Family Planning for a Healthy Pakistan

On need of protecting a fundamental human right

Family planning is the need of every married couple today. However, some people follow it while some dither on the issue and some even do not have access to proper facilities in this regard. So, balking at opting for the family planning methods and scant availability of requisite facilities has caused an unbridled growth in our country’s population. Huge population often carries along the menaces of privations and violation of human rights. It is every individual’s right to have access to education, employment, better healthcare facilities, adequate food, safe drinking water, security and other social and civic amenities. But, when available resources are not sufficient to meet the growing needs of the people, then a race between the haves and the have-nots starts. Hence, it is always wise to cut your coat according to your cloth for which allowing population growth only in accordance with available resources is imperative. It is also necessary to provide every individual with his/her fundamental rights. It is undeniably true that the provision of human rights is possible only when family planning is followed as a policy in a country because this ensures the sufficient provision of a number of other rights. In addition, easy access of married couples to family planning facilities is, in itself, a fundamental right that was acknowledged at the 1968 International Conference on Human Rights, where family planning was, for the first time, globally affirmed to be a human right. In this context, World Population Day 2018 is being observed on July 11 with the theme: “Family Planning is a Human Right.”

Every woman has a right that she is provided a violence-free environment, her decision on not getting married prematurely and getting pregnant and on determining the number and spacing of pregnancies for her better health is respected; she has access to proper diet and healthcare facilities in antenatal and postnatal periods, childbirth is handled by trained medics and both mother and child are provided with proper nutrition. She has also the right to get proper care, and to take care of herself, after childbirth. Similarly, every newborn has the right to be physically and mentally healthy at the time of birth, be breastfed by her mother, be vaccinated on time, be provided sufficient opportunities to play and learn, be provided access to quality education and, above all, be given an environment where (s)he may lead a safe childhood.

Here one may ask a very pertinent question: what all these things have to do with family planning?

If seen from this angle, we find that every couple that follows family planning methods is, in reality, fulfilling all these rights, one way or the other. For instance, a family having fewer kids will have sufficient resources to look after and rear them properly. Availability of sufficient resources also means less domestic violence, and it will also help eradicate the menace of child marriage the biggest reason behind which is economic compulsions. In addition, children will get quality education and there will be no dropouts.

Family planning also means respecting a woman’s decision on getting, or not getting, pregnant. It also keeps women safe from going through the laborious process of childbirth time and again. Moreover, avoiding frequent pregnancies results in better health of the mother as well as the baby. And, when a couple would intend to have another child, they would have all the resources required to provide better care to the expectant mother and the child in her womb. So, rights of every new child can be sufficiently fulfilled.

It is also to be noted here that there is absolutely no doubt that the real Sustainer is Allah Almighty but He has ordained it as a responsibility of parents to rear their children and provide them with as best of everything as they can. However, with more number of children, how would they be able to sufficiently fulfil their parental responsibilities in this regard? A person, who is already finding it difficult to provide shelter, clothing, education, medical treatment and to give proper time to his kids, as well as in fulfilling his responsibilities toward his spouse, gets further burdened when a new child is born to him. Resultantly, he is either crushed under this encumbrance or renegades on his responsibilities. And, both these situations are unacceptable in any case. In short, the only key to avoiding these onerous responsibilities is family planning because by adopting it, many other human rights can also be fulfilled. Family planning in itself is a human right that can be fulfilled from four dimensions: one, requisite facilities are adequately available; two, they are accessible to everyone without any physical or economic constraints; three, individually and culturally acceptable; and fourth, of high quality.

However, presently, we seem unwilling to acknowledge family planning as a fundamental human right. It is because of this indifference and lethargy that Pakistan, which was the 14th most populous country in the world in 1951 – the year first census was held in Pakistan – has become the 6th largest country in terms of population in 2017, as per the results of the sixth census. Indices on population vividly reflect our individual and collective behaviours toward family planning.

As per the World Population Prospects – The 2017 Revision, published by the United Nations Department of Economic and Social Affairs, between 1950-55 and 2010-15, following changes have taken place in Pakistan:

Moreover, in terms of population density (number of people per square kilometre), it was at 95th place in 1951, but it had achieved the 54th place in 2017. If the growth rate recorded during 2010-15 remains the same, Pakistan’s population will double within 33 years – in this context, Pakistan was 85th out of 146 countries for which data were available.

