Population programmes and directions

Success or failure of a development endeavour would ultimately depend on the willingness of the stakeholders, particularly the beneficiaries (target population) to accept development services and participate in the development interventions. And the people (the beneficiaries) would not participate in the development initiatives unless they themselves rationalise their priorities matching with the particular development interventions or initiatives. Population programme was launched in the sixties. Since then the programme has been growing in size expanding its sphere of operations. Initially, a single focused vertical programme succeeded to raise awareness and introduce a new behaviour -- contraception. As the programme grew, the need for changing knowledge, attitude and practices (behaviours) became evident and the success depended not only on the single focused interventions, instead it required inputs from allied developmental interventions, such as Health and other multisectoral programmes including support of NGOs. Accordingly, the population programme in Bangladesh, which is officially known as MCH based Family Planning Programme, has gone through at least four major phases of transformations starting from single focused government run FP programme in the sixties to Integrated Health and FP programme, again as family planning programme, followed by MCH based FP programme and lastly Health and Population Sector Program (HPSP). Globally, since ICPD Cairo strategies in 1994, Family Planning is being viewed as part of an overall Reproductive Health Initiative.

Initially, FP Programme in the sixties was launched with massive deployment of Family Planning Field Workers prioritising domiciliary visit as major strategy. This raised the level of awareness about contraceptives to more than ninety percent in about fifteen years. But the level of practice of contraceptives, remained at ten percent till early eighties. Introduction of Child Survival (EPI) programmes both globally and also in Bangladesh made a breakthrough in accelerating the pace of acceptance of contraceptives among the target population at a constant rate of increase of 1.5 per cent annually. The reason was that the mothers, the primary stakeholders, could perceive that the gap between births of children and their survival was narrowing -- a confidence which induced greater levels of acceptance among many other direct and indirect influences. To-day when contraceptive prevalence rate has reached at more than 50 per cent level and with a continuing drop out rate of equally 50 per cent among the users of temporary methods, the issue of quality of service has become a predominant concern.

Acceptance or non-acceptance of behaviour pertaining to use of methods of family planning by the remaining 50 per cent of the target population is certainly not as simple as those falling within the category of first 50 per cent. Bangladesh Demographic Health Survey, 1999-2000 (BDHS) also reflects that there is an unmet demand for FP to the extent of 15 per cent, but concerns for health and side-effects of the methods exist almost at the same level. How much of the remaining 50 per cent would be attracted by mere messages of Family Planning and through the field workers alone is a matter to be seriously pondered. One may argue that the field workers can effectively disseminate messages on integrated health and FP issues, but what good the field worker is worth for, if she cannot ensure the corresponding services, particularly on RH and also beyond the domiciliary services. Institutional facilities (centre/clinic based services) are key to achieving quality and effective services on Reproductive Health including FP. The other issue is how many of the remaining 50 per cent require contacts at the domiciliary level. How much domiciliary services can achieve in terms of quality and also comprehensiveness of service required by a target audience to be measured in terms of cost effectiveness and benefits accrued. Again are we only concerned to reduce the number of population or are we concerned with quality of population, meaning population free from malnutrition and other quality deficiencies at birth and also during their periods of growth.

The most effective indicator of a programme on Family Planning nationally on a relatively long term basis is the achievement in the reduction of total fertility rate. Bangladesh has achieved a remarkable success in this regard with a TFR declining from 7 to 3.3. But the rate is stagnated nationally at that level for nearly a decade. The accompanying table specifies the levels of TFR and allied indicators on Reproductive Health for the period 1999-2000 comparatively by divisions (regions).

The table shows that Khulna Division has achieved the best results not only on TFR and CPR, but also on all other allied RH indicators, while Sylhet Division has achieved the lowest on TFR, CPR and so also on the allied RH indicators. Results in the table demonstrate an interesting level of positive correlation between achievements of TFR, CPR and the allied RH indicators. Data in the table imply that those mothers who pursue improvements on RH status also pursue to achieve fertility control and vice versa. If the intent of the beneficiaries is integrated, should the programme of health and FP be segregated? Would it be wise to emphasise on a single focused FP, where field workers are accepted as the key instrument to achieve the ultimate goals of reducing fertility levels in the country or should one strategise to combine the efforts of both health and FP workers with institutional facilities (Health and FP Centres) as central to achieve fertility, mortality and morbidity reductions not just fertility control alone? Because, the nation needs both quality and productive manpower without which development is hard to occur.

Dr. Syed Jahangeer Haider is MD of Research Evaluation Associates For Development.