Khurum Khan and Muhammad Feroze Khan
The estimated mid-2015 population in Pakistan stands at 199.0 million, which ranks 6th amongst the highest populated countries in the world following China, India, United States, Indonesia and Brazil. With the ongoing pace and momentum the population of Pakistan in mid-2030 and 2050 will reach to the tune of 254.7 and 344.0 million, respectively. One of the main reasons for this perseverant rise in population size during the recent years could be attributed to a marked difference between crude birth rate (CBR) and crude death rate (CDR) due to steep decline in the death rate in Pakistan, which (7/1000) compares favourably with more developed countries of the world.1
Thus, the death rate in Pakistan matches the rest of the word, while the CBR at 30/1000 is one of the highest in the world, which created an imbalance between CBR and CDR that resulted in unprecedented population rise. The developed countries and some of the Asian countries attained a balance in population growth by reducing CBR by virtue of adopting advanced contraception methods and popularizing the concept of small family norms in their societies; their rate of growth has almost become zero. Similarly, other demographic indicators have remained disproportional and unresponsive to economic growth as in Pakistan (table 1).
One of the important determinants of fertility is Infant Mortality Rate (IMR), which is known to be directly proportional to fertility (i.e., if IMR reduces, the fertility comes down) – with low IMR, parents feel safe and don’t plan larger families. Unfortunately, the IMR at 69/1000 and Total Fertility Rate (TFR) at 3.8 live births (per women during her reproductive age) stands as the highest one (as demonstrated in table 1). Concomitantly, the expected life at birth has not risen to more than 66 years whereas; in developed countries it is more than 80 years such as Canada, UK, USA and France etc. and in developing countries like Iran, Sri Lanka, Malaysia, Thailand, and China etc. The low level of life expectancy at birth in Pakistan is due to poor health facilities resulting in high IMR, high Maternal Mortality Rate (MMR) and incidence of high poverty rate.2
This disproportional rate of population growth and IMR has generated a broad-based population with age less than 15 years representing 36% of the overall population. Such a high rate of increase coupled with high IMR doesn’t support the major part of population to reach 65 years of age (this proportion in Pakistan being 4%) and it might require more than 20 years to achieve a stable or stationary population structure which is attained when TFR becomes 2.3 (still 3.8 in Pakistan) while most of the countries, except Philippines (2.9), have already witnessed this level.
Besides these factors, an overwhelming majority of population (62%) in Pakistan still lives in rural areas, in contrast to other countries where urbanization has been spread to more than 80% of the population. The higher rural population leads to lack of awareness of hazards associated with bigger family size and consequently a low Contraception Practice Rate (CPR). The country could not exceed the CPR beyond 35% while the CPR in majority of the countries achieving large per-capita income is above 80%. It is worth noting that CPR in some of the Islamic countries is also very high such as Turkey (74%), Bangladesh (62%) and Iran (82%). Early age at marriage has also been identified as an important factor of proximate determinants of fertility.3
A recent tendency in the rates of early marriage rose from 15 years to less than 18 years in countries such as Bangladesh (65% to 29%), Ethiopia (41% to 16%), Egypt (17% to 2%) and Peru (19% to 3%) because of the realization that early marriage undermines the rights and livelihood opportunities of young girls pushing them to vulnerable hazards of early pregnancy and neo-natal complications.4 Whilst the Bangladesh government has launched a programmes of appointments of young girls in garment factories in a bid to lower the chances of early marriage and other countries have launched media public awareness programmess to encourage the frequent use of modern methods of contraception in order to enhance its effectiveness in preventing births, such awareness plans have significantly lacked and failed in Pakistan despite the fact that population welfare programmes has been striving in the country for more than 60 years with an aim to raise CPR.5
An important aspect of this article is to relate the ability of demographic indicators either by responding or depleting the economic growth in the country. The economic growth is defined as the increase in a country’s productive capacity in terms of goods and services as measured by Gross National Product (GNP) in the current year compared with other countries during that year. The GNP per capita as per 2015 World Bank data sheet at $5,100 per person per year in Pakistan shows a substantial difference when compared to other countries of the region such as Philippines ($8,300), Sri Lanka ($10,270), China ($13,110), Thailand ($13,950), Malaysia ($23,580), Japan ($37,920) and Singapore ($80,270); whilst the GNP in the West is consistently and expectedly high (for e.g., $38,370 in UK, $45,840 in Germany and 55,860$ in U.S.). Similarly Gross Domestic Product (GDP) in Pakistan at 243.6 billion displays a grim picture of the country’s economy particularly since a significant number of countries in the region have actualized their GDP in billions and trillion of dollars (Table 2).
The consequences of this situation have been unemployment and poverty still at 22.3%, whereas, it has reached 6.7% in Sri Lanka and 0.6% in Malaysia. Ironically more than 60% of the people in Pakistan have no access to basic necessities of life. Consequently, poor health facilities, one of the basic human necessities, has led to increased MMR (170/100,000). More people as a result of this situation are emigrating to urban cities, further worsening the situation in the absence of adequate resources or emigrating to other countries (2% per year) causing brain drain in their home country (Table 2).
In fact, the demographic and economic growth factors are inter-related and interwoven. The rate of population growth is the core factor in deteriorating the economy or accelerating the pace of economic growth as explained in (Figure 1).
The aforementioned discussion highlights the urgent and unmet matters which require immediate steps in order to bring a meaningful change in the current scenario. Some of the steps that may help change the current preposition are:
1) Government should announce a realistic and achievable population policy in order to increase demographic indicators for achieving considerable increase in economic growth.
2) Entail social milieu in favour of small family norm by propagating the benefits of small family size
3) Enhance the level of CPR to at least 60% for attaining TFR of 2.3; an essential requirement of population stabilization.
4) Enrich quality of data by introducing effective and regular monitoring system and by implementing proximate determinants of fertility; viz, increased age at marriage, promotion of breast feeding and continuous use of contraception would enhance CPR, as the mono-purpose family planning couldn’t reduce the rate of population growth.
5) Engage youth to enhance economic growth by raising the income through newly established small industrial set-ups in rural areas, even on loan basis under the supervision of provincial governments.
Finally, it is imperative that the government takes serious steps to bridge the gap between the demographic indicators so as to accentuate the pace of economic progress of the country.
Dr. Khurram Khan is a cancer specialist based in UK and serves at honorary Assistant Professor at Aga Khan University.Dr. Feroze Khan is a professor at Karachi University & NIDA.
3 Khan MF, Shirmeen A. Proximate determinants of fertility and reproductive health. Ulster Medical Journal. 2007 Jan; 76(1):6-7.