Population Challenges in a Changing World: An Overview of the 22 nd Annual Research Conference of the Population Association of Pakistan

The Population Association of Pakistan (PAP), established in 2000, continues to emphasize the crucial relationship between population and development. The population and development programs in Pakistan have not progressed as steadily as in most of the countries in the region or other Muslim-majority countries such as Egypt, Indonesia, Iran, and Turkey. PAP provides a platform that offers an opportunity to bridge the various social sciences disciplines including economics, public and social policy, statistics, demography, public health, sociology, geography, and anthropology to deliberate upon solutions for pressing population and development related issues of Pakistan in this changing world


INTRODUCTION
The Population Association of Pakistan (PAP), established in 2000, continues to emphasize the crucial relationship between population and development.The population and development programs in Pakistan have not progressed as steadily as in most of the countries in the region or other Muslimmajority countries such as Egypt, Indonesia, Iran, and Turkey.PAP provides a platform that offers an opportunity to bridge the various social sciences disciplines including economics, public and social policy, statistics, demography, public health, sociology, geography, and anthropology to deliberate upon solutions for pressing population and development related issues of Pakistan in this changing world.
The 22 nd Annual Population Research Conference of PAP was held at the National University of Sciences and Technology (NUST), Islamabad from 7 th to 9 th December 2021 in a hybrid mode encompassing both virtual and inperson participation at the NUST.The theme of the Conference was "Population Challenges in a Changing World" with three specific sub-themes: I. Population, Universal Health Coverage, and Family Planning, in the context of COVID 19.II.Social, Economic, and Demographic Implications of High Population Growth; and III.Opportunities and Challenges for Resilience to Climate Change.
Spanning these three sub-themes, divided across technical and plenary sessions, 18 research papers were presented and discussed in the technical sessions, while in the four plenary sessions key population challenges in Pakistan were discussed by the experts.Findings of 13 additional research studies were displayed on posters, which provided the respective authors an opportunity to interact directly with conference participants. 2All these sessions of the conference provided a holistic view of the contemporary challenges to the population and discussed the opportunities available for Pakistan.The President of Pakistan, Dr. Arif Alvi chaired the inaugural session of the Conference.
Based on the presentations and discussions held during different sessions of the conference, the rest of this paper is divided into the following sections: (i) setting the context; (ii) population challenges for Pakistan; (iii) key findings of the plenary sessions; (iv) key findings of the technical sessions, (v) recommendations; and (v) the key take away.

SETTING THE CONTEXT
A key highlight of the Conference was the invited lecture on "Population Challenges in a Changing World" by Dr. Adil Najam.His lecture set the context for the Conference, showing that the world is changing, and that the confluence of multiple transformations in economics, politics, globalization, security, health, and human behaviors makes the current change greater, different, and more significant than all changes that have ever been witnessed.Three pertinent changes at the forefront of all discussions, synthesis, and policy directives are: climate change, change in age structure of populations, and the new normal of the world post-Covid19 pandemic.

POPULATION CHALLENGES FOR PAKISTAN
Seven key population challenges for Pakistan were highlighted and discussed during the Conference.These include: a) Despite considerable political will, and a commitment to raise contraceptive prevalence rate (CPR) to 50% by 2025 by the Council of Common Interests (CCI), CPR has stagnated around 30-35% since 2007.The progress on the other population targets of reducing total fertility rate (TFR) to 2.8 children per woman and the population growth rate to 1.5% by 2025 set by the CCI is slow as well.Because of the continued ineffectiveness of family planning campaigns, unmet need remains high.There are no perceived incentives for provinces with low populations to reduce population growth due to population-based funding sources.b) Although the decline in fertility in Pakistan is slow, the ongoing demographic transition has opened the window of opportunity in the form of youth bulge and changes in working age population.How to leverage this opportunity, however, continues to be a challenge which remains unaddressed?c) Climate change, poverty and food insecurity are the biggest challenges to Pakistan in this century.There is no federal body for supporting a coordinated, national response to climate change.
While provincial bodies exist, the response is fragmented, providing discrepant policy actions across the country.d) COVID 19 is identified as a big challenge over the past two years.
Pakistan fared very well on both health and economic aspects through the revolutionizing formation of its departments and the rapid use of data to take decisions across departments.The challenge is how to switch back to ordinary life after COVID?e) The government of Pakistan is planning to conduct a fresh population and housing digital census.Considering the serious issues and concerns related to the 2017 census, the holding of 7 th census is a challenge for the country.f) Globalization was also identified as a challenge for the country in that Pakistan continues to lag behind other nations in this regard.However, there are various strategies through which Pakistan is becoming global and setting its mark in the larger world through modernization of agriculture, trade liberalization, promotion of science and technology, improving information technology and communication, and upgrading its human development.g) Pakistan's slow uptake of digital technology and the consequential digital divide in the country is a challenge for the nation.

