GOVERNMENT OF PAKISTAN UNITED NATIONS POPULATION FUND

PAKISTAN POPULATION ASSESSMENT

JANUARY 2003

Executive Summary

The Country Population Assessment 2003 presents a situation analysis of Pakistans current demographic and socio economic environment and the recent governmental efforts towards structured adjustment in various sectors to establish good governance and involve civil society. The CPA chapters 1,2 and 3 provide updates of recent trends in population, related developmental factors and reproductive health. Some important changes have taken place in the recent past: the annual population growth rate has declined to 2 percent, and the total fertility rate to 4.5 births per woman. Perhaps the most notable change in the TFR has occurred in the urban areas of the country, particularly in large cities where fertility has declined to 4.0 births per woman (from 6.1). Fertility in rural areas has also shown a modest decline in the TFR. Data supports huge differentials in fertility by educational levels of women. There is a remarkable gap between reproductive intentions and contraceptive practice with unmet need for family planning services estimated at 33 percent indicating huge potential for further fertility decline. Mortality levels have also declined with the crude death rate reaching 8 per 1000 in 2000 and expected to fall to below 5 per 1000 in the coming decade. Maternal mortality closely related to frequent and numerous births and unattended births remains alarmingly high at above 300 per 100,000 live births. While IMR declined to 82 per live 1000 births (from113-139 in the 1960-80 period to 82 more recently), the proportion of neonatal deaths linked to the risks faced by pregnancy and delivery, remains high. Other areas of concern in womens health are the relatively less explored and neglected areas of reproductive tract infections, cancers, sexually transmitted infections and domestic violence and mental illnesses. Available evidence confirms that these represent serious concerns for womens well being and scarce services to address for them. Internal migration depicts significant relocation of the population mainly from rural to urban areas: about 32 percent of the rural population has moved to urban areas. This also affects interprovincial spatial relocation whereby 60 percent of internal migrants originated in the Punjab and 67 percent in the NWFP, and Sindh received the majority of these migrants. Pakistan is the most urban country in South Asia : 24% of the urban growth can be attributed to migration, while the overall natural increase in urban areas remains 2.6%. This trend poses daunting challenges for housing, environment and employment. International migration with influx of Bangladeshis, 2 to 3 million other illegal entrants, and 3 million Afghan refugees, amounts to additional strains on overstretched resources. The last few years have seen some diverse trends in the social and economic indicators. Literacy rates have risen with some encouraging rise in enrollment rates at the primary level especially for girls. But literacy and enrollment rates still remain low. Unemployment and poverty have risen due to global economic recession and political events and macro adjustment policies. Environmental degradation, urbanization and deforestation etc. have been major problems. The international policy climate has changed significantly in the 90s. This decade set action guidelines and benchmarks for member signatory countries, including Pakistan in the form of the International Conference on Population and Development 1994, the Beijing Conference 1995 and the eight Millennium Development Goals (MDGs) outlined at the United Nations Millennium Summit of 2001. Pakistan is a signatory to these conventions which prioritize issues of reproductive health, universal education and gender equality in country strategies.

Recognition of population growth as a major cross cutting issue requires inter-sectoral linkages for the effective resolution of all issues related to it or those that result from it. These interlinkages are supported in more recent polices of the Government of Pakistan in the form of the Ten Year Perspective Plan, 2001-2011, and other initiatives such as Interim Poverty Reduction Strategy Paper. This paper addresses rising poverty to improve access to income generating employment activates, social sector development and to protect vulnerable sections through national and provincial safe nets schemes also incorporate population issues. The Population Policy 2002 formulated by the MoPW is a comprehensive statement regarding population. In departure with earlier practices it strongly endorses close collaboration with stakeholdersgovernment departments, NGOs and experts focuses on checking rapid population growth, increasing per capita income and poverty reduction strategies. The targets in the short term are reducing the annual growth rate to 1.9 per cent per annum and the TFR to 4.0 by 2004. By 2010, the policy envisages universal access to family planning services and replacement level fertility by 2020. The Ministry of Population Welfare has been mainly responsible for family planning services since the 60s. However, the Ministry of Health with its larger service delivery network, has a greater share of responsibility of providing reproductive health services. In particular, the National Programme for FP and PHC represents the largest scale intervention for the delivery of FP and RH services in the form of the Lady Health Workers (LHW) now integrated with the Village based family planning workers. Another indicator of increasing integration of reproductive health services is the jointly formulated National Reproductive Health Services Package, which clearly defines the priority areas for intervention and training. The private sector, which accounts for about 60 percent of the total health expenditures, also provides services in reproductive health. With the exception of some good quality hospital and clinics, there is also a large informal sector of hakims, homeopaths, untrained quacks who operate outside of regulatory laws and mechanisms. Greenstar Social Marketing and Key Social Marketing have turned around the situation rapidly by co-opting registered medical practitioners, by helping them improve their RH services including family planning, through comprehensive training and subsidized supplies of contraceptives. NGOs have taken an increasing share of overall reproductive health efforts and developed permanent clinics, operating community-based contraceptive distribution programs, providing FP and RH services. Their numbers remain small, funding insecure and their outreach in rural areas is limited. Serious constraints of the reproductive health services are insufficient coverage and poor access in rural areas and in urban slums and particularly among the poor that cannot afford private facilities. Certain types of services are particularly deficient such as necessary emergency obstetric care, and treatment of RTI and STIs. Also the referrals system require attention, in particular linkages such as those between traditional birth attendants and family health workers in rural areas, with tertiary or secondary hospitals of their areas. Reproductive health outcomes have also to be seen in the context of the prevailing environment in Pakistan. Constraints among women and households, which prevent them from utilizing services, are seriously embedded in social and cultural factors. Despite considerable health and education infrastructure being in place and a positive shift in the direction of national policies in favour of the social sectors, Pakistan continues to have unfavourable indicators of womens health and education. Indicators depict women lagging behind men in all socio-economic, educational and political aspects of life. Gender inequities and the weak autonomy of women permeate most reproductive health outcomes such as unmet need for family planning where husbands present perceive of actual

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obstacles to using family planning, in seeking care during pregnancy and delivery and in the recognition of symptoms and treatment of RTIs, STIs and AIDs. Chapters 4 lays out the availability of resources for the population and related sectors and Chapter 5 the recommendations for bringing about the changes in outcomes as laid out by the various policy documents and agendas. Financial resources allocated to the population and health sectors by the Government have risen. However as mentioned in the population policy of Pakistan, Rs.49.5 billion requirements are estimated for the next 19 years for achieving the fertility replacement. Undoubtedly unattended population pressures are likely to contribute to the creation of disastrous social and political environment in the country. Pakistan requires support to achieve replacement level fertility by 2020. Strategic actions are proposed to capitalize on the decentralization process and on the unique opportunity for multi-sectoral approaches in order to focus on reducing MMR, fertility and poverty. Furthermore, new and emergent needs such as the potential threat of HIV/AIDS and the needs of the largest cohort of adolescents have to be tackled in innovative and strategic ways.

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REPRODUCTIVE HEALTH PROFILE

Most Recent Figure Population Total population Population growth rate: Inter-censal Current estimate Urban population Age composition: Below 15 years 15-24 years >65 years Sex ratio (m/f) Health Life expectancy at birth Infant mortality rate Under 5 mortality rate Maternal mortality ratio Deliveries at home Births attended by skilled personnel Ante-natal care Post-natal care HIV/AIDS: Reported cases Estimated cases Family Planning Awareness of a modern method of family planning: Overall Urban Rural Contraceptive prevalence rate: Overall Urban Rural Unmet need for family planning: Overall Urban Rural Total fertility rate: Overall Urban Rural 146 m 2.69% 2.16% 32.5% 43% 19% 3.5% 108/100 63 yrs 82/1000 lb 103/1000 lb 300-700/100,000 lb 77% 19% 51% 28% 1,800 70,000-80,000

Year

Source

2002 1981-98 2002 1998 1998 1998 1998 1998 2001 2001 2000 2002 2000 2001 2000 2000 2002 2002

Economic Survey, 2001-2002, Govt of Pakistan, 2002. Ibid Ibid 1998 Census Report of Pakistan, Govt. of Pakistan, 2001 Ibid Ibid Ibid Ibid Ec. Surv. op.cit. PIHS Round IV,2002 Pakistan Reproductive Health and Family Planning Survey, 20002001, NIPS, 2001. Estimate. See Chapter 3. PRHFPS op. cit. UNICEF PRHFPS op. cit Ibid UNAIDS UNAIDS

95.0% 97.3% 93.9% 27.6% 39.7% 21.7% 33.0% 30.1% 34.4% 4.77 3.67 5.40

2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000

PRHFPS op.cit. Ibid Ibid Ibid Ibid Ibid Ibid Ibid Ibid Ibid Ibid Ibid

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A Note on Statistics and Figures Key statistics on population, health and family planning, mostly taken from the official government documents, are given in the Reproductive Health Profile. The source of information is also cited. In the main text of the document, however, at places, different figures would be found. This is due to the use of different source of data which has been quoted as well.

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TABLE OF CONTENTS C HAPTER 1 .......................................................................................................................13 POPULATION AND DEVELOPMENT............................................................................13

I. A. B. C. D. E. F. G. H. I. J. K. Relationship between Population, Sustainable Development and Poverty....................................13 ICPD CONTEXT ...........................................................................................................13 DEMOGRAPHIC AND SOCIAL CHANGE ...............................................................................13 THE M ACRO-ECONOMIC SITUATION .................................................................................14 INTER-SECTORAL LINKAGES ...........................................................................................16 POPULATION AND DEVELOPMENT POLICIES: CHALLENGES AND REALITIES...............................16 HUMAN RESOURCE DEVELOPMENT ..................................................................................17 LITERACY AND EDUCATION............................................................................................17 HEALTH AND REPRODUCTIVE HEALTH STATUS...................................................................18 LABOUR FORCE AND EMPLOYMENT..................................................................................19 GENDER EQUALITY AND EMPOWERMENT OF WOMEN:..........................................................20 POPULATION AND ENVIRONMENTAL ISSUES. ......................................................................21

CHAPTER 2.......................................................................................................................22 POPULATION LEVELS, TRENDS AND CHARACTERISTICS.......................................22 I. II.

A. B. C. D. E.

Overview......................................................................................................................22 Human Development, Demographic and Reproductive Health Indicators ......................22

POPULATION GROWTH...................................................................................................22 SPATIAL DISTRIBUTION OF THE POPULATION......................................................................23 AGE-SEX COMPOSITION OF THE POPULATION .....................................................................24 PROJECTED POPULATION................................................................................................26 M ORTALITY ................................................................................................................27

Infant and Child Mortality..................................................................................... 28 F. FERTILITY .................................................................................................................30 1. Trends in Fertility................................................................................................. 30 2. Fertility Differentials ............................................................................................ 30 G. M IGRATION .................................................................................................................31 1. Internal Migration ................................................................................................ 31 2. Urbanization and Growth of Cities......................................................................... 32 3. International Migration......................................................................................... 34

1.

CHAPTER THREE ..........................................................................................................36 REPRODUCTIVE HEALTH AND FAMILY PLANNING.................................................36 I.

A.

Reproductive health in Pakistan.......................................................................................36

M ATERNAL AND INFANT MORTALITY................................................................................36

1. 2. 3. 4. 5.

Maternal Mortality:.............................................................................................. 36 Maternal Morbidity: ............................................................................................. 38 Infant Mortality:................................................................................................... 39 Major Issues in Safe Motherhood:.......................................................................... 39 Evidence-based Decision-making in Safe Motherhood Programming:...................... 40

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B.

FAMILY PLANNING.................................................................................................41 Contraceptive prevalence ...................................................................................... 42 Unmet need of family planning:............................................................................. 43 C. SEXUALLY TRANSMITTED INFECTIONS AND HIV/ AIDS .......................................................44 1. Response TO HIV/AIDS and STIs........................................................................... 44 D. OTHERS...............................................................................................................46 1. Abortion:.............................................................................................................. 46 2. Cancers of Reproductive Tract............................................................................... 46 3. Infertility:............................................................................................................. 47 E. A DETERMINANT GROUP : ADOLESCENTS............................................................................48 1. 2. II.
A.

The offer of services..................................................................................................50

PUBLIC SECTOR............................................................................................................50

Policy framework.................................................................................................. 50 Population policy framework ..............................................................................50 Health policy framework.....................................................................................53 2. Ministry of Population Welfare.............................................................................. 54 3. Ministry of Health ................................................................................................. 56 4. Issues................................................................................................................... 57 a) Harmonization of RH services.............................................................................57 b) Devolution and Reproductive Health Services......................................................58 c) Human Resource Development .............................................................................59 d) Quality of services..............................................................................................60 e) Logistics and availability of contraceptives ..........................................................61 f) Health Management Information Systems (HMIS) ...............................................62 B. PRIVATE SECTOR ..........................................................................................................63 1. Organized Public and private sector ...................................................................... 63 2. Private health care................................................................................................ 63 3. NGO/For non profit.............................................................................................. 64 4. Social Marketing Organizations............................................................................. 64 5. Issues................................................................................................................... 65 a) Regulatory issues ...............................................................................................65 b) Linkages with public sector.................................................................................65 c) Affordability ......................................................................................................66 d) Support to NGO sector .......................................................................................66 a) b) III.
A. B. C.

1.

An insufficient demand for services..............................................................................67

AN UNDERUTILIZED PUBLIC SECTORS................................................................................67

LACK OF AWARENESS WITHIN THE COMMUNITY ..................................................................67 SOCIAL AND CULTURAL FACTORS.....................................................................................68

Gender................................................................................................................. 68 Male involvement.................................................................................................. 69 D. THE POTENTIAL ROLE OF CIVIL SOCIETY ............................................................................71 1. Community participation....................................................................................... 71 2. Devolution and local political environment............................................................. 72 a) Political Leadership:...........................................................................................72 b) Devolution and its Implications on District Health Services ..................................73

1. 2.

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CHAPTER 4....................................................................................................................74 MOBILIZATION OF FINANCIAL RESOURCES FOR POPULATION AND REPRODUCTIVE HEALTH PROGRAMMES..................................................................74 I. Introduction ..................................................................................................................74 II. Public Sectors Planning, Budgeting and Financing Structure and its Rela tionship with the Population Programme..........................................................................................................74 III. A review of social sector expenditures in Pakistan and assessment of reasons for these being historically low ............................................................................................................75 IV. Resource allocations and expenditure of the Population and Reproductive Health Programme and their relationship with the policy recommendations ........................................76 V. The Role of External Assistance in Financing the Population and Reproductive Health Programme...........................................................................................................................79 VI. NGOs and Private Sectors Role in Financing of Population and Reproductive Health Activities .............................................................................................................................81 VII. The Financial Resource Gap of Pakistans Population Welfare Programme ...................81 VIII. Expenditure on Pakistans Population Planning Programme in pre- and post-ICPD period, and a Comparison With Countries in the South Asia Region.........................................82 IX. Devolution of Authority.............................................................................................84

CHAPTER 5:....................................................................................................................85 RECOMMENDATIONS FOR STRATEGIC ACTIONS IN POPULATION, REPRODUCTIVE HEALTH AND GENDER....................................................................85 I. II.
A.

Overview......................................................................................................................85 Child spacing A national cause ................................................................................85

ADJUSTING EXISTING POLICIES ........................................................................................86

Achievements........................................................................................................ 86 Recommendations................................................................................................. 86 B. NATIONAL ADVOCACY AND COMMUNICATION STRATEGY......................................................86 1. Achievements........................................................................................................ 86 2. Recommendations................................................................................................. 87 III.
A.

1. 2.

Serving and managing better the path to improved service delivery............................87

SERVING BETTER AND REACHING OUT ...............................................................................87

Achievements........................................................................................................ 87 Recommendations................................................................................................. 88 B. SAVING MOTHERS.........................................................................................................89 1. Achievements........................................................................................................ 89 2. Recommendations................................................................................................. 89 IV.

A.

1. 2.

Family health for human wealth..................................................................................90

BUILDING ALLIANCES AND SUPPORTING COMMUNIT IES.........................................................90

1.

Achievements........................................................................................................ 90

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2. V.
A.

Recommendations................................................................................................. 90 Knowing better..........................................................................................................91

ENHANCING NATIONAL EXPERTISE ...................................................................................91

Achievements........................................................................................................ 91 Recommendations................................................................................................. 91 B. POPULATION AND RH M ONITORING .................................................................................92 1. Achievements........................................................................................................ 92 2. Recommendations................................................................................................. 92 VI.

A.

1. 2.

Managing better towards a reliable supply and optimal use of resources.....................93

DEVOLUTION , AN IMPORTANT STEP ..................................................................................93

Achievements........................................................................................................ 93 Recommendations................................................................................................. 93 B. ENHANCING DISTRICT MANAGEMENT CAPACITY..................................................................93 1. Achievements........................................................................................................ 93 2. Recommendations................................................................................................. 94

1. 2.

