Successful family planning programmes worldwide have had one feature in common — sustained high-level political will to reduce population growth to levels that support well-being and a high standard of living for all citizens. The history of population planning in Pakistan, meanwhile, has been marked by frequent policy and programmatic shifts due to wavering political commitment. As a result, our progress in lowering our population growth rate has been sub-optimal.
Pakistan was one of the first countries in the region to start a full-fledged family planning programme nearly fifty five years ago. Field Marshal Ayub Khan, who initiated the programme, can be credited with taking a bold and forward-looking stand on the need for population planning. His pronouncements came at a time when other heads of governments shied away from openly speaking on the issue. Given the president’s interest, all government functionaries, including district administrators, felt accountable for programmatic progress.
Unfortunately, family planning became a contentious issue when it was opposed by the opposition in its campaign to oust Ayub. The PPP government that came to power in 1972, although initially reticent on the subject, soon revitalised the programme and tried to popularise it through the mass media. The Two-Child Prosperous Family slogan became popular during this period. However, after the imposition of martial law in the late 1970s, the new regime decided to curtail all FP programme activities for ideological reasons. This ban lasted for two years. Later, programme activities were allowed to recommence but without a media campaign for delivering information and creating awareness.
In the minds of many, the curtailment of the programme generated various ambiguities, mainly regarding the utility and benefits of family planning. The insinuation lingered that it was Western agenda aimed at reducing the number of Pakistanis. Many asked whether family planning was permissible in Islam. In some quarters these ambiguities persist even today.
The democratic era, ushered in in the late 1980s, again saw both a waxing and waning of programme support. In 1994, Benazir Bhutto represented the country at the landmark International Conference on Population and Development in Cairo where she introduced a new paradigm — linking the population agenda to maternal, child and family health. Subsequently, the Prime Minister’s Programme for Family Planning and Primary Health Care, more commonly known as the Lady Health Worker (LHW) Programme, was launched. The programme has been a victim of frequent shifts in programmatic direction whereby the LHWs have been distracted from their original mandate to offer doorstep family planning services as they are now more involved in other activities, such as polio prevention.
The start of the new millennium saw, once again, the imposition of martial law in Pakistan. A twelve-year Population Perspective Plan and the county’s first explicit Population Policy were announced during this period. However, the policy and plan could not be translated into the sort of cohesive national movements witnessed in Bangladesh, where the leadership took an active interest in its implementation — so much so that President Ershad of Bangladesh received a UN award in recognition of his efforts.
Since devolution in 2010, Population Welfare has become a provincial subject. The responsibility for action now lies with the provinces and they are doing whatever is possible within their limited fiscal space and jurisdiction since the population agenda is much wider and cannot be dealt with by the Population Welfare Department alone. These stumbling blocks could be obviated if the subject was accorded a high priority and urgency, galvanising the entire state machinery, including all relevant departments, to focus their attention on lowering our population growth rate to sustainable levels.
Today we have the opportunity to bring about real change. It requires political will and a commitment to take bold steps and major decisions. We have in place at the federal level an advisory body on health and population comprising seasoned experts to guide policy and programmatic direction. The current advisor on health has formed an inter-ministerial health and population council comprising health and population welfare ministers of all four provinces. And a road map exists in the form of recommendations for accelerating progress. It has been developed by a task force especially commissioned by the chief justice of Pakistan and endorsed by the Council of Common Interests (CCI) in November 2018.
Based on these recommendations, National and Provincial Population Task Forces headed by the prime minister at the federal and chief ministers at the provincial level have been announced. The newly announced social protection programme, Ehsaas, also includes a reference to the need for universal access to family planning services for the marginalised and vulnerable populations.
What we need is political will at all levels to usher in structural reforms to ensure that the recommendations enshrined in the National Action Plan jointly prepared by the provinces are fully implemented. These reforms will have to focus on revisiting approaches adopted in the past to deliver services; reach out and mobilise communities; informing and educating young people through new media; ways to involve men in family planning; garnering religious support and fostering linkages with other departments and the private sector.
A crucial element that has been missing in the past is accountability which should be institutionalised at the provincial and district levels involving the elected representatives and political leaders who should hold programme implementers accountable for delivering key results based on predefined indicators that should ideally be monitored by the provincial chief ministers. Certain key legislation will be required, such as those adopted in neighbouring countries. In Iran, for instance, the family planning bill introduced in 1993 paved the way for improving access to family planning services. Equally important will be putting in place mechanisms that would ensure the implementation of the laws, which has been a foremost deficiency in the past.
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Other fundamental reforms may be required. Importantly, a major political decision that must be taken is to revisit the NFC award formula so that it is linked to improving social indicators, and not predominantly population size.
Courageous decisions taken today and sustained in the future will have monumental consequences for Pakistan’s development trajectory in the years to come.