Yasmin has five children and she is just 27 years of age and has been married for nine years. The youngest son was born in July last year and was unplanned. In fact Yasmin had been quite happy with the one boy and three girls she already had.
When she came to me to break the news, she just said, “Baji, I have a problem.” These words captured succinctly the failure of the population planning programme in Pakistan. How else would you put it when a woman is saddled with an unwanted pregnancy, besides poverty and lack of education?
Over the years, the various governments in office in Pakistan and the mass media have done a great job in creating awareness of birth control and the need for small families. The clock cannot be turned back. Many surveys prove that millions of married women of reproductive age (MWRA) in Pakistan who already have a few children do not want any more — and yet they feel helpless when it comes to preventing more births. They constitute what is termed the “unmet need”.
The conventional wisdom that religion has a part to play in this has also been proved to be wrong. It is known that women are not influenced by the clergy, a section of whom insists that family planning is a sin. Yet the myth persists. The Pakistan Demographic and Health Survey (PDHS) 2007, the last such documentary evidence recorded, states that only five per cent of the women questioned gave the reason for their opposition to the use of contraceptive as “religious prohibition”.
Then why is it that the contraceptive prevalence rate in the country is so dismally low? It is said to be 30 per cent (actually only 21 per cent married women of reproductive age use modern contraceptives). Small wonder the population growth rate has been on the rise. By 2009 the population growth rate was said to have gone down to 1.9 per cent. Now it is above two per cent per annum according to the Pakistan Economic Survey 2011-12.
It is a pity that from the brink of a breakthrough the programme has pulled back to show a sharp slide. There are two reasons that account for it. First, the government has been disengaging itself from this sector and is not playing the role it was expected to play in delivering contraceptive services to the 24 million MWRA in the country (this figure is for 2007 when the PDHS was conducted). The government’s performance has been appalling. In 2006-07, of the 2.9 million women who used any contraceptive services (a third of the users had been sterilised) barely only 33 per cent availed of a public sector facility. Only four per cent of the measly health budget goes for family planning. It is, therefore, left to the private sector, mainly the NGOs, to provide these services.
Can NGOs act as a substitute for the state which has more resources, manpower and outreach? Their performance is better but their contribution cannot reach the entire country. Research and Development Solutions, which conducts research on various health and population related data, did a comparative analysis of the family planning delivery services in the private and public sectors.
Its policy brief observes that “most private sector services constitute self procurement of condoms and oral pills from stores by women without using a health provider. The public sector provides FP services through the ministry of health (MoH) and ministry of population welfare (MoPW). The MoH accounts for 18 per cent and the MoPW accounts for 15 per cent of all FP services…. Both ministries of population welfare and health combine to reach less than a million women or around four per cent of all MWRA.”
The problem is not just the low outreach. Inefficiency and corruption are major factors affecting success rate. According to Research and Development Solutions the government’s programme costs about Rs2,414 per woman served, which is much higher than the regional average. Since the MoH, which serves more rural women who are also poorer than the clientele of the NGOs, it calls for greater efficiency and regularity in performance that is missing.
The MoH mainly offers temporary and short-term measures such as pills, condoms, injectables and IUDs. Hence any carelessness in delivery is enough to lead to an unplanned pregnancy. Besides, the women being poor and uneducated need closer supervision and monitoring which is not forthcoming from a public sector programme.
This is only one aspect, namely, the delivery structure, which is vital for the success of any programme of this scale. What cannot, however, be ignored is the social environment that has a profound impact on the family planning programme in any country. If women have a poor status in society, the parents’ preference for sons inevitably increases several folds.
Moreover poor reproductive and maternal healthcare for women — an offshoot of low status — means that maternal and infant mortality rate is high which also pushes up the birth rate and family size. The failure of our education policies have also contributed in a big way to the galloping population growth rate of Pakistan. It has now been conclusively established that educated mothers provide better healthcare to their children and plan their families better. We have been denied the dividend that education offers to the family planning sector in any country.
With women having little say in family decision-making, it is an anomaly that our family planning strategies are directed mainly towards women. The need to include men in family planning activities has been emphasised for long but failure to do so underlines the patriarchal character of our society Hence, family planning needs to be seen in its holistic context. It is as much a health issue as a socio-economic one. The relationship between each of these is symbiotic with one affecting the other. It is not strange that poor women who lack education have bigger families which add to their poverty. And when the services are poor what can one hope to achieve.