Unbelievable as it sounds, Pakistan’s population programme began way back in 1953, well ahead of other South Asian countries. All Pakistan Women’s Association (APWA) stalwart Saeeda Waheed, strongly advocated birth control and population planning, and was fully supported by the government.
A National Board for Family Planning was formed in 1958, serving as a policy advisory body to the federal government.
Pakistan launched its first FP scheme, which became part of the Third Five Year Plan (1965-1969). The Medical Reforms Commission and the Pakistan Nursing Council encouraged this initiative, and recommended that nurses and midwives receive training in family planning.
Tragically, population planning now has become a victim of government neglect, characterised by lack of services and misconceptions. It has been unfavourably affected by political influences, frequent policy and programmatic changes, religious extremism, internal fighting, corruption, and now, political turmoil and terrorism. It is the country’s misfortune that woefully little progress has been achieved to date.
The programme has plodded on for almost the last four decades. Following the 18th Amendment and devolution in 2012, a high-powered constitutional implementation commission has been instituted for smooth transition from federal to provincial levels; this step was most essential, because presently there is no central, federal policy-making body. Currently there is no direction in any province. Reproductive health services are receiving even less attention than before.
Imtiaz Kamal, president of Midwifery Association of Pakistan, has a wealth of historical detail: “In 1955, serious efforts were afoot to incorporate population issues in the ministry of health, because maternal health is so closely linked to population planning. But the Director General Health, Col Jaffer, was against this move. Because the money was coming in for population, he wanted to keep it exclusively for population issues, and not allow any of it to go to the health sector — a virtual impossibility, but achieved at the cost of the population programme itself. A political divide set in; the ministry of population was instituted, separate and distinct from the ministry of health, each with its own agenda. Having two ministries, when one was needed caused its downfall.”
From 1965 to 1979, USAID contributed $30 million, about 40 per cent of Pakistan’s population budget. But during this period, there was severe setback and political turmoil. Ziaul Haq’s rule from 1977 onwards saw the advent of strict laws against rape, adultery and intoxication; religious extremist ideologies predominated. USAID funding was suspended.
A national study in 1970 revealed that nursing teachers were not equipped to teach the subject of family planning. The situation in 1981 was equally depressing: little visible change had taken place; in fact, in the absence of follow-up or refresher courses, the teaching of family planning and midwifery deteriorated. Nurses and midwives consequently did not value their own critically significant role. Unfortunately the population programme remained static for about 35 years, largely due to over-centralisation, dominant influences of religious conservatism and extremism.
Besides this, our social setup also played a role: decision-making power is usually in the hands of men. While determining the number of children a couple should have, the balance invariably tipped in favour of male opinion. National statistics highlight these attitudes: left to themselves, women opt for a maximum of three children — but findings show that on average each woman is giving birth to four children.
The same attitudes of deficient teaching and training that were apparent in the nursing cadre permeated the medical sector; at present, family planning is not a part of the medical curricula. It is only a small part of community medicine.
The bottom line: the average health provider is not trained to provide basic information or services to the community for spacing pregnancies or limiting family size.
Today, the dichotomy between population and health ministries translates into separate and distinct family welfare centres and health outlets, each functioning under its own set of rules, and completely isolated from each other. The result is predictable: women or couples would go to a health facility when they needed to, but rarely bothered visiting a FP centre. The delivery of efficient FP services requires both widespread access and preferably, mobile services; both are missing.
The lady health workers scheme was initially launched as a merger initiative of population and health ministries, with focus on delivery of primary health care and family planning. But slow work pace was a characteristic: LHWs were authorised to administer both intravascular and intravenous injections, yet it took the two ministries more than a decade to authorise them to dispense injectable contraceptives.
Even the media, including TV, has not been open about messages regarding FP. It took 30 years for the word condom to be used on TV — and it was removed within a week! The ostrich approach continues: rumours and false beliefs predominate, often leaving communities confused, not knowing quite how to deal with repeated pregnancies. The wide-scale support of an efficient system of contraceptive distribution still remains sub-optimal at best — there are too many outlying rural areas still waiting for family planning services.
We must learn from history: there is no time to lose — the impact of the fast-growing population is impinging unfavourably on every aspect of development, be it economic, social, environmental, educational, food security or health. Poverty is growing.Pakistan has huge potential for development, if only it would seize the opportunities.