June Issue 2015

A book written in 1798 should be made compulsory reading in all Pakistan’s academic institutions. Titled Principle of Population, the book is written by an Englishman named Thomas Robert Malthus.

In it the author proposes a theory that if no check is placed on population growth, the rate of increase in human population will outpace the means of increasing subsistence, since population increases geometrically while production increases arithmetically.

So, if we start with a couple who have four children, the population is six. If each of the four children produce four more children, the population rapidly progresses to 22. A generation later, things get much more crowded, with the new figure standing at 82.  This means that in three generations the population will have increased from 6 to 82! This is known as geometric increase.

Unfortunately, resources do not grow geometrically. So if we were producing X amount of food at the beginning and are able to double the production every one generation, it would become 2X, 3X and so on. During this time the population would be growing at a faster rate. At some point in time it would not be possible to produce enough food to feed the population.

Pakistan’s population stood at 37 million in 1950. In 2015, the population has burgeoned to 180 million — an increase of 143 million in 65 years. The annual increase has averaged about two per cent, and assuming no reduction in the growth rate, the current 180 million population will grow to a whopping 360 million by 2050, i.e. twice today’s population in just 35 years.

Currently, Pakistan is the sixth most populous country in the world. But with approximately four million people being added to the Pakistani population every year, at current international population growth rates it will become the fourth most populous country after India, China and USA in 2050.

According to the Pakistan Demographic and Health Survey 2012-13 (PDHS) conducted by the National Institute of Population Studies (NIPS), the fertility rate in urban areas is 3.2, versus 4.2 in rural areas, while contraceptive use is 45 per cent in urban areas versus 31 per cent in rural areas.

Pakistan’s population growth rate between 2001 and 2011 was the highest among the 10 most populous nations in the world. Pakistan’s fertility rate of 3.4 children per woman is the highest in South Asia. And countries with similar economic indicators, like India and Bangladesh, have done much better than Pakistan in this regard.

In addition to resulting in a decline in socio-economic conditions, the increase in population also has a direct implication on food needs. Pakistan is primarily an agricultural country and thus dependent on the availability of water for crops.  A comparison of water demand and supply indicates a serious shortfall in water availability for agriculture by 2025.

The figure below illustrates the water supply and demand situation in Pakistan, based on a two per cent annual growth in population even with a 25 per cent increase in crop yield. Even assuming that the dams under construction will be completed by 2025, there will still be a shortfall in food supply.

In fact, the figure shows that there will be a 50 per cent shortfall in water availability for agricultural production in the year 2050. The country is thus facing a direct threat of severe food shortages.

If the population increase was an average of one per cent per year (instead of the expected two per cent), the population in 2050 would be 255 million. Resultantly, the water demand for agricultural production would drop down to 198 from 280 million acre feet, and the shortfall would be 29 per cent compared to 50 per cent. While still not ideal, it could be a more manageable scenario.

Even the usually ostrich-like  Pakistani government seems to be waking up to this doomsday scenario. In a recent statement, the minister of water and power warned of a serious looming water crisis. However, there is still an unwillingness to recognise that excessive population growth is one of the major reasons for the country’s housing, water, food, and power crises.

In fact, Pakistan’s record in achieving family planning targets is abysmal. The family planning policy developed in 2002 is still the guiding document for population control. The plan targets reducing population growth from 2.1 percent in 2002, to 1.3 per cent by 2020, reducing fertility through family planning from four births per woman in 2004, to 2.1 births per woman by 2020.

Also, as a signatory to the Program of Action developed at the International Conference on Population and Development organised by the UN in Cairo in 1994, Pakistan committed to provide universal access to family planning by 2010, and Pakistan’s Poverty Reduction Strategy Paper stated the objective of increasing contraceptive use to 57 per cent by 2012.

None of these targets have been even remotely met. The population growth continues to hover around 2 per cent, while the fertility is still 4 children per woman. 2010 has come and gone, but  there is still at least a 25 per cent unmet need for contraception. Contraceptive use has, in fact, remained unchanged at 30 per cent for the past 5 years.

