Realizing population goals: Translating strategies to actions

Brig Gen Shahedul Anam Khan, ndc, psc (Retd), Associate Editor, The Daily Star

Bangladesh Population Policy 2012 has six objectives and 16 strategies, with most strategies having 10-12 sub-texts. Therefore, there are actually 75 strategies. Limited objectives should be set so that achieving them within the given timeframe is not too difficult. When we try to over-achieve, we end up achieving very little.

It is the job of the print and electronic media to disseminate information about critical issues such as realising population goals. I hope we can come up with directives for the stakeholders, people and the government to consider.

Dr. Nadira Sultana, Country Lead, Options Consultancy Services Limited

WISH2ACTION is a global program supported by DFID. We are a consortium of four partners working together. The International Planned Parenthood Federation (IPPF) is leading this consortium. Marie Stopes Bangladesh helps us implement the family planning programme with MOHFW here. We also have Humanity & Inclusion – Handicap International, as a valued partner for addressing people with disability. Power and Participation Research Centre (PPRC) facilitates our activities, advocacy and actions with the media and others to make our communication effective with external entities.

Dr Hossain Zillur Rahman, Executive Chairman, Power and Participation Research Centre (PPRC)

If we take the long view, Bangladesh has had major successes on the population front impressing the world with a demographic transition despite low levels of income. More recently, however, some “mission confusion” have crept in on the question of population policy. Is there a continuing necessity to keep population growth in check while we also strive to make our population, in particular the youth, more productive and skilled to meet today’s challenges. This ‘mission confusion’ is impacting on the policy and budgetary attention to the family planning agenda.

The exposure to family planning messages declined from 47 percent to 30 percent, during 1994-2014. In addition, there has been an unexplained jump in individual opposition to contraception among older women (aged 30-49), something which researchers need to look into. The rate of unwanted adolescent pregnancies is highest in urban slums, thus the “urban poverty angle” needs to be addressed with the utmost importance.

Child marriage is an issue which cuts across many things: adolescent pregnancies, violence against women, reproductive health and the demographic dividend realisation. The reality is that, in the last decade, the average age of marriage has been stagnant at 16. Therefore, there must be gaps in the current strategies in place. That is why we strongly feel that we must re-think the narrative to try and build new momentum.

The family planning (FP) implementation strategy needs to be re-thought to incorporate both home- and institution-based elements. One item which has somewhat disappeared in the global discourse is the issue of male contraception. Women, especially in third world countries, are usually pressurised to take the initiative in such matters. That is ineffective and unfair. The responsibility of males, in this process, has to be brought to the fore. Otherwise, even bureaucratic ideas will not suffice. The urban poor must be thought of as a priority group. Integrated family planning and primary healthcare services for them are key. We also need to think about gender-based violence. Policies and laws are in place in regards to GBV, but the reality is that it is not decreasing in any manner.

There are many initiatives and commitments but we need to ensure that there are actual progress on the ground. We need specific indicators against policies and commitments and strengthen monitoring of these indicators. Monitoring should not be seen as merely a bureaucratic exercise. We must think of innovative partnerships between the government, CSOs, NGOs, private sector, academia, media, etc. We also need to engage the youth in all the population-related activities. We must focus on the issue of demographic dividend.

Much progress has been made since Cairo 1994, but “unfinished business” remains. However, this should not be seen only as a “bureaucratic drive” to increase contraceptive prevalence rate (CPR). The adolescents, poor, urban poor and post-partum women are all experiencing problems. We need to realise that SRHR education and awareness will go nowhere if it is not seen as “conversations of trust”. Curriculum may support the material, but if students are not comfortable with respective teachers, it will not improve the overall situation. We must get away from the notion of just bureaucratic delivery of some services. That will not work unless there is trust on the other end.



 

Toslim Uddin Khan, Chief of Program Operations, Social Marketing Company

Over the last four years (according to statistics of Bangladesh Demographic and Health Survey), there has been upward growth from 38 percent to 50 percent in institution delivery, which is tremendous. The contributors of this are mainly from the private sector. The public sector contribution has increased by one percent during this time while private sector contribution has seen a 10 percent growth. Meanwhile, NGO contribution has increased by two percent. That is directly linked with issues like maternal mortality and family planning. We are at the “last mile” in the journey towards reaching our goals. The policymakers need to change their mindsets in order to prioritise new programmes.