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Acronyms

ADB AIDS AJK/NAs ARI AusAID BHU CBD CBO CBR CDR CIDA CPR DFID EAD EOC EPI EU FATA FBS FLCF FP FPAP FWC GDP GNP GoP HDI HDR HIV HRD ICPD ICPD/PoA IE&C ILO IMR IUD JICA KFW LHV LHW M&E MCH MIS MMR MOH MOPW MSU

Asian Development Bank Acquired Immuno Deficiency Syndrome Azad Jammu & Kashmir/Northern Areas Ante Respiratory Information Australian Agency for International Development Basic Health Unit Community-Based Distribution Community-Based Organization Crude Birth Rate Crude Death Rate Canadian International Development Agency Contraceptive Prevalence Rate Department for International Development/UK Economic Affairs Division Emergency Obstetric Care Expanded Programme of Immunization European Union Federally Administered Tribal Areas Federal Bureau of Statistics First Level Care Facility Family Planning Family Planning Association of Pakistan Family Welfare Centre Gross Domestic Product Gross National Product Government of Pakistan Human Development Index Human Development Report Human Immunodeficiency Virus Human Resource Development International Conference on Population and Development ICPD/Programme of Action Information, Education and Communication International Labour Organization Infant Mortality Rate Intra-Uterine Device Japan International Cooperation Agency Kredi-tanstalt Fuer Wiedeeraufbau Lady Health Visitor Lady Health Worker Monitoring and Evaluation Maternal & Child Health Management Information System Maternal Mortality Rate Ministry of Health Ministry of Population Welfare Mobile Service Unit

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MWRA NATPOW NA NGO NGOCC NIPS NPA NRIFC NUESCO NWFP PAVHNA PCO PCPS PDS PFFPS PFS PHC PIHS PMA PMP PMRC PPAF PRSP PSDP PWD PWPP PWTI RH RHIYA RHS RTI RTIs SAP SAPP SIDA SMC SOWCR SoWPR STD TBA TFR TR TT UNDP UNEP UNFPA UNICEF VBFPW WB WHO

Married Woman of Reproductive Age National Trust for Population Welfare Northern Areas Non-Governmental Organization NGO Co-ordinating Council National Institute of Population Studies National Plan of Action National Research Institute of Fertility Care United Nations Educational Scientific & Cultural Organization North West Frontier Province Pakistan Voluntary Health and Nutrition Association Population Census Organization Pakistan Contraceptive Prevalence Survey Pakistan Demographic Survey Pakistan Fertility and Family Planning Survey Pakistan Fertility Survey Primary Health Care Pakistan Integrated Household Survey Pakistan Medical Association Prime Ministers Programme (for FP&PHC) Pakistan Medical Research Council Pakistan Poverty Alleviation Fund Poverty Reduction Security Programme Public Sector Development Programme Population Welfare Department Population Welfare Programme Project Population Welfare Training Institute Reproductive Health Reproductive Health Initiative for Youth in Asia Reproductive Health Services Regional Training Institute Reproductive Tract Infection Social Action Programme Social Action Programme Project Swedish International Development Agency Social Marketing of Contraceptives State of Worlds Children Report State of World Population Report Sexually Transmitted Disease Traditional Birth Attendants Total Fertility Rate Terms of Reference Tetanus Toxoid United Nations Development Programme United Nations Environment Programme United Nations Population Fund United Nations Children Fund Village Based Family Planning Worker World Bank World Health Organization

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ACKNOWLEDGEMENT

The preparation of Pakistan Population Assessment was achieved through the expertise of Pakistani experts and through wide ranging formal consultations with federal and provincial governments, NGOs and other stake-holders. To oversee the preparation, a working group was set up with representatives from the Ministry of Population Welfare, Ministry of Health, Economic Affairs Division and UNFPA. Individual chapters were assigned to Dr. Naushin Mahmud of PIDE, Dr. Mehtab Karim of Aga Khan University, Mr. Mehboob Sultan of NIPS, Dr. Rehana Ahmad of SMP, Dr. Farid Midhat of Population Council, Dr. Shahina Manzoor of Fatima Jinnah Medical College and Mr. Masood Hayat of Dataline. Dr. Zeba Sathar acted as the Report Advisor. Ms. Farida Ali provided secretarial assistance. We gratefully acknowledge the contribution by all the aforementioned individuals, and also those from the federal ministries, provincial departments, NGOs and others, too numerous to mention, who invested their considerable time in reviewing the document and providing their comments.

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Chapter 1
POPULATION AND DEVELOPMENT I. RELATIONSHIP BETWEEN POPULATION, SUSTAINABLE DEVELOPMENT AND POVERTY

While the number of employed people doubled between 1970 and 2002, the number of unemployed people increased eight-fold during the same period. The investments made in social sectors, s uch as education, health, housing, water and sanitation and infrastructure have not kept pace with the rapidly growing population. A consequence of high fertility rates is the unusually high number of young and adolescent population, leading to a continually growing labour force, which now requires much larger resources to create more employment opportunities for this section of the population. It is, therefore, important that population issues are explicitly integrated into economic and development strategies to achieve mutually reinforcing gains both for development and for an improved quality of life of the people of Pakistan.
A . ICPD CONTEXT

Moreover, the population welfare programme frequently underwent structural, administrative and policy changes within a fluctuating political environment, adversely affecting its commitment for realizing its objectives. After the 1994 ICPD, there has been a gradual shift in achieving demographic targets through an integrated approach which addresses the needs of individuals and families in all matters relating to their social and economic well-being in general, and reproductive health, in particular. Since Pakistan is a signatory to the 1994 ICPD Programme of Action, the government has taken various measures to make reproductive health an important component of the programme by expanding its outreach to rural and under-served segments of population. The subsequent section assesses the progress Pakistan has made in terms of demographic, social and macro-economic situation in the ICPD context.
B . DEMOGRAPHIC AND SOCIAL CHANGE

Pakistans population increased from about 34 million in 1951 to nearly 132 million according to the 1998 census. It was estimated as 146 million in mid-2002, (Source: Population Census Organization, 1998 Census Report of Pakistan and Economic Survey 2001-02) and is expected to reach 220 million by the year 2020. In the post-ICPD period, Pakistan has shown some progress in the field of population and development. The population growth rate has declined from an average annual estimate of 2.69 percent during the inter-censal period of 1981-1998 to 2.16 in 2001. The total fertility rate (TFR) has also exhibited a modest decline from more than five births per woman in the early 1990s to 4.8 births by 2000-01, while contraceptive prevalence rate (CPR) has risen steadily from 18 percent in mid-1990s to around 28 percent by 2001-2002 (Source: National Institute of Population Studies, Reproductive Health and Family Planning Survey 2001-02). However, with 33 percent of the population living in urban areas, the urban population has registered higher growth rates of 3.5 percent, with an increasing demand for basic civil and social amenities. About 50 percent

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of the total population lives in one-room houses with inadequate access to sanitation and sewerage facilities. Changes in other major indicators relevant to population and development show that literacy rate has progressed at a very slow pace, increasing from about 35 percent in 1990-91 to around 45 percent in 1998 for the total population. For females, it changed from only 20 percent to 30 percent during the same period, still leaving about 70 percent as illiterate (Source: Population Census Organization, 1998 Census Report of Pakistan). The total labour force in the country has increased from 33.6 million in 1995 to 41.5 million in 2002. Of these, more than 3 million persons are unemployed, indicating an unemployment rate of about 8 percent. If under-employment is also taken into account, the unemployment rate rises to around 15 percent. Furthermore, inadequate coverage and access to primary health care and reproductive health services, are additional sources of concern for the countrys population and development programmes. The poverty level has increased from 27 percent in 1993-94 to about 35 percent in 1999-2000, and this level is very close to 40 percent in rural areas (Source: Arif G.M., 2001, Measuring Poverty in Pakistan: A Critical Review of Recent Poverty Line, PIDE). This indicates that more than one-third of the total households in Pakistan are living below the poverty line. Although Pakistan appears to have made a breakthrough in achieving a declining trend in fertility and population growth rate, these changes are modest and below the desired level. The population growth in Pakistan is still among the highest in Asia, making it the sixth most populous country of the world and the third in the Asian region. With low levels of adult literacy, and high infant mortality rate, the value of human development index (HDI) in Pakistan is low (0.522), ranking it as 135th country of the world.

C . THE MACRO-ECONOMIC S ITUATION

In the decade of the Nineties, Pakistans reasonably high growth rate of 6 percent as its Gross National Product (GNP) declined to 4 percent, and possibly even lower to 3 percent, during the years 1999-2001. The per capita income was estimated at US $495 in year 2000-01 (Source: Planning Commission 1998, 9th Five Year Plan 1998-2003, Government of Pakistan). The persistence of large fiscal and current account deficits during the 1990s were the main underlying cause of macroeconomic instability, which in turn affected investment adversely and impeded economic growth. Consequently, the country experienced sustained inflation ranging between 10 to 13 percent during the 1990s, along with a large fiscal deficit of around 7 percent of GDP. The inflationary pressures have, however, diminished to around 3 percent in recent years, mainly due to tight monetary -4 policy, fiscal management and improved supply of food items in the country, as a result of Pakistans efforts to improve its macro-economic stability through the consolidation of its economic policies and human resource development. The economic policies and liberalization process set in motion during the past decade have contributed to the diversification of the production structure of the economy, showing mixed results. During 1990-91, the share of exports of primary commodities in the agricultural sector has declined from 19 percent to 13 percent, and of semi-manufactured goods from 24 percent to 15 percent, while the share of manufactured and industrial goods increased from 57 percent to 72 percent during the same period. However, the annual growth rate of exports stagnated at 13.6 percent of GDP, or around the value of US $ 8 billion, during the 1990s. The composition of imports, on the other hand, has not witnessed any appreciable change, largely concentrating in capital goods machinery, petroleum products, chemicals, edible oil, fertilizer, tea, e The trade deficit and the balance of tc.

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payment position of the country during the 1990s has remained under pressure, with an average estimate of 4.5 percent of GDP or US $ 2,557 million per annum. The external debt burden increased from $15.5 billion in 1990-91 to $36.5 billion by end-2002. Debt servicing as percentage of GDP has increased from 2.9 to 3.3% during the same period (Source: Economic Survey, Government of Pakistan, 2002). Pakistan initiated the implementation of a number of structural adjustments and stabilization programmes in the 1980s and carried them through the 1990s in order to make the economic system more efficient and bring about macro-economic stability. In this regard, the market friendly policies including deregulation and privatization of public enterprises were adopted to promote investment, growth and productivity. However, the Structural Adjustment Programmes that were pursued also affected various segments of population disproportionately, accentuating both poverty and related socio-economic problems in the country, as well as resulting in rising levels of unemployment, especially among the youth. The evaluation of these programmes point out their limited success in realizing the intended objectives. (Source: Amjad and A.R.Kemal, 1997, Macro-economic Policies and their Impact on Poverty Alleviation in Pakistan. The Pakistan Development Review, Vol.36, No.1, Islamabad). Studies have also shown that poor households are higher in number in rural than in urban areas. Estimates reveal that in rural areas, the proportion of poor households has increased from 27.0 percent to 39.8 percent during the years 1992-1993 to 1999-2000, and in urban areas, from 19.8 percent to 31.7 percent during the same period (Table 1.1). Table 1.1: Poverty Trends in Pakistan and Urban-Rural Areas:1990-91 to 1998-2000 Year 1992-93 1993-94 1996-97 1998-99 1999-2000 Total 24.9 27.7 24.5 30.6 35.2 Urban 19.8 15.2 14.8 20.9 31.7 Rural 27.0 33.0 28.7 34.7 39.8

Source: Arif (2001) Notes: Poverty estimates are based on basic needs approach. * From 1993-99, estimates are based on 2350 calories per adult at national level. 2450 calories for rural areas and 2150 calories for urban areas (Planning Commission, 1998-99. Official Poverty Line) * Estimates for 1998-2000 are based on 2250 calories per adult for rural areas, and 2295 calories per adult for urban areas (Qureshi and Arif, 2001).

The evidence shows that poverty-afflicted groups are generally the landless and small farmers, unskilled labourers, the u nemployed, female-headed households, and the aged in poor families. The poor households are generally characterized by larger family size, lesser or no education, and devote a large proportion of their consumption expenditure on food as compared to those in non-poor households. The percentage of literate household heads in non-poor households is 52 percent as compared with 27.9 percent in poor households. (Source: Government of Pakistan 2002). Despite the efforts made to reduce poverty during the past decade, the economic growth rates have not been adequate enough to benefit the poor. The Poverty Reduction Strategy of Pakistan (PRSP), initiated in 2000-01, incorporates a comprehensive economic revival programme aimed at accelerating economic growth and social development (Source: Interim Poverty Reduction Strategy Paper, 2001, Government of Pakistan). The core principles and objectives of this strategy

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are: reforming macro-economic imbalances; improving access to income generating activities and employment opportunities; improving social sector development and outcomes; and reducing vulnerability to shocks through social safety net schemes at the national and provincial levels. A number of programmes framed under this strategy are expected to serve a substantial number of the poor and the youth in the country.
D. INTER-SECTORAL LINKAGES

Population is recognized as a major cross-cutting issue in all development plans of Pakistan. The current Ninth Five Year Plan (1998-2003) views population issues in broader terms than those relating only to reproductive health and family planning delivery services, and takes into account both the impact of development programmes on population growth and the direct contributions to the population welfare programme of other sectors, including NGOs and the private sector. Given the urgency and critical situation of the population issues in terms of its high momentum of growth and a fast- growing dependent and youth population, the Five Year Plan involves all sectors in exploring ways in which population problems and their consequences can be comprehensively addressed. These sectors include education, health, employment and training, physical planning and housing, women in development, information and the media, etc. Hence, the foundations for a multi-sectoral approach have been laid down to ensure integration of population into overall and sectoral planning.
E. POPULATION AND DEVELOPMENT POLICIES: CHA LLENGES AND REALITIES

Pakistans development strategy in the past was growth-oriented, based on the premise that the effects of economic growth would filter down to the masses. Therefore, investments in such social sectors that lay the foundations for future growth have remained low and human development has continued to suffer in the process of economic development. Consequently, progress in literacy and education has been much below the desired levels. The Government of Pakistan fully recognizes the severe socio-economic implications of high fertility and rapid population growth and the focus is now on the implementation of an effective population policy operating within the framework of well-defined development goals. The new population policy 2002 plans to bring down population growth rate from its current level to 1.9 percent by the year 2004 and 1.3 percent by 2020. To achieve this end, fertility is planned to be reduced to 4 births per woman by 2004 and reach a replacement level by the year 2020 (Source: Ministry of Population Welfare, 2002). One major focus of the Population Welfare Programme is to provide information and services on reproductive health to a large group of adolescent population (aged 15-24 years) who have great potential for increasing population growth after entering into the reproductive phase. Under the new population policy, the programmes include service delivery, training and capacity building, advocacy and operational research in population and development, to find ways and means to help maintain a balance between the resources and population growth in accordance with the principles of the 1994 ICPD Programme of Action. The United Nations Millennium Summit of 2001 to which Pakistan is a signatory, has declared eight Millennium Development Goals (MDGs) which fit seamlessly into the 1994 ICPD Programme of Action, and provide guidelines for the operationalization of population and development policy of Pakistan. These goals are: i) eradicating extreme poverty and hunger; ii) achieving universal primary education; iii) promoting gender equality and empowering women; iv) reducing child mortality; v) improving maternal health; vi) combating HIV/AIDS, malaria and other diseases; vii) ensuring environmental sustainability; and viii) developing a global partnership for development. Working

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towards these goals would reinforce the important goals adopted by the ICPD, including better reproductive health, universal education and gender equality. In this context, a major challenge for Pakistans development agenda is to achieve rapid economic growth, enhance investment in its basic social sectors, especially education, to produce a well-trained and educated workforce, and reduce its fertility and population growth rate to maximize its gains for population welfare, and to the benefit of the poor.
F. HUMAN RESOURCE DEVELOPMENT G. LITERACY AND EDUCATION

Attainment of education is one of the major components of human resource development which affects economic growth, occupational structure of the labour force, adoption of new technologies, personal income and demographic behaviour of population. Literacy rates in Pakistan have increased gradually over the past decades from 18.4 percent in 1961 to about 44 percent according to the 1998 population census results. This percentage increased from 27 to 55 for males, and for females from as low as 8 to 32 during the same period (Table 1.2). This indicates that about 50 million of the total population, around 21 million males and 29 million females (10 years and above) are counted as illiterates in Pakistan. Although the female literacy level has almost doubled between 1981 and 1998, yet about two-thirds of them are unable to read and write with understanding and still remain much behind the males in improving their literacy status.

