Population management: A springboard for rapid development

A. K. M. Nurun Nabi

Photo: Amirul Rajiv

'Will Bangladesh be a middle income country by 2021, sir'? One of my students asked me the other day.

I didn't understand the reason behind the question. The answer to the question has multiple development issues attached to it. What was he getting at with that question? Well, to give him an answer, I said, 'it is possible'.

'Are you sure about it'? He hit me right back.

'How will I be so sure? I can only be hopeful, because there are so many things to fall in places for that to happen'. The dialogue continues…

'I am hopeful too, sir, but little by little, doubts have started to creep in into my mind. When I look at the development indicators, our resource base, socio-economic and political practices, market condition, value of taka in the international market and other issues, they just don't add up.

'You sound like a pessimistic person. Don't you see that we have made a lot of progress in different sectors since the independence? The country's demographic and socio-economic indicators have shown a considerable improvement in the expected direction. And all of these have happened as a result of some promising policies, strategies and interventions taken by the governments, either independently or in collaboration with the international fora.

The Family Planning Program was reorganized in 1972. Special programs were taken during 1972-1975 to reduce rapid population growth. An official National Population Policy was formulated in 1976, revised in 2004 and a revised draft has been prepared in 2009; National Population Council was formed in 1998; Community Clinics have been established; Health and Population Sector Program was executed during 1998-2003; Two chapters of Poverty Reduction Strategy Papers were adopted; Health, Nutrition and Population Sector Program was implemented during 2003-2010; National Education Policy has been formulated; Health Policy was drafted in 2010; and a Population, Health, and Nutrition Sector Program for 2011-2016 is being designed'. I was trying to put things into perspective.

'Yes, I do agree with you that we have made a lot of progress, but a lot of challenges are there too. The most important one is the lack of continuity due to shifts either in policies and priorities or in efforts and commitments, the momentum has been halted from time to time. As a result, the expected outcome could not be accrued to the balance sheet.

I am not a pessimist, sir. But I wonder, with such a huge unplanned and unmanaged population size, how could we be able to catch up to make up for the lost ground? Bangladesh has an estimated population size of over 160 million in an area of 147,570 sq km. The historical trend of population growth rate suggests that the estimated population of 17 million in 1700 took 230 years to double in 1931. The second doubling took only 43 years, i.e., the population of 1931 doubled its size in 1974. Third doubling occurred in just about 30 years in 2005. Each year, the population increases by 1.8 to 2.0 million. The population is likely to grow up to 222 million by the year 2051 and will stabilize at 250 million by the year 2081, even if replacement level fertility is achieved by the year 2015, due to the built-in population momentum inherent in the young age structure'.

'If you are not a pessimist, then you are a skeptic in yourself. The population size of over 160 million is an overstatement. The Bangladesh Bureau of Statistics suggests that the population of Bangladesh is around 150 million'. I intended to correct him.

'I see people debate on numbers. Whether it is 150 or 160 millions -- should that be the moot Question? Of course, the difference between the two numbers is 10 million. Choosing one or the other may have different meaning to different people. To some, it is a difference in numbers. To some, more labor force to export. To others, it is 10 million more or less voters. To those who take advantage of the hapless poor people, it is a boon. To still others, it matters in terms of success and failure in programs, depending on the value of indicators going up or down.

No matter which number I pick, the implications for the nation are almost the same and very serious. Do you think that the sufferings will be less if I accept the figure of 150 million, or more if 160 million is taken? Numbers are different on papers, but reality remains the same. Is anyone serious about the overgrowing population size of this country? An unplanned and unmanaged population of this size could be a national security question from within, if it is not managed properly. If there is to declare any emergency in Bangladesh, population emergency is to be called first.

When the area of the country (only about three-thousandth part of the world) is taken into account, Bangladesh becomes one of the most densely populated countries in the world. Currently, more than 1100 people live in one square kilometer area. How higher can we go over the current population density? If we look at the top six populous countries in the world, situations are not that depressing there. China, for instance, being the number one populous nation in the world (with a population size of about 1.4 billion), has a population density of only 140 persons per square kilometer. In India (the second populous country with about 1.2 billion people), 362 persons live in one square kilometer area. The other four populous nations -- USA (310 million), Indonesia (235 million), Brazil (193 million) and Pakistan (185 million) -- have population densities of 32, 124, 23 and 232 persons per square kilometer, respectively.

