As Pakistan’s second most populous province, with the population projected to increase to 61.7 million by the year 2030, Sindh has a lot to achieve. Out of a conservatively estimated population of 46 million, as per the Sindh Population Policy (SPP) 2016, a majority of which resides in urban areas, the actual population has the province bursting at the seams, with massive numbers of people migrating to Sindh, particularly the mega city Karachi.
The indexes are not encouraging. Sindh fares lower than the blue-eyed and better governed Punjab when indicators of both provinces are juxtaposed. The developmentally nascent Khyber-Pakhtunkhwa is also showing more promising upward trends.
Sindh has had successes, but numbered and calculated. While the Total Fertility Rate (TFR) declined from 5.1 births (in 1990-91) to 3.9 births (in 2012-13) in Sindh, the contraceptive prevalence rate (CPR) for Sindh seems to be stuck in a status quo at 29.5 per cent during 2001-2013. Though 96 per cent of the population is aware of at least one method of family planning, the unmet need for contraception in Sindh is still stuck at 21 per cent. In 2015, 13 million women were of reproductive age (ages 15–49), a number expected to rise to 15 million by 2020.
The SPP 2016 shares its high hopes and important but farfetched aims. One of them is to ensure contraceptive commodity security up to 80 per cent at all public service outlets by 2018, while another aims to increase access to Family Planning (FP) and reproductive health services to the most remote and farthest areas of the province by 2017. With almost three quarters of 2017 having passed, this is a good point in time to take a look at the state of family planning in Sindh.
At such a time, the Costed implementation Plan (CIP) promises a glimmer of hope — hope that is conditional to implementation. As a five-year actionable roadmap designed to help the Sindh government achieve its FP goals, the Sindh CIP can play a critical tool in achieving targets. Sindh is Pakistan’s first province to develop a CIP on family planning. The motivation, perhaps, is not just the challenges a large population puts in front of Sindh’s developmental efforts. The political will of late prime minister Benazir Bhutto still looms large as an influence over Sindh’s policy makers. “I dream of a Pakistan, of an Asia, of a World, where every pregnancy is planned and every child conceived is nurtured, loved, educated, and supported,” she once said.
The government of Sindh allocated PKR 890 million (US$8.5 million) during the last fiscal year (July 2015–June 2016) to CIP activities for 2015–2019. If the CIP, the cost of which is an estimated PKR 79.12 billion (US$ 781 million), does get implemented, the positive ramifications can be immense. It can have an impact not just on the FP efforts, but will also impact health, education, women’s empowerment, employment, as well as demographic and economic activities. Experts predict that if the proposed interventions are carried out, 1,848 maternal deaths and 29,470 child deaths could be averted by the year 2020. Some 1,774,367 unintended pregnancies and 193,332 unsafe abortions could be averted.
This is sorely needed. Earlier this year, Dr Talib Lashari, Technical Advisor, Costed Implementation Programme of Sindh Population Welfare Department, shared with members of the media that Sindh’s birth rate is 1,240,467 per year. This high birth rate, he commented, would not only result in poverty, but also in an insufficiency of resources available to the people of the province.
The estimated cost of the Sindh CIP includes an infrastructure upgrade and mass media campaign. These two aims will help increase awareness among not just the masses but also help sensitise on-ground staff, medical personnel and government officials towards FP. The hope, then, is to eventually reach a point that results in a change of the mindset and not just the numbers.
One of the key tools in the practical implementation of the CIP are the lady health workers (LHWs) who can play an effective role. LHWs carry out layered and multiple roles, and work on activities related to community awareness, maternal health, nutrition, immunisation, FP, as well as providing guidance on minor ailments and health education. They have access into the homes of their communities, and have social impact.
A weak infrastructure and social attitudes make mobility of women to the distant and numbered public health units difficult. LHWs fulfill the need to go door-to-door and convince the communities regarding FP. Pakistan’s FP 2020 commitment requires that the role of the LHWs in FP be enhanced. It is encouraging that the CIP team recently concluded that 50 per cent of allocations for the LHW Programme would be dedicated for family planning work, rather than the earlier 25 per cent.
Other important parts of this jigsaw puzzle that cannot be afforded to be missed are the Lady Health Visitor (LHVs), Community Midwives, Rural Health Centres (RHCs) and Basic Health Units (BHUs). There are some 22,575 LHWs and 770 Lady Health Supervisors (LHS) working in Sindh.
An exhaustive consultative process with stakeholders enabled the PWD and Department of Health (DOH) in identifying six strategic areas for investment in FP, all equally important. They are well planned out and focus on both increasing knowledge and awareness among the communities as well as better governance, improved coordination among the government departments working on it, and consistent government spending on this cause.
Looking at data from Sindh, it is clear that one of the most important factors is increasing the awareness among the population. A case in point is that the two most frequently used FP methods in Sindh are female sterilisation and condoms. While people are aware of short-term methods like condoms, pills and injections, the use of these methods remains low, and will remain low till the people are made aware and the contraceptives are made readily available. There are vast disparities in the provinces urban and rural development landscapes. The CPR rate in urban areas is of 42.7 per cent, compared to 17.4 per cent in rural areas.
If this province has any hope of attaining success with regards to the Sustainable Development Goals (SDGs) 2030, FP will have to be a key focus. It is hoped that the CIP fulfills its aims, and alongside effective FP, also positively impacts literacy and education in Sindh, as well women’s empowerment via increased work participation and economic self-sufficiency.