The News on Sunday (TNS): What are the biggest challenges Pakistan faces when it comes to reducing our population and our birth rates?
Zeba Sathar (ZS): Our biggest challenge is this situation of ambivalence and the state of limbo that we find our nation in regard to the gaping unmet need for family planning services, the high maternal and child mortality rates and malnutrition levels. The most important group that must regain clarity and control the decisions and resources are the managers and policy makers and they must be churned into action.
Some simple efforts at expanding information sources and choices of service delivery in the private sector, especially through non-medical providers would shake things up positively. We have a lot of evidence that shows that small-scale projects can be run very successfully.
One instance of a successful large-scale project run by the Population Council with its partners was called FALAH and it produced real change in a short period of three years; the way we did this was by improving the quality of birth-spacing services.
Our focus needs to be on those men and women who are unsure about how to space between children and about the number of children they want. This can be largely influenced by improving access to birth-spacing services. If we do this, we would lower fertility rates and the population growth rate. We should not focus on just lowering population growth rates; we must focus on a human-centred population policy. The ability to meet people’s needs is the most lasting and sustainable strategy which will ultimately lead to the completion of the fertility transition.
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TNS: What is your opinion on employing religion to convey the concept of family planning to the public, the way the latest Sindh government campaign has done?
ZS: I think it is important to have the endorsement of religious leaders as is being done in the current campaign. At the Population Summit 2015, religious leaders of different sects openly gave their approval and consensus on the importance of birth spacing between children in order to save mothers and children’s lives. This is a huge difference from the earlier campaigns which emphasised that two children or fewer children was better. The problem with those campaigns was that this idea is adversarial to most religious leaders.
Having said that, much more clarity is required in the campaign. Currently, there is a conveyed sense of ambivalence about what Islam says regarding birth spacing and family planning. The current ideas in the campaign won’t solidify in the minds of a major portion of service providers, which includes pharmacists and distributors. One way to achieve this clarity is by holding intense and informative training and orientation sessions with service providers. The current campaign is only increasing the acceptability of the idea among general audiences, but they need more information. Such campaigns must also include interpersonal sources of providing information.
TNS: Do you think family planning campaigns should be more fact based? What are the ideal components of a family planning campaign that the government should be focusing on?
ZS: The health benefits of birth spacing, the benefits in terms of positive aspirations for children education and health. But above all, there is a substantial proportion of women and couples in Pakistan that have ‘bought into’ the positive aspects of family planning. According to our estimates, 7-9 million people want to do something about birth spacing and stopping the growth of their families but are unable to do so due to informational and service gaps. The benefits of family planning and the direct link it has between maternal and infant mortality and birth spacing and the numbers of lives that can be saved through birth spacing, needs to be highlighted.
The campaign has to address these gaps. In particular, the campaign has to address the providers, the policy makers, the stakeholders to improve access, to ensure commodities, to reduce the cost of services. The campaign needs to use the media to provide direct information about the benefits and also the side effects of contraception and how these can be dealt with. Millions of women and men use contraception but then they leave it because of the poor quality of information, and weak or no counselling from our current providers.
TNS: Iran and Bangladesh in the 1980s are two countries that considerably brought down their population rates. Should we be looking to other countries for inspiration or do we need to devise our own campaigns?
ZS: I think we need campaigns to correspond to our own situation and not adapt to other countries’ campaigns. Each country is quite different. A major part of the campaign has to address the lack of response from those who plan, provide and fund services that are falling behind in delivery. The federal government, especially, may not see this area as one of their priorities, since provincial governments have more direct responsibility for health and population services.
But it is very important that the issue of family planning becomes an issue of national interest, a national priority, and a national consensus is built to decide to prioritise this area for reasons of the rights of men and women and children to have a better life. I would go as far as saying that we have lost our way in the area of family planning and we are already suffering the impacts: look at the number of out of school children, maternal deaths, child deaths, malnutrition, and the environment to name just a few.
TNS: Since you have been working with the Population Council, many governments have come and gone. Have some parties been more responsive than others?
ZS: The PML-N in Punjab and the PPP in Sindh are both equally responsive. The real challenge is that all involved parties have to put in a lot of effort because we keep losing momentum due to other critical and burning political issues. The issue of family planning has to constantly compete against critical political problems. That is why continuous and sustained advocacy is needed to make sure that family planning remains on the government’s priority list, regardless of the political party in power.
TNS: Many say that Benazir’s government and their Lady Health Workers (LHWs) and Lady Health Visitors (LHVs) programme truly improved family planning, what is your opinion?
ZS: The LHW programme is really the best achievement for Pakistan’s health sector. It began under Benazir’s government but continued under subsequent governments. At this point, much of the programme is being challenged after their regularisation and devolution of powers but this cadre of workers are valued very highly. We must remember, however, that at the end it is the families they serve who are responsible for good outcomes in family planning and primary health. At least that was the case in the 1990s. Right now, I would say that the whole cadre of LHW has to be carefully reviewed to ensure that they would provide the same impact on these families, especially since their demands have changed since the 1990s.
TNS: What has been Pakistan’s most successful family planning campaign so far?
ZS: It is hard to say. Perhaps the one that is yet to come? A successful campaign must be based on sound evidence of what the people of Pakistan are yearning for. I think what we need is strong clarity in our messages and the endorsement of birth spacing as a fundamental right, and, of course, we need our audiences to be receptive.