Photo: Amirul Rajiv

These figures clearly indicate that the main constraint for Bangladesh is the land size. The land-man ratio is decreasing every year, as we lose one percent of agricultural land to accommodate the need of additional 1.8 to 2.0 million people every year. The future of rural agricul¬ture suggests that Bangladesh is close to the limits of availability of agricultural land and productivity. Ensuring food security would be impossible to maintain under the circumstances. Could we afford to risk our nation to be in that situation? As an alternative, importing food could be an option, but for how long? On top of it, numbers of rice exporting countries are decreasing globally, and as a result, price is increasing in the world market. A large population size coupled with increasing food price creates a complex situation for the nation. Technological innovation in food production could be another option to stave off the problem. We hope that it happens before it is too late.

The country's population is young in terms of age structure. More than 35 percent of the total population is under 15 years of age. A young population implies strength, energy, vigor, pool of work force and a full potential for future leadership. For Bangladesh, this is a demographic bonus. This demographic bonus could bring a huge dividend for us, if this raw capital is converted into circulatory capital. This window of bonus opens for a population only once. If we fail to grab this opportunity immediately, this young population could create a disastrous hazard for the nation. But considering the existing condition, it seems like a long shot.

A young population also implies a ticking bomb, as it creates a built-in momentum in the population. Currently, the largest proportion of young population ever is waiting to enter the reproductive age. The estimated number of women of reproductive age is 40.8 percent and will increase to about 48 percent by 2021. Despite the legal age at marriage for girls set at 18 years, they are being married off at an earlier age. According to the BDHS 2007, the female median age at marriage is 15.3 years. The trend shows that it has increased only by one year in last ten years.

About 23 percent of total population of Bangladesh is adolescent. Among them, 68 percent of adolescent girls are married by age 18 and 55 percent of them are becoming mothers before reaching 19. Young mothers are contributing more to the total fertility rate (TFR) now. The adolescent fertility rate is one of the highest in the world. In spite of decline in adolescent fertility from 179 per 1000 women in 1991 to 126 in 2007, its contribution to TFR rose from 20.8 percent to 23.6 percent during the same period.

A key demographic shift in the age structure demands immediate response is the rapid ageing of the population. The current growth rate of the aged population supersedes the annual population growth rate. Due to declines in the fertility and mortality rates, numbers of young people will not increase, whereas, numbers of elderly people will increase six-fold by mid-century, creating a large burden on the health system, especially for chronic illnesses.

The elderly population will face many difficulties due to poverty, disintegration of family and community support network, changing family structure, social and cultural norms, inadequate health care facilities and poor transportation. The decrease in the relative size of the working age tax base to the growing demands for healthcare by the elderly group, who are prone to non-com¬municable diseases, should be a major concern in response to changing needs.

Another demographic phenomenon that demands an immediate attention is that of rapid and unplanned urbanization. The high rate of population movement and resulting pace of urbanization could be regarded as a driving force for modernization, economic growth and development. However, that is not the case with Bangladesh as urban centres in Bangladesh grew out of context without sufficient concomitant social and economic development. There is increasing concern about the effects of expanding cities, principally on human health, livelihoods and the environment.

Cities are growing rapidly and unevenly. While the rural population has grown at rate of about 1.5 percent per annum, urban population in Bangladesh has grown at an annual rate of more than 3 percent since 1961. The implications of unplanned rapid urbanization and demographic trends for employment, food security, water supply, shelter and sanitation are staggering. In most of the cases, the poor and homeless new migrants to cities are accommodated in the slums and shanties. The urban growth rate for Bangladesh is 3.5 percent per annum, while the slum growth rate is 7.0 percent, implying a doubling time of less than a decade. Is it healthy?