Achieving CCI Targets
The first-ever right-based National Narrative on Population that is focused on the balance of resources and responsibilities is acknowledged as a breakthrough in documenting a policy position on population dynamics and providing a national standard for social and behavior change communication for family planning.This narrative has been developed with broad-based political support, is constitutionally sound, and culturally congruent for positive communal reception.The core of the new narrative positions family planning as a right, and underscores the importance of individual choice, rather than viewing family planning as a policy position that only reinforces prevalent social and religious teachings.The narrative is approved by both the federal and provincial stakeholders as well as the Council of Islamic Ideology.
Pakistan's policy and programmatic approach to family planning in the 1960s used to be cited as a model for other developing countries.After a prolonged period marked by fragmentation and stagnation of a coherent national family planning response, there is a resurgence of coordinated efforts by provinces to accelerate nationwide adoption of family planning.Panelists in the conference presented a province-wise analysis of efforts and progress to achieve the targets set by the CCI.In Sindh, a provincial task force has been established.The annual allocation in budget for population welfare has increased from PKR 2.16 billion to PKR 5 billion.Other initiatives include training of District Population Welfare Officers (DPWOs), capacity building of providers and facilities, and mobilization of support from religious scholars for family planning.Further work on contraceptive commodity security was done through allocation of PKR 9 million which indicate Sindh's commitment to achieving goals set by the CCI.In Balochistan, however, unique challenges related to difficult geographic terrain were identified as barriers to mounting an effective province-wide response.While health and hygiene contents have been included in secondary school education, and legal ramifications for early childhood marriages are in consideration with support from religious scholars, no meeting of the provincial task force could be conducted and the allocation of budget for family planning is low with only PKR 30 million annually.Punjab on the other hand has shown a relatively greater success in making family planning a priority of the government.The panellists identified high turn-over of bureaucratic leaderships and lack of continuity in leadership as a set back to the efforts.Funding and cross programmatic roadblocks were reported as additional hindrances for advancements in Punjab. 3or moving forward, four key questions were raised for the CCI.First, whether services are reaching women at the ground level regardless of the efforts at the top.Second, whether there is contraceptive commodity security which accords women access to a wide choice of methods.Third, what is the role of Lady Health Workers (LHWs) and whether sufficient provisions were being made in order to facilitate the family planning function of their job?Finally, whether provincial health departments were entirely on board with family planning as a component of the larger health service delivery paradigm.

Social, Economic, and Demographic Implications of High Population Growth
Four major implications of high population growth in Pakistan were presented and discussed during the Conference.First, parallels were drawn between population growth trends observed in Pakistan and those observed in other Low-and Middle-Income Countries (LMICs) and countries with large Muslim populations, in particular India and Bangladesh.Inadequate public sector infrastructure resources supporting health and education, have resulted in the current population predicament in Pakistan.These include underinvestment in public health measures supporting fertility reduction, addressing preference for large family sizes (with only 20% of women with 2 children and 48% with 3 children expressing a need for family planning respectively), untapped latent demand for contraceptive methods as evident from persistently high unmet need, and preference for short-term contraceptive methods.Second, the population growth in Pakistan was cited as both an asset and a threat depending on whether it is properly managed.Fertility levels in Pakistan are high and managing the population boom is not a short-term goal.Third, it was also argued that the population size in Pakistan is not a threat to the country but represents a mismanaged resource.While Pakistan has high population growth, it does not have high population density.The use of stratified data helped to understand population challenges in Pakistan, e.g.gender and age-based disparities exist within the overall unemployment rates and even those with degrees of higher education are included in the unemployed workforce.However, there are a few consequences of rapid population growth such as increasing inflation, poverty, inequality, unemployment, and intergenerational wealth disparity.There are also social consequences which include tensions and conflicts, rising demands, poor quality of education, political instability, migration, emigration, changing family structures, and demographic factors such as large youth cohort, increasing number of the elderly, and individuals needing quality reproductive healthcare.
Fourth, grass root initiatives that focus on shifting social norms through self-generated incentives and monetary resources were highlighted as a missing element in the current population initiatives -such initiatives serve as a great motivator for women to not only participate in the workforce but also support efforts in increasing contraceptive use.

