POPULATION GROUTH IMPACT ON THE MELLENIUM DEVELOPMENT GOALS
Pakistan as an important partner of Millennium Development Goals (MDGs) is moving forward in accordance with its agenda towards achieving objectives of MDGs and Cairo Conference on Population and Development (ICPD). However, with advent of new Government in 1999 a number of structural reforms were introduced in the country to reduce poverty ensure sustainable growth and moving towards a progressive state. These policies aim on reducing poverty, fertility, infant mortality, unmet need for contraception, etc. The last few years have also seen international focus on Millennium Development Goals and initiation of Poverty Reduction Programmes by low-income countries like Pakistan.
The international community in a series of UN conferences during the 1990s recommended a set of goals and provided a broad framework within which to achieve the same. The Cairo Conference on Population and Development (ICPD) 1994 gave a 20-year vision to overcome low development, population and health indicators. The Millennium Summit 2000 reaffirmed these commitments for sustaining development and eliminating poverty as a high priority pursuit. The Millennium Development Goals (MDGs) evolved out of the resolutions agreed in the UN conferences, including the ICPD. Interestingly, all the UN Conferences echoed benchmarks for achieving the established goals and marked 2015 as the culmination year. Though ICPD reviewed its progress in 1999 and readjusted its goals keeping on the basis of in-depth research findings, asserted the relevance and validity these goals warranting uninterrupted attention yet. The MDGs, on the other hand, extended an overarching framework with a broader set of ambitious goals for comprehensive achievements of the targets related to life expectancy, education, gender equality, housing, and environmental sustainability. The Millennium Declaration has, in fact, become the reference point for all UN activities with eight major goals, which nevertheless, missed out a specific and obvious goal on reproductive health.
Millennium Development Goals / ICPD + 5Eradicate extreme poverty and hunger / Achieve universal access to primary education by 2015
Achieve universal primary education / Ensure all health care facilities provide the widest range of safe and effective family planning methods
Promote gender equality and empower women / Close the gap between contraceptive use and unmet need
Reduce child mortality / Ensure 60 percent of all births are assisted by skilled attendants
Improve maternal health
Combat HIV/AIDS, tuberculosis, malaria and other diseases / Provide HIV prevention services to young men and women age 15-24
Ensure environmental sustainability
Develop a global partnership for development
Demographic Profile
Pakistan is the sixth most populous country in the world (after China, India, USA, Indonesia, and Brazil) and has the highest rate of growth among these countries. At the time of independence in 1947, the population was 32.5 million, which increased to 132.5 million in 1998 (National Report: Population Census Organization). The population growth rate mostly remained at or above 3% during 1970s and 1980s and only began to decline during 1990s. Estimates of crude birth and death rates derived from Pakistan Demographic Surveys suggest that noticeable decline in the annual population growth rate started only in the mid-1990s and by the end of the 2004 it had touched 1.96 percent. This estimated annual growth rate implies that population could double in just 34-35 years, if continued at the existing rate. Government recognizes that high population growth in the past has resulted in a significant proportion of population below poverty line. The estimated population for 2005 is around 151.4 million[1] and will increase to 167 million by 2010 and 181 million by 2015.
Historically, birth rate remained persistently high in Pakistan, while mortality declined speedily with improvement in income, standard of living and health facilities. Due to improvement in life style and economic conditions, the CDR is expected to further fall to 6 meaning thereby that fertility decline has to occur faster to sustain the downward trend in growth rate.
Poverty and Hunger
The Millennium Development Summit 2000 though focused on poverty, hunger, gender and equity, etc. yet priority on education, maternal and child health, HIV/AIDS was maintained along with focus on sustainability and global partnership. The attention to ICPD got strengthened due to common target year (2015), greater commitment to funds by international donors to meet development needs and greater attention for efficient use of available resources.
The Poverty Reduction Strategy Paper formulation process got initiated in 2001 and after series of rounds of consultation final shape was given to it in December 2003. Though the focus of PRSP remains the MDGs but National Health Policy, Population Policy, Education Policy, etc. are integral part to ensure achievement of goals with in the stipulated time. The PRSP provides exclusive strategy for poverty reduction based on four pillars---accelerated and broad-based economic growth while maintaining macroeconomic stability, improving governance and consolidating devolution, investing in human capital, and targeted programs with emphasis on social inclusion – all are important ingredients for meeting the MD Goals and ICPD.
