Tuesday April 23, 2024

The population denominator

By Dr Sania Nishtar
July 25, 2023

Earlier this month, on July 11, the world commemorated World Population Day. To mark the occasion, the Supreme Court hosted a conference to underscore the importance of population as a public policy agenda. This was the second in the series, the first being held in 2019. While the Supreme Court can have an important role in advocating, it is the executive which must prioritize this agenda, and that is where the problem lies – our lack of will and capacity to implement.

We know how terrorism, corruption, earthquakes, floods, droughts, and other crises have impacted our nation. But one of the biggest threats, Pakistan’s exploding population, remains unrecognized. Pakistan is the fifth most populous country in the world. From 34 million in 1950 to around 240.5 million today, our population is expected to rise to 403 million by 2050. This unfettered growth rate of 1.9 per cent per annum is unsustainable and far outstrips our economic growth rate, which is expected to be a mere 0.29 per cent next year.

Even today, Pakistan is severely under-resourced. This will be exacerbated by further population explosion; 36.9 per cent of the population faces food insecurity, and 44 per cent of children under the age of five are stunted. While the annual demand for food production is increasing, Pakistan’s water availability per capita is declining, pushing the country from a ‘water-stressed’ classification to a ‘water-scarce’ classification. Simultaneously, Pakistan’s extreme vulnerability to climate disasters may further limit potential for food production, as evidenced by last year’s devastating floods. These variables could have grave implications for food and energy security if population growth is left unchecked.

Many factors have contributed to the population explosion – poverty, illiteracy, societal and social factors; therefore, the solutions are also multifaceted. While women’s education, economic empowerment and societal change are essential, the role of health and population sectors in family planning is equally critical. However, after 60 years of investment in family planning, the contraceptive prevalence is a mere 34 per cent and the “unmet need for family planning” is 17 per cent amongst the highest in South Asia.

To a certain extent, this lack of progress is illustrative of the implementation challenges which are germane to every sector in Pakistan. However, the population sector presents another challenge also, because in this case we have systematically decimated systems we built earlier.

Let’s look back in history to qualify this statement.

There was a time when Pakistan was viewed as a best practice country in family planning, after having adopted the policy goal of universal health coverage for family planning nearly six decades ago.

Our first five-year plan had a population planning stream. Ahead of other countries, the government forged a public-private partnership with the Family Planning Association of Pakistan in 1955 and gave them an allocation to spearhead family planning, country-wide.

A nation-wide family planning infrastructure was created to provide free access to family planning. Donors (UNFPA and USAID) provided free commodities and supported the supply chain for over fifty years. Pakistan was a global leader in social franchising in the 1900s. Training institutes, a cadre of human resource, and service delivery systems, were established. The latter includes networks of Family Welfare Clinics, Reproductive Health A Services Centers (RHSC-A) in public hospitals, Reproductive health B (RHS B) centres inside women’s community centres, cadres of male mobilisers and village workers, and mobile health units.

Information systems, warehouses (the public sector’s only ISO certified warehouse is in the population sector) and contraceptives’ supply chain were established. Several important research institutes were established: the National Research Institute for Fertility Control, (NRIFC) the National Institute of Population Studies (NIPS), and the National Trust for Population Welfare (NATPOW).

This ecosystem was dismantled after the 18th Amendment. Provinces were slow to take ownership of the devolved population infrastructure.

After devolution, RHS Bs were abandoned; their surgical theatres present a sorry picture of wasted investment. Promising social franchising models were never scaled up. Provinces bickered endlessly on procurement, not being in favour of centralized procurement of contraceptives, since provincial-level procurement was more lucrative for vested interests. Rather than serving the research needs of the sector, NIPS became a parking space for bureaucrats. NRIFC, and NATPOW, which could play a key role in overcoming demand side issues, and harnessing the role of the private sector, respectively, became defunct.

Beyond the messy politics of devolution, the population welfare sector is also plagued by entrenched collusion in service delivery, which worsened over time. Male mobilizers soon became an easy route for political appointments, and mobile clinics opened avenues for rampant corruption.

Malpractices in family-planning outlets became deeply entrenched as described in detail in my book ‘Choked Pipes’ – absenteeism, illegal use of fees, contraceptive pilferage, ghost satellite clinics, outright theft of supplies, wastage, false reporting to meet targets, to name a few. Contraceptive consignments often expire lying around on shelves, boxes of contraceptives are dumped in rivers to show utilisation, and the higher value ones, such as injections are stolen and taken to private clinics or sold to pharmacies.

Moreover, the intransigence to keep health and population as separate institutional hierarchies purely to enable health and population sector staff to have their own perks, privileges and kingdoms has created obstacles to women accessing family-planning services in Pakistan’s conservative society, where women don’t want to be seen going to family-planning clinics.

There is an urgent need for reform. At the system level, there needs to be a coherent national strategy for population welfare, with input and alignment from the provinces, in line with the country’s economic strategy. There needs to be a clear division of responsibilities between the federal and provincial governments on funding and implementation of population welfare policies and institutions, and adequate implementation of the action plan set out by the Council of Common Interests in 2018 to achieve Contraceptive Prevalence Rate of 50 per cent by 2025.

At the provincial level, population welfare needs to be urgently prioritized, with a concrete roadmap to improve KPIs, monitored at the highest levels. Population welfare should be integrated into provincial healthcare agendas, to ensure it gets adequate funding and prevents duplication of resources.

Pakistan stands at a crossroads today. It has a short window of opportunity to benefit from the demographic dividend. To cash in on this dividend, the country needs aggressive investments in human capital development, through education and skills-building of the youth, and creation of employment opportunities. This is what the Ehsaas Program focused on, amongst other things. More needs to be done to build on these efforts.

Our failure to promote family planning could have serious repercussions. Pakistan’s galloping population is imposing an unmanageable demand on the economy, the social sector, and the environment. It is not just the future we have to worry about. We are facing the crunch as we speak. Our hospitals, schools, roads, cities are all crumbling under pressure. There are serious implications for food, energy, and water security. Today Pakistan’s exploding population is the real crisis that threatens the prosperity of our generations. In the face of resource scarcity, and constrained economic opportunities, population growth is simply pushing the youth into the hands of gangs and mafias.

We must stabilize our population. This is not just an imperative for women’s health, wellbeing, and poverty reduction, but also for national progress, economic growth, and security of our nation.

The writer is a senator andformer special assistant to the prime minister for poverty

alleviation and social safety.

She tweets @SaniaNishtar