Table 1.2:
Census Year 1961 1972 1981 1998

Trends in Literacy Rates (population 10 and above) by Sex: Pakistan 1981-1998

Both Sexes Population (10+) 26,129,939 42,916,910 56,338,856 89,842,800 Literacy Rate (%) 16.7 21.7 26.2 43.9 Population (10+) 14,411,941 23,351,460 30,077,890 46,889,751 Males Literacy Rate (%) 25.1 30.2 35.1 54.8 Females Population (10+) 121,100,998 19,565,450 26.260,966 42,953,049 Literacy Rate (%) 6.7 11.6 16.0 32.0

Source: Population Census Organization, Population Censuses of Pakistan. 1961, 72, 81,98

The statistical evidence based on the 1998 census results shows that of the total formal literate population, more than 90 percent have attained education up to matric and intermediate levels. Of these, 18 percent have attained below primary and 51 percent have completed primary and middle levels. School enrolment has also increased considerably, especially for girls at primary and secondary levels. Enrolment of primary level increased from 10 million in 1990-91 to 18 million in 1998-99. The corresponding gross enrolment ratio (GER) at primary level is estimated at 71-80 percent for boys and 61 percent for girls. However, the net enrolment rate, which accounts for the over-age children enrolled at primary level, is reduced down to 42 percent for total primary school age population (5-9 years), being 47 percent for boys and 37 percent for girls. The ratio of female to male enrolment has improved at all levels of education during the past two decades, and has

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contributed towards the lessening of gender inequities in education in recent years. At primary, middle and college level of education, females constitute more than 60 percent of male enrolments, while at secondary and university levels, sex ratio of enrolment is 58 percent and 31 percent respectively for the year 2000-01 (Table 1.3). The recent improvement in school participation is attributable to increased investments in public primary schools which targeted at least one school per village, and the opening up of significant number of private schools, especially in towns and cities. Table 1.3: Changes in Sex Ratio of Enrolment by Education Levels (% of female enrolment to male): 1971-72 to 2000-01 Years 1971-72 1981-82 1991-92 2000-01 Primary 35.8 49.7 52.9 68.2 Middle 25.5 35.2 40.4 64.5 Secondary 25.7 32.1 37.0 58.5 College/Tertiary 35.8 49.7 51.9 71.5 University 28.4 21.7 23.9 31.6

Source: Federal Bureau of Statistics: 1998, and Economic Survey of Pakistan: 2000-01

One major change in the educational policies over the past decade has been a shift of resources from tertiary level of education to elementary level. However, the allocated share (48%) remains insufficient in achieving the target of universal primary education by the end of the 9th Plan (Source: Planning Commission 1998, 9th Five Year Plan 1998-2003, Government of Pakistan, Islamabad). Pakistan on an average has allocated 2.5% of GNP to education during the development plan periods, which is below the UNESCO recommendation of at least 4%.
H. HEALTH AND REPRODUCTIVE HEALTH STATUS

The effects of high population growth are also reflected by the low reproductive health status indicators of Pakistan in comparison with other countries of the Asian region. Some basic facts about the countrys reproductive health situation indicate that more than 20,000 women die each year due to pregnancy-related complications and maternal mortality remains between 300-700 per 100,000 live births. The contraceptive prevalence rate is around 28 percent (2000-2001) one of the lowest in the region. About 33 percent of married women do not want to have more births after three children, yet do not protect themselves against unwanted pregnancies. Nearly 80 percent of deliveries take place at home, most often attended by untrained personnel (Source: Reproductive Health & Family Planning Survey, National Institute of Population Studies, 2002). To meet the challenges of the health sector, a National Health Policy of 2001 with the motto of Health for All was framed, aimed at reforming ten major areas in the health sector to reduce mortality, morbidity and malnutrition, especially among infants and mothers. These include reducing prevalence of communicable diseases, improving primary and secondary health care services; manpower capacity building; improving nutritional deficiencies, correcting urban b regulating ias, private medical sector, creating mass awareness about health and reproductive health matters. These reforms, if implemented, are likely to improve the access to health care services and raise the health status of population (Ministry of Health, 2002).

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Pakistan, on an average, has allocated 0.7 percent to health during the previous development plans. Moreover, the development budget on health is only a small fraction of the total, and large amounts are spent on non-development/recurring expenditures to support the large infrastructure and salaries of the staff (Table 1.4). However, if deflated by GDP growth and inflation rate, the real expenditure on health does not show a significant increase over the years (Macro-economics of Pakistans Economy, Pakistan Institute of Development Economics, 2000).

Table 1. 4: Expenditures on Health as Percentage of Gross Domestic Product : 1995-2002 Year Total Budget 1995-1996 1996-1997 1997-1998 1998-1999 1999-2000 2000-2001 2001-2002 16.35 18.34 19.66 20.81 22.08 24.28 25.05 (million Rs) Development 5.741 6.485 6.077 5.492 5.887 5.944 6.688 Recurring Budget 10.44 11.857 13.587 15.316 16.190 18.337 18.717 % of GDP 0.8 0.8 0.7 0.7 0.7 0.7 0.7

Source: Pakistan Economic Survey, 2001-2002

I.

LABOUR FORCE AND EMPLOYMENT

Given the high fertility experience during the past decades, the current rate of growth of Pakistans labour force is over 2 percent per annum. Of the estimated population of 143 million in the year 2001, about 41 million are in the labour force, with a crude economic activity rate of about 29 percent, and a refined activity rate of 43 percent for all Pakistan. The majority of the labour force is employed in agriculture and related work (48%), followed by the services (15%), trade (14%) and manufacturing (11%) sector, and the remaining are employed in construction, transport and other sectors (Economic Survey, 2000-01).

Table 1. 5: Unemployment Rates Among the Youth Population: 1993-94 to 1999-2000

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Age Group Total 15-19 20-24 25-29 9.0 6.7 3.4

1993-94 Urban 13.4 9.0 5.1 Rural 7.6 5.7 2.7 Total 15.2 11.6 6.2

1999-2000 Urban 19.1 14.7 8.2 Rural 13.4 10.5 5.3

Source: Labour Force Surveys: 1993-94 and 1999-2000

To deal with the severity of the problem, the Government of P akistan has launched many employment promotion programmes in recent years. The Khushal Pakistan Programme, was launched in 2001 to improve poor peoples access to credit for their self-employment. This has created one million temporary jobs in the rural areas and small towns with an expenditure of Rs. 24 billion, and additional Rs. 15 billion allocated for the year 2002-2003. The small and medium enterprises (SMEs) programme launched in 2002 aims to provide small loans to the poor, and has created about one thousand jobs. Further initiatives have also been undertaken to involve the private sector in expanding technical, vocational and apprenticeship programmes for both men and women, in accordance with the labour market needs and demands of the growing labour force. Greater opportunities for women to access credit through programmes such as the First Women Bank and the Agricultural Development Bank of Pakistan are steps in that direction.
J.

GENDER EQUALITY AND EMPOWERMENT OF WOMEN :

Pursuant to the principles o utlined in the 1994 ICPD Programme of Action regarding gender equality and equity in different spheres of life, Pakistan fully recognizes the need for the enhancement of womens participation in national development and their full integration into all development programmes. Currently, Pakistan ranks low in terms of gender development index (GDI) with a value of 0.489 and a gender empowerment measure (GEM) with a value of 0.179 (UNDP, 2000). Recent changes in the socio-demographic dimensions suggest that women have not only contributed but have gained from the development process, but in an uneven and a disproportionate way. Some progress has been achieved in developing womens capabilities and productive activities. However, it has been generally observed that gender discrimination prevails at all stages of life cycle. Both as children and growing adults, females have a greater incidence of malnutrition, child mortality, and lesser opportunities in access to education and employment than males. As a result of the continuing high rate of population growth, the age structure of both women and men is heavily weighted towards younger and unproductive ages. About 43 percent of population is below 15 years of age, 21 percent in the case of females and 22 percent f males. Recent census and survey or estimates indicate an improvement in sex ratio and female life expectancy at birth, implying that there is a better health coverage of the female population and a resultant change in their mortality rate. With the beginning of fertility transition in recent years, and the existence of a latent demand for family planning in all population strata, women can play increasingly important roles in reducing family size through realizing their reproductive goals. While in recent years women have considerably benefited from increased education facilities, vast gender disparities still exist in literacy and school enrolment rates. The literacy rate for females is almost half of that of males. The gender gaps in literacy are more evident in rural than urban areas,

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as only 20 percent of rural females were literate compared with 48 percent of rural males as reported in the 1998 census, and the number of illiterate women (29 million) are about 60 percent of total illiterates in the country (Source: Mahmood, Naushin, 2002, Gender Issues and Socio-economic Development, Country Report of Pakistan. Low levels of education among women, limited employment opportunities and cultural constraints in working outside the home combine to limit womens employment in the formal sector. There are few options for paid jobs in rural areas and most women work as unpaid family helpers on farms and agricultural activities. All labour force statistics indicate that more than 80 percent of the female work force is not gainfully employed compared with 25 percent of male work force. Hence, their productive work for the household and the economy remains invisible and undervalued. However, the changing socio-economic conditions have resulted in increased participation of women in the wage sector, especially in urban areas and in informal employment. It is encouraging to note that the achievement of gender equity is recognized as a cross cutting theme for all development programs in Pakistan. The Ministry of Women Development has initiated various programs to improve womens situation and has identified 12 critical areas for mainstreaming gender into developmental activities.

K . POPULATION AND ENVIRONMENTAL ISSUES.

The rise in urban population as a result of population growth and rural-to-urban migration has increased pressure on urban infrastructure and social services. Besides overcrowding, air pollution has increased markedly as a result of vehicular emissions and industrial pollution, particularly in the industrialized world. If measured in terms of carbon dioxide emissions, it has increased from 31.6 million metric tonnes in 1980 to 94.3 million metric tonnes in 1996 (Source: Human Development Report, 2000). This is damaging the ozone layer and entire ecological cycles affecting animal and plant life, crop cultivation, and other economic activities on which human survival itself depends. Increased urbanization is likely to change occupational structures, consumption patterns and life style. It is, therefore, necessary to plan the growth of cities in a scientific manner. Population pressures have also resulted in the over-use of land resources and acute water shortages. Such a situation has resulted in a massive soil and land degradation affecting agriculture, fishery and livestock productivity. Water-logging and salinity and the extensive use of extremely toxic pesticides in agriculture adversely affect land productivity and health of the people. Moreover, inadequate sanitation facilities and waste disposal systems create environmental and health hazards for millions of people living in the low socio-economic strata of population. It is anticipated that demands on natural resources and social services will continue to grow as young people establish their families and enter into economic activity. Pakistan is also confronted with the problem of deforestation. Only 5 percent of the total land area is under forest, of which 30 percent is economically utilized (SDPI, 1997). Estimates show that during 1990-95, the annual rate of deforestation was 2.9 percent per annum as compared with 0.7 percent for low income countries. Besides the adverse effects of unplanned urban growth, lack of implementation of the quality standards for industrial pollution and the lack of defined property rights are contributing to environmental degradation in Pakistan.

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Chapter 2

POPULATION LEVELS, TRENDS AND CHARACTERISTICS

I. OVERVIEW

The demographic scene in Pakistan has two distinct features. Firstly, it has one of the highest population growth rate in South Asia: in mid-2002 it was estimated to be 2.16% per annum. Secondly, migration has had a pronounced effect: there has been substantial in-country migration, large scale influx of war-driven Afghan refugees and entry of other illegal migrants seeking domestic employment. This has brought about significant demographic changes. Urban population growth has accelerated and there has been a shift in the share of the provinces in the total population. In this chapter the changes and differentials that have occurred are examined under three demographic parameters, namely, fertility, mortality and migration.
II. HUMAN DEVELOPMENT, DEMOGRAPHIC AND REPRODUCTIVE HEALTH INDICATORS

Even though at the end of the 1990s, Pakistans per capita GNP was higher than several of its immediate Asian neighbours, Pakistan was lagging behind in most human development, demographic and reproductive health indicators. Of special concern is the slow pace of improvement in these indicators in the country in the recent past. Similarly, over time, as compared to other countries in the region, Pakistan has made slow progress in reducing its total fertility rate.
A . POPULATION GROWTH During the first half of the 20th century, in the areas now constituting Pakistan, the population growth rate averaged 1.01 percent per annum, while during the second half, the growth rate averaged about 3 percent per annum. As shown in Table 2.1, between the first post-independence Census of 1951 and the last census conducted in 1998, the population of the country increased four times, adding about a 100 million people. By the time of the 1972 Census, the annual rate of population growth in the country had peaked at 3.6 per cent during the 1961-72 inter-census periods. However, it showed a gradual decline to 3.1 percent during the 197281 inter-censal period and to 2.7 per cent during the 1981-98 inter-censal period. Table 2.2, showing the crude birth and death rates derived from Pakistan Demographic Surveys, suggests that until the early 1990s, the annual population growth rate was still 3 percent and that a noticeable decline in the growth rate started only in the mid-1990s, reaching 2.2 percent at the end of the decade.

The State of Population in Pakistan, 1987, NIPS.

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TABLE 2. 1:
1951 1961 1972 1981 1998

POPULATION GROWTH RATE IN PAKISTAN: 1951-2002

Population (000) 33,817 42,978 65,321 84,254 132,352
Sources: Population Censuses of Pakistan.

Census Year

Percent Annual Growth Rate during the Inter-censal period 1.80 2.45 3.67 3.06 2.69

TABLE 2.2: CRUDE BIRTH, CRUDE DEATH AND RATE OF NATURAL INCREASE IN PAKISTAN: 1984-2000
Period 1984-88 1990-93 1994-97 1999-2000 Crude Birth Rate (per 1000 population) 43 40 35 30 Crude Death Rate (per 1000 population) 11 10 9 8 Rate of Natural Increase (percent) 3.2 3.0 2.6 2.2

Source: Federal Bureau of Statistics, Pakistan Demographic Surveys.

B . SPATIAL DISTRIBUTION OF THE POPULATION

As shown in Table 2.3, Pakistans population is quite unevenly distributed among the four provinces. Balochistan, which contains about 44 percent of the land mass, has only five percent of the countrys population and has a density of 19 persons per square kilometer. Punjab on the other hand, is the most densely populated province; with only one-fourth of total land area of the country, it contains over 55 percent of population. Thus, Punjab has the highest population density (358 persons per sq km) followed by NWFP (238 persons per sq km) and Sindh (216 persons per sq km). Due to rapid increase in the population the overall population density in the country has increased from 43 persons per sq km in 1951 to 166 persons per sq km in 1998. The provincial percentage share in the total population of the country has been changing. Thus, the share of Punjab declined from 61 percent in 1951 to 57 percent in 1998. On the other hand, during the same period, the share of Sindh has increased from 18 percent to 23 percent. While the share of NWFP has remained somewhat similar (about 13.5 percent), that of Balochistan increased from 3.5 percent in 1951 to 5 percent in 1998. This has partly been due to inter-provincial migration and different fertility rates.

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TABLE 2.3: 1998

POPULATION DISTRIBUTION AND DENSITY BY PROVINCES, 1961-

Population (in 000) 1951 Pakistan (Area 796,095 Sq K.M.) Density per square Percent of Pakistans total population Punjab (Area 205,344 Sq K.M.) Density per square Percent of Pakistans total population Sindh (Area 140,914 Sq K.M.) Density per square Percent of Pakistans total population NWFP (Area 74,521 Sq K.M.) Density per square Percent of Pakistans total population Balochistan (Area 347,190 Sq K.M.) Density per square Percent of Pakistans total population FATA (Area 27,220 Sq K.M.) Density per square Percent of Pakistans total population Islamabad (Area 906 Sq K.M.) Density per square Percent of Pakistans total population
Source: Population Censuses of Pakistan

1961 42,978 54 100.0 25,500 124 59.3 8,374 59 19.5 5,752 77 13.4 1,385 4 3.2 1,847 68 4.3 120 132 0.3

1972 65,321 82 100.0 37,612 183 57.6 14,158 101 21.7 8,392 113 12.8 2,433 7 3.7 2,491 92 3.8 235 259 0.4

1981 84,253 106 100.0 47,292 230 56.1 19,029 135 22.6 11,061 148 13.1 4,332 13 5.1 2,199 81 2.6 340 375 0.4

1998 132,352 166 100.0 73,621 358 55.6 30,440 216 23.0 17,744 238 13.4 6,566 19 5.0 3,176 117 2.4 805 889 0.6

33,816 43 100.0 20,557 100 60.8 6,054 43 17.9 4,587 62 13.6 1,187 3 3.5 1,137 49 4.0 094 104 0.3

C . AGE-SEX COMPOSITION OF THE POPULATION

Age-sex composition of the population, presented in Table 2.4 and in Figure 1, shows a typical pattern of higher percentage in the younger age groups. However, it also reveals a smaller proportion of population in the youngest age group, confirming the findings reported in Table 2.3, that during the recent past Pakistans birth rate has declined. However, due to the persistently high birth rate in the recent past, the overall age structure of the population is heavily weighted towards

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the younger age group (below 15 years), which constitutes around 43 percent of the total population. Besides resulting in a high dependency ratio, it will also take Pakistan much longer to achieve a stable population as this large cohort will remain in the reproductive age groups for the next several decades. Table 2.4 also indicates that while the percentage of females is higher than males in the youngest age group, as they grow older, especially when they are in the early teens, the percentage of females declines substantially, which could be due to higher mortality among them. TABLE 2.4: Age 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ PERCENT DISTRIBUTION OF POPULATION BY SEX AND AGE, 1998 Both Sexes 14.8 15.6 13.0 10.4 9.0 7.4 6.2 4.8 4.4 4.7 3.2 2.1 2.0 1.2 1.1 1.2 Male 14.5 15.7 13.3 10.3 8.7 7.3 6.3 4.8 4.4 4.7 3.3 2.2 2.1 1.3 1.2 1.3 Female 15.1 15.6 12.6 10.5 9.3 7.5 6.1 4.7 4.5 4.8 3.1 2.1 2.0 1.1 1.0 1.2

Source: Population Census Organization, 1998 Census of Pakistan.

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FIGURE 1: POPULATION PYRAMID, PAKISTAN 1998

90-94

Male
80-84 70-74 60-64 50-54 40-44 30-34 20-24 10-14
14 18 16 12 10 8 6 4 2 0 0-4 0 2 4 6 8 10 12

Female

14

16

18

Percent

D.

