THE preliminary results of the 2023 census show that Pakistan has been growing at an inexplicably high intercensal population growth rate since 2017. The country’s demographic statistics present an alarming picture. Fertility rates are estimated at 3.6 children per woman, a number that has not changed much over the last 15 years.
Meanwhile, other countries in South Asia are reaching replacement fertility levels (less than two births per woman), with population growth rates of one per cent or less — thus placing Pakistan among the demographic laggards of the region and possibly the world.
These alarming statistics merit serious introspection and discussion regarding the behavioural patterns of the population as well as government policies in the country.
After all, Pakistanis are not culturally dissimilar to the citizens of Bangladesh or India — so there is nothing intrinsic to explain the vast divergence in fertility behaviour. However, the policy response of the other countries to population growth has been distinctly different from ours.
Starting in the 1960s, Pakistan did make efforts to lower fertility in order to restrain population growth rates, but successive epochs of political instability impeded the process.
It was one of the first countries in the region to announce a population programme and it provided leadership in five development plans related to population projections. However, the programme came to a halt in the Ziaul Haq period (1977-1988).
Despite the setback, the country managed to revamp its efforts and fertility rates fell quite rapidly from six to four births per women from 1991 to 1998. It was a time when democratic governments made passionate public statements in support of family planning.
Much beyond endorsement, programmes were financed and institutional machinery mobilised to measure the impact over time by following up on fertility rates. During that period, the then prime minister Benazir Bhutto launched the National Lady Health Worker Programme for Family Planning and Primary Health Care. Till today, it is one of the largest community-based programmes in the world.
Pakistan’s alarming population statistics merit serious introspection and discussion.
So why has Pakistan not been able to lower its population growth in the last 20 years?
It can be argued that, as the years passed, the country’s policy structure — dominated by politicians, the bureaucracy, power groups and international donors — deprioritised fertility decline.
It is also true that a large part of the current political leadership of Pakistan believes that a higher population size equates with political and economic power. This contradicts worldwide evidence that high population growth rates impede economic prosperity.
Other countries have had to deal with financial and governance challenges similar to those of Pakistan, like Indonesia and India, but have worked around them to achieve population sizes that do not burden their economy.
Neither has the distribution of resources (such as Pakistan’s National Finance Commission Award formula, which is highly skewed in favour of population [82pc], thus reinforcing the need for greater resources for the increasing population numbers), obstructed their efforts.
Unlike other countries, Pakistan has struggled to implement strategic reforms pertaining to governance and structural issues, such as instituting rewards for provinces for lowering population growth rate.
After the 18th Constitutional Amendment was passed in 2010, bureaucrats found it difficult to cope with the new administrative landscape that gave provinces autonomy over policy areas including population welfare and health.
The step curbed the federal government’s ability to develop a long-term vision and plans, and culminated in ambiguity between the federal and provincial governments regarding resources and responsibility.
In the midst of this lack of clarity, attention was diverted away from the vital issue of balancing population growth with Pakistan’s resources and development priorities.
While the donor agencies’ discourse is focused on issues, including maternal mortality, malnutrition and early childhood development, the reproductive health needs of women, especially fertility and family planning, have not featured as their top single priority.
How then can we resolve this impasse?
Exceptional leadership is required to design and implement policies that bring down fertility rates so that Pakistan can have sufficient resources to meet the needs of its population. Furthermore, a consensus among the country’s key stakeholders has to be achieved to ensure a shared vision on population growth that is reflective of the different needs and dynamics of the population.
Population welfare should not be reduced to jargon. It needs to be adopted as a policy tool to ensure the well-being of every individual, especially vulnerable groups such as women and children. Health services must extend to those millions of families whose children are malnourished and out of school. It will have to be directed towards millions of women who undergo unwanted pregnancies and complications during childbirth.
The federal and provincial governments must both invest in structural reforms and enhance fiscal space to expand access to family planning services to improve the shameful state of women’s health.
The Population Fund mandated by the Council of Common Interests in 2018, which was aimed at financing greater family planning coverage, has not been operationalised. The Fund should be expeditiously utilised to meet the unmet demand for family planning services by incentivising provincial health programmes and private-sector providers for providing easily accessible and efficient reproductive health services.
While donors can support government efforts, by demonstrating innovative solutions, they are unable to singlehandedly finance impactful large-scale programmes. Therefore, governments must take the lead in implementing schemes that are designed to sustain the innovations beyond donor support.
Finally, interventions aimed at reducing population growth can only be successful if the government leadership at the highest level monitors them. The prime minister’s strategic roadmap, which deals with pertinent policy matters such as the economy and energy, must also give due importance to reducing fertility rates.
Pakistan has been commended for handling the Covid-19 pandemic well and almost eliminating polio when responsibility was shared between the federal and provincial governments.
The same approach should be used to meet the fundamental rights of our 240 million-plus citizens to basic reproductive health information and services. This government and the next have a golden opportunity to right this wrong. The test of leadership lies in whether they will take up the challenge.
The writer is Country Director, Population Council.
Published in Dawn, June 8th, 2023