situation analysis of family planning in pakistan

2. By the end of the
session, participants will be able
to:
• Define Family Planning (FP) and
related terms.
• Briefly describe how Family
Planning contributes to the MDGs.
• Describe the evolution of Family
Planning interventions from 1947
to present.
• Illustrate vital trends (situational
analysis) in health indicators
related to Family Planning.
2/4/2013 2

3. Continued
• Discuss the role of funding
agencies, public sector, and private
sector in implementation.
• Sensitize the unmet needs of
vulnerable population.
• List the program shortcomings in
Pakistan.
• List a few recommendations for
health reforms.
• Illustrate one key paper.
2/4/2013 3

4. FAMILY PLANNING -
Definition
“Family planning allows individuals and couples
to anticipate and attain their desired number of
children and the spacing and timing of their
births. It is achieved through use of contraceptive
methods and the treatment of involuntary
infertility. A woman’s ability to space and limit
her pregnancies has a direct impact on her health
and well-being as well as on the outcome of each
pregnancy.”
(WHO. Family Planning. http://www.who.int/topics/family_planning/en/ (accessed 12 November 2012).)
2/4/2013 4

5. FAMILY PLANNING -
Importance
FP directly promotes Millennium Development
Goals 3 through 8…
• MDG 3: Promote Gender Equality and Empower
Women
• MDG 4: Reduce Child Mortality
• MDG 5: Improve Maternal Health
• MDG 6: Combat HIV/AIDS, Malaria and Other
Diseases
• MDG 7: Ensure Environmental Stability
• MDG 8: Develop a Global Partnership for
Development
2/4/2013 5

6. FAMILY PLANNING -
Importance
• MDG 1: Eradicate Extreme Poverty and Hunger
• MDG 2: Achieve Universal Primary Education
2/4/2013 6

7. BACKGROUND

8. 2/4/2013 8

9. 2/4/2013 9

10. FERTILITY DECLINE
• At the inception of population
program Pakistan’s fertility
decline rate (6.6 births per
woman) was between India’s
(5.9) and Iran’s (7) but
experienced fertility decline the
slowest in the region (1990s).
• Pakistan’s total fertility rate (TFR)
is one birth more than India and
Bangladesh and two births more
than Iran’s TFR.
• With current TFR rate Pakistan is
set to reach the proposed 2020
goals ten years even later.
2/4/2013 10

11. FERTILITY REGULATION
Contraceptive Prevalence:
Contraceptive Prevalence rates
in Pakistan remained relatively
below 10 % during the seventies
but increased significantly by
1990s to almost 28 %. CPR
increased from 21 % in 1991 to
49 % in 2007 amongst married
women. Use of contraceptives
in rural areas has increased over
the past two decades still lacks
behind significantly.
2/4/2013 11

12. FERTILITY REGULATION
The Contraceptive Prevalence Rate (CPR) is 30% in
Pakistan – a figure that has virtually remained the
same over the last decade – which is
considerably low as compared to other Muslim
countries. Iran has 74 % CPR, Turkey
71%, Morocco 63%, Indonesia 61%, Egypt
60%, Bangladesh 56% and Malaysia, 55%.
SOURCE: Sadiah Ahsan Pal. Family planning: Pakistan still has a long way to go.
http://tribune.com.pk/story/442532/family-planning-pakistan-still-has-a-long-way-
to-go/ (accessed 5th November 2012).
2/4/2013 12

13. SOURCE: National Institute of Population Studies (NIPS) [Pakistan] and
2/4/2013
Macro International Inc. 2008. Pakistan Demographic and Health Survey 13
2006-07. Islamabad: NIPS and Macro International Inc.