PROJECTED POPULATION

Different Population Growth scenarios for Pakistan are projected in Table 2.5. In the year 2003 the population will be about 150 million. During the next 10 years, even under the low variant scenario of a substantial decline in the TFR (estimated at 3.4 in 2008 and to 2.3 in 2018), the population would probably exceed 180 million, with an estimated additional increase of 30 to 35 million people in the next 10 years. Should the TFR decline follow a medium variant path, (from an estimated 3.7 in 2008 to 2.8 in 2018), in the next 20 years about 69 million people will be added to the countrys population. To arrest this growth, Pakistan has to put a major thrust on reducing fertility to replacement level. With further improvements in the quality of life and because of the young age structure of the population, in the coming decade the crude death rate is likely to decline to below 5 per 1000 population, further adding to the increase in the dependency ratio.

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TABLE 2.5:

PROJECTED POPULATION OF PAKISTAN: 2003-20232

High Variant* (Population in 000) Medium Variant** (Population in 000) Low Variant*** (Population in 000)

2003 2008 2013 2018 2023

149,913 167,901 186,869 206,143 224,922

149,487 166,615 184,384 201,768 217,987

149,126 165,033 180,663 194,847 207,793

TFR will decline from 4.9 in 1998 to 3.9 in 2008 and to 3.2 in 2018

** TFR will decline from 4.9 in 1998 to 3.7 in 2008 and to 2.8 in 2018 *** TFR will decline from 4.9 in 1998 to 3.4 in 2008 and to 2.3 in 2018

E. MORTALITY

From the early 1980s to 2000, the overall crude death rate in the country has declined from 11 per 1000 population to 8 as given in Table 2.2. Age and sex-specific mortality rates as presented in Table 2.6, suggest the usual U-shaped pattern, with mortality high in early and older ages and low in middle ages. The mortality rate for females as compared to the males is lower during infancy but becomes higher in the age-group 1-4 due to the continuing practice of cultural and social discrimination against the girl child.

Source: A. Hakim, Population Projections for Pakistan and Provinces, National Institute of Population Studies, 2002

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TABLE 2.6: AGE & SEX SPECIFIC DEATH RATES (PER 1000), PAKISTAN, 2000
Age group All ages Below 1 01-04 05-09 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Both sexes 7.8 111.6 9.4 5.3 2.7 1.2 1.4 1.6 1.4 2.3 3.4 3.3 8.0 11.7 18.4 45.9 Male 8.2 122.5 8.2 4.6 2.6 1.4 1.7 2.0 1.0 3.0 3.7 3.3 7.6 15.1 19.8 46.6 Female 7.4 100.3 10.7 5.9 2.7 1.0 1.1 1.2 1.8 1.7 3.1 3.3 8.5 7.9 16.5 44.9

Source: Federal Bureau of Statistics, Pakistan Demographic Survey-2000

1.

INFANT AND CHILD MORTALITY

During the 1960-80 period, infant mortality rate (IMR) in the country had declined from 139 to 113 per 1000 live births, although it remained somewhat stagnant during much of the 1980s and was reported as 82 per 1000 live births during 1997-2000. When further disaggregated into different categories of neonatal, post-neonatal, infant, child and under five mortality, these differential rates are useful for evaluating the countrys health policies and programmes. Table 2.7 presents early and later childhood mortality rates based on retrospective histories of births and deaths of children born to women who were interviewed in two identical cross sectional surveys conducted by the National Institute of Population Studies (NIPS), one done in 1996-97 and the second in 2000-01. These findings suggest that the risk of death during early childhood is the highest during the first four weeks following birth, compared with the remaining 48 weeks of the first year. The proportion of neonatal deaths is higher compared to post-natal deaths, indicating a need to focus both on pregnant women as well as neonates in the child survival strategy. During the period 1982-86 to 1997-2000, child mortality declined from 25 to 20 per thousand live births and under-five mortality has declined from 136 to 103. In the most recent period (1997-2000), an interesting pattern of sex differential in early childhood mortality is reported. For example, the mortality rates for males are higher during the neonatal, post-neonatal period as

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well as during infancy, as expected. However, thereafter the child mortality rate is substantially higher for females, suggesting that less attention is given to the overall health of girls and, therefore, they are at a higher risk of dying than the male children. Differentials in IMR, presented in Table 2.8, could be reflective of the relative absence of quality maternal child health care services and facilities in the province. The IMR is reported to be lower in the major urban areas, particularly among mothers with middle or higher levels of education, and when they received both antenatal and post natal care during the period of pregnancy and subsequent childbirth. TABLE 2.7:
Sex and Period

EARLY AND LATE CHILDHOOD MORTALITY RATES BY SEX, PAKISTAN:1982-2000

Neonatal mortality/ 1000 LB Post-neonatal mortality/ 1000 LB Infant mortality/ 1000 LB Child mortality/ 1000 LB Under-five mortality/ 1000 LB

Both sexes 1982-86 1997-2000 67 54 50 33 113 85 25 20 136 103

Males 1982-86 1997-2000 77 68 52 33 125 99 21 15 143 112

Females 1982-86 1997-2000 56 40 48 32 102 71 30 24 128 93

Source: National Institute of Population Studies, Pakistan Reproductive Health and Family Planning Survey, 2000-01

Neonatal Mortality: probability of dying within the first month of life. Post-neonatal Mortality: probability of dying between the first month of life and exact age one year, having survived the first month. Infant Mortality: probability of dying before the first birthday. Child Mortality: probability of dying between the first and fifth birthday, having survived the first year. Under-five Mortality: probability of dying before the fifth birthday.

TABLE 2.8:

DIFFERENTIALS IN INFANT MORTALITY RATES BY BACKGROUND CHARACTERISTICS: 1992-96

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Background Characteristics

Pakistan

Infant mortality rate 92 97 91 69 106 104 98 65 51 40 75 53 97

Province: Punjab Sindh NWFP Balochistan Education: No education Informal or Quranic Primary Middle Secondary or higher Type of maternity care received: Antenatal care only Both antenatal and postnatal care Postnatal care only or no antenatal or postnatal care

Source: National Institute of Population Stu dies, Pakistan Fertility and Family Planning Survey, 1996-97

F.

FERTILITY

1.

TRENDS IN FERTILITY

The fertility rates in Pakistan remained high until the 1980s, when the total fertility rate (TFR) was about 6 births per woman. Since then a gradual decline in TFR has led to 4.8 births per woman, which was reported at the end of the decade (Table 2.9). The most notable change in the TFR has occurred in the urban areas of the country. During the 1985-2000 period, the TFR declined from 5.5 to 3.4 in the major urban areas and from 6.1 to 4.0 in other urban areas, whereas in the rural areas the decline has been quite modest (from 6.2 to 5.4). During this period, it is notable that the gap between the rural and the urban areas has widened substantially. There are several reasons for this rapid decline in urban fertility. Foremost among them is the higher level of female education and higher age at marriage among urban women. Also urban areas have been provided regular family planning services by the government, NGOs and the private sector (social marketing and commercial sales), whereas in much of the rural area such services remain scarce. TABLE 2.9: TRENDS IN TOTAL FERTILITY RATE, 1984-2000
Area Major Urban Other Urban Rural Total 1984-85 5.5 6.1 6.2 6.0 1986-91 4.7 5.2 5.6 5.4 1992-96 3.9 4.8 5.9 5.4 1997-2000 3.4 4.0 5.4 4.8

Source: National Institute of Population Studies, Pakistan Reproductive Health and Family Planning Survey, 2000-1

2.

FERTILITY DIFFERENTIALS

As shown in Table 2.10, a slightly lower fertility is reported in the two provinces of Punjab and Sindh, which are more developed economically as compared to the two less developed provinces of

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Balochistan and NWFP. However, overall illiterate women report substantially higher fertility than those who have completed even up to middle or higher levels of education, the former on average having a TFR which is about one-third higher than the latter. This difference could be due to inaccessibility to contraceptives by the poor, which is clearly indicated when TFR is classified by the economic status of the household. Women in the poorest households on an average have about two additional children (or 37% more) as compared to those who are in the upper-middle or upper social strata. TABLE 2.10: FERTILITY DIFFERENTIALS BY PROVINCE EDUCATION LEVEL AND SOCIOECONOMIC STATUS IN PAKISTAN, 1997-2000
Background Characteristics

Overall
Province Punjab Sindh NWFP Balochistan Education Level of Woman None Up to Primary Up to Middle Up to Secondary Above Secondary Economic Status of the Household Very Poor Poor Lower Middle Upper Middle Upper

Total Fertility Rate (per woman) 4.8 4.7 4.7 5.1 5.4 5.1 4.2 3.6 3.2 3.8 5.6 4.7 4.0 3.8 3.3

Source: National Institute of Population Studies, Pakistan Fertility and Family Planning Survey, 2000-01

G. MIGRATION

There are three main aspects related to migration in Pakistan: (a) inter-provincial; (b) rural to urban, and (c) international. These are discussed in this section.
1. INTERNAL MIGRATION

With the help of information on duration of continuous residence, the number of persons who migrated during the ten years preceding the 1998 Census was estimated at 4 million. Over two-thirds of these recent migrants settled in urban areas where they constitute 6.3 percent of the population, as compared to 1.5 percent in the rural areas. Urban areas of all the four provinces combined had 5 to 6 percent of their population classified as recent migrants. In the rural areas of Punjab, the percentage of recent migrants was about twice that of the other three provinces. This suggests that in Punjab rural-to-rural migration is more prevalent. Since the 1950s, Sindh has been receiving migrants who have mainly originated in the Punjab and NWFP provinces (Karim, 1986). Continuation of this pattern has been confirmed by 1998 Census as well. Of all those who had migrated within the country, over 40 percent had originated in Punjab and over 37 percent in the NWFP (Table 2.11). Less than 30 percent settled in the Punjab and less than 10 percent settled in the NWFP. Sindh

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received the majority of these migrants, about four times of those who had originated within the province. Another important feature of migration during the past ten years is the pattern of intra- and inter-provincial migration in the country. Over 70 percent of migrants in Sindh had originated outside the Province whereas about 60 percent of migrants who originated in the Punjab and the NWFP migrated within the provinces (they are inter-district migrants within the same province). The province-wise origin and destination of out-migrants indicate that over 60 percent of those who left Punjab settled in Sindh and about 25 percent settled in Islamabad. One-sixth of those settled in Punjab had originated in the NWFP and only 33 percent in Sindh. About 50 percent of those who originated in the NWFP settled in the Punjab and over 40 percent in Sindh. On the other hand, over 75 percent of those originated in Sindh were settled in Punjab and less than 5 percent in the NWFP. This evidence suggests that internal migration is responsible for a substantial amount of the relocation of population is occurring between the provinces as well as within provinces. This phenomenon may contribute largely to the rapid pace of urbanization in the country. TABLE 2.11: DISTRIBUTION OF RECENT INTER-PROVINCIAL MIGRANTS BY ORIGIN, DESTINATION AND NET MIGRATION TO AND FROM PROVINCES
Province Population Percent Origin Numbers Percent Destination Numbers Percent Net Migrants Numbers

Punjab Sindh NWFP Balochistan Islamabad FATA

73,621,290 30,439,893 17,743,645 6,565,885 805,235 3,176,331

55.6 23.0 13.4 5.0 0.6 2.4

467,830 130,376 418,819 56,968 11,451 45,414

41.4 11.5 37.0 5.0 1.0 4.0

326,671 500,223 81,736 55,894 166,334 *

28.9 44.2 7.2 4.9 14.7 *

-141,159 369,847 -337,083 -1,074 154,883 -45,414

Pakistan

132,352,297

100.0

1,130,858**

100.0

1,130,858

100.0

Source: Population Censuses of Pakistan, 1998 *Information on In-migration to FATA not available. ** Additional 389,062 persons originated in other countries, 108,599 originated in AJK /Northern Areas and 522,666 did not report their place of origin.

2.

URBANIZATION AND GROWTH OF CITIES

As shown in Table 2.12 rural-to-urban migration has resulted in an upward growth of population in the urban areas, which is much higher and faster than in the rural areas. The urban population has grown over seven times from about six million in 1951 to about 43 million in 1998. Between 1951 and 1998, the urban population doubled 17.7 percent to 32.5 percent. This rapid urbanization has already resulted in Pakistans being the country with the highest proportion of urban population in South Asia. The provision of basic amenities in urban areas has not kept pace with the growing

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urban population, adding to a host of problems through the increasing slums within cities and townships. Urban poverty exists and itself is a breeding ground of many social problems from drug and child abuse to HIV/AIDS/STIs and social violence. Table 2.12: Estimated Contribution to Population Growth due to Migration During the 1980s and 90s Province Urban Areas Average Average Growth Natural Rate* Growth Rate** (19811998) (1) (19841997) (2) Difference in Growth rate due to Migration Rural Areas Average Average Growth Natural Rate Growth Rate (19811998) (19841997) (6) Difference in Growth rate due to Migration

Actual

Percent

Actual (7)=(5)(6) -0.7 -0.9 -0.6 -1.2 -0.7

Percent (8)=(7)/(6)*100

(3)=(1)-(2) (4)=(3)/(2)*100 (5)

Punjab Sindh NWFP

3.3 3.5 3.5

2.6 2.7 2.7 2.9 2.6

0.7 0.8 0.8 2.0 0.8

20.5 22.9 22.2 40.7 23.8

2.2 2.1 2.6 1.9 2.3

2.9 3.0 3.3 3.1 3.0

-27.0 -41.6 -24.4 -59.6 -31.8

Balochistan 4.8 Pakistan 3.5

Source: Population Censuses of Pakistan and Pakistan Demographic Surveys *Intercensal growth rate during 1981-98 **Average based on Pakistan Demographic Survey conducted during 1984-97

During the 1981-98 inter-censal period, urban areas of the country, on an average, recorded over 1.2 percent higher population growth rate per annum than the rural areas. Based on the Pakistan Demographic Surveys conducted during 1984-97, the overall rate of natural increase in the urban areas of Pakistan was reported as 2.6 per cent. This implies that 0.8 percent, or about 24 percent of the total urban growth was due to migration. On the other hand, the rate of natural increase in the rural areas was 3 per cent per annum, while the average rate of population growth during the intercensal period was only 2.3 per cent. Apparently the rural areas of the country lost about 32 per cent of their population due to migration. This conclusion is supported by the fact that the number of large cities (those with over one million population) has increased from two in 1961 to four in 1981 and to seven in 1998.

As shown in Table 2.13, during 1981-98, the twelve largest cities recorded an annual growth rate of 3.5 percent and during this period their combined population increased from 13.8 million to 24.9

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million. In most of these cities, basic civic amenities remain scarce and the municipalities are unable to cope with the rapid increase in their population. TABLE 2.13:
Rank 1 2 3 4 5 6 7 8 9 10 11 12

POPULATION OF TWELVE LARGE CITIES OF PAKISTAN, 1998

Name of City 1981 Karachi Lahore Faisalabad Rawalpindi Multan Hyderabad Gujranwala Peshawar Quetta Islamabad Sargodha Sialkot Total 5208 2953 1104 695 732 752 601 566 286 204 291 302 13,694 Population (000) 1998 9339.0 5443.5 2008.9 1409.8 1197.4 1166.9 1132.5 982.8 565.0 529.2 458.4 421.5 24, 655 Inter-census Growth rate (percent) 3.50 3.66 3.58 3.43 2.94 2.60 3.80 3.30 5.92 5.77 2.71 1.98 3.52

Source: Population Census of Pakistan, 1998 Census [note that totals are rounded].

3.

INTERNATIONAL MIGRATION

An accurate estimate of those who entered Pakistan since 1980 (which is when the Soviet Union invaded Afghanistan leading to a huge exodus of Afghan refugees into Pakistan) is not available, although newspaper reports suggest that there are between 2 to 3 million of them are now living in the country. According to the statistics maintained by the Ministry of Interior, about 3.7 million Afghan refugees were living in Pakistan by the end of the 1990s. Following the events and situation in Afghanistan in the post September 11, 2001 period, and as a result of the Bonn Agreement between Afghan groupings in exile, the installation of the Interim Administration in Kabul, according to UNHCR sources, led to the return of close to a million refugees to Afghanistan. However, uncertain conditions in Afghanistan saw about 200,000 Afghans re-entering Pakistan. During the visit of an official Afghan delegation to Islamabad, both the governments signed an agreement on the repatriation of about 3 million Afghan refugees over the next three years. It is estimated that about 1.2 million refugees are living in camps and another 2 million dispersed in the cities. In the 1998 Census, a conscious decision was made not to include Afghan refugees, and other illegal aliens, in the census count. Besides the Afghan refugees living in the urban areas, about one million people mainly from Bangladesh are believed to have also settled in the country. There is a small number from Iran, Sri Lanka and India as well. A newly established organization, the National Alien Registration Authority (NARA), has begun the difficult task of registering refugees and unregistered aliens in the country. The Ministry of Labour and Overseas Pakistanis keeps records of all those workers who emigrate from Pakistan through official channels. However, those who emigrate unofficially are generally not accounted for. Based on the Ministrys records, the trend in emigration, as shown in Table 2.15, suggests a substantial decline beginning from 1983 when it averaged about 120,000 persons annually. It dipped to as low as 58,000 by 1985 and then rose again to early 1980 levels. The number of emigrant workers increased substantially during the early 1990s peaking at 191,000 in 1992 and remaining between 114,000 to 155,000 during much of the rest of the decade for which

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data is available. The vast majority of Pakistani emigrants go to the various Middle-Eastern countries where they work at a variety of skilled, semi-skilled and unskilled jobs and are a source of substantial inflow of foreign exchange. Summing up, from the foregoing analysis, three main conclusions can be drawn. Firstly, although population growth rate is high, there is evidence that a fertility transition has set in. However, there are variations in fertility decline: it is more in urban areas as compared to the rural areas; fertility is significantly higher among those classified as poor and very poor; and it is highest in Balochistan and NWFP as compared to the other two provinces. Secondly, 23.4% of population is within the age group 10-19 years which underscores the need to meet the requirements of the adolescents. Thirdly, every where the gender disaggregation of mortality figures reveals vulnerability and low status of women: female mortality is higher in the age group 1-9 years due to the comparative neglect of the girl-child, and it again becomes high as compared to the males between the ages 30-34 which are the stressful years of child-bearing. Lastly, there is a trend of large scale migration to the cities in search of employment adding to the problems of poverty and urbanization.