These are the facts extracted from reports published by international institutions but when we analyze different reports of the Housing and Population Census, the facts coming to the fore are, too, very alarming. For instance, the country’s population has risen by 516 percent during a period of 66 years between 1951 and 2017. The biggest increase during this period – a whopping 1990 percent – was recorded in Islamabad Capital Territory (ICT). It was followed by Balochistan (958 percent), Sindh (692 percent), Khyber Pakhtunkhwa (570 percent) and Punjab (436 percent), whereas the population of the now-defunct Federally Administered Tribal Areas (FATA) increased by 275 percent. Even if we take the period between the fifth census (1998) and the sixth one (2017), we find that during these 19 years, an increase of 57 percent has been recorded in the country’s population. The analysis further reveals that ICT witnessed the biggest population growth (149%) and was followed, on this index, by Balochistan (88%), KP (72%) and Sindh & FATA (57%) while Punjab recorded the least growth with a ratio of 49%.

In addition, the state of affairs regarding population density also indicates the growing burden on provincial/regional resources. Between 1951 and 2017, the population density in Pakistan rose by 521 percent, with the figure soaring from 42 to 261.

The ICT, again, topped the list with 1989 percent increase while Balochistan with 1085% occupied the second place. Sindh, KP, Punjab and FATA occupied, respectively, third, fourth, fifth and sixth position. As per the results of the Housing and Population Census 2017, the ICT is the most densely populated region of the country where this ratio is 2215 persons per square kilometre whereas Balochistan is the least densely populated province with 36 persons per square kilometre. Punjab (536 persons), KP (410 persons), Sindh (340 persons) and FATA (184 persons) occupy the second, third, fourth and fifth place, respectively. Population density is more in urban centres than in rural areas. Currently, Pakistan’s 36.3 percent population lives in cities as against 28.3 percent in 1981.

These geographical indicators of population growth are calling the attention of the policymakers toward the areas where the expected results of family planning could not be achieved and also toward regions where they should focus their attention as well as efforts in this regard.

On the one hand, a limited use of family planning methods is burdening us with growing population while is also posing daunting challenges to the sector of women’s reproductive health, on the other. For example, owing to a lesser use of family planning methods, Pakistan recorded the fourth biggest number of childbirths in 2016 – 5,438,600 babies. Hence, the fertility rate of a woman if she lives her reproductive age, that is, 15 to 49 years, is 3.4. An analysis of the UNICEF report “The State of the World Children 2017,” the UNFPA’s “State of World Population 2017,” and figures released by the World Bank suggests that Pakistan has a maternal mortality rate of 178 deaths per 100,000 live births, putting the country at 54th place on this index. A major cause of threats to the health of mothers and the newborns is short inter-pregnancy interval (IPI). As per the Pakistan Demographic and Health Survey 2012-13, average IPI in the country was 28 months whereas in 37 percent cases, this interval was below 24 months. As per the Population Report by John Hopkins School of Public Health, a baby born after an IPI of 3-5 years is healthier that the one born after a 2-year IPI.

In Pakistan, family planning services are provided by both private and public sectors. Private sector launched the family planning in the country in 1953 while the public sector entered this domain in 1966 when the government formulated a state policy. Dedicating a special federal ministry to this sector, on 12 June 1990, the government launched a comprehensive family planning programme. It was a step in the right direction, especially for mothers and their reproductive health.

Later, in 1994, the government started family planning and family healthcare programme and provided these facilities to the people, especially those living in rural areas. However, in the post-18th Amendment scenario, the federal government abolished the family planning ministry and devolved the subject to the provinces. This led to a lack of uniform policies as provinces had their own preferences. For instance, Balochistan wants its population to increase because it is the basic criterion for the National Finance Commission (NFC) Award. In this situation, how would this province would encourage the use of family planning methods? Moreover, the subject is faced with a stiff opposition from social, political and religious circles – a big factor behind limited use of family planning techniques. Moreover, there is a lack of congruence in facts and figures presented by various national and international organizations. As per the UNFPA’s “State of World Population 2017,” 40 percent of Pakistani women aged between 15 and 49 years use one method of family planning while 31 percent use, at least, one modern method, putting Pakistan at 142nd and 140th place, respectively, in the world.

