The Islamic Republic of Pakistan celebrated its Golden Jubilee in 1997, 50 years after the partitioning of United India from the British Raj. For Pakistan ([fig 1](#fig1){ref-type="fig"}), this was also a time to evaluate the health and population status of its people. In Pakistan, during the 1940s, population growth rates begin to accelerate as health improvements lengthened life expectancy and birth rates remained high. In 1947, at the time of independence, Pakistan\'s population was 31 million. By 1995 it had escalated to 140 million[@b1]

![Map of Pakistan](umj7603-122-f1){#fig1}

Family planning programmes were started in the 1950s and 1960s by private and government institutions. Donors such as World Bank and the UN along with the government of Pakistan funded the programmes for family planning (FP). For years these institutions focused only on women as it was thought that FP was the preserve of women, therefore the audience was 100% female.

In 1947, the fertility rate was 7.5 per women and the population growth rate 4.5% per year. In the 1990s these were reduced to 5.1 and 2.9, respectively, but this reduction is negligible. Presently, 41% of the total population in Pakistan is under the age of 15 years. A large number of young people are about to enter their reproductive years, virtually guaranteeing continued rapid population growth for the foreseeable future ([fig 2](#fig2){ref-type="fig"}). By the year 2035, Pakistan\'s population is projected at 260 million (UNFPA, Pakistan).

![Rapid population growth](umj7603-122-f2){#fig2}

More than 50 years have passed, millions of dollars have been spent, multiple resources have been exhausted and Pakistan still adds four million people to its population each year. Contraceptive use went up from 6% in 1969 to just 18% in 1995[@b2]. Pakistan\'s average of six children per family has barely fallen since 1960s[@b2] and the population density is 169/km^2^([fig 3](#fig3){ref-type="fig"}). In comparison, the USA population density is 28/km^2^.

![Increasing population density](umj7603-122-f3){#fig3}

Pakistan faces a daunting challenge. With 140 million people, it is currently the world\'s seventh largest country and will become the third biggest contributor to world population growth. According to United Nations projections, the Pakistan population will grow to over 380 million by the year 2050, surpassing the United States, Indonesia, Brazil, and Russia to become the world\'s third largest country behind India and China. With the highest population growth rate for any large Asian nation, Pakistan will certainly experience dramatic declines in per capita availability of arable land, water, and forest resources. Already rapid population growth at three percent per year is eroding economic gain. The question arises - what went wrong and why?

The profile above reflects the lack of success to date of Pakistan family planning programme, which is also one of the world\'s oldest programmes. Inconstant political support has been a prime reason for programme failure. Frequent changes in leadership have contributed to constantly shifting strategies coupled by weak implementation. Population programmes lack adequate geographical coverage and community outreach[@b3]. In addition, the following factors explain poor performance and make the picture of reproductive health in Pakistan grim: Each year, about 30,000 women die from complications of pregnancy, childbirth or unsafe abortion reflecting high maternal mortality ratio of 600 deaths/100,000 live births and frequent pregnancies, which increase the risk to maternal death. During her life time, a Pakistani woman has a 1 in 23 chance of dying from maternal causes compared to 1 in 5,000 in the industrialised world.Religious controversies about women\'s role in society have spilled over into the family planning debate. The organised religious political parties officially oppose the population programmes and many people still believe that family planning is un-Islamic thus undermining political support for family planning issues.The practice of purdah (public view through veiling) makes it more difficult for women to obtain social services, including family planning. In 1991, only a quarter of women could go unaccompanied to a clinic. Poor programme outreach exacerbates the problems facing women who observe purdah[@b3].A preference for sons over daughters for labour and old age security leads to higher fertility rates[@b4].Poor communication between spouses aggravates differences in family size desires. In a survey in 1991, one third of both husbands and wives did not know their spouse\'s attitude towards family planning. Among those women who believed their spouses disapproved, one third were mistaken -- their spouses actually favoured family planning.Literacy rates in Pakistan of 21 percent for women and 47 percent for men are among the lowest in the world. The positive relation between education and contraceptive use holds in Pakistan as almost everywhere. Women with secondary education are more than three times as likely to use family planning as those who never attended the school as education confers women higher status with marriage and greater voice within household and reproductive decisions[@b5].In many developing countries and even in the developed world, most family planning services are still geared towards the female population. Population development and medical institutions have often neglected men\'s influence on decisions related to family planning.Uncertainty regarding government and international donor\'s willingness to continue to provide adequate financial support also remains. Budget deficits and economic pressures pose a constant threat to social spending especially population programmes.The federal and provincial population programmes with the government system has not enjoyed the same standing as most other government agencies and departments. Staff working in these agencies usually do not receive full civil service status leading to poor workers\' morale and productivity because of the programmes ambiguous position within government.Besides the huge problem and relatively low priority of programme issues such as weak supervision, overextended training capacity, problems with contraceptive supply systems, tension in the relationship between the government and private sector family planning NGOs, and weak involvement of private physicians, all compound the problem.

CONCLUSIONS AND RECOMMENDATIONS
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Despite this grim picture, we cannot afford to stop and have to move forward. Issues relating to family planning and reproductive health services are complex and intertwined. Solutions also need to be comprehensive and integrated. The government of Pakistan along with UNFPA and a host of private NGOs are working on these issues and many others, to contain the population. Population stability may eventually be achieved[@b6].

The Population Action International report[@b2] recommendations relate to strengthening organisational and management issues of family planning programmes to achieve its coverage and effectiveness; and other relate to changing approach to delivering family planning services and improving the overall status of women. The most important of actions suggested include: expanding family planning concept beyond FP to reproductive health services, generating positive attitude among high public and political officials, organizing effective media campaign through celebrity endorsements, improve existing service quality, involving men by providing vasectomy and other reproductive services, strong emphasis on women social status and education, involving religious leaders voice to endorse the programmes and the role of donor agencies to continue with their responsibility to support a struggling economy and a young nation.

The author has no conflict of interest.