Opportunities for Resilience to Climate Change
Climate change is an integral part of the Sustainable Development Goals (SDGs) and it is related with all the other 18 SGDs.While all SDGs are interlinked with one another in some manner, climate change is one that impacts all aspects of development.The very real threat of climate change to Pakistan is identified by its status as a continuously impacted country, sharing the title with only Philippines and Haiti.The focus of climate change policy is currently solely on environmental issues which is an opportunity to reprioritize and reinvest in people-centered systems.Climate change justice for food, water, and agriculture are key priority areas of efficient and effective response to climate change.
The participants of the Conference were also briefed on the adverse implications that are being brought on due to rising temperatures such uninhabitable conditions of the planet, should climate change continue as it is.The water crisis as a consequence of climate change, the rising sea levels and depleting freshwater resources was highlighted.In this context, the immense importance of the Himalayan ice reserves and Pakistan's responsibility as a bordering nation to preserve those reserves was also highlighted.The specific impact of climate change as faced by citizens of Pakistan, include shortening of growing seasons, heat stress, growing need for water, and food insecurity.Pakistan is vulnerable to climate change and there are hotspots in the provinces of Sindh and Punjab impacting 10.2 million and 34 million people, respectively.The climate crisis is also connected with other population challenges and its role as a catalyst for causing internal conflict in the country needs to be understood.
Pakistan's effort in the fight against environmental degradation includes the "10 billion tree plantation" project, protecting reserves, and intentions to invest in water preservation.Pakistan has begun to develop a rich foundation for climate justice in the domestic legal system that is forward looking.

Population and Housing Census
The Pakistan Bureau of Statistics (PBS) has announced that the next population and housing census will be digital and is likely to be held soon.In the Plenary session, E-census experiences of Egypt and Iran were shared and discussed in detail to assess the preparation of PBS for the next census.The benefits of an E-census include enhanced data systems, security systems, data quality and consistency, monitoring, and control of census activities, ensuring communication among workers, and reduction in overall costs, with improved management of monitoring and control of census activities and reduced time for releasing the findings or outcomes of census.
In Egypt and Iran, the design and planning for the E-Census took two years with several dedicated working groups and committees with a formal organizational structure and organogram.In Iran, two pilot tests were conducted in 2014 and 2015 to test the methodology whereas the formal census data collection occurred in two phases: households completing the online questionnaire and with face-to-face follow-up by enumerators who then conducted a physical visit to the site.Absent households (those who could not complete the online questionnaire) were followed up by telephone.The concerned departments of Egypt and Iran invested heavily into campaigning and messaging for the E-Census.Moreover, popular opinion, traditional, and religious leaders were also encouraged to endorse the census.
For the next population census, the PBS is involving stakeholders into their work planning.It is also considering a National Census Coordination center in the pattern of a National Command and Control Centre.Plans for expansion include geo-tagging every structure for real-time monitoring which will also avoid overlapping of coverage, following the De Jure method, and not linking CNIC/Verification with NADRA.Data collection plans include tablets and piloting and extensive testing of self-enumeration.A pilot testing of this Ecensus is being planned before the census.It was promised that the controversies of the last census will not happen this time.
Regarding the use of census data, it was argued in the Plenary Session that population growth rate is the aggregate of many development indicators and showcases the limitation and challenges of the government.An important element of this is the population being led by financial and political dividends.However, it also showcases the lack of accountability afforded to the politicians for not responding to high population growth rates as they fail to link and the media also fails to link the very important relationship between development and population.

Reproductive Health and Maternal Mortality
Over a 30-year period, a shift from at home births to facility-based births was observed.This was highest in Punjab and lowest in Balochistan at the provincial level.The quality of facility-based services is highly volatile and dependent on region.Treatment patterns also outline certain practices repeatedly resulting in stillbirths.Maternal complications include anemia and nausea as the most common issues whereas care-seeking behavior is dependent on socioeconomic factors including monetary assets and women's education.Women at high risk of maternal mortality were around the 35-39-year age and were more likely to have history of multiple pregnancies with virtually no contraceptive use between each pregnancy.Moreover, women from rural areas and low-income households were more likely to be at high risk of maternal mortality.

