An Oft-ignored Fundamental Right
“Human development is adequate provision of fundamental human rights.” This idea was propounded by Dr Mahboob-ul-Haq, an outstanding visionary social thinker from Pakistan. Ironically, Dr Haq’s own country has failed the cause of human development as it was ranked 147 out of 188 countries on the Human Development Report 2016. The abysmal state of human rights in Pakistan and our inanition in fulfilling the pledges that we, as a nation, made to the international community, is manifested by the alarming situation of women’s reproductive health. Pakistan had ratified the Programme of Action (1994) of International Conference on Population and Development; was a signatory to Millennium Development Goals and is a party to Convention on the Elimination of All Forms of Discrimination Against Women, but still the state of sexual and reproductive health and rights here is far from satisfactory.
Right to sexual and reproductive health is an important pillar of the human rights framework as this not only has a direct bearing on people’s economic conditions, education, employment, life standards, familial issues, social and gender relations and legal structures they live in, but is itself affected by these factors. The government should have prioritized the SRHR, but, unfortunately, policymaking or the provision of requisite facilities in this regard is still a neglected domain. This oblivion is exhibited in the 9,700 deaths that made Pakistan the world’s fifth largest country, in 2015, in terms of maternal mortality. More alarmingly, with 178 deaths per 100,000 live births, the country was at 54th place on this index – better only than Nepal and Afghanistan in South Asia. Similarly, in terms of lifetime risk of maternal death, Pakistan is at 153rd place, out of 165 countries for which data were available. And, one in every 140 women has the lifetime risk of maternal death. Adding insult to injury is the Unicef report “The State of the World Children 2017,” which suggests that Pakistani women’s right to life, to safe pregnancy and to childbirth are being consistently undermined.
Women’s reproductive health is also important because Pakistan hosts the world’s sixth largest population of women of reproductive age i.e. 15-49 years. According to data published by US Census Bureau, with 54.5 percent of women of reproductive age, Pakistan is the 34th largest host of such women. Furthermore, the number of women falling in this age group is on the rise – as per a study by the National Institute of Population Studies, in 2006, 46.2 percent of Pakistani women belonged in this age group while the figure soared to 54.3 percent in 2016 – during the decade, women’s overall population grew by 52.3 percent but that increase in 15-49 years age group was 78.8 percent.
The first element, i.e. availability, is of pivotal importance as all the other three are directly dependent on it. If we take a look at the element of availability, we find that, at present, there is only one hospital available for 45,919 women in reproductive age group. And, as regard other facilities, there is one dispensary for every 9,505 women, one basic health unit for 9,994 women, one maternity centre for 75,443 women, one rural health centre for 80,745 women.
The availability of trained doctors is also far from being satisfactory – one doctor for 264 women of reproductive age. It is important to acknowledge that owing to social and cultural constraints, most women either avoid consulting a male doctor for matters related to pregnancy and childbirth, or they are not allowed to do so. This highlights the pressing need for having more female doctors. As of 31 December 2017, there were 94,108 female doctors and specialists – merely 45 percent of the total – registered with Pakistan Medical and Dental Council. The ratio of paramedics available for women of reproductive age is: one lady doctor for 586 women, one nurse for 556 women, one midwife for 1518 women, and one lady health visitor for 3172 women.
The principal reason behind this scant availability of medical facilities in Pakistan is the paltry budget allocated to health sector. Pakistan spent a mere 0.5-0.8 percent of national GDP on health during the past decade; way below the WHO’s 6 percent benchmark. Similarly, according to a World Bank report, Pakistan’s per capita spending on health is only 36.2 US dollars, far less than the WHO’s benchmark of 86 US dollars set for low-income countries. And, in that, too, mother child health facilities receive the least (0.44 percent as per the Poverty Reduction Strategy of the Ministry of Finance) and the lion’s share goes to general hospitals and health centres.
On the other three elements, i.e. access, quality and acceptance of these facilities, the state of affairs is also not so encouraging. Take, for instance, antenatal and postnatal checkups. These medical examinations help women know about the symptoms and risks involved from conception to childbirth, as well as on vaccination, nutrition and precautionary measures for better care of the infant. Although the WHO advises women to have, on average, 4 checkups during a pregnancy, Unicef reports reveal that only 37 percent do so, thus placing the country on 139th positions.
