Conceiving a better tomorrow

May 26, 2018

Email

IN 1973, the average Bangladeshi woman was projected to bear around seven children. This number, known as the total fertility rate, was slightly higher than the equivalent in what remained of Pakistan.

From that point, had Bangladeshis procreated with the zeal of their former compatriots, there would have been 46 million more Bangladeshis today than there actually are. That’s almost the entire population of Sindh, averted.

Because, of course, Bangladesh didn’t continue down that path. The average Bangladeshi woman is now projected to bear just over two children over her reproductive life, while Pakistan’s total fertility rate stands at 3.5. While around a quarter of married Pakistani women of reproductive age regularly use modern contraceptives, nearly 60 per cent of Bangladeshi women do. These trends have helped take Bangladesh, once synonymous with overpopulation and deprivation, to per capita income that is, by some measures, higher than Pakistan’s.

How did two parts of the same whole, both, at the outset, backward and largely illiterate, both overwhelmingly Muslim, end up on such different paths? And what can Pakistan learn from Bangladesh’s journey?

What can Pakistan learn from Bangladesh’s demographic journey?

Studying what Bangladesh did to forestall explosive pressure on land, water resources, public healthcare, and schooling is crucial for policymakers, especially at a time when they are unveiling shiny new plans for the future.

A few divergences between the two countries stand out.

The first pertains to attitudes about family size. All the free contraceptives in the world are of little use if families want to have a large number of children. And while attitudes in Pakistan have changed over the years, they haven’t changed fast enough. A Gallup Pakistan survey conducted this year revealed that 37pc of the population thought the ideal number of children was four or more. That’s why the World Bank pegs Pakistan’s average desired fertility rate at over three and Bangladesh’s at nearly half that.

Female education helps drive this difference. Girls who go to school, even briefly, have fewer children over their lifetimes than those who don’t. There is a long list of reasons for this — suffice it to say that the causal link is well established. And in this area, Bangladesh shines bright.

Post war, roughly half the girls of primary age on both sides were out of school; 28pc of Pakistan’s girls remain so today, while only 2pc of Bangladeshi girls are that unlucky.

The policy implication is clear: the state must take emergency measures, including mass-scale cash handouts, to make sure girls go to school. Obviously, the benefits would extend far beyond fertility impacts.

As for more direct measures to shape hearts and minds, much of the existing literature credits successful media campaigns with changing Bangladeshi attitudes.

On such report, Reducing Fertility in Bangladesh, part of a case-study series published by the Centre for Global Development, is particularly instructive. While Pakistanis have been exposed to persuasive ads over the years, the study yields insights about Bangladesh’s programme that have been ignored in Pakistan. Beyond the adverts that have been common here, the Bangladeshi family planning programme, as early as the ’70s, collaborated with renowned writers to develop compelling TV dramas and radio shows to promote its message — particularly to men. Marketing and behavioural experts helped fine-tune the communication for maximum impact. In particular, the study cites the mass influence of a popular TV heroine, Laila, playing a family planning worker, in a series commissioned by Bangladesh’s programme in its early days.

Developing a TV serial such as this is an example of cheap impact. A humorous production with big name stars and excellent writers, aimed at rural audiences, contrasting the challenges of large families with the health and prosperity of small ones, should be high on our policy agenda.

While inviting clerics to promote family planning messages could be useful, the importance of this shouldn’t be overstated. Surveys show a consistent decline in respondents explicitly citing religious prohibition as a reason for not using birth control — with some putting it as low as 5pc (Pakistan Demographic and Health Survey, 2006-07). This is supported by data showing contraceptive use rising with the number of children a woman has already borne. The attitudes that lead people to desire large families, and avoid contraceptive usage are primarily societal, not religious, and must be responded to accordingly.

People who want smaller family sizes need access to contraception. This is the supply-side of family planning — led in both countries by lady health workers going from home to home providing materials and advice. While, Pakistan’s programme is massive, with over 100,000 workers making monthly visits, Bangladesh’s experience differs in two main ways.

The first is a ship which has sailed. Bangladesh developed a large-scale health-worker programme in the ’70s, and Pakistan didn’t follow suit until the ’90s (an earlier programme in the ’60s met with limited success). Those lost years, during which Pakistan’s contraceptive prevalence stagnated while Bangladesh’s soared, were critical — and we will never get those back.

Secondly, while Pakistani health workers, perpetually short of supplies, report as few as 100 condoms a month to be distributed amongst 300 families, their Bangladeshi counterparts come well stocked with a wide array of contraceptive options, and are well-trained to treat side effects. This is perhaps why the percentage of Bangladeshi women using the pill is 10 times the percentage in Pakistan. Indeed, oral contraceptives account for almost all the difference in contraceptive prevalence between the two countries — the rate for other methods is around the same.

The changes required to push Pakistan towards a sustainable population growth path are not earth-shattering. The investments required largely pay for themselves — the Bangladeshi programme spends less than $20 per birth averted. Any manifesto for the upcoming elections that ignores a discussion of these investments is a plan that wilfully ignores an existential threat. Conceiving a better tomorrow is fanciful without tackling this threat head-on.

The writer is a Lahore-based columnist and consultant with a background in finance, public- and private-sector strategy, and energy.

Twitter: @assadahmad

Published in Dawn, May 26th, 2018