A rather startling statistic that forms part of this picture is the number of unwanted pregnancies. The  Population Council, a major international NGO, reported in 2007 that the annual unwanted pregnancy rate is 77 per 1,000 women.  The report also states that one out of every seven pregnancies is aborted — nearly 14 per cent.

And it is not difficult to understand why. The spending on family planning is both skewed and insufficient.  According to the Economic Survey of Pakistan 2006-2007, the government spent on average  Rs 4 billion (USD 42 million) a year on family planning, but nearly 90 per cent of this went towards salaries and overheads, and commodities accounted for 7-14 per cent of these funds (PDHS 2006/2007).  Also, the government seems to have relegated a major portion of family planning responsibility to NGOs.  According to PDHS 2012, that year the government provided 44 per cent of the required family planning services, while the NGOs provided 40 per cent.  Increasingly it seems, the government is trying to put the onus of family planning on the NGOs, to avoid any backlash from religious quarters opposed to such projects.

According to the World Health Organisation report, Investing in Maternal, Newborn, and Child Health — the case of Asia and the Pacific published in 2009, each year, Pakistan spends US $15 per capita on health, while the average for South Asian countries is US $26. And note that the figure of US $26 for South Asia is already the lowest of any region in the world.

The per capita cost of providing complete contraceptive coverage in developing countries has been estimated to be $5. Pakistan’s per capita spending on family planning was $1.21 in 2012.

The only mechanism for reaching women in the reproductive age (15-49) is through the Lady Health Workers (LHWs) Programme that was introduced in 1994.  This programme is not exclusively for family planning assistance, but one of its objectives is to provide family planning materials and services like condoms, pills and IUD placement referral for a hospital. While the overall impact of the LHWP program on women’s health has been positive, there is little evidence to indicate any major improvement in the family planning status.  One study conducted in 2002 indicated a 7 per cent increase in the use of contraceptives where at least 2 LHWs were available in a defined area.

There is no doubt that the LHWs is a critical resource for improving family planning services, but the programme is understaffed and lacks the required level of both training and materials necessary for successful implementation.

Given this situation, there is little hope of the growth rate slowing down in the near future.
The only time in the history of Pakistan when a serious population control plan was attempted was during the Ayub Khan era of 1958-68.  A concerted campaign was put in place that propagated the benefits of smaller families. Slogans like, “Bachey kam, khushaal gharana” (fewer children, happier household) became popular. In movie houses, hair-raising advertisements showing the consequences of too many children were shown before every movie.  The radio and print media had advertisements aimed at convincing families to limit the number of children to two. Combined with the family law ordinance of 1961, which gave women some degree of control with regard to marriage, polygamy and divorce, there was hope that the population growth in Pakistan, that was increasing at a rate of 2.5 per cent, could be stemmed.

As part of the programme, condoms and Intrauterine Devices (IUDs) were made available at a very low price. In the latter part of the campaign, IUDs were the main birth control method prescribed — this was most likely due to the reluctance of men to use condoms.

After the fall of Ayub Khan following mass agitation against his dictatorial rule, the family planning campaign got derailed. Too busy to survive and too eager to neutralise the pressure from the religious right, Prime Minister Zulfikar Ali Bhutto did not risk undertaking a serious population control plan. The last nail in this coffin was driven when General Zia ul Haq deposed Bhutto and brought in a brutal dictatorship. A religious fundamentalist, Zia rolled back the family planning programme and stopped all advertising related to it.

When the dark years of the Zia rule came to an end in 1988, one would have expected the revival of a socially and economically important campaign like population control. However, that did not happen during the civilian governments following the Zia regime, and family planning stayed on the back burner.  The most likely reason was that in the very religious post-Zia Pakistan, successive governments did not have the political will to implement measures that could be perceived as being against the tenets of Islam.