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CHAPTER THREE REPRODUCTIVE HEALTH AND FAMILY PLANNING

I. REPRODUCTIVE HEALTH IN PAKISTAN

Introduction:

At Pakistans last census in 1998 the population was 132.4 million with an inter-censual growth rate of 2.69 %3. The Total Fertility Rate (TFR) for all of Pakistan was recorded at 6.2 in 1970-754, and 5.4 in 1986-915. The average TFR for the last four years is estimated at 4.86. However, fertility is higher in the rural areas (TFR of 5.7, according to PFFPS 1996-7), for all of Balochistan (6.7) and among uneducated women (6.0). Pakistan has an estimated 33 million women of reproductive age. Each year, about 5.4 million women go through pregnancy and childbirth, resulting in 4.5 million new births. A large number of these women suffer unnecessary risks associated with childbearing, indicating a high burden of disease and death. About two-thirds of pregnant women receive no prenatal care7. Almost 80% of births occur at home, usually attended by untrained birth attendants. Inspite of gradual decline of infant mortality in the country, the perinatal mortality rate has remained high with no significant change.
A . MATERNAL AND INFANT MORTALITY 1. MATERNAL MORTALITY:

Maternal mortality ratio (MMR) is considered to be one of the most sensitive indicator of womens health and of the quality and accessibility of health services available to women. Unfortunately, there is n reliable national MMR figure available in Pakistan, with the exception of o an indirect estimate of 533 per 100,000 live births (circa. 1990)8. The community-based studies would suggest that the MMR in Pakistan ranges between 300 and 700 per 100,000 live births (Table 3.1). These studies also suggest that the levels and causes of maternal mortality vary between districts, depending upon accessibility of emergency obstetric care (Table 3.2). Hospital-based studies over-or under-estimate the MMR, depending upon the population they serve. Two extreme examples are a study done in Civil Hospital Karachi in 1979-19839, which reported MMR of 2736 per 100,000 live births, and another study from Aga Khan University
3

Interim Population sector perspective plan 2012 Pakistan Fertility Survey, 1976 Pakistan Demographic and Health Survey, 1991 Reproductive Health and Family Planning Survey of 2000-01

PIHS 98-99
National Institute of Population Studies. Pakistan Reproductive Health and Family Planning Survey, 2000-2001: Preliminary Report. Ahmed Z. Maternal mortality in an obstetric unit. J Pak Med Assoc 1985 Aug;35(8):243-248.

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Hospital of Karachi10, which reported the MMR of 20 per 100,000 live births among booked clients during 1988-1999. Most hospital-based and community-based studies confirm that the major causes of maternal mortality in Pakistan are similar to those in other developing countries, namely: postpartum hemorrhage, toxemia of pregnancy, obstructed labor and puerperal sepsis. A small but significant percentage of maternal mortality is attributed to unsafe induced abortions. Available data do not permit estimation of trends in maternal mortality levels. Since independence, however, there have been significant and considerable improvements in the access and quality of emergency obstetric care available to population, particularly in the rural areas. Moreover, the decline in fertility may be directly associated with a decline in maternal mortality rate. It may, therefore, be assumed that maternal mortality levels might have declined considerably over the last few decades, particularly in the rural areas. Unfortunately, there are no hard data to substantiate this assumption.
Table 3.1. MMR in various Pakistani sites, Maternal and Infant Mortality Survey (MIMS) 1988-199311 Site Area MMR Pishin District (Balochistan) Rural 280 Lasbela District (Balochistan) Rural 450 Khuzdar District (Balochistan) Rural 690 Loralai District (Balochistan) Rural 610 Haripur, Mansehra and Abbottabad Districts (NWFP) Rural 430 Peshawar Division (NWFP) Rural 240 DI Khan Division (NWFP) Rural 410 Kurram and Khyber Agencies (FATA) Rural 280 (Purposive sampling excluding remote and insecure areas) Overall (average for all sites listed above) Rural 392 Urban squatter settlements of Karachi12 Urban 281

Qureshi RN, Jaleel S, Hamid R, Lakha SF. Maternal deaths in a developing country: a study from the Aga Khan University Hospital, Karachi, Pakistan 1988-1999. J Pak Med Assoc. 2001; 51 (3): 109-111.
10

Midhet F, Becker S, Berendes HW. Contextual determinants of maternal mortality in rural Pakistan. Soc. Sci. Med 1998; (46) 12: 15871598.
11

Fikree F, Karim MS, Midhet F, Berendes HW. Causes of reproductive age mortality in low socioeconomic settlements of Karachi. J Pak Med Assoc. 1993; 43 (10): 208-212.
12

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Table 3.2. Cause-specific MMR by access to emergency obstetric care (EmOC), Mortality Survey (MIMS) 1988-199313 MMR in districts having: Cause of maternal death Better access to EmOC Postpartum hemorrhage 95 Antepartum hemorrhage 25 Eclapmsia 30 Puerperal sepsis 49 Obstructed labor 15 Other direct causes 25 Indirect causes 85 Total (All Causes) 324

Maternal and Infant

Poor access to EmOC 160 95 55 60 42 80 120 612

While it is difficult to amass data about MMR, certain process and output indicators can be used for monitoring MCH interventions. Available data point towards these indicators being poor, suggesting high levels of maternal mortality. For example: the prevalence of severe anemia among pregnant women was about 10% in 198814; two-thirds of pregnant women do not receive any prenatal care15; over 80% of all deliveries occur at home16; and only 18% of deliveries are performed by skilled professionals17.
2. MATERNAL MORBIDITY:

It is believed that one-sixth of all pregnancies in Pakistan are complicated and that 10 percent of pregnant women develop obstetric complications requiring medical intervention. Unfortunately, data on the prevalence and determinants of obstetric complications are scarce and unreliable. However, small-scale studies and hospital-based information suggest high prevalence of anemia, prolapsed uterus, genital fistula, rupture of the uterus and puerperal psychosis18. In a study at the Pakistan
Institute of Medical Sciences, Islamabad, about 3.5% of all deliveries conducted at the hospitals Obstetrics Department were regarded

as near-miss defined as a life-threatening obstetric emergency19.

Midhet F, Becker S, Berendes HW. Contextual determinants of maternal mortality in rural Pakistan. Soc. Sci. Med 1998; (46) 12: 15871598.
13 14

National Institute of Health. National Nutrition Survey , 1988. Hakim A, Cleland, J, Bhatti MH. Pakistan Fertility and Family Planning Survey 1996-1997. National Institute of

15

Population Studies, Islamabad, December 1998.

16

Ibid. World Health Organization, 1999-2001.

17

Saleem. Sarah. A Review of Research on Maternal Health, Pakistan. The Aga Khan University and Population Council, 2002 (under publication).
18

Mehmood G, et al. Severe Maternal Morbidity at Pakistan Institute of Medical Sciences: The Near -miss Concept, an Indicator of Maternal Care. Proceedings of the First Annual Conference of Population Association of Pakistan, Karachi, 2000.
19

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3.

INFANT MORTALITY:

Although infant mortality rate (IMR) in Pakistan has declined considerably since independence in 1947, the rate of decline is slow compared to most developing countries. Pakistan has an IMR of 82 infant deaths per 1000 live births20. Even with a decline in the IMR, neonatal mortality (death of children within first month after birth) has remained high: While the IMR declined from 178 in 1950 to 95 in 1992, the reduction in the neonatal mortality rate was from 94 to 55 during the same period21. Moreover, the perinatal mortality rate (stillbirths and infant deaths during the first week after birth) has also remained high ranging from 56 to 72, based upon various small studies22. Because many risk factors of perinatal mortality are the same as those of maternal mortality, a consistently high perinatal mortality rate indicates high levels of maternal mortality and low quality and accessibility of obstetric care available to women.
4. MAJOR ISSUES IN SAFE MOTHERHOOD:

During the 1970s and 1980s, the emphasis of the national MCH program shifted more toward child survival strategies (growth monitoring, oral re-hydration therapy for childhood diarrhea, breastfeeding and immunization). The only major intervention directly related with obstetric care during this period was that of training a large number of traditional birth attendants (Dais). A 15-days intensive Dais Training Program was developed and imparted in all rural areas of Pakistan, and about 53,000 traditional birth attendants were trained in safe delivery care and early recognition and referral of cases with common obstetric danger signs. During 1992-1999, the Family Health Project in Sindh again trained about 650 Dais in 10 districts23. Similar training programs were organized in other provinces. Many professionals have questioned the impact of Dais training on the maternal health indicators in developing countries. There is no evidence that Dais training programs in Pakistan have worked to reduce maternal mortality, although many programs have reported improved knowledge, skills and performance of Dais for sometime after training. Generally, it is believed that these programs failed to cause a significant decline in maternal mortality, mainly because there was no follow-up, supervision or support system for the Dais trained under this program. The only alternative to traditional birth attendants is trained community midwives. In 1996-7, there were about 2130424 trained midwives (including nurses) in the country. Although most districts hospitals have midwifery schools attached to them, their quality of tutors, training, and, therefore, the quality of their product is not of standard.

20

Economic survey of Pakistan 20002-3 Integrated Household Survey Round IV, 2001-02 Save the Children USA. State of the Worlds Newborns: Pakistan. 2001.

21

22

Islam A and Malik FA. Role of traditional birth attendants in improving reproductive health: lessons from the Family Health Project, Sindh. J Pak Med Assoc 2001 June: 51(6): 218-222.
23 24

Health policy 1997

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Government health services in Pakistan are comprised of fixed facilities providing curative care. Emergency obstetric care (EmOC) is available only in district or Tehsil hospitals that are difficult to access for a majority of rural women. Basic health units or rural health centers provide prenatal care or family planning, however the quality and sustainability of which is questionable. There is no organized system to provide health education and/or counseling to expectant mothers except for the lady health workers programme which covers 48% of rural area. Mechanism for monitoring the performance of government health facilities is weak. Government health personnel are not accountable to communities, who, in turn, have little interest or faith in the government health system. The government realizes these shortcomings, and there have recently been efforts to harmonize the field operations of the two ministries responsible for women's reproductive health needs. An ambitious national reproductive health services package is promoted, which encompasses almost all aspects of the national MCH program. Pakistan has a specific traditional culture of birthing in its rural areas. This culture comprises predominance of traditional values, beliefs and practices related to pregnancy and childbirth; reliance on untrained traditional birth attendants and older women of the family for assisting in the delivery; lack of awareness regarding MCH issues; lack of faith in the modern medical system; physical, social, economic and cultural barriers to accessing and utilizing essential obstetric care. High levels of maternal mortality and morbidity in Pakistan are a direct result of the interplay between a variety of factors: low status of women in society; poor nutrition; a significant proportion of high-risk pregnancies (such as those to grand-multiparous women); poor access to health services; poverty and illiteracy. Womens health cannot be improved without addressing each of these issues, and without moving from the traditional culture of birthing to a modern system of maternal and child health services.

5. EVIDENCE-BASED DECISION-MAKING IN SAFE MOTHERHOOD PROGRAMMING:

Ideally, national level intervention programs should be based upon the lessons learned from the past; many of these lessons arise from smaller scale projects that are implemented on a pilot basis. There is enough information available from various localized and regional studies within Pakistan that can be used to design large-scale interventions. Some of these projects are listed here25:
1. Balochistan Safe Motherhood Initiative (BSMI) is an operations research study of the Asia Foundation, which has developed and tested a package of community-based interventions to reduce maternal mortality in a rural district of Balochistan. Preliminary results suggest that providing focused health education to women and husbands, training Dais in recognizing and referring obstetric emergencies and setting up transport and telecommunication systems can significantly reduce perinatal, neonatal and maternal mortality. An operations research study similar to the BSMI is currently underway in rural Karachi, the results of which will be available shortly.

This is only an illustrative list and is not meant to be exhaustive. Many other important projects and programs (completed and ongoing) exist, which have contributed significantly to the countrys experience in reproductive health and safe motherhood programming.
25

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2.

3. 4. 5.

6.

7. 8. 9.

10. UNFPA is assisting the Government of Pakistan in training selected Lady Health Workers from the National Programme on PHC/FP in midwifery skills. The catchment area of this worker would be 2000-5000 rural population depending on the geographical considerations. In addition, the project will assist in community sensitization on maternal health, developing a referral system, up-gradation of selected RHCs and THQs for basic and comprehensive EOC, training necessary staff and strengthening of district midwifery schools. Pre intervention and post intervention baseline surveys (qualitative and quantitative) will be conducted in control and intervention areas. Project will be implemented by the National Programme on PHC/FP, Ministry of Health in five districts.
B. FAMILY PLANNING

Medicins du Mond, in collaboration with the UNFPA, had launched a project to strengthen and upgrade EmOC services at primary and secondary level government health facilities in Rahimyar Khan district of Punjab. The project has successfully increased health services utilization by women and percent of deliveries performed by skilled birth attendants. Columbia University of New York, in collaboration with UNICEF, is currently implementing a project to strengthen EmOC services at secondary care hospitals in selected districts of Sindh province. The results are awaited. HANDS, a NGO, has incorporated Dais training and community health education in MCH in its primary health care project in rural areas of Sindh province. The results are awaited. APPNA Sehat is another NGO that has trained Dais and provided health education to women and families in the Murree district of Punjab, with an objective to increase health services utilization by women and improve womens access to EmOC. Preliminary results indicate a significant reduction in MMR in the project area. The MCH Department of the Pakistan Institute of Medical Sciences, Islamabad, has recently concluded its community outreach project that facilitated womens access to EmOC through mobile clinics and training of lady health workers. The project has recorded significant increase in obstetric referrals from the project site. Maternal and Child Welfare Association of Pakistan also has a number of intervention projects in various parts of the country but most notably in Punjab. Even though the projects are not designed as operation research studies, the Association has a wealth of data that can be used to evaluate their interventions. Aga Khan University of Karachi has to its credit the only large-scale, multi-district community-based study of maternal and infant mortality, which was conducted during 1989-1993 in urban and rural areas several districts. Population Council is in the process of concluding the first-ever study to test the impact of a clientcentered approach training to health care providers on selected reproductive health indicators. The study was conducted in rural Punjab.

Pakistans RH programme aims at improving the quality of life of the people by enabling couples to decide the number and spacing of their children and by providing the information and the means to do so. In recent years, there has been a substantial rise in knowledge about different FP methods, and 96% of currently married women are aware of at least one method26. Their knowledge about where to obtain modern contraceptives is also quite high, and nearly 76% know a place for female sterilization versus only 37% in 1990-9127.

26

NIPS: Pakistan Reproductive Health and Family Planning Survey, 2001. NIPS/IRD-Macro: Pakistan Demographic and Health Survey, 1991.

27

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1.

CONTRACEPTIVE PREVALENCE

Among modern methods, the facilities and community-based distribution systems of the MOH and MOPW offer oral contraceptive, two types of injectables, one type of IUD, condoms and voluntary surgical contraception. The following Table shows the progression in the use of contraception since 1984. Table 3.3. Percentage of Currently Married Women who are Currently Using Specific Methods
PCPS28 Method Any Method Any Modern Method Pill IUD Injectable Vaginal Methods Condom Female Sterilization Male Sterilization Any Traditional Method Periodic Abstinence Withdrawal Others Number of Respondents 1984/85 9.1 7.6 1.4 0.8 0.6 0.1 2.1 2.6 0.0 1.5 0.1 0.9 0.5 7405 PDHS 1990/91 11.8 9.0 0.7 1.3 0.8 0.0 2.7 3.5 0.0 2.8 1.3 1.2 0.3 6364 PCPS29 1994/95 17.8 12.6 0.7 2.1 1.0 0.0 3.7 5.0 0.0 5.2 1.0 4.2 7922 PFFPS30 1996/97 23.9 16.9 1.6 3.4 1.4 0.1 4.2 6.0 0.0 7.0 1.9 4.6 0.5 7582 PRHFPS 2000/01 27.6 20.2 1.9 3.5 2.6 0.0 5.5 6.9 0.0 7.4 1.6 5.3 0.5 6370

Results of the five studies reveal increasing use of all modern methods. Female sterilization remains the method of choice, although it has a low demographic impact because the majority of women seek it after completing their family size (four or more children). The less effective traditional methods of family planning are also quite popular. The most popular temporary method is the condom, closely followed by withdrawal, while IUD also makes an important contribution. According to the PRHFPS survey 2000-01, nearly 45% of all acceptor couples rely on methods that require the initiative or compliance of husbands. This is an interesting finding and is discussed in some detail below.