The mother-child healthcare is directly dependent on proper birth spacing, for which adopting family planning measures is crucial. In Pakistan, there are still numerous impediments to proper family planning including lack of health facilities and restricted access to them, the fear of side-effects of contraceptives, little awareness, low literacy rate among females, dependence in decision-making, and so on. Due to these problems, the use of contraceptives presents a sorry picture. As per the UNFPA’s “State of World Population 2017,” 40 percent of Pakistani women aged between 15 and 49 years use one method of family planning while 31 percent use, at least, one modern method, putting Pakistan at 148th and 146th place, respectively, in the world. As regards the use of family planning methods, the Pakistan Demographic and Health Survey 2012-13 reported that married women of reproductive age, who already have up to six children, 42.3 % do not wish to bear more of them. In addition, 98.9 percent of such women know, at least, one family planning method while awareness among males of the corresponding age group is 95.7 percent. It means they are more aware than men but still they prefer not using these methods.
Dr Fayeza Rabbani, Agha Khan University’s Champion for Leadership Family Planning and Reproductive Health, finds a number of lacunae in health and population welfare sector in the post-18th amendment era. She suggests:
“It is necessary that constitutional and policy reforms are brought for effective devolution of the federal ministries looking after the sectors of health, women development, social welfare and population. The government must bring family planning in the mainstream through consolidated efforts. In this context, more and more attention must be paid on resolving the issues like lack of family planning services, paucity of paramedics and infrastructural needs. And, the lack of awareness on these issues must be coped with through public campaigns so as to fulfill the needs of a growing population. The government must do so from a human rights perspective rather than a utility view that revolves around economy.”
In our cultural and social setup, a woman has to seek permission from her family if she wants to avail herself of medical facilities because, women are considered a lesser being in our patriarchal setting. Women’s dependence on others and their insignificant participation in decision-making peril their health and restrict their access to healthcare facilities. As per the PDHS 2012-13, only 11.1 percent of married women take independent decisions while 40.8 percent do so after consulting their husbands. 63.2 percent of women of reproductive age have restricted access to healthcare. The biggest problem for the 53.1 percent of them is that no one is there to take them to a medical facility – they either do not want or they are not allowed to go alone. For 40.2 percent arranging conveyance is not possible; for 37.1 percent facility is located faraway, for 29.7 percent financial constraints and for 17.7 percent getting permission are the biggest problems.
Dr Afshan Amin, the provincial programme manager MCSP Punjab of JHPIEGO says, “The state of affairs regarding the availability of reproductive health facilities and services in Punjab is far better than that in other provinces because round-the-clock availability of doctors and paramedical staff, as well as that of surgical instruments and medicines at the facilities has been ensured here at administrative level. Now the need is the provision of quality facilities, for which there should be programmes for capacity-building of the staff. Besides, putting in place a system of supportive supervision is also inevitable. In addition, modern techniques of family planning should also be provided at the time of childbirth so that the trained staff that provides services for safe delivery may also provide postnatal family planning facilities.”
In our country, just like the psychological ailments, sexual problems are not considered a disease rather they are taboo subjects. Particularly, young people are more vulnerable to these issues as they have no proper information or guidance, let alone the access to the concerned facilities. Owing to a lack of proper knowledge and the requisite guidance, they fall in the hands of quacks who add to their miseries and complications, depriving them of enjoying a healthy and prosperous life.
Another risk involved is that they might become a vector for the spread of the disease. In case of HIV/AIDS, for instance, the biggest cause is unsafe sex. If we analyze the situation of comprehensive awareness on this killer disease among our adolescents, it dawns on us that only one percent Pakistani girls of the age of 15-19 know about it – Pakistan is at 111th place among the countries for which data were available. This ratio among adolescent boys is 5 percent and on this list Pakistan is at 81st position among 186 countries. So, provision of requisite facilities to cure such diseases and availing of those by people is very important.
Dr Aniqa, who has been a trainer with the Green Star Social Marketing, says, “There are huge lacunae in sexual and reproductive health sector. Owing to cultural values, there is hardly any open discussion on such topics. And, it is the reason why there are a lot of misconceptions as well as apprehensions on the objectives of discussing the reproductive health of the youth. So, it is imperative to remove the stigma related to availing facilities for sexual and reproductive health. When young men and women need proper guidance on these issue, they must is provided with complete and effective consultation.”
Another important indication of our slackness has been our glaring failure in achieving the Millennium Development Goals. For example, under Goal 5 of the MDGs, Pakistan could achieve a success rate of 79 percent on the target of reducing maternal mortality rate to 140 deaths per 100,000 live births, while the success ratio for skilled delivery was 64 percent. Similarly, we could achieve 64 percent of the target related to the use of family planning methods whereas that for fertility was only 53 percent.
This failure in achieving the targets set under the MDGs suggests that we must review our policies in order to be on the right track to achieve the targets set under the UN Sustainable Development Goals, especially Goal 3 that sets the target to, by 2030, reducing the global maternal mortality ratio to less than 70 per 100,000 live births, ensure universal access to sexual and reproductive healthcare services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes; keeping also in view the outcomes of the conferences held under the International Conference on Population and Development and Beijing Platform for Action.
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