The first-ever family planning policy was issued in 2002 during General Pervez Musharraf’s government.  The policy set out some long-term targets that included reducing population growth from 2.1 per cent in 2002 to 1.3 per cent in 2020. Two related targets were increasing the CPR from 30 per cent to 57 per cent, and reducing the number of births per woman from 4 in 2004 to 2.1 by 2020. None of these results are likely to be achieved. Population growth continues to be around 2 per cent while the CPR, that was 30 per cent in 2004, has stayed stagnant.  No significant change has taken place in the family planning policy since 2002.

With the 18th Constitutional Amendment, the responsibility for health (and population related activities) was transferred from the centre to the provinces.   This meant that family planning did not remain a centralised objective any more. Each province was now free to develop its own strategy for population control.  Balochistan wanted to increase the population since it is very sparsely populated.  On the other hand, Punjab, the most populous province, started developing its own family planning programme. However,  the lack of centralised planning on the issue of population may have further stymied population control efforts.

A comparison of the divergent approaches to population control in Pakistan and Bangladesh provides some important insight into this issue.

A World Bank study ‘Family Planning — an unfinished agenda’ published in October 2006 in the reputable public health journal The Lancet compares the results achieved by the two countries in population control over the same period.

Bangladesh started a strong family planning campaign in 1976. A community-based approach was used in which married women were hired from their communities to provide women with both family planning counseling and contraceptive products. This provided access of family planning services to even the large number of women who observed purdah. Also, voluntary sterilisations were provided at district hospitals. By 1990, 30 per cent of Bangladeshi couples were using contraception. This figure jumped to 60 per cent in 2011. During the same period, fertility rates went down from 4 children per woman to 2 per woman.  The dramatic reduction in the fertility rate of Bangladesh is illustrated in the graph.

During the same period, Pakistan was embroiled in political chaos. With the right-wing General Zia ul Haq having come into power, all family planning advertising and campaigning came to a grinding halt. The result: contraceptive usage in Pakistan plummeted from 25 per cent to just 12 per cent by 1990.

For the year 2012 the rates of contraceptive usage for Iran, Bangladesh, and Pakistan were 74 per cent, 54 per cent, and 30 per cent respectively.

Iran had a high population increase rate of 3 per cent between the years 1956 and 1986. A comprehensive family planning plan was implemented in the 1990s that resulted in the population growth dropping to 0.7 per cent in 2007. Iranian leaders declared that a two child family was in line with Islamic teachings. Condoms and other contraceptives were provided at highly subsidised rates and vasectomies were allowed in state and private hospitals. It was made mandatory for couples to attend family planning counseling sessions before marriage. And paid maternity leave and other social subsidies were eliminated after the third child was born.

However, politics changed all that. A campaign for reversing the trend and increasing the population was initiated under President Ahmadinejad in 2006. Large families were shown as happy, while small families as lonely and miserable. Subsidies on family planning aids were removed and maternity benefits were increased.

The government declared family planning as a western ploy to keep the developing nations under their thumb.  “I am against saying that two children are enough.  Our country has a lot of capacity. … for many children to grow in it. … Westerners have got problems. Because their population growth is negative, they are worried and fear that if our population increases, we will triumph over them,” declared Ahmadinejad in an interview to The Guardian, in 2012.

Back in Pakistan, there are eight main factors that are contributing negatively to the efforts to control the country’s population increase:

1) A large number of pregnancies in Pakistan are unplanned.  Lack of availability of detailed information and material and methods of contraception is the main reason for unplanned births. According to the Pakistan Demographic and Health Survey (PDHS) 2012—13, 96 per cent of women of reproductive age are aware of family planning.  The survey also indicated that while 30 per cent of married women of reproductive age use contraception, 20 per cent have an unmet need for contraception.

Most women do not have a channel available, like doctors or lady health visitors, through which they can acquire sufficient knowledge regarding birth control and acquire the required contraceptives.