We need strong partnerships between public and private sectors. They should work together and come up with required solutions. One of the approaches of Long-Acting and Permanent Methods (LAPM) services is engaging private sector, obstetrician-gynaecologists (OB-GYNs) and SMCs. This is the time to regulate the appropriate role of the private sector, as more engagement from them should be encouraged.



 

Dr. Alia El Mohandes, Senior Family Planning Advisor, USAID Bangladesh

The Directorate General of Family Planning (DGFP) of Bangladesh has carried out a pilot project in Sylhet city which involves urban slums in the area. It was so successful that the government wishes to scale this up. One of our projects, “Shukhi Jibon,” is working closely with the health ministry to build up their capacity to replicate and scale up this pilot project. It basically contracts out to the private sector and the NGOs to provide services to the poor. If we can reach up to six different urban municipalities in the next three to four years, the actual public-private sector experience, that the ministry has already begun, can be expanded.



 

A M M Nasiruddin, Former Secretary, Ministry of Health and Family Welfare

Ministries other than the ministry of health also need to be proactive in controlling the child marriage issue, and population-planning in general.

Delivery of clinical services is especially under threat due to disputes between employees of the family planning and health sectors. For the permanent methods to truly take effect, clinic heads and the ministry of health must take initiatives. From upazila health complexes to district hospitals, the family planning department does not have any people to employ in clinical services. The smooth cooperation and collaboration among the departments of the ministry of health and family welfare is critical.



 

S M Shaikat, Executive Director, SERAC Bangladesh

Adolescent pregnancy is a major concern. To address this issue, we must eradicate child marriage. DGFP has a field service delivery programme, which is based on school education, but this is not sufficient. Another solution could be coming “out of the box” and mingling with the youth at the grassroots level. The gatekeepers (parents, school teachers), influencers (social, educational) and peers can all help find solutions. Harassment of girls in public spaces must be stopped. We need to reach them with particular messages and appropriate interventions. In addition, youth-friendly services should be provided on a large scale. The youth should be made to feel comfortable so that they can share what they want, even with consultants at health service facilities. Hence, inclusion of young people in such facilities is highly important.

Dr. Abu Jamil Faisel, Freelance Consultant, Senior Technical Director, IRD Bangladesh and Chairman, Health21

Total fertility rate (TFR) is not influenced only by the use of contraceptives but also by social and educational factors. During 2018-19, the use of all contraceptive methods, including injectables, has decreased. But TFR, in some parts of the country, has gone down to 1.9 percent. We have lofty targets for the increase of CPR. In spite of that, the TFR will probably decrease.

Post-partum contraception should be the focus for the family planning and health sectors.

The unwritten policy of the government is that they cannot provide contraceptives to unmarried youth. Unmarried youth need to learn about the use of emergency contraceptive pills.

Dr. Kamal Biswas, PM, Ipas

The aspect of clinical training is lacking. Clinical training is expensive and resources in Bangladesh are limited in this area. Carrying out implants, performing vasectomies, and inserting IUDs require huge training costs. The limited number of training institutes does not help the cause. Many training institutes do not have any scope for practical medical practice. The government, particularly DGFP, needs to work in this sector.

Md. Azam Ali, Strategic Advisor, Options UK

Community clinics are sort of a flagship programme of the present government. We should monitor whether these clinics include family planning, and health services. A proper governance structure is required at all levels, starting from villages, to unions, to upazilas, and up to district levels. Engagement of the civil society, local government bodies, and union councils is essential.

Sudarshan Neupane, Technical Unit Coordinator, Handicap International - Humanity & Inclusion

The SRH needs of people with disability remain largely ignored. The barriers that people with disabilities face in accessing the required services need to be identified. Partnerships with disabled persons’ organisations (DPOs) are required so that they have a say in designing SRH services.

M A Faiz, Professor of Medicine, Former Director General DGHS

Health education should not only be a priority agenda for the government, but it should also be an in-built component of the education system. School curriculum should be developed in line with the essential life skills education required for the community.

