THERE may be a great deal of talk about poverty alleviation but we have not been able to do much about it. There are two main reasons. The first is that left to the market, without appropriate government intervention, income disparities tend to increase. There is some sort of a trickle-down effect, but it is so slow as to be imperceptible.

The other is that the population of the poor has tended to increase faster than the population of the better off. This increase has resulted from the efficacy of modern medicine which has brought the death rate down and also decreased child mortality.

Because of these developments between 1951 and 1972 the average annual growth of population rose from 1.8 per cent per annum to 3.6 per cent per annum. It has since declined to around two per cent per year. Between 1951 and 2001 the population grew from about 30 million to 150 million within 50 years. The multiplication of the low-income population has progressively increased the pressure on already inadequate social services such as education, health, sanitation, potable water, etc. and has led to general environmental degradation. The result is a paradox. More of the poor live longer, the more miserable their existence.

For poverty alleviation to be taken seriously, two things are necessary. Development plans for each sector should indicate the number of jobs expected to be created. The other issue which is perhaps more important is the reduction of population growth. Coordination and linkages between population growth and other relevant sectors is essential. Complementary alliances with credible institutions within the public and private sectors are necessary to build adequate momentum for this purpose. Without a strategic multi-sectoral approach a strong multiplier effect cannot be generated.

To improve the quality of life of the poor, one needs to promote amongst them a voluntary desire to have smaller families which can be provided with better nutrition and care. This automatically reduces the pressure on the provision of supporting social services such as education, health, etc. Unfortunately, the old concept of birth control or family planning seems to have run head on into concepts of political correctness. It was therefore transformed into family welfare and population welfare and has finally come to rest after the ICPD conference of 1995 as reproductive health, which is so vague that nobody quite knows what it means. However, as far as we are concerned, the simplest is to take it back to its original meaning, namely birth control and family planning. That is what I have been involved with, off and on, for the last 30 years.

The other problem which happened fairly early with family planning was that it was handed over to the medical profession. Family planning has something to do with medicine but it is essentially a social welfare issue. Doctors are not particularly interested in promoting birth control. As a matter of fact, pregnancy and birth are likely to be more financially rewarding.

Because this problem has been handed over, at least in theory, to the medical profession, it does not get the kind of guidance and leadership required. One of the supposed advances in Pakistan was the handing over of family welfare workers to the ministry of health to be merged with their Lady health Workers (LHWs) programme.

The LHW programme is not doing particularly well, besides family planning is not one of their priorities. Attempts to improve matters have resulted in all kinds of complicated proposals for greater coordination between the ministries of health and population welfare. In practice, these are not likely to work. The focus of the ministry of health is on drug quality and pricing, the medical and allied professions and in the supervision of some large hospitals.

The provincial health departments are focused on medical teaching institutions and nearly all hospitals in the public sector. Rural health tends to be neglected along with family planning which is highlighted by the low contraceptive prevalence rate (CPR) in rural areas.

The obvious thing to do is to amalgamate rural health and population welfare at the grassroots level under a department of rural health and population welfare at the provincial level. The change would be reflected at the federal level also. In effect, this would mean combining the ministry of population welfare with a newly created ministry of rural health, with the necessary consequential adjustments in the field.

The two biggest and most successful proponents of birth control in the UK and the US were Marie Stopes and Margaret Sanger — neither were medical doctors. When practising nursing on the Lower East side of New York City, Margaret Sanger witnessed the close relationship between poverty, uncontrolled fertility and high rates of infant and maternal mortality. In 1914 she published “Birth Control Review” and opened the first birth control clinic in Brooklyn in 1916.

For doing so, Margaret Sanger was chastized by the authorities for maintaining a public nuisance. In the same vein, 20 years later, in 1936, a federal court classified contraceptive literature and devices as obscene material and only allowed physicians to prescribe contraceptives to patients who, in their opinion, needed them. The efforts of these two pioneers are represented in Pakistan by Marie Stopes International and the Family Planning Association of Pakistan which is affiliated with the International Planned Parenthood Federation founded by Margaret Sanger.

Pakistan’s programme is behind India, Bangladesh and Sri Lanka’s but it is not an absolute failure. From a contraceptive prevalence rate (CPR) of about 12 per cent in 1990-91, we had achieved a contraceptive prevalence rate of about 30 per cent for modern methods by 2004: but this is not good enough if our ambition is to stabilize population growth by the year 2015: which means that a fertility rate of a little less than four has to be brought down to about two within the next 10 years — the average number of surviving children to all women throughout their reproductive age.

At present, according to government statistics which are biased in favour of government efforts, two-thirds of the national programme for promoting modern contraceptive use is done by the government and one-third by the private sector. The real proportion may nearly be half and half. As a result, there is a great deal of talk about public-private partnership, but the specific proposals for doing so are moving far too slowly. It is the first time that the government has woken up to this possibility, but it is still too novel a concept and a great deal of humming and hawing is going on in the relevant ministries.

NGOs are divided into two groups — FPAP and Marie Stopes who operate through their own clinics and the two social marketing organizations which operate largely through the private sector. There is a difference in social marketing also. One model promotes existing manufactures of contraceptive material. The second sells its own branded products at subsidized prices.

International experience seems to indicate that the manufacturer’s model is more suited to middle income countries. Subsidised sale is more successful in low-income groups. In the NGO sector, the social marketing organizations provide 75 per cent of private sector contribution to contraceptive use. The evaluation is done through couple years’ protection (CYPs). Each contraceptive method has a certain weight estimated on its effectiveness over a year of use.

According to present surveys, there is an unmet need in 30 per cent of married women of reproductive age who want to practise family planning. The problem is not so much a lack of demand as it is a lack of supply. The problem is more acute in the rural areas which have a much lower CPR. In urban areas it is around 40 per cent and in the rural areas about 20 per cent as estimated in 2001.

The largest demand appears to be for voluntary surgical contraception which means that women think they have achieved the desired family size and want to avoid further pregnancies. Unfortunately, this is the most difficult to organize. The lady doctor has to be trained in the surgical technique, but the more difficult part is setting up the physical facility, i.e. an operating theatre which ensures a sterile environment. In rural areas, the logistics of travel between home and the clinic present a serious hurdle. Mobile surgical units are an answer, but they are expensive and difficult to manage efficiently.

The problem, mentioned earlier, which Margaret Sanger had with the authorities, was the result of attitudes embedded in American society. We have a similar attitudinal problem in Pakistan. There is little religious hostility and family planning is widely accepted but people, nevertheless, feel shy about openly supporting it. For instance, the organization I am associated with rented a place for a family planning clinic.

However, as soon as the landlord discovered its purpose, he revoked the agreement, as the neighbourhood was averse to such a development. The same happens with philanthropy in the private sector. They are prepared to contribute time and money towards education and health and other good causes, but they feel shy about family planning: although large families amongst the poor is the main cause of problems in the social sectors.

The same attitude is reflected in the government. The present government has thrown money at it. However, the government has not given it administrative priority. For example, since the beginning of the year 2000 we have the seventh secretary of the ministry of population welfare, and it is not unlikely that we may soon have the eighth.