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PAKISTAN - FAMILY PLANNING: A
MISSING PRIORITY IN PAKISTAN'S HEALTH SECTOR?
According
to Alex Ezeh and colleagues, “Pakistan's failure to promote family planning in
the 1970s and 1980s” has already had, and will lead to, great repercussions: a
population that is anticipated to be “41% larger than Bangladesh's” by 2050.1
Currently, Pakistan's population is estimated to be more than 180 million,
increasing at a rate of 1·9% per year. It is projected to be between 266
million and 342 million by 2050 (figure),
largely to be determined by the uptake of family planning and consequent
fertility decline.2
Pakistan
has a poor record of reducing fertility: although the fertility rate has fallen
from about six births per woman in 1990 to 3·6 in 2012, it is higher than that
in the rest of south Asia.3
Family planning is perhaps the most overlooked and neglected component of
women's health in Pakistan. Contraceptive use rose sharply, from 12% to 28%,
during 1991—98 (corresponding to a 2% increase per year), but the rate of
increase has slowed and reached a plateau at about 30% since then. There is,
however, a renewed possibility after the 18th Constitutional Amendment4
to focus on family planning as a means to improve maternal and child health
with each newly evolving provincial health strategy.
More
recently, in research leading up to the London Summit on Family Planning in
July, 2012, the association between the fall in fertility and a period of
favourable age structures resulting from falling dependency ratios has been
linked strongly to the economic wellbeing of families and macroeconomic growth.5—7
The opportunity to capture the demographic dividend in the next few decades has
led to a growing realisation in Pakistan that investments in a strong family
planning programme and in human development are imperative.2
It is now a question of matching the realisation with a strong policy and
programmatic response, especially in Pakistan's provinces.
Many
economists and academics still doubt that Pakistan will achieve a substantial increase
in the use of family planning because of religion, social conservatism, or
preferences for larger families. Yet these apprehensions are not borne out by
the evidence—there are at least three strong arguments that go against this
premise.
First,
a quarter of women in the reproductive age group (15—49 years) in Pakistan have
an unmet need for family planning.8
In Khyber Pakhtunkhwa and Baluchistan, the unmet need for family planning is
greater than 30%. Nearly 1 million women in Pakistan seek unsafe abortions
every year, a decision determined by the high level of unwanted pregnancies.
Improved access to quality services will reduce the number of abortions and
maternal and child deaths.
Second,
it is clear from inequities in unmet need for family planning and contraceptive
use by income levels, and across urban and rural populations, why women who are
poor have as many as two unwanted pregnancies compared with a quarter of this
number for women who are not poor. The health system, unable to cater for the
unmet need in family planning, is at fault here and not the determination of
women to reduce the number of unwanted pregnancies.9
With the exception of the Lady Health Worker Programme, the delivery of family
planning services is not a priority for the public health system. The private
sector is active mostly in urban areas but the costs are unaffordable for women
who are poor. Services need to be prioritised for women who are poor and those
living in rural areas.
Last,
there is evidence that an increase of 2·5% per year in contraceptive use is
achievable even in mainly rural districts of Pakistan.10
The Family Advancement for Life and Health project, designed to revitalise
family planning, used the evidence available in Pakistan about factors that
prevent the adoption of family planning to improve communications and
strengthen existing service delivery structure by making it functional and effective.
The project, implemented in several districts in all four provinces of the
country, was designed to test different approaches to community mobilisation,
communication, training, and district strengthening efforts. The final
assessment has shown that unmet need is real and can be reduced and that
contraceptive use can be increased for rural, poor, and younger women.
Religious and social resistance has been disproved as a result of an impressive
uptake of contraception of more than 10% in 4 years in Khyber Pakhtunkhwa. The
results of tested approaches show that change is possible and that programmes
can be scaled up.
Renewed
and focused efforts for a strong family planning programme can change the
future trajectory of population growth in Pakistan. What is clearly required is
strong new investment in family planning that would not just ensure better
health and a lower mortality rate, but would strike a better balance between
resources and population size. If Pakistan is to increase the prevalence of
contraception, huge effort and commitment are required both programmatically
and financially at the provincial level. The effort to prioritise family
planning as a public health and development priority will have to be supported
by donors, and coordinated and monitored by the federal government. Although
the financial requirement will be about US$150—200 million per year,11
it is the clarity of priority and the capacity to reach this goal that will
determine the turnaround in outcomes.
I
declare that I have no conflicts of interest.
References
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a Population
Council Pakistan, Islamabad 44000, Pakistan