28

Pakistan Contraceptive Prevalence Survey 1984-85 Pakistan Demographic and Health Survey, 1991. Pakistan Fertility and Family Planning Survey, 1996-97.

29

30

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Information about couples experiences with the use of contraception is somewhat limited as there are very few studies investigating user satisfaction with the methods and services. In 1997, UNFPA commissioned the Population Council to conduct the User Satisfaction and Longevity Study (USLS), which reported the findings from a national sample of 2,722 women). The USLS found that contraceptive continuation rates for condom, withdrawal and periodic abstinence were between 75 and 80 percent at the end of the first year, and were closely comparable with those for IUD. Interestingly, continuation rates for the pill and injection users were much lower (55% and 46%, respectively)31. Many users of female methods complained of negative effects, including those relating to menstruation and sexual relations. Fewer women reported similar complaints related to natural methods. Women having surgical sterilization were quite satisfied with the method, especially with regard to sexual relations. Generally, the contraception use continuation rates for modern contraceptives were high as compared to other developing countries and were certainly within international norms. Miller et al.32 hypothesize that this may be a result of only those couples using the modern contraceptives who are resilient and determined to use them. This hypothesis is supported directly or indirectly by many other studies, including those reporting the causes of high unmet need of family planning 33.

2.

UNMET NEED OF FAMILY PLANNING:

The survey of NIPS34 reported a total unmet need of family planning of 33%, including 12.1% women who wished to delay their next pregnancy and 20.9% who wanted no more children. The two main causes of this rather high unmet need are explained as (1) a weak attachment on part of the women to their fertility preferences, perhaps with influence from the husband, and (2) the economic, social and physical costs of using modern contraceptive methods, as perceived by women35. Contrary to popular beliefs, studies have revealed little inter-spousal disagreement between husband and wife on fertility issues, and this disagreement cannot be regarded as sole explanation for unmet need 36. A distrust on modern methods of contraception, perceived or real fear of undesirable side effects, social taboos against the use of family planning, lack of faith in the health and family planning delivery systems, provider behaviour, lack of follow-up services, etc., could be the main reasons that can explain both the high levels of unmet need and relatively high rates of use of traditional methods.

31

Miller PC, et al. On the Dynamics of Contraceptive Use in Pakistan. Population Council, 1999. Ibid.

32

See, for example, Sathar and Casterline. The Gap Between Reproductive Intentions and Behavior: A Study of Punjabi Women Population Council, 1997.
33 34

Pakistan reproductive health and family planning survey 2000-2001. The Gap Between Reproductive Intentions and Behavior: A Study of Punjabi Women Population Council, 1997 Ibid.

35

36

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C . SEXUALLY TRANSMITTED INFECTIONS AND HIV/ AIDS

In considering HIV/AIDS, several socio-economic, demographic, and behavioural factors make Pakistan a high-risk country, even though at present it is a low-prevalence one (<0.1% of the adult population being affected). Although currently, Pakistan has very low levels of HIV infection, however, the country is considered to be at high potential risk for a number of reasons. Among these are widespread cultural denial of behaviours that spread HIV (and STIs in general); low literacy rates and a poor educational environment; pervasive poverty; gender issues; and a young population (63% being under 25 years).37 In particular, there are large concentrations, in the major cities, of individuals with behaviours that make them extremely vulnerable to rapid spread of HIV and of classical sexually transmitted infections (STIs) such as chlamydia, syphilis and gonorrhoea. These individuals include male and female commercial sex workers, men who have (unprotected) sex with men (MSM), hijras or transvestites, injecting drug users and highly mobile occupational groups, such as truckers.38 It is likely that Pakistans HIV epidemic will start in one or more of these groups and then spread to the general population through individuals who have contact both with high-risk groups and the general population. In epidemiological parlance, individuals who spread the infection from concentrated high-risk groups to the general heterosexual population are termed the bridging group (or population). Typically these are married or unmarried men who are clients of sex workers, or bisexuals, or share needles with injecting drug users. Rather little is known about the sexual conduct of men in Pakistan but the available evidence suggests that both pre-marital and extra-marital sexual contacts either homosexual or heterosexual are sufficiently common to create and sustain a generalised HIV epidemic. Immediate and effective action is required to avert the threat of an HIV epidemic in Pakistan. While some classical STIs are reproductive tract infections (RTIs), other RTIs are not, or not primarily, transmitted by sexual intercourse. They can be acquired iatrogenically such as during the insertion of intra-uterine devices (IUDs) or abortion. They may also arise endogenously due to proliferation of organisms normally present in the body. Among the RTIs, bacterial vaginosis (BV) has become increasingly recognised as a major public health concern especially in countries where maternal and child health outcomes are poor such as Pakistan.

1.

RESPONSE TO HIV/AIDS AND STIS

The Ministry of Health (MOH) is well aware of the growing challenge of HIV/AIDS in Pakistan and has elaborated policies and programmes for its prevention and control. A National AIDS Prevention and Control Programme (NACP) has been created, with provincial implementation units. NACP has managed a noteworthy IEC programme since 1994/95. This programme has led to a

37

Fikree, F., Reproductive Health in Pakistan: what do we know? , a paper presented at the Conference on Pakistans Population Issues in the 21 st Century in Karachi, October 2000. Fikree reports 12.3% prevalence of reproductive tract infections in the general community and 25% in commercial sex workers.

This and the following four paragraphs are taken from the Summary Chapter of the National Study of Reproductive Tract Infections and Sexually Transmitted Infections, a proposed research strategy and study design prepared by the National AIDS Control Programme, MOH, Government of Pakistan (Sept.2002).
38

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significant increase in awareness about HIV/AIDS from a low of 4% in the year 1991-92 to 75% in the evaluation undertaken during 2000. Similarly the Ministry of Population Welfares National Population Policy announced in July 2002 calls for more active intervention in areas of reproductive and sexual health, including the reduction of RTIs and STIs for improving the reproductive health of men and women. As the number of reported HIV infections and AIDS cases is steadily on the rise in all provinces, the MOH has drafted an Expanded Response Programme of about US$ 40 million with the assistance of the World Bank and other funding agencies to be implemented over next five years. The objective is to prevent HIV from becoming established in vulnerable populations and spreading to the general adult population. Two key aims of the Expanded Response Programme are to achieve: Increased prevalence of safe behaviours and improved availability of STI services among vulnerable populations. Improved knowledge and practice of HIV preventive measures including the use of high quality STI services by the general population The Pakistan Reproductive Health Services Package (RHSP) jointly developed by the MOH and MOPW in 1999 also includes as components: (a) prevention and management of RTIs/STDs and HIV/AIDS, and (b) management of reproductive health related problems and issues in women and men. The Pakistan Reproductive Health Project (RHP) to be launched in 2002-3 with the support of the Asian Development Bank will focus on these service delivery components. Hence, on part of the Government, there is visible commitment to the ICPD plan of action regarding RTIs and STIs and also for limiting the spread of an HIV/AIDS epidemic in Pakistan. However, there is lack of data needed for sound programme planning and monitoring of progress. MOH and NACP envisage that the proposed National Study of Reproductive Tract and Sexually Transmitted Infections will provide the benchmarks for monitoring the progress of the Expanded Response Programme. UNICEF, UNAIDS and UNFPA have been active in the arena of advocacy and service delivery. UNICEF funding has focused on NGO support, with particular emphasis on in-school youth, while UNAIDS funding has supported programmes targeting injecting drug users in Lahore. This latter activity has been extended to Karachi and three other sites, with the support of United Nations Office for Drug Control and Crime Prevention (UNODCCP). UNFPA is assisting an NGO for the prevention of HIV transmission among the street drug users and is about to initiate a project for commercial sex workers. With assistance of UNAIDS, and other stakeholders, in 1999 and 2000 GOP organized a strategic planning exercise resulting in a National HIV/AIDS Strategic Framework covering several priority areas and goals, such as:
An expanded, multi-sectoral, coordinated and sustainable approach towards controlling of infections. Specific interventions managed by NGOs addressing high-risk populations and youth. Improved surveillance and research. STIs reduction and treatment. Blood and blood product safety. Care and support to people living with AIDS (PLWA).

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An increasing number of NGOs in Pakistan are involved in HIV/AIDS prevention, and today there are over 70 NGOs participating against this silent and largely invisible epidemic. These NGOs are working in all provinces, in both urban and rural areas, but very few are currently supported by external donors. Instead, they rely upon self-financing mechanisms or community contributions. Some of these NGOs target their activities towards specific vulnerable groups, while others are working to raise the level of awareness among the general public.
D. OTHERS

1.

ABORTION:

In Pakistan, abortion is illegal unless it is performed to save the life of a pregnant woman. It has to be acknowledged, however, that in response to a variety of needs, induced abortions are often practised in Pakistan even though the numbers are a matter of conjecture. If a woman wishes to terminate an unwanted pregnancy, she usually turns to an unskilled provider who performs the procedures under unhygienic conditions. Complications arising from unsafe induced abortions are a significant cause of maternal deaths all over the world. In the Pakistan Country Paper submitted to the Fourth World Conference on Women, 1995, the government estimated that around 15% of maternal deaths could be related to abortions. Limited community based information is available on induced abortions in Pakistan, though hospital based data offer some indications on linkages between induced abortion and maternal morbidity and mortality but this has the limitation of not being representative of Pakistan. Most women do not even know that induced abortion is illegal, and use this measure in clandestine fashion essentially because of cultural and religious reasons. Many grounds are cited for dealing with unwanted pregnancies39 , including too many children, incorrect or inconsistent contraception and rape. The typical profile of women seeking abortion is that of a married woman with a minimum of three children, of whom at least two are boys. Thus induced abortion is often used for limiting family size, and such women opt for illegal induced abortion with the concurrence of their husbands.

2.

CANCERS OF REPRODUCTIVE TRACT

In any country, cancers of the reproductive tract, both among men and women, constitute a sizable and significant proportion of the burden of disease. In the developed countries where cancer prevalence is generally high, the cancer registries provide valuable information on prevalence, incidence, trends and risk factors associated with cancer. Unfortunately in Pakistan, information on cancer prevalence and risk factors is patchy and unreliable.

39

Fikree et al. 1996

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Adequate data are not available to estimate the incidence and age-standardized rates (ASR) for cancer among men and women in Pakistan. The only study on incidence of cancer was conducted in Karachi South District40, which found the rates of 137/100,000 for men and 163/100,000 for women. Among women, breast cancer was the commonest (ASR = 52/100,000), followed by cancer of the oral cavity (ASR = 14/100,000) and ovarian cancer (ASR = 10/100,000). Epithelial ovarian cancer patients were found in one study41 to have unusual presenting features, including a high prevalence of family history of young age breast and/or ovarian cancer and a younger age at presentation. These findings indicate that genetic predisposition plays a greater role in the causation of ovarian cancer in Pakistan, as compared to Western countries. Another study42 in Karachi found that patients of breast cancer present at a very later stage as compared to the Western countries. About 93% of the 506 patients studied over a period of five years (1994-1999) had discovered the lump in the breast accidentally. Due to a lack of training of and motivation for breast self-examination (BSE) a large number of women in Pakistan will continue presenting at an advanced stage of breast cancer. A study of over 3,000 confirmed cancer patients in Lahore43 determined that a majority of the patients presented at a relatively advanced stage; the reason for not contacting a medical care provider included poor socio-economic status and illiteracy. Associated co-morbid conditions were a major cause in delay in cancer treatment. A majority of patients did not receive adequate treatment. All these factors contributed to poor cure rates among cancer patients in Pakistan.

3.

INFERTILITY:

In Pakistan infertility is usually held to be the wifes problem, since the possibility that her husband may be infertile is rarely considered even though scientific research shows that nearly 30% of infertility is due to male causes. National data on infertility is not available. Small-scale studies estimate that prevalence of primary infertility is 3.4% and secondary infertility 18.4%. Secondary infertility is associated with unsafe abortion and reproductive tract infections, particularly STIs. Thus it is both preventable and
Bhurgri Y, Bhurgri A, Hassan SH, Zaidi SH, Rahim A, Sankaranarayanan R, Parkin DM. (Dow Medical College and Karachi Cancer Registry, Karachi): Cancer incidence in Karachi, Pakistan: first results from Karachi Cancer Registry. Int J Cancer 2000 Feb 1;85(3):325329.
40

Malik IA. (National Cancer Institute Karachi): A prospective study of clinico-pathological features of epithelial ovarian cancer in Pakistan. J Pak Med Assoc 2002 Apr;52(4):155-158.
41

Malik IA. (National Cancer Institute Karachi): Clinico-pathological features of breast cancer in Pakistan. J Pak Med Assoc 2002 Mar;52(3):100-104
42

Aziz Z, Sana S. (Department of Oncology, AI Medical College Lahore): Cancer treatment in Pakistan: Challenges and obstacles. Gan To Kagaku Ryoho 2002 Feb;29 Suppl 1:4-8.
43

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often treatable. However, the diagnosis and referral of infertility cases is also very low in Pakistan. In a small study in Jhelum District of Punjab, the total prevalence of infertility was estimated at 13% (15% in urban area and 10% in rural area), while the referral rate among the infertile couples was just about 15%. The referral rates for infertility were higher in rural area (3%) than the urban area (1%)44 .
E. A DETERMINANT GROUP: ADOLESCENTS

The realization that adolescence is a separate stage in life has acquired attention only in very recent times. Adolescence is defined as the period of transition from childhood to adulthood, occurring during the second decade of life, and is a complex phase of physical, emotional, mental, and social maturation. Serious attention to adolescents in Pakistan should be accorded due to their large (and growing) numbers. Pakistan currently has the largest group of adolescents in its history with nearly 30 million individuals45 almost a quarter of its population - between the ages of 10 and 19. This figure will continue to grow, as will the proportion of the population represented by adolescents, due to the population momentum built into the current age structure. The adolescent population 10-19 (30.13 mill) in 1998 constituted 23.3% of the total population. This cohort is estimated to increase by 9.10 mill to a total of 39.23 mill by 2010. Though adolescents is most often associated with physical changes accompanying puberty, the transformation in social roles, expectations, activities and responsibilities that occur as individuals move from childhood to adulthood distinguish adolescents as a formative time with significant consequences for individuals, families, communities, and the country46.

Hakim A and Z. Zahir Reproductive health indicators in Pakistan: Experience of a pilot study. In: Pakistans Population Issues in the 21st Century: Proceedings of the Annual Conference of Population Association of Pakistan, Karachi, 2000.
44 45

Population Census 1998

46

Adolescent Girls and Boys in Pakistan: Valerie L.Durrant, Population Council December 2000

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Population Pyramid The population pyramid of Pakistan generated out of the 1998 census shown above is a smoothened data which helps to adjust the under reporting in the age group 0-4. It is estimated that the population of Pakistan will increase to approximately 171 million by the year 2010. The 0-14 cohort (55.54 million) in 1998 constituted 43% of the total population will increase to 62.79 million. Thus, by the year 2010, there will be an increase of 7.25 million in absolute number but would be decrease by 6.25% in relative percentage of the total population. Likewise the adolescent population 10-19 (30.13 million) in 1998 constituted 23.32% of the total population. This cohort is estimated to increase by 9.10 million to a total of 39.23 million with a relative decrease of 0.38% of the total 2010 population. The women in reproductive age 15-49 (28.8 million) in 1998 constituted 22% of the total population. This cohort is estimated to increase by 13.56 million to a total of 42.36 million with a relative increase of 2.48% of the total 2010 population.

Adolescent marriage particularly among girls is still common in Pakistan. However the age of marriage has been rising in the past few decades. A clear gender difference remains in the timing of marriage. The singulate mean age of marriage (SMAM) has increased from 16.7 in the 1960s to 22 years in 1998 for girls. For boys the current SMAM is 26.5 and has leaped from 23.3 in 1961. A closer look at the married adolescent population in Pakistan reveals interesting findings. In the age group 15 19 years 3 to 4% of males and 17% females are married, while in the 20 24 years age category 17 % of males and 54% of females are married. There is also an urban/rural difference in adolescent marriage practices, indicated by the fact that 15% of the urban girls fewer than 19 years of age are married whereas 42% of the rural girls under age 19 are married. The rural adolescent population is more vulnerable to maternal and infant morbidity and mortality due to high prevalence of teen-age pregnancies and limited availability of MCH/RH

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services. Regarding fertility and family planning, contraceptive prevalence is extremely low in married adolescents with 22% reported unmet need. 47 Women are taught chastity and it is expected that once married they will automatically understand reproductive health. Young girls are not supposed to have any information on reproductive health; it is considered a social taboo to talk to them. Young unmarried adolescent girls are not taken to the health facility even if they are sick because socially in many cases it is not accepted. According to PCPS 1994-95 only 5% of married girls aged 15 19 years had ever used any method, traditional or modern where as in the 20-24 year age group the contraceptive use is about 17%. To improve the fertility regulation and contraceptive utilization among married adolescents, their attitudes towards contraceptive use and childbearing choices should be adequately explored. Their access to information and tailored services for their age group should be enhanced in order to serve their unmet needs. The Government of Pakistans National Health Policy 2001 promotes primary and secondary health care services, greater gender equity and aims to provide reproductive health services t o childbearing women but does not provide clear strategies to address adolescent health issues. Similarly, the education as well as population policies and strategies do not address and encompass sex education or reproductive health programs for adolescents and youth.