14. FERTILITY REGULATION
2/4/2013 14

15. FERTILITY REGULATION
• Induced Abortions: Induced abortions being
illegal still prevail with an estimate figure of
890,000 in 2002. On a rough scale every 29 of
1000 pregnancies end up with induced
abortions. This trend is heavily exercised by
women bearing more than three children.
2/4/2013 15

16. UNMET NEED
• In 1991, 40% women wanted to limit
childbearing, in 2007 it increased to 52%.
• Although more than 50 percent of women wish to
limit childbearing and around 20 percent wish to
space their next birth, only 30 percent are using
contraception, indicating unmet needs.
• The proportion of recent births that are
unplanned rose from 21 percent in 1990-91 to 24
percent in 2006-07 which lead to potentially
unsafe abortions. These problems are even
intense in rural areas.
2/4/2013 16

17. UNMET NEED
Rahnuma-FPAP President Mehtab Akbar Rashdi
said that London Summit will be the largest
family planning event where 69 poorest
countries with HIGHEST UNMET NEED of
family planning will participate.
“Unfortunately, Pakistan is one of them.”
SOURCE: Myra Imran. Pakistan has worst family planning indicators in the
region. http://www.thenews.com.pk/Todays-News-6-112757-Pakistan-
has-worst-family-planning-indicators-in-the-region (accessed 5th
November 2012).
2/4/2013 17

18. UNMET NEED
Out of those women who opt against contraception,
• 28% choose to do so by “leaving it to God”.
• This reason is closely followed by opposition from
husbands;
• fear of side-effects;
• and lack of knowledge.
• Only 5% have a perceived religious prohibition.
SOURCE: Sadiah Ahsan Pal. Family planning: Pakistan still has a long way to go.
http://tribune.com.pk/story/442532/family-planning-pakistan-still-has-a-
long-way-to-go/ (accessed 5th November 2012).
2/4/2013 18

19. Vulnerable Group – POOR!
• Fertility rates in Pakistan vary by women’s education
and household wealth status.
• Women across all wealth circles desired for lesser
childbearing in 2007 than 1991, but richer women used
contraceptives much more to prevent such cases. This
gap of contraception usage has raised alarmingly
between women of different wealth status over the
past decade.
• Unmet needs during 1991 stood better for poor
women but lack of contraceptive usage in comparison
of desire to limit childbearing takes it to 30% while
unmet needs of richer women are practically
nonexistent.
2/4/2013 19

20. LACK OF ACCESS
• Access to FP services in Pakistan varies from urban to
rural areas.
• It takes 40 minutes on average to reach a RH facility in
urban areas while it takes 96 minutes in rural areas.
(1991 DHS)
• Distressingly, the amount of poor population in rural
areas is far higher causing lack of contraceptive usage
and superfluous childbearing.
2/4/2013 20

21. QUALITY OF SERVICES
• Quality of FP services remains
a huge block in the path of
applying population policies.
• It is found that over time
increasing numbers of
women have reported fear of
side effects and health
concerns as their primary
reason for not intending to
use contraception in the
future both in urban and rural
areas.
2/4/2013 21

22. The National Programme for Family
Planning & Primary Health Care
• Also known as the Lady Health Workers
Programme (LHWP) was launched in 1994 by the
Government of Pakistan.
• The Lady Health Worker Model: employment of
over 100,000 Lady Health Workers (LHWs).
• Recruitment and trainings: First Level of Care
Facility (FLCF).
• Scope of work: 1 LHW = 1000 person/150 homes.
• Supervision and monitoring: Lady Health
Supervisors and Field Program Officers.
2/4/2013 22

23. The National Programme for Family
Planning & Primary Health Care
4th third party evaluation:
“LHWs play a substantial role in preventive and
promotive care and in delivering some of the
basic curative care in their communities, as well
as providing a link to emergency and referral
care”.
It also concluded that “LHW Programme has
significant impact on the population it serves”
and “it has maintained the impact despite
significant expansion of the Programme” (Oxford
Policy Management: 2009)
2/4/2013 23

24. CURRENT SITUATION

25. CONTRACEPTIVE PROCUREMENT
• Directorate of Procurement
Material and Equipment (PME).
• Expected to increase from
reported 8.4 million in 2008-09
to 10.8 million in 2014-15.
• Dependant on international
funds.
• Local manufacturing of pills and
injectables is already underway
and feasibility studies are under
consideration for establishing
IUD/CU-T manufacturing units in
Pakistan.
2/4/2013 25

26. FUNDING STREAMS
• Funds were primarily produced
by Federal government and
then distributed to provinces.
• Shift in international funds
from FP to RH in 1990s and to
HIV/AIDS recently has
damaged the progress of the
FP program.
• Major funding is provided by
KFW, UNFPA and USAID.
• Bulk of these funds are used in
social marketing acquiring
contraceptives.
2/4/2013 26

