SOME may find the title of this article provocative and others may find it amusing. But this is a very serious issue: Pakistan needs contraception and contraceptives are not available.
In a special report in Dawn on Aug 14, 2021, Javed Jabbar wrote a brilliant article counting the things to be proud of in contemporary Pakistan. Despite giving a marvelously optimistic perspective he couldn’t help saying that “the failure to substantially reduce the rate of population growth has become an albatross which stalls our speed and erodes gains…”. Absolutely!
In Pakistan today, the biggest development challenge, both social and economic, is unhindered population growth. National development visions and plans would not be able to beat the rising population tide. High population growth, an unstable economy, depleting resources and climate change challenges coupled with high poverty and poor human development indices are all ingredients to land and live in a classic Malthusian trap. And the biggest issue is that it is not being perceived as an issue. We have an eyes-wide-shut policy attitude when it comes to the population elephant in the room.
At the time of independence, the then West Pakistan had a population of around 36 million, today we are over 220m, more than a six-fold increase. We have become the fifth largest country in the world, only after China, India, the US and Indonesia. With an annual population growth rate of 2.4 per cent (the Asian average is 0.92pc), Pakistan adds 5.2m people every year to its headcount which is close to adding one Norway annually! At this rate of growth, we are going to be 350m by the year 2050. Last year, an average woman in Saudi Arabia bore 2.34 children whereas a Pakistani mother bore 3.5 children. In the backdrop of these depressing stats, the most disturbing is our contraceptive prevalence rate (CPR).
Couples don’t have timely access to and actionable information about contraceptives.
CPR is defined as the proportion of women of reproductive age who are using or whose partners are using a contraceptive method at a given point in time.
Pakistan’s CPR is extremely low at 34.5pc. To put this in perspective, Iran has a CPR of 77.4pc, Turkey’s is 73.5pc and even Bangladesh’s CPR has climbed to 62.4pc. Pakistan’s CPR of 34.5pc means that 65.5pc of women of reproductive age or their husbands are not using any contraceptive method. And this is why Pakistan needs contraception.
The Population Council estimates that there are around 9m pregnancies in Pakistan annually. Half of these are unintentional. And around 2.25m end up in abortion — which is mostly unsafe. Had these couples had access to contraceptive methods and the appropriate information about their use, these unwanted pregnancies would not have occurred in the first place.
With such grave numbers, let us now look at the contraceptive situation.
A range of contraceptives, implants, condoms and intrauterine devices (IUD) continue to remain in short supply in government as well as private facilities in Pakistan. There are continued and unattended stockouts which reflect the federal and provincial governments’ neglect of this mega development issue. According to reliable data available from the Pakistan Logistics Management Information System, between January and March this year, 50pc of districts in Pakistan didn’t have a government supply of condoms, a situation which only worsened between April and June when 68pc of districts were out of condom stocks. Likewise, combined oral contraceptive pills were out of stock in 41pc and 47pc of districts during the same months, copper IUDs were not available in 59pc and 65pc districts and injectable contraceptives were out of stock in 38pc and 49pc of districts during the first and second quarters of this year. This dismal picture is not only of the first six months in the current year, rather it is a trend seen year after year.
Whatever the causes, the consequences are clear: a burgeoning population increase. Couples don’t have timely access to and actionable information about contraceptives even when they want to control the size of their families. No wonder, out of 9m pregnancies each year in Pakistan, 4m are unwanted.
Why are there continued stockouts of contraceptives? Drilling into the causes would reveal supply chain issues, fragmented and discordant procurement cycles, unappealing business volumes to producers, overwhelming reliance on imports with no indigenous production and so on. This situation has only worsened in the last 10 years or so since the 18th Amendment has made it extremely difficult to have nationally coordinated procurement and supply of contraceptive commodities.
There is also no policy to guide and facilitate the local manufacturing of contraceptives. Out of around 650 licensed pharmaceutical manufacturers in Pakistan there are less than 10 companies involved in oral and injectable contraceptives production. Despite having put up expensive dedicated injectable hormonal production plants, some of these companies have more than 90pc unutilised production capacity. No company in Pakistan produces condoms and there is no local production of simple IUDs in the country. There have been two failed attempts at condom production in the past but because of lack of facilitation by the government these initiatives couldn’t see the light of day.
The non-availability of contraceptives and chronic stockouts, however, are indicative of a much bigger problem. The hard reality is that population control has not been a major priority for successive governments in Pakistan. Instead of taking the population bull by the horns, sadly, the only trend we see is that government interest has gone down further over the years in this area. Population ministries and departments are chronically underfunded and badly governed, and have been pushed to the public policy junkyard. Staff working in population ministries/ departments is least motivated. One way of mainstreaming population issues is by merging population departments with health departments. In some provinces it has happened and in others such efforts are politically stalled due to power and trough issues.
Unless Pakistan undertakes a complete paradigm shift on the population issue, we will only be compounding the problem.
The writer is a former SAPM on health and currently serving as a WHO adviser on Universal Health Coverage.