Rapid urbanization together with other associated problems of housing and infrastructural facilities has caused a pernicious effect on the eco-stability of the country. In addition to the huge inconvenience, the traffic congestion causes enormous economic loss in terms of the additional fuel consumption, additional driving time, and the environmental and climatic cost of additional carbon emission, increased accidents, and so on.

The rate of population movement in Bangladesh is much higher than that of the national population growth rate. National population growth rate is 1.4 percent per annum, while the national internal migration rate is 4.5 percent. For Dhaka, the in-migration rate is about 6.0 percent. Rural landlessness and subsequent poverty, and shrinking economic and employment opportunities, river erosion, flooding, cyclonic storms and other natural disasters contribute to this huge population influx.

Dhaka was the second fastest growing mega city during 1975-2007 with 5.65 percent urban growth and it would continue to be the fastest growing mega city up to 2025 in spite of having lower growth rate of 2.72 percent from 2007 to 2025. The inevitable consequence of this situation will be urbanization on a scale which risks overwhelm¬ing the capacity of the urban authorities to provide housing, water and sanitation, healthcare, educa¬tion, and other essential services to incoming mi¬grants'. Dhaka city with a slum population of about 40 percent has become unliveable.

Cities and towns in Bangladesh are already in a state of chronic poverty and poor health condition, whereas, the health care services are very inadequate to meet the demand. The Ministry of Health and Family Welfare (MoH&FW) doesn't have any program for the urban areas. It is the Ministry of Local Government, Rural Development and Cooperatives (MoLGRD&C) that takes care of the urban health care situation through some NGOs, which is not sufficient enough to meet up the need. Currently, 6 city corporations and 4 municipalities are being covered by the MoLGRD&C. Existing capacity and coverage of MoLGRD&C has become limited with the rapid growth of urban centres. Under the circumstances, would you suggest that the MoH&FW takes over completely, or the MoLGRD&C develops its capacity and expands coverage'?

He paused for a moment. I kind of started liking his approach as he made some interesting points, which fascinated me. Therefore, I didn't want to put a cap on him. To see where he leads the dialogue to at the end, I encountered him again…

'Why do you only look at the negative things? Try to look at the brighter side too. The Bangladesh Maternal Mortality and Health Care Survey (BMMS) 2010 shows that the TFR has declined from 6.3 per woman in 1975 to 2.5 in 2010. Contraceptive prevalence rate (CPR) has increased from 7.7 to 63 during the same period. Bangladesh has received a UN Award for the success in achieving MDG-4, i.e., reducing child mortality. According to the BMMS 2010, maternal mortality ratio (MMR) has fallen from 322 in 2001 to 194 per 100,000 in 2010. Although further decline would be very hard to attain, we are in the right track in achieving the MDG-5 target of 143 per 100,000 by 2015. I'm sure that this achievement will bring another UN Award for Bangladesh. Life expectancy at birth is now over 67 years. Proportion of population living in urban areas has also increased substantially. These trends suggest that we are progressing toward achieving the Goals set in the vision 2021'.

'Why do you consider my points as negatives, sir? Isn't this what you want us to do as population scientists critically analyzing the population and development dynamics to help policy makers for future program and strategy formulations'? He challenged me.

'Do you think that the MMR of 194 is real under the existing dismal health care services in Bangladesh'? He threw a question at me.

'Yes, on the face of it, it is as real as it gets. If we could reduce MMR from 574 to 322 in a decade time under the same dismal condition, a reduction from 322 to 194 is possible in another decade'. I asserted.

'Well, the figures look nice at the aggregate level. But the detailed breakdown tells a different story'. Even If we accept the 194 figure, other findings show that whatever improvements occurred in the maternal mortality situation, it happened due to the activities in the private sector. The findings also show that improvements occurred only for the educated and well off people. That tells the story of existing inequity in the use of health facilities for delivery, maternal complications and other purposes. That means the poor and the less educated are still in the same dock. One also shouldn't ignore the fact that half the reduction of MMR is contributed by the extent of reduction in TFR. Credit should go to the well off and educated people because they have invested in the health sector and they are utilizing them. The public sector health care services still remain far behind. What do you say about this'?.

