Pakistan, a country of more than 170 million, has a high population growth rate and could become the fourth largest country in 2050 with population surpassing 300 million. Our country hence has always been in the forefront of news for population issues. In the last few months a flurry of articles appeared in different English language newspapers of Pakistan related to (over) population, for reference see, here, here , here, and here. Despite the numerous articles, I decided to blog about this topic because I could not find any recent article that would point out the multitudes of causes behind our population issues.
(For this blog I have mostly used journal articles and survey publications to avoid my personal bias. However, several articles used in this blog, unfortunately, are not available for free access.)
Whenever the question of population growth arises in our country, we tend to think of our family planning program which became part of government policy in the Fifties in first Five-Year Plan but launched as a formal program by the government in 1965. In the last five decades, the program has been successful in increasing level about awareness about contraceptive methods. During this period, the use of family planning methods rose from around 5.5 in 1968-69 to 35 percent in 2012-13 (Sathar and Casterline 1998; NIPS 2013). However despite these successes, our current population growth rate, as reported in Economic Survey 2015-16 is 1.89 (quoted to be 2.03 by Prime Minister Gilani on population day) and total fertility rate is over 4 (it went down to 3.1 in 2016) and population continues to rise with alarmingly.
While population growth might spur economic growth (esp. when in conjunction with demographic dividend), an unchecked growth with no matching economic infrastructure to subsume the population efficiently can create a burden also (to read more on this check this and this). According to Deputy Chairman Planning Commission Nadeem Ul Haque for current rate of population of our country to keep the same standard of living would require a corresponding national growth rate of over 7 percent (which is currently project to grow at a little over 3 percent). We would also need to add 2 million new jobs every year, to keep the incoming cohorts employed.
The million dollar question is why population programs in Pakistan haven't been successful? It would not be fair to label the Pakistan population program as failure. It has been successful in achieving an almost a universal level of contraceptive knowledge leading to increase in family planning usage which ultimately brought the fertility rates under some checks. However, it would be useful to critique why it has not been successful in meeting its targets consistently, from the very beginning. A common comparison of Pakistan's program is done with Bangladesh because at the time when it separated from Pakistan, "there were 5 million more people in Bangladesh than Pakistan... as result of their successful program, by 2050 Pakistan will have 62 million more people than Bangladesh" (Campbell et al. 2007).
The reasons for its lackluster performance is attributed to our government's lack of commitment (including switching family planning between ministries of health and population welfare (which has been devolved to the provinces after the 18th amendment in 2010)) to meet population goals and in general corruption in the system. Another reason is not being able to spread the reach of contraceptives despite deployment of more than 100,000 Lady Health Workers reaching 90 million population and multitude of smaller health centers geared towards rural areas. The third reason attributed to this (particularly to the stalled family planning usage rate) is the drastic reduction of international donor funding (which is the major funding source) for family planning programs, since the 2000. (Also see this).
The program and supply side success has brought Pakistan contraceptive use at 30 percent and a similar proportion of married women also show unmet need for family planning. Combining the current FP usage with unmet need for limiting childbearing (desire to have no more children) would bring up contraceptive use to more than 50 percent. Just to give the reader an idea of how Pakistan fares in the region, the family planning rates of other countries in the region like Bangladesh, India, Iran, Nepal and Sri Lanka are 54%, 48%, 73% , 38% and 68% respectively which are clearly at much higher level than Pakistan.It might be interesting to note that the top method choice in Pakistan is Pakistan Female Sterilization (8%), in Bangladesh it is pill (43%) and in India it is female sterilization (37%). For details on these statistics see various demographic and health studies).
One of the best way to gauge fertility demand is to ask about ideal family size (because some people may end up with than their ideal because of lack of access to family planning). According to the latest demographic survey the ideal family size in Pakistan is 4.1, which is the same as actual TFR. Moreover the demand for larger families continues to persist. "Only 13 percent of women prefer a two-child family and another 14 percent consider three children as their ideal family size." One should ask that why desired fertility has not gone down despite decades of promotion of two children as better family campaigns.
Another strong reason for low use family planning is sex preference of children (which for some reason is not talked about that much in our country), especially the desire to have sons or lack of satisfaction with sex composition of current children. According to one study, in order to have one male child people are willing to have as many female children as needed (source missing). The lack of a son or a daughter among one’s living children increases the likelihood that a woman will have another child in all four regions. For example, women who have more than 5 children but no sons, 24% of them still want to have more children, while "among women with three children, 65 percent of those with three sons want to have no more children compared with only 14 percent of those with three daughters." Despite these preferences, I should point out here that abortion (or feticide) based on sex preference is rare in Pakistan.
Other strong indirect factors in contraceptive non use are lack of autonomy of women, lack of education and formal work opportunity, poverty and a general sense of fatalism and/or religiosity.
Direct reasons of lack of contraceptive use and/or discontinuation of use include actual or perceived side effects of modern contraception (hormonal) and method failure, failure of method (resulting in pregnancy), barrier in access including cost, distance, social stigma, lack of knowledge of a method and its source, religious and social barriers in use of family planning. (For more info see this and this.)
Family planning programs have come under fire because some contend that "fertility rates in some countries will drop only when couples decide they want fewer children. And the strongest predictors of a woman’s desired family size are her income, her education level, and her infant’s chances of surviving." The supporters of economic growth and its link to fertility reduction purport that "when the motive is strong, couples will find ways to achieve small families, and state-sponsored family-planning programmes are not a necessary." However, Cleland (2006) contends that though that might be true but "family-planning programmes can accelerate the pace of change." Sharing similar views Bongaarts and Sinding (2009) also note that "voluntary family planning programs are intended to reduce the number of unplanned pregnancies, but they also legitimize and diffuse the idea of smaller families, thus accelerating the transition to lower fertility."
It is surprising that despite more than four decades of family planning program the ideal family size has remained as high as more than four children which shows that lack of family planning use is not only due to supply side factors but married men and women go through a matrix of choices before opting to limit their families.
Family planning: The unfinished agenda.
Fertility in Pakistan: Past, Present and Future.
Pakistan Demographic and Health Survey 2006-07.
Does Family Planning Bring Down Fertility
Future of Pakistan family planning
National Program for Family Planning and Primary Health Care.
Bongaarts, J., & Sinding, S. W. (2009). A response to critics of family planning programs. International Perspectives on Sexual and Reproductive Health, 35(1), 39-44.
Campbell M, J Cleland, A Ezeh, and N Prata. 2007. "Public health. Return of the population growth factor". Science (New York, N.Y.). 315 (5818): 1501-2.
Cleland, J., S. Bernstein, A. Ezeh, A. Faundes, A. Glasier, and J. Innis. 2006. "Family planning: the unfinished agenda". The Lancet. 368 (9549): 1810-1827.