Similarly, as per the Family Planning 2020, an organization that works with governments, civil society, multilateral organizations, donors, the private sector and the research and development community to enable 120 million more women and girls to use contraceptives by 2020, Pakistan is 5th among 69 countries where families make use of family planning methods with the number of users exceeding 10.05 million. However, according to Contraceptive Performance Report 2015-2016 released in April 2017 by Pakistan Bureau of Statistics, “Overall Contraceptive Prevalence Rate on the basis of modern contraceptive methods (mCPR) by estimating each method users, during the year 2015-16, has been computed as 35.5%, showing an increase of 8.6% from 2014-15. However, departmental modern Contraceptive Prevalence Rate(mCPR), during the year 2015-16 is 14.8% for Population Welfare Departments (PWDs); 9.6% for Department of Health (HF & LHWs) and for three eminent NGOs i.e. Rahnama-FPAP, MSS, GSM, mCPR is 1.5%, 3.6% and 6.0% respectively. In the Provincial / Regional setup, mCPR for Punjab is 38.9%, Sindh 25.0%, Khyber Pakhtunkhwa 46.0%, Balochistan 13.8%, Federal district Islamabad 81.8%, AJK 17.6%, FATA 10% and for Gilgit-Baltistan (GB), mCPR is 22%, during the year 2015-16. Further, overall mCPR for the year 2014-15 has been computed as 32.7%. In this way, mCPR during 2015-16 has increased by 8.6%, as compared to that in previous year.”

Amidst this state of affairs, the question is that how we, who could bring the use of family planning methods to 35.5 percent only during the past 67 years, would be able to take it to 50 percent by 2020, a figure Pakistan has already pledged as per the document of Family Planning 2020? It is to be kept in mind that for this purpose, we will have to effect an increase of 6.7 million users and that is not possible sans allocating additional resources – an estimate suggests that we have to spend at least 2.5 US dollars on family planning programme as against 0.40 US dollar spent in 2016-17. Moreover, we will have to ensure that every married couple has adequate access to family planning facilities. As per the Economic Survey of Pakistan 2017-18, there are 4033 family planning service-delivery centres in the country which is inadequate to meet the needs of a growing population. Experts opine that to make up for this deficiency, the government will have to mainstream this sector with consolidated, comprehensive efforts. In this context, exclusive attention should be paid to providing for proper and adequate facilities of family planning, more and more medical staff and building the required infrastructure. Moreover, the lack of awareness on these facilities should be dealt with through awareness campaigns so as to fulfil the growing needs.

Pakistan’s Commitments to Family Planning 2020

The Government of Pakistan updated its commitment at the Family Planning Summit in London, UK on July 11, 2017.

Commitment 1: Raise the CPR to 50 percent by 2020, by ensuring the optimal involvement of the public and private health sectors in family planning, and move towards universal coverage of reproductive health services meeting the SDG target 3.7 by 2030.

Commitment 2: Offer greater contraceptive choices through an improved method mix, by better counselling and expanding the use of long acting reversible methods, availing all possible opportunities in the health system (especially antenatal and post-delivery consultations) and training 33 percent of all LHVs, FWWs and community based workers (LHWs and CMWs) to provide a wider range of contraceptive products.

Commitment 3: Expand the program focus by providing services and information to men and gatekeepers so as to reduce unmet need among those women who cite husbands/social/religious opposition as reasons for non-use.

Commitment 4: Focus on addressing the information and FP service needs of nearly 100,000 married adolescent girls aged 15-19 thereby reducing their unmet needs and meeting the reproductive health informational gaps of unmarried youth by providing life-skills-based education.

Commitment 5: Provincial Ministers of Finance assure an increase in financing, moving towards the 2020 goal of $2.50 per capita that includes both private and public funding for family planning, (especially new initiatives) with support from the Federal government.