One of the top priorities in relation to the urban poor should be to have only one ministry (MoHFW) that will take care of health in both urban and rural areas, not the ministry of local government, rural development and co-operatives (MoLGRD&C).

Shishir Moral, Special Correspondent, Prothom Alo

The government did not agree with the information in the primary maternal mortality rate (MMR) report formulated in November 2017, and so it has still not been released. The latest Bangladesh Demographic and Health Survey (BDHS) 2017-18 report has not been released yet either. The Bangladesh Health Facility Survey which portrays the poor conditions of our health facilities has been halted from release by the ministry of health. DGFP is badly suffering from corruption.

Dr Nurun Nahar Begum, Deputy Director & Program Manager (Quality Assurance), Clinical Contraception Services Delivery Program (CCSDP), DGFP

People can get family planning and adolescent reproductive health related information by dialling 16767 which provides 24/7 service.

If every medical education level does not include family planning in their curriculum, then this service will not reach all places properly.

As we know, Bangladesh is a male-dominant country. However, all family planning service centres cater to females. Males do not have the proper facilities to seek information about obtaining family planning methods for themselves or for their wives. This needs to be addressed at the policy level.

Shirin Akhter, Chairperson, Women with Disabilities Development Foundation (WDDF)

Women with disabilities are deprived of SRH and family planning services. Wish2Action is the first formal large-scale project in Bangladesh which has tried to include women with disabilities in family planning.

Dr. Abu Sayed Hasan, Programme Specialist, UNFPA

In addressing the population dynamics of a country, the right to people's sexual and reproductive life, particularly for women and adolescent girls to exercise their agency in making informed decisions, is key.

Regarding abortions, UNFPA helps governments strengthen their national health systems to deal effectively with complications of unsafe consequences of these actions, thereby saving women's lives.

Umama Zillur, Founder, Kotha

Men are not engaged as clients of contraception, rather partners of women who are taking contraception. This view needs to change so as to increase contraception use in men.

A re-evaluation of the indicators used to judge success in this area is also essential. CPR does not give insight into the health costs of women when they take contraception, since methods like the injection or IUD are highly invasive and have both mental and physical health costs.

Dr Shamsul Alam, Member (Senior Secretary), General Economics Division (GED), Bangladesh Planning Commission

Lessons to take away from the last ICPD25 are reducing GBV and maternal mortality, ending child marriage, promoting reproductive health, empowering women, and meeting unmet family planning demands.

The SDG target is to reduce MMR to 70 per 100,000 live births by 2030. In 2017, the number was 172 per 100,000 live births according to BDHS. Our MMR should be 121 by 2021. It will be a big challenge to attain this goal.

The average child marriage rate in South Asia is 59 percent, whereas the rate in Bangladesh on average is 54 percent. This is still a high rate as it has cross-effects on other factors such as maternal mortality.

Dr Margub Aref Jahangir, Health Officer, UNICEF

Bangladesh is deemed to be among the worst sufferers from the effects of climate change. Climate change (including air pollution) has a huge impact on human health, particularly on children’s nutrition. For example, malnutrition causes low immunity and high susceptibility to diseases. Moreover, there will be both re-emergence of old diseases and the emergence of new diseases due to climate change.

Samia Afrin, Project Director, Naripokkho

The combination of the facility-based committees of the government is good, comprising of government officials, local representatives, civil society and journalists. If we can activate these committees, we can attain greater results regarding family planning.

Dr Reena Yasmin, Director, Health Systems Strengthening, Marie Stopes Bangladesh

Regarding family planning services, the government has very good infrastructure, systems and plans. However, are we doing enough to ensure access to services? Currently, we are unable to retain doctors in the hard-to-reach-areas. Are the Family Welfare Visitors (FWVs) and Family Welfare Assistants (FWAs) in rural areas supposed to provide Long Acting and Permanent Methods (LAPM) of contraception which are very important now? We want to increase the number of FP counselors and service providers at the community level so that women can get access to services, which can contribute effectively to the LAPM and TFR.

Dr Md Billal Hossain, Professor, Department of Population Sciences, University of Dhaka

The government is going through a serious “mission confusion” between population control and population management. The government has shifted its focus away from population control towards population management. However, the population control agenda is not finished yet.