Covid-19, Women and Gender Gap
The impact of COVID-19 had severe effects on women by aggravating economic difficulties and growing domestic tensions often leading to abuse.Most women suffered from economic hardships as the Benazir Income Support Program (BISP) funds did not accommodate for major household expenses.Women cited food insecurity as a consequence of economic stress.They also reported suffering verbal, psychological, emotional, and even physical abuse at the hands of the spouses.Contraceptive use also suffered as diminished services from LHWs impacted women's access to modern contraceptives, leading women to return to unreliable traditional methods.
Considering Pakistan's lack of uptake of digital technology and the consequential digital divide that followed, access to remote learning technology was identified as one of the main dividers of education during COVID-19 due to socio economic access of different classes.Private schools were quick to adapt to changes in learning while public schools were not.This translated into an economic divide as public schools are more often frequented by children from marginalized populations.Similarly, for lower income households, affordability of internet services was a challenge for online learning.Additionally, it was found that gender played a role in children's access to technology with girls having limited technological access as compared to boys.

Climate Change
Rising temperatures in Sindh over 40-year periods from 1961 to 2020 was reported by researchers, e.g. a one-degree upstroke in temperature over the years in Umarkot and Thatta districts of the province.Drought floods, unprecedented rain, frequent cyclones, sea intrusion, and freshwater depletion, are more common than before.These changes have led to lifestyle changes such as wearing slippers in the farm, and changes in agriculture such as decreased longevity of crops like tomato and chili.Regional crisis such as drowning and sea intrusion in coastal areas, and hot summers, drying crops, food deficiency, livestock deaths, water shortages, and consequent lifestyle changes in inland areas are common.Spillover effects on health, education, and socioeconomic conditions have been heavily experienced especially by women and other marginalized and underserved populations.Consequentially, migration, change in preferred crops, diminished live stocking, loan financing are now common realities.

Participation of Women in Workforce
It was observed that 8-9% of women are routinely excluded from the population censuses.Approximately three-quarters of the employed women of Pakistan engaged in unpaid domestic work.The involvement of women in the workforce led to decreased gender inequality, and increased gender ratio in the household whereas urbanization, with strong evidence from Punjab, also impacted the unequal sex ratios.

Lady Health Workers (LHWs)
Ranging in age from 25-35 years and working within their own communities, LHWs worked with little to no equipment, limited mobility, and a high propensity to harassment from local leaders.

Marriage Market -Consanguinity
Almost half of Pakistani marriages result in consanguinity often with younger, less educated brides who move on to give birth at a young age.A significant relationship between consanguinity and educational assortative mating is established.Consanguineous marriages are more likely to be hypogamous than non-consanguineous marriages.Moreover, contraceptive use is lower among women in consanguineous unions.An inverse relationship between the mean fertility (so far) and cousin marriages has been found.Women in consanguineous marriages are likely to have fewer children than women in non-consanguineous marriages.Overall, consanguinity patterns are stable, and there is no evidence that the societal changes such as improvement in women's education and urbanization over time have led to a decline in cousin marriages in Pakistan.

Poverty, Food Security and Subjective Wellbeing
Pakistan's Human Development Index (HDI) ranking score is 0.557, and it is lagging 153 countries.The likely reasons for this are food insecurity, poverty, and high population growth.Poverty, food insecurity, and high population growth have a negative impact on HD.Specifically, a 1% rise in per capita income and food production leads to a 0.4947% and 0.3499% increase in HDI respectively.Similarly, a 1% rise in population growth leads to a 1.83% decline on HDI due to a strain on resources.
Women in households receiving remittances were more likely to report higher subjective wellbeing making it positively related with economic wellbeing.However, the same was not true for men sending the remittances home to Pakistan.Migrant working men were highly dissatisfied in terms of subjective wellbeing making it negatively related with economic wellbeing.

Urbanization
The Population Council's work using sensing technology, namely satellite images, of Pakistan determines the population density across the country.This methodology included machine learning algorithms implemented on satellite images of Pakistan obtained between years 2016 and 2018 as two data points conflated with the census documentation from the 2017 census.The results show that machine learning algorithms are highly regular in identifying dense populations in urban and semi urban areas.However, they are not as effective in sparse rural populations.Remote sensing technologies are the future of mapping populations as they provide visual and reliable data.

