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Population denominator


Published in The News International on July 11, 2010:

July 11, World Population Day, holds special significance for Pakistan, the sixth most populous country in the world where the importance of Population as the denominator for planning and development must be clearly appreciated. In a country where food, water, energy, education, healthcare, social welfare, and job opportunities are already scarce for the existing population of 173.5 million, the addition of another 173.5 million over the next 34 years will pose a crippling burden in view of prevailing resource constraints. Population therefore, is a true denominator for development. Additionally, a burgeoning young population with limited economic opportunities and social welfare means fuelling the fire of extremism, given that these ‘bleak youths’ would be the perfect targets for exploitation in extremists’ hands. For Pakistan population is also, therefore, the denominator for internal security.

We tend to place the responsibility for rising population on the population welfare program. That shouldn’t be the case. International experiences show that fertility decline is correlated with the level of socioeconomic development in a society. In other countries where it has been achieved, regulatory measures—as in the case of China’s one child policy—have been at play. The former is not the context in Pakistan and the latter not possible owing to the mistaken notion by the masses that family planning is forbidden by religion. All hopes are therefore pinned on the performance of the country’s population program. This perhaps, is also the reason for the current interest in the National Population Policy 2010, which is in the final stages of review. The policy is important as it will come at a time when many structural changes are taking shape. In essence, therefore, the policy will be indicative of how the state system is adapting. With resources now shifted to the provinces, the 18th Amendment calling for wrapping up the Ministry of Population Welfare (MoPW) after abolishing the concurrent list and IMF’s conditionality stipulating likewise, a policy issued from a federal level in a domain which is normatively and fiscally provincial will have to make very good sense in order for it to be palatable. These points are likely to be raised at the next meeting of the National Commission on Population Welfare (NCPW), the inter-provincial forum where the policy is likely to be discussed prior to Cabinet’s review.

Within this context, this comment outlines three areas, an emphasis on which may enhance the policy’s relevance.

First, the policy should be commensurate with stipulated mandates in the sector; it must garner provincial ownership and clearly outline roles and responsibilities. With population as a sector now completely in the provincial domain, would it be possible to carve out a role to justify MoPW’s existence? The answer to this can be in the affirmative if the MoPW devolves its service delivery responsibilities and focuses on a normative role. The MoPW has an untapped potential to assume a leadership role in the population-development paradigm, which remained overshadowed because service delivery responsibilities had previously crowded out the space for normative functions. A new transformed, albeit lean and competent MoPW could be a good economic investment even in today’s resource-challenged environment given the strategic importance of population control.

A service delivery mandate doesn’t mean provinces shouldn’t pay heed to evidence. An earlier, pre-18th Amendment draft of the policy—the current draft is not in the public domain—had outlined an ambitious plan for increasing infrastructure with targets outlined for increase in the number of Family Welfare Centres and Reproductive Health Centres. Even if this has provincial consent, the strategy needs revisiting for a number of reasons: there is currently a moratorium on new infrastructure in many government polices, with which this clearly conflicts. Additionally, there is no convincing evidence of existing arrangements being efficient, which is why the fundamental premise of ‘state owned and operated infrastructure’ is under question. This is evidenced by reform initiatives mushrooming. A policy should outline evidence-based innovations to improve performance rather than signalling intent to increase numbers.

Secondly, the policy should be clear on one of the burning governance issues in the population/health sectors, relating to the standalone status of respective ministries. Pakistan is one of the two countries in the world—Egypt being the other—where the health and population ministries are separate. Several attempts have been made by the government in the past to merge both the institutional hierarchies. When this didn’t appear feasible, UNFPA coined the term ‘functional integration’ in 1998 which then became the mantra and endpoint in efforts to achieve institutional collaboration. However, reluctance on part of both sides—federal and provincial—has been evident with many directives remaining unimplemented, including directives of the Executive Committee of the National Economic Council, Federal Cabinet and NCPW in 1985, 1991, and 2006 respectively. The rationale for functional integration is strong. Health and population have shared agendas, as also emphasized by the International Conference on Population and Development (ICPD), which aimed at a paradigm shift from family planning being a demographic target to a reproductive health end-point. Current fiscal constraints also create an imperative.

A special supplement of the Journal of the Pakistan Medical Association featured an analysis on this subject last year outlining actions that could be taken to bridge the health-population disconnect (http://www.heartfile.org/pdf/SHPP-JPMA.pdf). It would be an imperative for a new policy to come out loud and clear with the specifics of ‘what’, ‘how’ and ‘when’ to eliminate duplications and maximize synergies. Since changes are also happening simultaneously in the health sector it appears that the sustainable long-term solution to the existing population-health disconnect centers on strengthening capacity of both the Ministries for normative and oversight functions and grouping and benchmarking health and family planning as essential services to be provided through reconstituted service delivery arrangements.

Thirdly, the policy should adequately recognize existing inefficiencies in the population program. MoPW functionaries are well aware of the pervasive collusion in field operations of the population program; as a result, commodities are pilfered, fees are charged for services that are meant to be provided for free and there is deliberate inattention to oversight to compel accountability—state resources are wasted as a result and service delivery is undermined. Changes within the existing payment and incentive systems to remedy these fault lines should be a priority for the new policy.

In a way this links to the critical question in governance—one relating to implementation of policies. There has been no dearth of population ‘policy instruments’ in Pakistan. The work of the Family Planning Association of Pakistan, an NGO, which predated the governments program, was supported officially by the government in the early 1950s. Since the early 1960’s every Five Year Plan has made allocations for the sector regardless of whether ‘population’ was housed under Ministry of Health and Labour (as during the First Four Plans) or the Planning Commission and later when it was a given the status of a ministry in 1990. Additionally, the Population Policy was enunciated in 2002 and the NCPW was created in 2006. Furthermore, all health policies, enunciated to date in 1990, 1997 and 2001 have focused on the population issue to some extent. However one view (utilitarian) on a policy is centred not on what a policy states but on what it delivers and on that score, all the previous policy instruments have performed poorly.

In theory, the Population Policy 2010 has been well articulated especially with respect to the domains, which needed to be covered in a policy document. However, this framework must be more than stated rhetoric. It must empower institutions to ‘do more’ so that the systemic constraints that stand in the way of implementing the policy can be overcome.

The author is the founding president of the NGO think-tank, Heartfile. sania@heartfile.org

July 11th, 2010
Sania Nishtar,
Health Systems,Governance,
Publication Type:
Op-ed columns,