In regards to population management, 2 million people are joining the labour force every year. Roughly speaking, only half of them can be absorbed by the local market. What are we doing in terms of managing this scenario?

There is a national population council headed by the honourable prime minister. However, in the last 10 years, we did not see any meeting take place in this council.

Dr Syed Abdul Hamid, Professor, Institute of Health Economics, University of Dhaka

Providing family planning counseling services along with marriage registration can be an effective solution. Proper information should be disseminated to husband and wife to avoid unwanted pregnancies. Contraceptive can also be given to them.

Pharmacies can be capacitated through providing training like SMC’s blue-star initiative to supply free contraceptives and FP services in urban slums, hard-to-reach-areas, and rural areas.

Dr Md Mainul Islam, Professor and Chairman, Department of Population Sciences, University of Dhaka

We haven’t updated our Population Policy since 2012. Unfortunately, most of the targets and objectives mentioned in Bangladesh Population Policy 2012 have not been achieved yet. We need to find out the limitations and what needs to be done to achieve the targets in the next plan.

The current policy advocates for two children (male or female). We, as academics, cannot comprehend the rationality behind such a slogan because if we go through BDHS 2017/18, the TFR is still stagnant at 2.3 births per woman. Unless we do not reach the replacement level for fertility, such decisions are infeasible. The adolescent fertility rate is very high in South Asia and we rank number one in it. We need to take into consideration the basic rights of the elderly population who currently comprise 8 percent of our total population. This rate will grow in the future.

The question now is: how will the ICPD25 and SDGs be integrated in the existing policies? Under the changing demographics, the policies should be updated and limitations of good governance need to be overcome. More coordination and integration among population policies are required. Funding is also very important for implementing the ICPD Programme of Action and the SDGs. Moreover, political interference and delay in releasing data are also big challenges.

Masrurul Islam, Country Director, Marie Stopes Bangladesh

Our existing method mix for family planning doesn’t effectively address the demand. The number of unintended pregnancies is also increasing in the country. As a result, maternal mortality is increasing. We need to formulate indicators for every strategy so that we can monitor our interventions in family planning diligently.

We need to increase male participation in family planning. As condom discontinuation rate is high (almost 40 percent), we need to promote permanent methods like vasectomy among men.

Dr Sanjida Hasan, Country Manager, Wish2Action Project, IPPF

In urban areas, the reach of family planning programmes is very limited. Even educated couples are not aware of existing varieties of methods. Along with hard-to-reach areas, we should focus on the urban gap.

Dr Nazmun Nahar, Professor of Pediatrics, Former DG, BIRDEM

We are already aware of the gaps. Now, we need to prioritise: which ones should be attended to immediately and which ones in the long term? Then we should bring relevant experts on those specific issues and formulate well-defined action plans.

Dr Nadira Sultana

The government health programmes primarily focus on establishing community clinics in rural areas and specialised mega hospitals in the capital and divisional cities. Family planning programmes are not getting adequate attention in these health establishments. The situation in health facilities such as district hospitals is also not very different. There is a huge gap in service delivery system which needs to be considered seriously. Family planning programmes should be integrated in our overall health infrastructure.

Dr Alia El Mohandes

Almost 80 percent family planning providers in Bangladesh are going to retire in the next few years. This is a pressing issue that needs immediate attention because it takes around 3-4 years to recruit and train a family planning provider. Again 57 percent of the existing facilities are not ready to provide quality family planning services. These establishments need to be upgraded.

USAID along with other donors are preparing a contraceptive forecasting and costing plan which we hope will be included in the next five-year plan so that it can provide accurate and realistic scenarios to discuss what the stakeholders need to do to achieve the commitments of Family Planning 2020.

Dr Shamima Akhter,  Health Financing Advisor,  Options Consultancy Services Limited

We need to ensure efficient use of our existing health budget.

Ashfaque Khan, Evidence and Accountability Advisor, Options Consultancy Services Limited

To manage the unsustainable population density, as well as maximize health and population service delivery, land zoning and land usage planning should be considered at the beginning of any planning.

Dr Hossain Zillur Rahman

We can take a civic initiative of arranging a population conference to update the population policy of 2012 where we can discuss all the important issues brought up in today’s seminar on a broader platform.