Child Mortality and Maternal Health
Major problem in Pakistan’s population growth is contributed by high fertility and infant mortality rates over the past. High fertility among the poor and illiterate women has a series of negative health and quality of life affects on them and their families. They continue to show high-risk reproductive behaviour indicated by too many births, too close births, too early and too late births. These experiences add to their maternal morbidity and mortality risks, which continue to be high. This segment of population experiences high infant and neonate mortality, which is also not showing any significant decline in the recent past. The decline in fertility and rise in contraceptive prevalence implies a decline in ‘unwanted’ pregnancies, which would have even added to the existing family size.
Even though decline in fertility is associated with rise in the quality of life of women, but the majority of women in the poor segments come from conservative background, need to be encouraged to use contraception. The other two proximate determinants of fertility including age at marriage, and use of contraceptive methods have shown vibrancy during 1990s in facilitating decline in fertility levels. The rise in use of contraceptives during 1990s from just 12 percent to 24 percent in mid 1990s and 34 percent now is worth mentioning. Lesser proportion of Pakistani women is marrying at younger ages. Age at marriage for women rose from 17 during 1951 to 22 by late 1990s.
Mortality has consistently shown a steady decline in all its indicators including crude rate and infant mortality rates. Infant mortality rate was between 150 and 180 at the time of independence has decline to 84 in late 1990s (as estimated by PIHS 2000-2001). The progress has been remarkable. Unfortunately, neonatal mortality level (currently around 53) has not come down over the last decade. At this stage, more than half of all infant deaths occur.
Pakistan still has the highest infant mortality rates, lowest female literacy rates, highest fertility and population growth rates, etc. Progress on all aspects is very slow.
The level is universal among married women reflecting the need to know about contraceptives among women and program’s focus to enhance the same among married couples. Campaign promoting small family size along with rising poverty levels contributed towards the desire for not having additional children. Forty four percent of married women desired not to have additional births in 2000-01. Estimates of unmet need for contraception too surged past mid 1990s reflecting seriousness among women who needed better access and knowledge about various methods of choice to enable them practice it. The desire to limit births though higher than birth spacing has also risen over time indicating the need to strengthen services in conservative society and ensure its access to those who need.
Birth delivery is considered a normal outcome of pregnancy. Therefore, delivering at home continues to be practiced quite conventionally and as a traditional matter in all parts of Pakistan. What makes home delivery unsafe is the individual delivering the pregnancy. Though several thousands of traditional births attendants (called dais) were trained during 1980s and 1990s but there continues to be high maternal morbidities and mortality, and unsafe practices during delivery. Those related to neonates indicate that efforts have gone waste without any significant impact. High maternal mortality is closely associated with rural residence and poor segments of population, which makes the issue a focus of development policy and an important indicator of MD Goals and ICPD.
Demographic Changes and Current StatusIndicator / Year / Level
Total Fertility Rate / 2000-01 / 4.8
Population (age less than 15) / 1998 / 42.4 %
Numbers / 55 million
Young Population (age 10-24) / 32 %
Singulate mean age at marriage
Male
Female / 26.3 years
22.1 years
Annual net addition in population / 2002 / 3.1 million
Infant Mortality Rate / 1997-00 / 84
Life Expectance at Birth* Male
Female / 2001
2001 / 64
66
Maternal Mortality Ratio / 2001-02 / 350-400
Gender equality and Women Empowerment
In line with the MDGs and ICPD Plan of Action, Pakistan has taken series of steps towards women empowerment and improving its gender development index. The government did recognize a number of critical areas regarding women and gender including: low participation in economic development, low literacy and educational attainment, low access to facilities by women, discrimination in opportunities and existing laws pertaining to women work, and social norms and values engendering serious disparity against women. Creation of Women Development Division in the federal government, appointment of women judges, establishment of Women Police Stations, establishment of free Legal Aid Centres, First Women Bank, Human Rights Cell within the government, special emphasis on increasing opportunities for female education in academic and technical institutions, special quota in employment, and higher exemption limits in income tax were major steps towards this end. One-third of total seats reserved for women councilors in District and local Councils, while 20 percent seats reserved in provincial and national Assemblies indicate Pakistan’s focus on improving gender index.