II. THE OFFER OF SERVICE S

A . PUBLIC SECTOR 1. POLICY FRAMEWORK

In Pakistan, the rapidly declining death rate driven by improvements in the medical field and increased access to health services laid the basis of population growth that started in the 1950s. Lowering population growth rate has become a permanent feature of 5 -year plans. The plans continued to highlight the consequences of rapid population growth on social and economic development, and the Governments resolve to support the population program.

a) Population policy framework

Pakistan recognized long-term consequences of high population growth rate for its future socioeconomic development in early the fifties. Accordingly, a strategy was adopted in the First Five-Year Plan (1955-60) by introducing family planning on a limited scale through voluntary organizations. During the Second Five-Year Plan, family planning services were provided through the health infrastructure. Later, an independent family planning infrastructure was created and mass scale IEC activities were launched and service delivery network established. Dais (traditional birth attendants) were used for door to door service delivery and motivation. Part-time doctors provided clinical contraceptives and sterilization services.
47

ibid

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During 1970-75, continuous motivation system (CMS) was introduced by employing male-female team of workers at union council levels. From 1975-80, the program operated at a low key due to reorganization, political unrest and suspension of IEC activities. In 1981, a major administrative reorganization was undertaken, and approach of the program was made broad-based by adopting a multi-sectoral and multi-dimensional strategy. Field activities were provincialized, Social Marketing of Contraceptives program was introduced and National Institute of Population Studies was established for undertaking research on population and development. During the Seventh Five-Year Plan period 1988-93, major policies of the Sixth Plan were followed with emphasis on lowering fertility level. This was to be achieved by pursuing multi-sectoral approach, open motivational campaign, shift towards more effective contraceptive methods, such as sterilization, IUD and Injectable along with provision for maternal and child health services through program outlets. Greater involvement of NGOs, registered medical practitioners, hakeems and homoeopaths was envisaged. A special IEC program and quality service facilities were developed for large cities of the country, with a view to set trends for rural areas to emulate. In fact, the breakthrough in the program occurred during the later part of this Plan (1988-93) with open and sustained political support, increase in allocation of funds, exception from budgetary cuts, restoration of more effective IEC campaign, association of the Private sector through the Social Marketing Program, expansion in service delivery infrastructure including mobile service units in the remote areas, experimentation of the village-based family planning workers scheme in eight districts of the four provinces. The scheme was experimented to improve low coverage in the rural areas. In addition Divisional and Tehsil tiers were created to strengthen monitoring, supervision and improve co-ordination at the implementation levels. The implementation phase of the program was further accelerated in 1992-93 when it was linked to the "Social Action Program" and accorded higher priority in the planning process, resource allocation and regular reviews as part of a social sector undertaking. During the Eighth Plan Period 1993-1998, the program received open and sustained political and administrative support. The rural coverage increased by extending the scheme of VBFPWs to all the districts of Pakistan. Simultaneously, the Ministry of Health also launched the Lady Health Workers Program of Primary Health Care and Family Planning. Both the schemes together have enhanced the coverage in the rural areas. Studies undertaken by the Population Council and NIPS reveal that contraceptive prevalence have doubled in the villages where these workers have been deployed. Review of the program was made a regular feature at all levels. In order to elicit broad-based support from the public representative Standing Committees were set up in the Senate, National Assembly and Provincial Assemblies. In addition, Parliamentary Group on Population and Development was constituted in the National Assembly wherein various resolutions were passed in support of the program. The program was backed by sustained promotional campaign through mass media and supportive events and activities with the involvement of private sector. Meet-the-Press sessions, group meetings, participation in national conferences, seminars, and awards for writing on population issues were institutionalized and implemented. Publications and give-away items were widely distributed. Involvement of NGOs was streamlined by establishing National Trust for Population Welfare (NATPOW) with financial and operational autonomy. The achievements of the Eighth Five-Year Plan provided a strong foundation and served as an important milestone to launch the Ninth Five Year Plan. Political commitment became visible and

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was demonstrated by the first ever unanimous adoption of a substantive motion on population policy by the National Assembly and setting-up of an Inter-Ministerial Committee headed by the Prime Minister. The environment was changing fast in favor of realization of the need to moderate fertility to contain population growth rate. The current Ninth Five-Year Plan 1998-2003, is guided by the principle of building on positive elements of the on-going program, ensuring continuity and consolidation of the gains. The scope and outreach of the program is being enlarged through enhanced and improved service delivery strategies with continued attention to rural areas. A broader reproductive health approach is being pursued with emphasis on mother and child health care. In 2000, under the directive of Chief Executive of Pakistan an assessment review of population program and its interface with the Health sector was undertaken by a Core Group co-chaired by the Ministers for Population Welfare and Health. The Group recommended that all the health outlets should provide family planning services as part of their duties. The Chief Executive in his address on 11th July 2000 directed to achieve a population growth rate of 1.9 percent per annum by 2003 instead of 2.1 percent as set in the Ninth Five Year Plan. In view of the paradigm shift to reproductive health and family planning, and predominant position of health infrastructure in terms of its vastness, it was proposed by the Review Committee to involve all health outlets to provide full range of family planning services. The involvement of health outlets will help to decrease unmet need and increase the family planning coverage. This proposal was submitted to the Chief Executive on 6th April 2001 and was approved. Therefore, once again the contraceptives were supplied to the Provincial Health Departments. Later, the workshops of EDOs Health and DPWOs were also held to demonstrate the mechanism of contraceptive logistics and forecasting for the district level in all the provinces. In accordance with the Chief Executives orders and the decisions of the Task Force reviewing the Population Welfare Programs performance, the merger of village based family planning workers and lady health workers was agreed to place under the Ministry of Health in September 2002. The impact assessment shows some progress on selected indicators such as CPR, which has shown an increase reaching 30 percent by 2000 from 12 percent in 1991. This shows a 2% percentage point increase per year. Similarly, the population growth rate recorded a decline to 2.6 percent in 2002 while CBR touched a level of 29 births per 1000 of population in 2000. The declines in TFR during the last decade also documents the achievements of the Population Welfare Program. The following table depicts the observed TFRs during the period. The decline in TFR indicates a reduction of 2 children from 1975 to 2000. Reduction of more than one child i.e., TFR of 5.4 in 1991 to TFR of new low level of 4.8 in 2000 is a big achievement. Reduction in the fertility of younger age groups while looking at the age specific fertility rates is more pronounced in the following table. The change in educational attainment by women, rising age at marriage and desire not to have large families are important reasons for adoption of family planning in Pakistan.

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Table 3.4. Age Specific Fertility Rates (ASFR), Total Fertility Rate (TFR) observed
Age-groups Pakistan Fertility Survey 1971-75 Pakistan Demographic and Health Survey 198691 Pakistan Reproductive Health and Family Planning Survey Pakistan Demographic Survey 2000

15-19 20-24 25-29 30-34 35-29 40-44 45-49

104. 266 314 264 204 93 6

84 230 268 229 147 73 40

65 211 258 206 128 61 26

33 195 244 204 225 54 23 4.3

TFR 6.27 5.4 4.8 Source: NIPS, Pakistan Reproductive Health and Family Planning Survey 2000-01,
and Federal Bureau of Statistics, Pakistan Demographic Survey 2000.

Despite the recent sharp increase in contraceptive prevalence during the 1990s, unmet need for family planning remained high. The proportion and level of unmet need for family planning is one of the highest in the developing countries. The factors that act as obstacles to the use of contraceptives are: husbands disapproval; religious hindrance; fear of side effects and health concerns. The first ever Population Policy approved by the Cabinet addresses all those which would reduce the unmet need for contraception and to increase the acceptability of family planning methods. The Population Policy aims at involvement of males in the decision-making of family size, increase in coverage and access to family planning services, efforts towards demand generation, joint efforts of private and public sectors, involvement of partnership and with NGOs, for provision of service to remote and underserved areas, human resource development, a quality of services, and regular monitoring and technical supervision.

b) Health policy framework

In the health sector, the period of 1990-2002 has seen the announcement of three health policies. The latest is National Health Policy 2001; the overall vision for the health sector is based on HealthFor-All approach. The new policy has three key features, 1) health sectors investments as part of Governments Poverty Alleviation Plan; 2) priority attention to primary and secondary sectors of health 3) and good governance as the basis of health sector reforms to achieve quality health care48 . In addition the government has announced several policy statements on MCH and FP on various occasions. One of these has been the Reproductive Health Package of 1999, which was a joint document of the Ministries of Health and Population Welfare.

48

National Health Policy 2001, Agenda for Health Sector Reforms, December 2001

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The analysis of health and population policies during the 1990s and early 2000 indicate growing awareness of increased burden of morbidity and mortality among women and children by the policymakers. This is reflected partly in the delineation of MCH in defining strategies for all policies. The priority areas of the health policy with reference to child health have been immunization, infant health care and childhood illness. All polices, programs and packages have emphasized maternal health, safe motherhood, and availability of female paramedics and health workers, family planning, RH and HIV/AIDS and STIs have received progressively increasing emphasis in all policy documents since 1990. However, the gaps in health policies with reference to safe motherhood are49 :
All policies have included various components of MCH agenda, however, an overarching comprehensive MCH framework to address the issues being faced by the population is lacking. Concrete steps could not be delineated for addressing nutritional issues like maternal anemia, child malnutrition, stunning and wasting that have major influence on the health of women and children. Provision of emergency obstetric care has not been taken up as a priority on the national agenda Policies have been largely silent on human resource development for maternal and child health. While the need for female paramedics has been mentioned, a strategic plan of action is lacking. Role of private sector and NGO sector in the provision of safe Motherhood and FP services and potential partnership between public and private segments of health sector has been inadequately addressed.

Pakistans strategy on reproductive health has roots in the population control program, which was first introduced in the early 1960s with the sole objective of curbing rapid population growth by promoting small family norms and enhancing the use of modern contraceptive methods. Provision of Reproductive Health services (RHS) has traditionally been a divided responsibility between the Ministry of Health (MOH) and the Ministry of Population Welfare (MOPW) at the federal level. Yet the size, the structure and the organization of the two Ministries are vastly different from each other.
2. MINISTRY OF POPULATION WELFARE

The Population Welfare Program was formally launched in the country in the Third Five Year Plan (1965-70) with the setting up of an autonomous National Family Planning Council under the Health Division. In 1976, the Council was abolished and the program was governmentalized and brought under the Population Welfare Division which was later on placed under the Ministry of Planning & Development. In 1990, it was upgraded as an independent Ministry of Population Welfare. After defederalization the Federal Ministry is now responsible for policy, planning, capacity building, setting standards and protocols, international coordination, contraceptive forecasting, procurement and supplies, advocacy and IEC, policy support to non-governmental organizations, promoting public-private sector partnership, monitoring, research and evaluation, and resource allocation.

49

A Critique of MCH policy in Pakistan: Implications for the future, January 7-9, 2003

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The MoPW, through its provincial Population Welfare Departments (PWDs) provides services at its own facilities, including the Reproductive Health Services Centers (RHSCs), the Family Welfare Centers (FWCs) and the Mobile Services Units (MSUs). Besides, there are 1300 male village based family planning workers for motivation and community mobilization. The organization and performance of various facilities is described in some detail below. The Ministry operates 275 RHS Centers for providing contraceptive services. Type A RHS Centers (numbering 106) are located in their own buildings constructed on the premises of public sector hospitals, and are staffed, equipped and managed by the MOPW. Type B RHS Centers (169 in number) are located inside selected government and private hospitals. While the annual number of clients for contraceptive surgery steadily increased from 1993 to 2000, it seems to have reached a plateau afterwards50. A National Institute of Population Studies (NIPS) study51 found that the clients were generally satisfied with the services provided at the RHS Centers. About half of the clients visiting the RHS Centers came for contraceptive surgery and the remaining half to get other contraceptives. FWCs are the most basic outlets for family planning and reproductive health services in urban and rural areas, and about 1,688 have been established. Their main function is to provide temporary methods of contraception, including pills, injectables, IUDs and condoms. A 1993 study of the functioning of FWCs52 found that the Centers were under-utilized (serving, on the average, 3 5 clients per day) and that the staff lacked training in counseling skills. A later study has found frequent stock-outs of contraceptive supplies at many Centers53. MOPW operates 131 MSUs, which provide RH services in remote rural areas. Each MSU serves a population of about 30,000. Managed and supervised by a Field Technical Officer (FTO), each MSU is expected to organize 10-12 camps each month to provide curative care and family planning services. While their area of coverage is small, the MSUs performance is quite satisfactory. A study done in 2001 by National Institute of Population Studies (NIPS)54 found that 48 percent of MSU in charges were not satisfied with their job, 21 percent of MSU had no proper arrangement for privacy, 25 percent of MSU in charges are not making follow-up visits and 23 percent MSU in charges have no vehicles. Client satisfaction levels ranged between low to medium, although there were complaints about the high price of contraceptives provided by the MSU. Some of the other problems included frequent breakdown of vehicles, lack of coordination with community leaders and staff absenteeism.

50 51

Service statistics of MOPW, 2001 Hakim A, et al. Situation analysis and users survey of Reproductive Health Services A Centers. NIPS, 2001.

Cernada GP, et al. A Situation Analysis of Family Welfare Centers in Pakistan. Population Council Working Paper Series No. 4, 1993.
52

Population Council: A Study of the operations of the contraceptive logistic system of the Population Welfare Program. April 1998.
53 54

Hakim A, et al. Evaluation of Mobile Service Units, Population Welfare Program. NIPS Islamabad, 2001.

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3.

MINISTRY OF HEALTH

In the health sector, role of Ministry of Health is policy development, coordination, monitoring, evaluation and research, collaboration with International agencies and provision of services through federal health institutions. In addition, during 1990s, the concept of National Programs materialized and proved to be successful. MoH designs National Programs/ projects in collaboration with provincial departments of health, arranges necessary funds, provide technical assistance, monitors and evaluates whereas the provincial departments of health and district health offices carry out the actual implementation of the Programs/ projects. In reproductive health, important initiatives of MOH are National Programme for FP & PHC (the LHWs Programme), National EPI Programme, MNT special immunization activities, National AIDS Control Program, Women Health Project, National Nutrition Project and Reproductive Health Project Since independence in 1947, health services have significantly improved and expanded. The health facilities network in each district comprises Basic Health Units (BHU) and Rural Health Centers (RHC) at the primary level and Tehsil Hospital and District Hospital at the secondary level. At the primary level, health facilities bearing various other titles also exist, such as: Sub-health Centers, Civil Dispensaries and Civil Hospitals, which are the remnants of the earlier experimentation of providing a national health system. In practical terms, all primary health facilities mainly provide outpatient curative care, some preventive services and referral to the next levels of care. The only preventive services provided at the primary health facilities are maternal and child health care and immunization. Additionally, the Tehsil and District Hospitals provide specialized services and inpatient care. Finally, the MOH/DOH owns and operates the largest number of tertiary care hospitals in the country. These hospitals are located in the major urban centers and are usually attached to medical colleges or other post-graduate medical institutions. The quality and scope of services provided at the government health facilities vary greatly between districts and provinces and even from facility to facility in the same district. The primary aim of the health facilities under the MOH/DOH is the provision of curative care, regardless of their level. They provide health services to the general population and nobody is denied these services for any reason except non-availability. Services are provided either free of cost, or at minimal charges. Clients expect free consultation and free medicines. The patient-load on public health facilities varies greatly, depending upon the nature of services provided. Teaching hospitals are usually over-crowded, while most peripheral facilities in the rural areas are underutilized, under-staffed and under-funded. Most staff members are unclear about their job description. Virtually all clinical staff members are involved in some kind of private practice. Each year, a large number of physicians graduate from medical colleges but a significant proportion among them remains without a job for extended periods of time due to unclear roadmap of HRD planning. Lack of female doctors and paramedical staff is another serious problem in all rural health facilities. One of the major reasons is the extremely difficult living and work conditions young medical officers have to face in out-of-the way places lacking basic amenities. At the community level, the National Programme for FP and PHC is the most promising large-scale intervention of the MOH. The Programme is exclusively an attempt to provide basic RH services and information to women at their doorstep. Independent evaluations of the Program are generally positive. However, few weaknesses of the Program include: (1) LHWs are seriously undersupplied with drugs and contraceptives; (2) Services are limited in health facilities to which patients are referred; (3) Need to increase effectiveness of supervision, also transport for supervisors; and (4) lack of training of LHWs in delivery care and newborn care.

