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Population policy: will it work?

March 14, 2010

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The best news Pakistanis have received in the past week comes in the form of the National Population Policy 2010. The policy recognises that demographics are the key to promoting economic development and security in Pakistan. It also prioritises family planning — particularly in an effort to promote birth spacing — as the best strategy for achieving ambitious population targets (2.1 births per woman in 2025).

In many ways, the story of Pakistan is one of a failure of family planning. Although the Family Planning Association of Pakistan was set up as early as 1952, we have seen a five-fold increase in our population between 1951 and 2009, from 34 million to 171 million.

The urgent need for revamped family planning service delivery cannot be understated. Although 96 per cent of married Pakistani women are aware of at least one modern contraceptive method, only 22 per cent are currently using modern contraceptives, while another eight per cent use less effective traditional methods. One quarter of married women want to wait before having another child, or do not want more children, but are not using contraception. And 24 per cent of married women admit that their last child was mistimed or unwanted.

Many Pakistanis bemoan the prevalence of abortion here (a 2004 Population Council study estimates that there are 890,000 abortions annually), but this too should be understood as a shortcoming of our government's family planning service delivery. According to the 2006-07 Pakistan Demographic Health Survey, 65 per cent of women who had an abortion were over the age of 30, while 80 per cent had more than three children. In this context, the population policy's emphasis on family planning is a welcome paradigm shift.

The focus on birth spacing — up to 36 months from the current 33 — is also laudable. After all, the language of birth spacing, as opposed to birth control, will win over more Pakistanis to family planning initiatives. Women perceived the famous 'do bachey hi achey' campaign as the state's attempt to dictate how many children they could have.

A call for birth spacing, however, does not have those implications. Beyond innumerable health benefits, an emphasis on intervals between pregnancies helps decouple family planning from other social and moral obligations — women who space births cannot be accused of absconding from maternal responsibilities, denying their husbands offspring, or shirking their religious duty to procreate.

No doubt, those who drafted the policy have the right idea about how to reduce the population growth rate. But implementation is another factor altogether. The policy calls for improved service delivery, increased availability of contraceptives and the expansion of service delivery from urban to rural areas.

Endless bureaucracy may, however, thwart these efforts. Family planning initiatives are overseen by both the ministries of health and population welfare in addition to social marketing and civil society organisations. Without robust plans for integrated service delivery and public-private partnerships, good intentions may never convert to action.

Moreover, the population policy does not include specific directives for the improvement of the Lady Health Worker programme, which is tasked with family planning service delivery, but has a high turnover, few resources, and is plagued with poor training and inefficiency.

The policy is also short on innovative solutions to address myriad shortfalls in service delivery. For example, little attention is paid to the fact that men must be included in all family planning initiatives. And while there is a call to engage religious leaders in spreading information about contraceptives, no concrete plans for training, outreach and counselling through mosques or madressahs is put forward. There can be no doubt, however, that such campaigns are necessary one study states that 'psychosocial' issues, including a husband's opposition and perceived religious condemnation, account for 50 per cent of barriers to contraceptive use reported by women.

Ultimately, even the most progressive and proactive policy document will not successfully reduce the population growth rate if women are not simultaneously educated. It has been well-documented that higher literacy rates for women result in increased female decision-making power, better awareness and understanding of health services, altered marriage patterns and renegotiated household dynamics — all of which are essential for family planning to become common practice. On a more practical level, too, contraceptives cost money; educated, working women will be better situated to access modern contraceptive methods. Given that Pakistan's teeming population is the root cause of many problems — from unemployment to inflation, crime to militancy — one hopes that implementing the population policy registers high on the government's to-do list.