Qassim University College of Medicine in Saudi Arabia.

Family planning does not end with simply prescribing a drug, Midhet continues: “It requires follow-up services which are not there in Pakistan.”

Distance to the family planning clinics is also a factor . “In Balochistan province, the average distance to a clinic is 48 kilometres,” Midhet says in an email reply to IPS.

Pakistan’s current draft population policy has gone through almost two years of rigorous revisions. It was presented to the Cabinet in June, and awaits a nod from the prime minister.

Other objectives to be achieved by 2015 include ensuring universal access to safe family planning services, reducing by two-thirds the number of women who give birth before 18 years of age, and reducing by 50 percent the proportion of mothers giving birth beyond 34 years old.

However, many remain sceptical that the National Population Policy 2010 will translate into any action.

“It went through much consultation, but the end result is a policy that is just words, like previous policies,” says Zulfikar A Bhutta, chairman of the department of paediatrics and child health at Aga Khan University Medical Centre in Karachi, and co-chair of Countdown to 2015, a global scientific and advocacy group tracking progress toward maternal, newborn and child health.

Although the policy alluded to governance issues and “implicit corruption”, it fails to offer any solutions to resolve, Midhet adds.

While it is “all-embracing in its approach from a theoretical standpoint”, Nishtar says, “articulating a policy is one thing, its implementation entirely another.”

Over the years, Pakistani government policies to slow down the population growth rate “have never been honoured,” says Nishtar, who wrote a book on health reform entitled ‘Choked Pipes’. “The state doesn’t have the institutional rigour or the fiscal space to implement the commitments,” she adds.

However, Bhutta points out one success story – the Lady Health Workers programme, whose army of 100,000 female primary healthcare workers provide basic family planning services to women door-to-door.

Bhutta doubts that Pakistan will be able to meet the fifth Millennium Development Goal – reducing by 75 percent the deaths of women related to childbirth and providing universal access to reproductive health – unlike its neighbours Nepal and Bangladesh.

“Unless there is a political will to do so,” Bhutta says, “maternal health will remain where it is. We would need more than a few magic bullets, and a lot of health systems strengthening”.

Among the more immediate things to undertake, advocates say, is a population census. One has not been conducted since 1998.