Authors: Fariyal F. Fikree ( Evidence to Action; Pathfinder/Path, 1201 Connecticut Ave NW, Suite 700, Washington DC 20036, USA. )
Extensive debate on the focus of family planning programming in Pakistan continues, often ignoring the fundamental argument for a strategicevidence based approach to addressing the underlying determinants of poor performance — a slowly increasing trend in contraceptive prevalence rate, continuing high unmet need — during the past 50 years. The emphasis seems to have always been on demand side creation with limited attention given to supply side as eloquently described in Adnan Khan\\\'s article in this issue.1 The most feasible next step is a more concerted effort on improving supply side determinants.
Provision of family planning services and counseling has largely been by the public sector though during the past two decades the private sector has captured a large portion of the demand for quality family planning services. Currently, the public sector serves around 35% of contraceptive users, with the private sector contributing the remainder.2 The Ministry of Health and Ministry of Population Welfare serve different populations and needs — rural and younger women with temporary and short-term methods; and urban with long-acting and permanent methods respectively. Can the private sector through innovative quality family planning services scale up to adequately serve the rural community? The Suraj social franchising model, an IUCD voucher scheme partnership between Marie Stopes Society and private providers in rural settings, provides ample evidence of increased uptake for long-acting methods if quality family planning services are available.3 What role should the Government of Pakistan play in scaling up services and embarking on new public-private partnerships?
Let us step back and examine one of the most significant public health achievements of the Ministry of Health-the Lady Health Worker\\\'s program. The increase in contraceptive prevalence rate in the 1990\\\'s was, by and large, attributable to their role at the community level - counseling and providing condoms and oral pills. The next decade witnessed a near stagnation of uptake in urban and rural areas served by the Lady Health Workers. The reasons, as described in the article by Abbas et al,4 included low number of women seen per week, sub-optimal counseling sessions and stock-outs among others. The Lady Health Workers spend around 6% of their time i.e. a meager two to three minutes per couple per week on family planning and seldom refer for long-acting methods. Public sector costs incurred for provision of family planning services, USD 21 per couple year protection, is high compared to regional averages. These are specific areas that are already identified which policy and programmatic priorities can immediately address to achieve immediate and clearly defined short and long term goals to increase the uptake of family planning programs.
Moreover the long term policy and programmatic directions that are of paramount importance also need to be brought to the attention of high level decision-makers. The perceived religious sanction for family planning has long been considered a barrier in Pakistan. However, many Islamic countries recognizing the impact that unfettered population growth will have on socio-economic development, quality of life and health of women and children have, with full support from religious leaders, successfully advocated for family planning information and services and achieved tremendous success.5 Experiences from countries such as Bangladesh,6 Indonesia, Iran and Egypt, regarding the positive role that religious leaders can play must be integrated in Pakistan\\\'s population policy and programmatic directions.7,8
Whereas there has been considerable debate on commodity security and costs incurred, the evidence belies the current situation. The costs incurred at USD 21 per couple years of protection, are significantly higher than regional averages of USD 3- 4.4 The current public sector family planning funding is adequate to increase the national contraceptive prevalence rate to over 50%. It is apparent from these costing data that funding is not the primary issue. And herein lie the dilemma that the Government of Pakistan must face urgently — why are the costs so high and consequently where are the inefficiency bottlenecks in family planning service delivery that hinders the uptake of family planning. Is it the geographic accessibility to quality family planning services, stock-outs at the community and/or facility level, lack of co-ordination between the Ministry of Health and Ministry of Population Welfare, poor referral linkage between community and facility or other bottlenecks?
Is the current family planning programmatic strategy optimally using every contact with a married woman to encourage uptake of family planning counseling and services? Are contacts during maternity care, specifically prenatal and postpartum; and well baby clinics including immunization visits missed opportunities? The Demographic and Health Survey 2006-07 shows that over 60% of pregnant women have at least one contact with a healthcare provider during pregnancy.9 Now is the golden opportunity for strengthening health care delivery systems at the district and sub-district level by integrating family planning services and counseling as a core component of maternity care — focusing on counseling during prenatal care and provision of family planning services in the postpartum period.
Irrespective of the focus of family planning programming, the stagnation in the contraceptive prevalence over the past several years demands a strategic re-thinking of the programming approach. At a time when Pakistan is facing several development challenges, the core demand for a holistic family planning program that is well integrated in the health care delivery system at primary, secondary and tertiary levels;provides high quality family planning services and counseling to couples via both thepublic and private sectors; andsupported by robust political commitment at the national, provincial and district levels is mandatory to meet the goals of a strong and vibrant Pakistan for the 21st century.Policy makers must also grapple with the broader development goals of education for girls and engagement of women into the paid labor force. Experience from other countries clearly supports the dogma that until society realizes an economic and social benefit in educating and employing women, family planning programs fail to achieve their full success.
The global attention to family planning through initiatives as Every Woman Every Child; Promise Renewed and Family Planning 2020, to which Pakistan is a signatory, illustrate the keen interest of the Government of Pakistan to improve the health of Pakistani citizens. The publication of this special issue of the Journal of Pakistan Medical Association presents evidence of the achievements, challenges and barriers faced in the past; and provideguidance for moving forward to reach the estimated 26 million married women of reproductive age with quality family planning services for improving maternal health and the well being of women and their families in the long run.
Keywords: Family planning, Pakistan, Programming, Policy, Service delivery, Contraception.
There are no conflicts of interest.
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