2) While most women show a desire for family planning, they still want 4 to 5 children.  This was concluded by a detailed survey conducted by the PDHS and the National Institute of Population Studies Pakistan (NIPS) in 2012-13. The desire for a large number of children, combined with the lack of availability of contraception, is a major reason for the high population growth.

Source: ‘Population, Fertility and Family Planning in Pakistan: A Program in Stagnation’, article by Population Action International, a USA-based NGO.

3) An important factor in the low Contraceptive Prevalence Rate (CPR) among women in Pakistan is the real or perceived fear of side-effects of some contraceptive methods, especially Intrauterine Devices (IUDs) and injectables which can, in some cases, result in heavy bleeding.

4) Early marriages are another contributor to the population explosion. The minimum legal marriage age in Pakistan is 18 years for males and 16 years for females. However, the number of women getting married before the age of 16 is anywhere between 50 per cent and 70 per cent. Such early marriages increase women’s reproductive time window and contribute towards a population increase.

5) A preference for boys has also contributed to the population increase. Families want women to keep reproducing until a male is born. This trend can be reversed only when the level of female education and employment opportunities increase to a point that their earning potential matches that of men.

6) Contraception is thought to be against Islamic beliefs. While the negative impact of this belief cannot be denied, whether it plays a major role in the lack of family planning is a moot point.  A study, ‘Obstacles to Contraceptive Use in Pakistan: A Study in Punjab’ conducted in 2001 by researchers of the Population Council stated, “ the qualitative interviews indicate clearly that deliberate fertility regulation, through modern family planning and other means, is becoming much more acceptable to both women and men on religious and social grounds. Old mores on this point are weakening.”  Another survey conducted in 2006-2007 stated that only 8 per cent of the respondents mentioned religion as the reason for not practicing contraception.The lesson learnt from the Iranian experience is that it is not so much the religious beliefs of the population that hinder population control, but rather, government policies. The Iranian experience clearly indicates that if a systematic and concerted effort is made to facilitate family planning, a drastic reduction in population growth is possible.

7) A key factor in the success of family planning and lower maternity related death (as defined by Maternity Mortality Ratio — MMR, which is the number of maternal deaths per 100,000 live births) is the literacy rate of a country. Studies have shown a strong correlation between literacy levels and the use of contraceptives (as defined by the CPR).

The table below provides the correlation between literacy rates, CPR and MMR for Islamic countries.  Iran, Turkey and Kuwait have the best figures, while Pakistan, Afghanistan and Nigeria are at the bottom.

8) Men are the main decision-makers in regard to whether a woman practices contraception or not.  The study conducted by the Population Council indicates that while a majority of men support contraception, the support does not translate into actual practice.  Most men do not like using condoms and the responsibility of contraception falls entirely on the women.

An analysis of the hurdles in family planning indicates five elements that should be put in place for a successful family planning effort:

1)  A clearly stated position by the government regarding the need for controlling population growth and an organisation and advertising campaign to match it.

2)  The provision of universal access to family planning information, services and supplies at a low cost and in a manner that is consistent with the social and cultural norms of the people.

3) The promotion of greater understanding among men of the need for family planning and sensitising them to issues faced by women due to an excessive number of pregnancies. Also, encouraging them to use condoms.

4) The deployment of a  larger number of LHWs to provide 100 per cent coverage to the target population.   And to provide these LHWs training to deal with the side-effects related to the use of contraceptives.

5) The enactment of a new law making 18 the minimum age for marriage for both males and females.

If the present trend in population growth continues, it will result in a serious disruption of all aspects of society.  With the population doubling by 2050 to 360 million, out of which 80 per cent will be below the age of 20, this horde of humanity, led by the youth, will demand food, water, power and employment which the overstretched economy will be unable to provide.

The potential consequences include starvation, severe malnutrition, and serious social strife inevitable in a large population fighting for scarce resources.

Throughout human history, famines, diseases and wars have been successful in reducing the human population. Maybe that is what the government has in mind: let the problem take care of itself.

This article was originally published in Newsline’s June 2015 issue.