HIV/AIDS
By the WHO/UNAIDS definition, Pakistan is low prevalence but high-risk country for spread of HIV infection. This high risk is based on demographic, socio-economic and behavioural matters prevalent in Pakistan. Pakistan is fortunate to have very low level of HIV infection. National AIDS Control Program reported 2141 positive cases[2] for HIV including 244 cases for AIDS in 2003. The statistics reveal that HIV/ AIDS is unevenly distributed across Pakistan but majority of the cases come from urban areas. The first case of AIDS was diagnosed in Pakistan in 1986, five years after the establishment of AIDS as a clinical entity. UNAIDS forecasts an estimated 70,000 to 80,000 persons, or about 0.1 percent of the adult population in Pakistan are infected with the HIV virus.
The males outnumber females by a ratio of 7:1, while most reported cases are in the age group of 20-44 years. Majority of reported cases (67%) accounts for heterosexual transmission; infection through contaminated blood and blood products (18%); homo or bisexual sex (6%), and injecting drug users (4%). Apart from these high-risk groups there are several other factors that add to vulnerabilities in Pakistan, which could rapidly change the situation from low prevalence to concentrated one. These include:
Poverty, low literacy levels, especially in women; low levels of awareness about HIV and knowledge of protective measures among adolescents and young adults; legal and illegal cross border mobility; wide spread commercial sex in all major towns, internal and external migration in large number; large number of truck drivers and their support persons (around 150,000 - Economic Survey of Pakistan, 2000-01), limited safety of blood transfusion - only 20-30% of the blood being screened for HIV before transfusion; Sexually Transmitted Infections are prevalent with limited access to quality care; use and reuse of syringes and other medical equipment without sterilization; Increasing number of drug addicts with a rise in Intravenous Drug Users (IDUs) (60,000) needle sharing is common among them (84%); low awareness among health workers regarding STIs, HIV/AIDS, etc.
The Government of Pakistan has endorsed the MD Goals on HIV/AIDS and is committed to their achievement by 2015. The Government will concentrate to raise awareness, encourage advocacy, build alliances and renew commitment at the country level, as well as strengthen national capacity for monitoring and reporting on the goals and targets and focus national debate on specific priority areas.
Effects of Population growth on Migration
Rural population makes the major contribution in the growth of this population but urban areas will face the brunt due to high migration pattern. According to Census 1998 data analysis, about 24 percent of the total urban growth was due to migration during 1981-98 (UNFPA: Pakistan Population Assessment 2003). The urban population is expected to double in less than 20 years.
Current Reproductive Health situation in Pakistan vis-à-vis the MD Goals and ICPD.
This section presents a review and progress on important reproductive health indicators and the gaps to achieve the MD Goals and ICPD.
Changing Situation of Pakistan’s Population
Changes in Population Size and Growth RateYear / Population size (million) / Inter-censal Growth Rate
Estimated1947 / 32.5 / 1.8
Population Census1951 / 33.7 / 1.8
Population Census1961 / 42.8 / 2.4
Population Census1972 / 65.3 / 3.6
Population Census1981 / 84.2 / 3.1
Population Census1998 / 132.5 / 2.6
2002 estimated / 144.0 / 2.1*
2010 projected+ / 167.0 / 1.8
2015 Projected / 181.3 / 1.2
2050 Projected@ / 349.0 / - -
+ Ministry of Population Welfare: 1999 January *FBS: PDS 2000, @PRB Population Data Sheet 2003
Pakistan is confronted with multiple challenges that have accentuated over the last two decades. Even with declining growth rate, the number of births that takes place annually will continue to be around 4 million. The proportion of young population (age less than 15) remained high ever since 1970s due to high population growth rate. With decline growth rate, the population under 15 has reduced in terms of overall proportion (from 45% to 43.4%) but has grown tremendously in absolute numbers. According to Population Census 1998 the absolute number of adolescents (age 10-19) was 30.1 million i.e. 22.7 percent of total population. This is the largest proportion of adolescents, Pakistan will ever have but with the existing momentum in the population growth the numbers will continue to rise at least for the next decade or two, thereby putting tremendous pressure on various avenues of decisions they make, regarding education, health and their lives, sexuality, and employment, will dramatically affect the future of Pakistan.