By Zubeida Mustafa

Recently, the Washington-based Population Crisis Committee released its 1992 edition of World Access to Birth Control. It is not too flattering to Pakistan which is ranked a lowly 55th among 95 developing countries in terms of availability of modern birth control information and services. What is more shocking than the low score (37/100) is the fact that Pakistan lags .behind countries considered more backward.

In South Asia, Pakistan ranks the lowest compared to Sri Lanka (80), Bangladesh (77), India (73) and Nepal (50) in providing contraceptive options, competent services and outreach of the population programme.

This finding should not come as a bolt from the blue. Pakistan’s dismal demographic realities are a result of years of calculated neglect of the population sector. If initially the impact of this was not felt, it was because the high crude birth rate was neutralised by an equally high death rate. But in the last three decades there has been a sharp fall in the mortality rate as many mass killers such as small pox and cholera have been curbed.

As a result, the population growth rate has jumped up to an alarming 3.1 per cent. It had taken 50 years for the population of the region comprising Pakistan to double in the first half of the twentieth century. The second doubling came in just 20 years. Today Pakistan’s population is estimated to be 117 million and is expected to leap to 150 million by the turn of the century.

Why has Pakistan failed so badly in an area where others have succeeded? It was one of the first Third World countries to launch an officially-backed birth control programme in the sixties.

Since then it has always had a family planning programme, the changes in nomenclature notwithstanding, along with an institutional infrastructure for propagating the small family norm and providing contraceptive services.

The basic problem has been the criminal lack of political commitment of the rulers to a programme to contain the population explosion. Political will is necessary to provide the thrust and dynamism to a campaign designed to change social attitudes and behavioural patterns.

The skewed and undemocratic power structure of the Pakistani state and society has ensured the failure of any plan designed to improve the socio-economic conditions of the masses. The success of the population programme depends primarily on the progress achieved in the dissemination of mass education, provision of health care, elimination of poverty and the emancipation of women. Since these are the very factors which would undermine the privileged status of the ruling classes, they have obstructed the process of change and the successful implementation of the population programme.

Hence the population strategies that have been adoplad from time to time have never really proved effective — they were not intended to be. Whether it was the blunt down-to-earth clinical approach of the Ayub Khan period, the contraceptive inundation and continuous motivation policy of the Bhutto years or the more subtle sociological methodology of integrating family planning with the social development of the people under the Zia regime, none of them created an impact on the demographic scene. Besides no concerted efforts were ever made to change the macro environment which is central to the success of a population programme.

What is most significant about Pakistan’s population sector is that the hostile climate notwithstanding, the awareness of the disastrous implications of a large family for individuals as well as the society has grown over the years. Although the organisers of the population programme would like to have us believe that this awareness is the result of their successful information, education and communication strategy, not everyone would agree. In an interview which he gave a few years ago, Dr Akhter Hameed Khan, the renowned social worker and founder of the Orangi Pilot Project (OPP), said: “There is now no need for active propaganda to convince the people to accept family planning, apart from a few exceptions the people are already convinced…. Actually economic forces have undermined the traditional perceptions… Inflation, urbanisation and the compulsion for female employment have brought about changes in attitudes. Now women with many children feel distressed. …the official programme is in no way responsible for this change in attitude…”

This observation is broadly confirmed by the report Pakistan Demographic and Health Survey 1990/99) published recently by the National Institute of Population Studies, Islamabad. According to this survey, 80 per cent of the women questioned reported knowing of at least one method of contraception. But when asked if they knew where to go to obtain the method they were aware of, only 44 per cent answered in the affirmative. The respondents’ ignorance about the facilities where contraceptive services and counselling could be obtained simply shows that they had not picked up their information from population workers, who would logically have told them where to go to obtain contraceptives.

The NIPS survey also demonstrated the ineffectiveness of the government’s communication strategy. The recourse to the electronic media to disseminate information about family planning has not produced much of an impact. Only 21 per cent of the women said that they had received the population planning message from the television or the radio. This shows that the government’s role in motivating married couples to limit their family size and space their children has been minimal. It has not even succeeded in familiarising the people with the contraceptive options available let alone tell them where to go to obtain contraceptive services.

One of the reasons why the government’s strategy has been counter-productive is that it is based on a host of false premises. Thus it is widely believed that religious beliefs — rightly or wrongly — are the main factor in the low contraceptive prevalence (12 per cent). But when asked, only 13 per cent of the women not using contraceptives said that they avoided contraception for religious reasons. Since the government has never tried to enter into a dialogue with the religious leaders on Islamic injunctions on family planning, a lot of ambivalence surrounds the issue. While Islamic scholars in al- Azhar and Iran have supported birth control, the ulema in Pakistan have not spoken categorically in favour of this practice. One of the religio-political parties has even opposed the population welfare programme. Instead of clarifying the confusion and taking a firm stand, the Establishment has adopted a low profile defensive population strategy. It is at least reassuring to know that a large number of people understand their interests better and do not blindly follow the dictates of those claiming to be the interpreters of the faith. Therefore population workers who tend to be on the defensive vis-a-vis the religious lobby should feel more confident.