RECOMMENDATIONS
The following recommendations were given during the Conference by the speakers, panelists, authors of research papers, discussants and chairpersons.
• The population policy of Pakistan must adopt a multi-sectoral approach that is fully integrated within comprehensive socioeconomic development plans as such effective population policies will achieve desired outcomes, particularly to meet the CCI recommendations and targets.In line with the current national goals of the country, a fourpronged approach may be adopted: lowering infant and childhood mortality, raising education for all genders, widening employability, and meeting existing family planning needs.Improvements in maternal and infant mortality would have a direct impact on trust and uptake of contraceptives.Contraceptives may be included in basic health plans and packages.The formation of population task forces, cross-sectoral development through increased funding, and synchronized development across sectors are the other necessary initiatives.• There is also a need to move beyond just managing population growth, and instead focus on the accommodation of the people that already exist through increased investments in education, health, social services, and human development.Efforts and direct policies to reduce population growth can contribute to development in the long run, but the impact would be limited in the absence of the right macroeconomic policies.
• The youth bulge is identified as a resource rather than a drain.
• There is a need to revisit the services of the LHWs to strengthen the workforce in their essential role as sole penetrative force at the grassroots level.A need for capacity building of LHWs was advised as well as lowering cost burdens on the end consumer.comprehensive pilot survey and a post-enumeration survey will improve the accuracy and quality of the census data.There is a need for mobilizing community support for holding the census.• There have been serious problems with the development narratives in politics regarding the population census.There is a need to debate, engage media, and understand why civil society does not talk of population issues and why and how to engage them better in this endeavor.• Pakistan's lack of uptake of digital technology and the consequential digital divide that followed is a challenge.Incorporation of digital technologies and increased investments in this sector to overcome this gap is suggested.The use of remote sensing technologies in conjunction with official records for urban planning and resource allocation is recommended.• There is a need for exploring missing links such as family in the domain of economics.This point can be a good avenue for new research.
Similarly, the perception of children's welfare indicators for lowincome households needs to be addressed.• BISP needs to be revitalized for the supplication of food packages and income support as well as education for children and public service messages for adults.• The switch back to ordinary life after COVID is an opportunity to also switch towards cleaner and greener programs and to help the population integrate in a better world than was left behind.Mental health service provision and the potential motivators for education as emerging topics requiring attention.• The need for advocacy of menstrual health as it is an often-undermined component of sexual and reproductive health and rights (SRHR) was highlighted.Its inclusion in the larger public health paradigm is recommended.
• The younger researchers are urged to connect their research with policies as that is a critical juncture to ensure implementation.
Researchers can play a role in ensuring that voices are heard by those who are decision-makers by highlighting as such in their research.

THE KEY TAKE AWAY
The 22 nd Annual Population Research Conference provided an opportunity to share the findings through an invited lecture, four panel discussions and 31 original research papers and posters from all over Pakistan, covering a range of topics related to population and human development, demographic transition, climate change, and policy directions to meet the challenges of a rapidly growing population in this changing world.This is admirable and underscores the need to nurture continuing scholarship on population and indicates increased investments and efforts to improve the utilization of research findings to inform critical policy reforms for the future.The PAP continually strives to look beyond demographic indicators and aim to influence Pakistan 's population and development policies and practices through good quality research to help the government make decisions that are fully-informed and evidence-based.Research also needs to strongly link up with policy direction, policy action, and implementation as simply generating evidence is not enough until it is used to build solutions.In order to fulfil the above recommendations, legislators, policy makers, implementers, and programmers need the right information and evidence to conceptualize and implement adequate policies and systems.The role of Population Research cannot be emphasized enough in this regard.

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Climate change is already happening and will impact every part of life, therefore the state should consider both inhibition and resilience strategies in response to climate change.Each shortcoming in this domain is an opportunity to expand and democratize and improve not only climate resilience but also other aspects of development such as Climate change justice for food, water, and agriculture as key priority areas of efficient and effective response to climate change.Additionally, investment in technological advancements in all sectors in response to climate change should be carefully considered.• A short questionnaire may be used for the next digital census.Both a Covid-19 on the contraception practices and rising rate of pop ulation; a KAP survey from the obstetricians of Rawalpindi and Islama bad.Asmat Safdar The Role of Women in Food Security and Its Effect on the Family Wel l Being: A Case Study in Rural Faisalabad District.Irfan Mahmood Farmer's perception and impacts of climatic impacts on natural resourc es and coping strategies: Variability in Semi-Arid Tropics of Pakistan