'I would rather not talk much about the findings of BMMS 2010. This is only a preliminary report on key findings. Elaborated data analyses have not been done yet. The findings are encouraging, however. We will have to wait for some time to get the detailed report'. I deflected his question, as I wanted to hear more from him.

'All right, let's go back to the BDHS 2007 report then. Yow know that after an impressive pace of decline in TFR during the 1980s, it stagnated for a decade, and then picked up very slowly in the last decade. However, a wide range of variations exist. While Khulna and Rajshahi divisions have the lowest TFR (2.0 and 2.4, respectively) and highest CPR (63 and 66, respectively), Sylhet and Chittagong have the highest TFR (3.7 and 3.2, respectively) and lowest CPR (32 and 44, respectively). Adolescents, poorest, least educated and slum dwellers have highest TFR and lowest CPR. Contraceptive discontinuation rate is very high (56%) and varies by methods.

Demand and supply for methods are mismatched. Unmet need is 17%. About two third of the women didn't want any more children and their demands for family planning remain increasingly unmet. Use of male methods has declined dramatically overtime. Long acting and permanent method use rate also very low. Campaign for behavior change communication (BCC) and advocacy for family planning are almost nonexistent and ineffective. The once globally famous family planning program of Bangladesh is almost invisible now. It appears that it is nobody's business anymore.

You know it very well that nationally and internationally, shifts in policies and strategies occur due to changes in the philosophy and attitude of national government and changes in the international development principles and priorities. Overtime, the policy has shifted from a focus on family planning to a more broad-based reproductive health approach, and has tried to capture a broad spectrum of issues to respond to the national population problem in a holistic manner. The policy shift probably didn't work very well for us. Family planning has become completely a missing issue.

Population has never been considered as a development paradigm. People lie at center of the development process, causing changes and being affected by the changes. The number of people, the speed of growth, the quality of life, the pressures on them, etc. are influenced by environmental, economic, political and social conditions. This is not a one way process. People influence these conditions by the decisions they take. The relationship between the conditions is constantly changing as the development process roles forward through time.

Photo: AFP

The issues of population and family planning have never been presented in the right perspective. They have always been presented in isolation in terms of a doom's element. You must not forget that population is not only a matter of control any more; it is also a question of management. From the management perspective, family planning is a matter of life style, taste, element of happiness, joy, achievement and glory. It is an attitude. It is a philosophy of life.

We must reposition our attitude, philosophy and thought about people and population. Since population issues do not exist in isolation and people are both producers as well as consumers, any development effort should take into account the parameters of population (i.e., its structure, composition, distribution, behavior pattern, attitude, values, norms, beliefs, practices and the whole life-style pattern) for the sustained economic growth and welfare of the society. Until and unless we do that, making Bangladesh a middle income nation by the year 2021 in the real sense of the term would be nearly impossible. Under the changed circumstances, can the Ministry of Health and Family Welfare handle the consequences of current population dynamics alone? Should we consider establishing a separate Ministry for Population Management and Human Resource Development as a way out'?

He stopped and begged permission to leave as his tuition time approached. I was really impressed with his ideas and thoughts. Since we couldn't continue anymore, I asked him a final question, 'You seem to be very serious about the whole issue, especially Bangladesh becoming a middle income county by 2021. May I ask you, why'?

'Why not? We have waited long enough. Many countries of similar socioeconomic conditions started their journey in the early seventies and they have gone far ahead of us. If they can do it, why can't we? I want Bangladesh to be a middle income country by the Golden Jubilee Year of our Independence, because my father was a freedom fighter and I want to see him happy before he dies. Besides, my career starts next year and I want to start it on a positive note'. He replied with sobriety.

Being a freedom fighter myself, it touched me very much. A genuine expectation, indeed! Surprisingly, it coincided with my dream as well. I also would like to see Bangladesh becoming a prosperous nation before I rest myself for ever. Our daughter is graduating this year and I also would like to see her career starting on a positive note. With my wet heart and all sincerity, I said, 'I don't know whom to blame for the failures, and whom to thank for whatever successes we have; probably, the governments for the former, and the people of the nation for the latter. Let's join hands together to make our dream come true'.

The writer is Professor & Project Director Department of Population Sciences University of Dhaka.