What has been ignored is that the major factor in the non-use o! contraceptives is the desire for more children. Over 42 per cent of the respondents in the NIPS survey cited that as the reason for not practising family planning. When seen in the light of the very strong preference couples have for sons — for cultural and economic reasons — the desire for more children becomes significant. Thus half of the married women who want another child have a strong desire for a son, while 92 per cent of those with two daughters want a boy. Given this bias in’ favour of male offspring, it becomes difficult to motivate couples to limit their family size until they have had the desired number of male progeny.

This also links the failure of our population policy directly to the low status of women in Pakistan. Unfortunately this dimension of the population question has not been addressed in real earnest. The appallingly low literacy rate of women (21 per cent), their low educational attainment (seven per cent with secondary schooling), their limited participation in the labour force (12 per cent), poor health conditions (6-8 per 1000 maternal mortality rate) and their low social and legal status testify to the failure of the govern– ment in emancipating the female population and involving women in the decisionmaking process. Pakistan’s population programme, which reaches barely a third of the people, has proved to be quite inadequate in terms of the contraceptive services offered. Not surprisingly so in view of the limited funds allocated to this sector. In 1992-93 a sum of Rs 3.4 million has been earmarked for the current expenditure of the population sector which is the same as it was last year. The development budget has mercifully registered a respectable increase arid envisages a spending of Rs 921 million; But this will not bring the cumulative development expenditure on population welfare in the last five years to the Seventh Plan target of Rs .3.5 billion. There will be a shortfall of Rs 500 million. This year nearly a quarter of the development budget is to be financed from foreign assistance — last year a third was — which underscores the overwhelming concern of outside governments and agencies at Pakistan’s high population growth rate.

Fiscal constraints as well as the pronounced thrust towards market economics have led to an escalation of the prices of contraceptives. In November 1991 the price of condoms went up five times-from Rs 10 for 100 units to Rs 50. Similarly, the pills registered an increase in price from Rs one to Rs three.

What makes matters worse is that the limited funds have not been put to optimum use. The population programme’s strategy is family welfare centre oriented which has proved to be costly as well as ineffective. The centres are not too many in numbers — there being less than 1300 in the public sector and as many set up by the NGOs for a population of 117 million providing coverage to an area of 796 square kilometres — which makes them quite inaccessible, especially to women who lack mobility. Small wonder two-fifths of all acceptors surveyed said it takes them over an hour to reach a source of supply for contraceptives. When the welfare centres are so insufficient in number and inadequately staffed they can hardly reach the people who need their services.

The government has since the mid-eighties sought to step up its utilisation of the population budget by channelling funds to NGOs in the field through the NGOCC. The approach of many NGOs is, however, basically a static one which in effect militates against the culture of the poor classes, whose women do not leave their homes to visit a doctor when they fall ill. For them it would be unthinkable to go to family welfare centres to obtain contraceptives. Hence the failure of the centres to extend considerably the outreach of the programme. The tragic failure of Pakistan’s population programme is demonstrated by the existence of a very large unmet need for contraceptive services in the country. The NIPS report points out that nearly 37 per cent of the married women said that they would like to practise birth control. But only 12 per cent of them actually do so. In other words 25 per cent of married women who are potential acceptors do not have access to contraceptive counselling and services.

Recognising the existence of this unmet need, the OPP’s health and family welfare programme is seeking to provide necessary counselling and services on an interpersonal basis which the government programme has failed to do. The success of the OPP programme — it manages to reach about 4600 families every year at a low cost of Rs 436,000 — shows that it is possible to fulfil the family planning needs of the people if the appropriate strategy is adopted. The OPP’s health and family welfare programme draws on the local manpower resources to involve the women of the locality in the project. Meetings are held in the homes of the lane activists where contraceptives and counselling are also provided. Since women do not have to go beyond their lanes to procure family planning services,, they readily make use of them.

The contraceptive prevalence rate in Orangi is now an impressive 46 per cent. What is more remarkable is that OPP’s strategy is most cost-efficient: it needs Rs 150 a year to motivate one couple to use birth control measures as well as provide them health education, immunisation, contraceptive counselling, TUD insertion and contraceptive injections. Only condoms and birth control pills have to be paid for. It must be pointed out, however, that it is also necessary to draw men into the population programme. Since they are the principal decision-makers, their participation is most essential. The limited participation of men has another major drawback. The programme has to depend on the widespread use of contraceptive methods that are female-oriented, such as tubaligation, lUDs and pills. These incidentally are more costly and can produce more side effects. The NIPS study identifies female sterilisation as the most commonly used method of contraception. This is also the most expensive (Rs 2740 per case).lf an irreversible method is found to be advisable, it can well be asked why the couple do not opt for vasectomy. It is certainly simpler and safer than tubaligation.

The condoms which are the second commonly used contraceptive method also need to be popularised further. They are low cost (Rs one per piece) and easily accessible under the social marketing scheme. They carry the least risks of side effects and offer protection against AIDS. But without the active cooperation of men, condoms cannot be made the mainstay of a family planning programme.

The success of the population programme will depend on the emancipation of women. The NIPS survey clearly establishes a corelationship between the educational attainment of women and their family size. The link between infant mortality rate and fertility rate has long been recognised. The employment of women does not emerge in the NIPS survey as a major factor in reducing the number of children. But it is bound to figure in due course as a determinant of women’s fertility. Hence it is time Pakistan began addressing the women’s issue. •

Source: Dawn 09-02-1992