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Economic notes

July 17, 2018

Economic reforms: Part - XXVIII


July 17, 2018

We now turn to the subject of population welfare to complete our coverage of social sectors. Nothing is more critical for long term economic and social stability of Pakistan than its most neglected subject: population.

From the very beginning, apprehensions had mired the true motives behind the euphemism ‘population welfare’ or ‘family planning’. Detractors labelled it as being against Islamic teachings, while advocates displayed a crusader’s zeal to thrust it on an unsuspecting population. Not surprisingly, the initial efforts did not meet the desired success as they lacked broader appeal.

Until the late 1980s, fertility rates in Pakistan were as high as they were 20 years ago. In 1985, the total fertility rate (TFR: number of children per women during the child bearing age) was 6.5, and Pakistan had four times more people in 1998 than it had in 1951 (33.8 million and 133.3 million respectively).

Since the 1990s, greater focus and seriousness has been accorded to population planning. The UN-sponsored International Conference on Population and Development (ICPD), held in Cairo in 1994, was a point of departure, as Pakistan became signatory to the Programme of Action signed by 179 countries. A new approach was adopted to integrate population welfare within the broader framework of healthcare, particularly reproductive and antenatal.

A major instrument evolved for this purpose was educating women through a well-trained and committed work force of lady health workers (LWHs), making women capable of overcoming the many barriers that inhibited their access to family planning methods. The programme was started in 1994. Each LHW was assigned 1,000 women (or 150 homes), which she would visit once in a month – covering 5-7 homes every day. She was supposed to perform some 20 tasks covering all aspects of reproductive and neonatal health and childcare.

LHWs acted like counsellors, imparting knowledge about nutrition, common ills and their treatment, helping in getting births and deaths registered, providing awareness about contraceptive methods and medication for family planning. The programme gradually grew, and by 2006 there were 96,000 LHWs deployed throughout Pakistan. They were further increased to 110,000 in 2010. A hierarchical but operationally decentralised system, starting with a national coordinator down to the point of delivery, was designed to bring a common service to the doorsteps of the people.

LHWs were selected through a strict recruitment criteria, and were imparted a rigorous 16-month training, enabling them to perform their assigned duties. Proper records of each woman being attended to were maintained. In 2008, the cost per one LHW was estimated at Rs44,000 annually. The programme was funded as a project of the development plan. Barring some initial years, when development partners provided up to 11 percent of the resources, the entire funding had been provided for from the government’s own development funds.

A number of studies – Oxford Policy Management (2002), Harvard Public Health Program (2014) – as well as medical practitioners and researchers have found that in areas where LHWs have been working primary health indicators relating to reproductive and maternal and antenatal health have improved markedly. For instance, the contraceptive prevalence rate (CPR) was just 11 percent in 1994, and improved to only 33 percent in 2007 at the national level, but rose to 42 percent in areas where LHWs were serving.

The millennium development goal (MDG) for CPR was to achieve 55 percent by 2015. The corresponding numbers for immunisation were 75 percent, 47 percent and 80 percent, whereas the MDG target was at least 90 percent. Skilled birth-attendant, infant and maternal mortality rates all saw even bigger gains. Research has also indicated that LHWs were most effective if they were from the same community and social background as the women they were serving.

Unfortunately, this effective instrument was not nurtured as required. The Population Policy, 2002, while otherwise furthering the cause of ICPD, recommended dismantling the Ministry of Population Welfare – much before its devolution under the 18th Amendment. However, the funding of the subject remained a federal obligation. In the initial years, the spending on population programmes (including the LHWs programme) declined in real terms. But after 2002, there was a significant spurt, as the spending went as high as 0.13 percent of GDP until 2007-08. Subsequently, the spending again started declining, registering a low of 0.03 percent of GDP. Shorter releases compared to allocations and delays in releases became routine. The project’s approval was also delayed as not all provinces could prepare the PC-1 in time.

Then came the twin changes of the 18th Amendment and the 6th NFC Award. These led to the federal government abandoning its support for the population programme. The provinces were asked to fund the subject since it was now formally devolved to them. The provinces pushed back and an understanding was reached in the Council of Common Interests whereby the federal government agreed to fund the programme until the end of the then current NFC period, which was 2014-15. Apparently, the federal funding has continued for now as a new project has been approved by the Executive Committee of the National Economic Council. However, the approved programme indicates that in real terms the spending on the programme is declining.

Funding issues had a severe impact on the motivation and morale of the LHWs. Their salaries were not disbursed for months, no increases in salaries were allowed, plans for their service structure were drawn and their ability to provide effective service was compromised as allocations decreased. All these factors occasionally led to the LHWs taking to the streets and holding protests. Most recently, in March, they staged a five-day sit-in in Lahore and left only after their salaries were promised to be released within 15 days.

On the other hand, the larger picture of our population control is constantly deteriorating. The TFR has surely declined to nearly four, but it is still the highest in the Saarc region. The 2002 policy had targeted to bring the TFR to replacement level of two by 2020. The CPR at 35 percent is also the lowest in the region and much below the MDG target of 55 percent in 2015. Maternal and infant mortality rates remain high and other indicators of family planning leave much to be desired.

The population growth rate was thought to be 1.9 percent until the 2017 population census made the shocking revelation that it had reached 2.4 percent in nearly two decades. This is way above the average in the region. Even within the Islamic world, Pakistan has the highest growth rate. In the next part we will reflect on the results of the 2017 population census and the stark challenges we face in dealing with the fearsome growth in our population.

To be continued

The writer is a former finance secretary. Email: [email protected]

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