27. PUBLIC PRIVATE PARTNERSHIPS
• Social Marketing
• NGOs and CBOs
• Public-Private Sector Organizations (PPSOs)/Target
Group Institutions (TGIs)
2/4/2013 27

28. CURRENT SOCIO-ECONOMIC FACTORS
• Economic growth but Low Education:
• economic growth  progress in social sector
 neglect of education + low social growth.
• Agrarian country 44% employment from
agriculture.
• Low focus on educational aids to use FP Services.
• Past 2 decades increased primary education , low
secondary education.
• Literacy rate 53% (poorest/lowest rate)
2/4/2013 28

29. CURRENT SOCIO-ECONOMIC FACTORS
• Low Participation of Women in Society: male
dominated society impedes women to use FP
services.
• RH and FP Survey 2003, one in three women was
not allowed to leave her home alone and 42% of
women who were able to go to health centers on
their own were using contraception compared to
half that proportion. 21%, who were not allowed
to go to these facilities at all.
• Pakistan has the highest gender gap in labor
force: women employment (19% from 13%).
2/4/2013 29

30. PROGRAM SHORTCOMINGS
• The Population Policy (2002) was strong in principles but frail in
application. No Proper planning before starting new programs.
• Instead of introducing new programs and addressing latest issues
only old plans were reinforced.
• Expansion of FP services remained restricted to urban areas. Use
of contraceptives remained confined to urban areas through
organizations such as Key and Greenstar Social Marketing.
• Lack of Understanding of Population Issues:
Politicians, bureaucrats and other organizations have rarely
considered population a huge issue.
• Other public-officials hesitate from even discussing it due to
religious pressures.
• Provinces often support population growth to get handed with
government awards and aid.
2/4/2013 30

31. 2/4/2013 31

32. RECOMMENDATIONS

33. FEMALE EDUCATION
Without making education accessible to all
corners of the society; particularly women
CPR of global standards can’t be achieved in
the long run. Women education can lead to
Pakistan’s transformation from agrarian
society to an industrialized base where gender
roles, abilities and powers will be worked
more imperatively leading to better
implementation of FP policies and RH services.
2/4/2013 33

34. ROLE OF STAKEHOLDERS
• The economic and finance partners, including the
Ministry of Finance who need to understand that
economic growth is directly proportional to better
FP services.
• The health partners: Improving FP and RH services
by working together and putting organizational
efforts would further help private and public
providers of health services in their own goals.
• International Community and Donors need to
emphasize on FP services along with other medical
aids as it can help reducing those medical issues in
the future. Furthermore, they must use this
opportunity to help Pakistan when it eagerly wants
to improve its FP record.
2/4/2013 34

35. OWNERSHIP TO STRENGTHEN PROGRAM
• GOVERNANCE: FP services in Pakistan can only
improve if responsibilities are fully owned by
people, organizations and authorities.
• SERVICE DELIVERY of family planning services at all
health outlets; with population welfare outlets playing
a complementary and specialized role.
• COORDINATION: Strong body to steer, assist and
coordinate the role of the private and not-for-profit
sector.
• ACCESS & EQUITY: Maximum number of NGOs and
CBOs providing services in areas where
underprivileged, hard to reach populations are located.
• Strong MONITORING and oversight role at the center
but with full participation of provinces.
2/4/2013 35

36. 2/4/2013 36

37. KEY PAPER
Karen Hardee, Elizabeth Leahy.
Population, Fertility, and Family
Planning in Pakistan: A Program in
Stagnation. Population Action
International.October 2008;3(3)

38. REFERENCES
• Karen Hardee, Elizabeth Leahy. Population, Fertility, and
Family Planning in Pakistan: A Program in Stagnation.
Population Action International.October 2008;3(3)
• USAID. Overview of Reproductive Health and Family Planning.
www.flexfund.org/workshops/cb_fp_2007/day1/day1no1.ppt
(accessed 5th November 2012).
• Richey C; Salem RM. Elements of Success in Family Planning
Programming. http://www.populationreports.org/j57/j57.pdf
(accessed 5th November 2012).
2/4/2013 38

39. Working toward success
in family planning
programming is part
science and part art.
(http://www.populationreports.org/j57/j57.pdf)
2/4/2013 39