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Under the recently introduced devolution plan, implementation of the reproductive health activities is the responsibility of the districts. In each district a Deputy District Officer Health (Preventive/ Reproductive & Child Health) will be in charge of reproductive health and population welfare services, which he/she will implement through the integrated network of BHUs and RHCs. He/she will work under supervision of the Executive District Officer (Health), and will be a member of the District Health Management Team (DHMT), which will also include the District Population Welfare Officer. MOH/DOH has always provided some FP services at its facilities, obtaining the supplies from the MOPW, and over one third of current users of modern contraceptive methods get their supplies from a government hospital. The Departments of Health have a vast network of health facilities (907 Hospitals, 879 Maternal and Child Health Centres, 541 Rural Health Centres, 5,230 Basic Health Units and 4,625 Dispensaries), which can be used to facilitate implementation of the national population welfare program. As pointed out in the fourth round of Pakistan Integrated Household Survey 2001-02 that Ministry of Health sources play an important role in supply, with MOH/ DOH facilities and workers supplying about 61% of all government services for family planning. It may be noted, however, that not all of these facilities are fully operational, and only an undetermined small percentage can actually provide a full range of family planning services to its clients. Staff absenteeism, inadequate timing of operation and stock-outs of medicines, contraceptive and supplies are common problems. Lack of female doctors and paramedical staff is another serious issue in all rural health facilities.
4. ISSUES

a) Harmonization of RH services
Pakistan is a signatory to the Program of Action (POA) approved by International Conference on Population and Development (ICPD), which took place in Cairo in 1994. Implementation of the ICPD Program of Action has been slow mainly due to lack of commitment, shortage of funds and disrupted donor support. In 1999, a National Reproductive Health Services Package was developed and adopted jointly by the Ministries of Health and Population Welfare. However, adoption and implementation of this strategic document has not made much progress. Although a National Steering Committee on Reproductive Health was formed u nder the Ministry of Health two years back, however it has not yet been fully operationalised. Of late, there has been a renewed emphasis on harmonization and integration of health and family planning services. According to the recent Population Policy, service provision in family planning and reproductive health will concentrate on improving access and expanding coverage with special emphasis on rural and under-served areas and slums. This will be achieved through Population Welfare Programs infrastructure and through the health service delivery infrastructure, partnerships with private sector and networking with civil society. MOPW would retain the responsibility for strategizing and planning the countrys family planning program and for arranging the finances required for its execution. Field activities would be the responsibility of the Provincial Population Welfare Departments and Provincial Departments of Health through their primary health care infrastructure.

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There are many challenges to the implementation of the above policy. Firstly, there are the expected problems of transition from the federal to provincial implementation. Secondly, the success of the decentralization plan depends in a large part on the functioning of the newly formed district governments that are still struggling with the initial difficulties of a complete change over to a different, planning and implementation mechanism. Finally, the ownership and complete adoption of Population Policy by the provincial and district health d epartments is still to come about. The relationship between the local, national and provincial representatives on the one hand and district Nazims on the other will impact on the success of the devolution plan. The National Reproductive Health Services Package (NRHSP) clearly defines the priority areas for intervention in RHS, gives job-descriptions and expected performances of various health and family planning workers and streamlines the joint and separate roles for the two Ministries. It can thus be used as a framework for future collaboration between the two Ministries.

b) Devolution and Reproductive Health Services

During 1980s and 90s, the health sector has not been subjected to major organizational or management reforms. There have been some isolated attempts of management reforms including delegation of some administrative and financial powers to various levels of health care and development of District Management Teams. 55 Most of these efforts had little impact due to short life span of these reforms. None of the reforms represented major changes to the basic model of provincial centralization. The Government of Pakistans Devolution Initiative envisages decentralized functioning of local governments by shifting of responsibilities from the provincial to the District governments and below to improve effectiveness of service delivery and accountability to the local population. The Federal Ministry of health is responsible for development of the health policy and providing guidance to ensure effective implementation; monitor health outcomes; and finance and provide technical leadership to key preventive health programs. The Provincial Governments are responsible for ensuring implementation of national policy ensuring access and equitable distribution of services, management of specialized and tertiary care hospitals; medical education; provision of technical guidance for preventive health programs and monitor health sector outputs. The Districts are responsible for management and implementation of health services including transfer of resources from provinces to the districts. The Federal Ministry of Population Welfare presently manages the Population Welfare Program with responsibility of policy, management and financing. The provincial governments are responsible for implementation. The Population Welfare Program is also being devolved to the district governments. The program is undergoing a significant organizational changes due to defederalization of the program from the federal to the provincial governments. It is envisaged that the districts will increase the effectiveness of health and population service delivery by opening up a range of opportunities, but there are also major risks. The opportunities include more equitable distribution of services and resources, reducing mal-practices such as staff
This and the following has been taken from the Aide Memoire, World Bank Mission with DFID and ADB (October 12 October 28, 2002)
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absenteeism through increased local accountability through local community representatives; increasing expenditures on key non-salary inputs to improve quality of services; improving monitoring of services and providing feedback to lower levels of health care etc. However, the success of this will hinge on the extent to which devolution is able to improve incentive and accountability mechanisms and the harmony between the districts political structures. Major challenges are to establish institutional structures for development of effective District Health Management with clarity of roles and responsibilities between provincial and district, ensuring that financial flows are predictable and, under all the circumstances, adequate, the District Health Management Teams are empowered sufficiently to ensure equitable distribution of resources and effective and efficient use of available funds, the staff capacity is adequate, and that flexibility in personnel management is sufficient to plug skills gaps, the local policy priorities and preferences emerge but national/provincial priorities such as family planning, immunization, HIV/AIDs and MCH services are addressed and ensure that a monitoring system is place to track results and outputs.

c) Human Resource Development

Within the ministry of Population Welfare the backbone of service delivery is the cadre of Family Welfare Workers. These workers are trained for 18 months in family planning and MCH services including safe delivery. However, they are not allowed to conduct delivery at the centers nor are they recognized by the Pakistan Nursing Council to undertake midwifery practice. Besides this she prescribes medicines for general ailments to children and the women. It has been observed that generally there is irrational use of antibiotics and other medicines, and that their knowledge of diagnosis, treatment, dosage and side effects management requires much improvement. Female medical officers, LHV, midwives, and community-based workers are the primary service provider to the children and women within the health sector. BHU, RHC and MCH centers form the main stay of the preventive and curative care through static health facilities. However, it is a common view that despite excellent infrastructure for health, the service delivery is inadequate, underutilized and of low quality. Besides many other issues, the availability and quality of female service provider is the most important contributing factor to poor status of MCH indicators in the country. According to one survey around 21% of the facilities did not have a female staff56. Male to female staff ratio is 7:1 in the field.57 Medical officers have extensive five year training in medical college but the medical education is curative care oriented rather than community and primary health care. Most of them are exposed to PHC activities during their postings at the first level care facilities. They are mostly reluctant to serve at these facilities due to lack of security, low salary, lack of civic amenities and less opportunities for professional growth. Midwife despite being the lynch pin in providing obstetrical first aid is one of the neglected and misunderstood profession in the country. According to the National Health Policy 1997, there are

56

PIHS Round IV A situation analysis and recommendations for evidence based approaches, MCH consultation 7-9 2003

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21304 midwives in the country (including nurses) but their exact whereabouts and presence in the community is not known. Pupil midwives are trained at the midwifery schools which are mostly attached to the district hospitals. However, the standard of this training is highly doubtful due to shortage of trained staff, lack of quality assurance mechanisms and minimum exposure to hands on training. LHVs and midwives differ in their job description and background but the curriculum being used is the same for the two categories. The last revision of curriculum took place in 1994. Further, there is no definite career structure for this midwifes once she acquires the license, majority of them work for the private sector and there is no mechanism for assessing their quality of services. The concept of Lady Health Visitor (LHV) was proposed in the first Five-year plan 1955-60, when it was decided to increase the number of MCH centers in the country. Although the public health nursing schools training this cadre has increased from 10 in 1994 to 23 in 2000, still there is a persistent shortage of female staff in health facilities. LHVs were primarily supposed to provide PHC and domiciliary midwifery services by visiting households in the communities, a practice which is no more followed. According to PIHS 1996/97, LHVs conducted only 3% deliveries in the country. However she remains the main female service provider to women and children at the first level care facilities. Even at the static health facilities, LHVs are unable to provide EmOC services round the clock due to the shortage in number, poor accommodation, shortage of equipment and out of facility private practice. Training component for both technical and non-technical functionaries of Health and Population Welfare Programs should be strengthened for skill development and to update knowledge to ensure quality service delivery. This becomes even more crucial when a large number of the experienced professionals are retiring in MOPW in the near future.

d) Quality of services
Government of Pakistan invested heavily in the infrastructure for health and population during its fifth five year plan. Sixth to eighth five year plan tried to address the issue of human resource at the facilities and community. However, wide gaps in the quality of services remain which are highlighted below. Most staffing issues pertain to the area of primary and secondary level care. As mentioned earlier, there is shortage of staff especially the female staff which really matter in case of services to women and children. Women medical officers are reluctant to work at the first level care facilities for want of security, lower salaries and lack of civic amenities. Female paramedics are short in number and their training is not well regulated and monitored for quality. Although introduction of community based workers has proved to be a very successful scheme, however, its coverage currently is around 3040%. Interpersonal communication skills of staff are mostly weak and lack of staff cooperation is cited as one of the reason for not accessing the health facility by clients. Concept of continual education has yet to be crystallized in the form of mandatory refresher trainings especially on case management protocols. Most of the first level care facilities and district hospitals are used by the low socioeconomic class of the population. They expect provision of free medicines, contraceptives etc at these outlets. According to the PIHS survey 1996, 22% respondents did not use the rural health facilities for lack of medicines. Similarly these facilities are not equipped well enough and in some cases where equipment is available, the staff is not there or they are not trained in its use or there are not enough

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funds available for its maintenance and repair. Even these facilities are not women-friendly due to lack of privacy and proper sitting arrangement, unfriendly environment and poor location. In the above mentioned PIHS survey only 33% basic health units were located within five kilometer. Another grey area is the issue of accountability, monitoring and supervision. Weak accountability of services and outcomes, coupled with less capacity at the district levels for monitoring and supervision is one of the major contributory factors to low quality of services. Perhaps constraints in resources available to district staff also play its part. The information collected is not fully analyzed at these levels and mechanisms for feedback are not functional. District managers are not empowered through management skills and delegation of administrative and financial authority.

e) Logistics and availability of contraceptives

Throughout the 1990s, the major sources of funds for the supply of contraceptives to the Population and health sectors were the donors including USAID, UNFPA, DFID and KfW. From 1998 onwards, the MoPW and MOH had to use IDA loans and Social Action Program (SAP) funding to obtain a large percentage of its contraceptive requirements after withdrawal of certain donors. As a result UNFPA was hard pressed to meet contraceptive requirements, investing over 40 percent of its country program allocation for the procurement of contraceptives. As the Government sees it, increasing prevalence by modern methods is essential to its development goals. The contraceptive requirement has been conservatively estimated to cost around $15 million in 2003. Additional funds are required for warehousing and data processing, distribution and monitoring. Technical assistance is also required in the areas of logistics and management information systems (LMIS) training. LMIS of MOPW, DOH and National Programme also should be strengthened by incorporating indicators regarding discontinuation, switching to other methods and removal of IUDs. There is need to develop tools and instruments by which the information could be used for improving the management of inputs, process and measuring output. The Ministry of Population Welfare maintains one central warehouse at Karachi from where contraceptive are supplied to all the public sector, organized sector like WAPDA and NGO outlets in the districts. In recent years availability of contraceptives to the outlets of MOPW has improved considerably. Until the year 1987, Ministry of Population Welfare (MOPW) had been providing contraceptives to Departments of Health (DOH) through Provincial Medical Store Depots (MSDs). However, smooth supply of contraceptives to DOH could not be ensured. One of the reasons was lack of commitment by the District Health Managers for providing family planning services. The other main reason was the issue of contraceptive pricing which will be further discussed later. Since July 2002, the supplies of contraceptives have again started through the Provincial Health departments, and their outlets are now providing FP services. In this regard a series of workshops on logistics management and forecasting techniques were held by MOPW in all the provincial headquarters in which EDOs Health and DPWOs participated to ensure uninterrupted supply of contraceptives. At the National Program of Primary Health Care and Family Planning all procurement is coordinated by the Federal Program Implementation Unit (FPIU) in Islamabad. The supply of contraceptives to National Programme has been disrupted after the closure of the UNFPA funded project PAK/94/P12 in 1999 and for other reasons already mentioned above. Lady Health Workers of the National Programme also faced stock out of condoms and oral pills during the year 2000 and 2001. Supply of contraceptives to the programme has been recently restored through UNFPA

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project PAK/00/P01, GOP funds from SAP-II and DFID grants. To avoid further interruptions the National Programme (MOH) should have a consistent and reliable supply of contraceptives. The Programme has stopped supplying injectables and IUDs since 2001 and no resources for procurement of IUDs and injectable has been allocated for the budget 2002-2003. Since referrals for contraceptive services are an important aspect of LHWs role and to offer wide range of choices to the clients, resources should be allocated to procure both injectable and IUDs. Due to frequent turnover of district managers of the National Programme, there is dearth of trained staff in the districts. Data on consumption and stock balances of contraceptives of the LHWs is not consistent and whatever data that exists, lack analysis. The MOPW, since long has implemented a policy requiring its facilities and workers to charge for the oral pills and condoms and return money from these sales proceeds to the GOP via banking channels. In mid-2000, the MOPW extended its pricing policy to include IUD and Injectable. As a result of this policy District Health Officers, in order to receive new supplies were required to deposit sale proceeds into the GOP bank accounts. Most DOH service delivery facilities could not get the re-supply as they did not have system for colleting sales proceeds. According to the supply system introduced in July 2002, DOH would also charge for the contraceptives from clients but deposition of sales proceed is no more required to get the re-supply. However the policy is silent about the use of money collected from clients. On the other hand, the National Program has allowed the workers to charge clients for supplies and the money collected could be kept by the individual worker as an incentive. In view of the above mentioned different pricing and cost recovery mechanisms there is a requirement for a uniform policy on this issue for the public sector. Departments of Population Welfare use targets as management tool for measuring the performance of service providers. Another reason of introducing the policy of charging contraceptive price was to prevent leakage and wastage of contraceptives and to check the service providers for providing inflated service statistics. Overall performance is measured in terms of CYPs produced by individual outlets and service providers. Service statistics gathered by MOPW show that contribution of IUD is more than 40% in overall method mix and this is not supported by RH&FP Survey 2000-01 which shows decline in the use of IUDs. Monitoring visits also reveal that there is overstating of performance particularly with respect to IUDs and this is resulting in wastage of contraceptives. Instead of improving the performance by setting targets and charging price on contraceptives, monitoring should be improved to prevent the wastage of resources.

f) Health Management Information Systems (HMIS)

In the late 1980s and early 1990s, the Ministry of Health received technical and financial support from USAID to design and implement a computer-based HMIS. In 1994 when the USAID withdrew its support to the government, the main task of technical assistance had been completed and the system had become operational in a few districts. However, UNICEF continued supporting some of the HMIS activities at the district levels and currently the system is operational in 120 districts and 91 districts are sending their reports to the provincial health departments. The issue related to HMIS is the lack of ownership of the system by the health departments, frequent transfers of trained staff, quality of the information generated, and non-utilization of the information by district, provincial and federal levels for decision making and planning.

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The National Programme for FP/PHC established an MIS for the Lady Health Workers in 1994, the system collects information on the services provided by the LHWs including information on the community served by the LHWs. The LHW-HMIS is a parallel system and is not a part of the HMIS. However, the data from the LHWs MIS is more reliable because of the monitoring and supervision system of the National Programme. UNFPA as part of its sixth country programme is providing support towards development of a common system for the MOH. The MoPW had a well-designed MIS for facility performance and a logistic MIS reporting on stock balances and supply statistics put in place in 1987. This system was further developed with the assistance of UNFPA between 1994 and 1998 through the provision of computer equipment and training. However, those inputs were limited to the central warehouse in Karachi and the federal administration in Islamabad. Recently, UNFPA through its Sixth Country Program has provided additional inputs and technical assistance including a mapping initiative for the MOH and MOPW facilities.
B . PRIVATE SECTOR 1. ORGANIZED PUBLIC AND PRIVATE SECTOR

The involvement of large public and private sector organization for the promotion of reproductive health and family planning dates back to the 80s. The institutions comprised 14 major public sector organizations employing a workforce of one million e.g. WAPDA, Fauji Foundation, The Armed Forces of Pakistan, Steel Mills, Pakistan Telecommunication & Postal Services, Pakistan Intl. Airline and Agricultural Development Bank. A total 450 health service outlets were involved in delivery of Family Planning services for their employees. One of the main reason for co -opting the organized sector was to increase the male responsibility towards parenting and more importantly in correcting the gender imbalance. The focus of earlier UNFPA support was on improving the knowledge of workers related Family Planning and the adoption of a small family norms. Assistance to these large industrial organizations was channeled through the Directorate of Workers Education of the Ministry of Labour and Manpower. Technical Assistance for these activities was provided by ILO. While no systematic evaluation of past experiences with the TGIs was conducted, existing information does not support any significant contribution to either of the three reasons stated above. (Source - NIPS Assessment).

2.

PRIVATE HEALTH CARE

Pakistans private health care delivery system, accounting for about 60 percent of the total health expenditures, is just beginning to participate in the efforts to improve the reproductive health status in the country. The quality of care and scope of health services provided by the private sector vary greatly between urban and rural areas. Large for-profit commercial hospitals located in big cities provide high quality care to those who can afford their services. On the other extreme are the small clinics and health centers run by general practitioners trained in basic medical care. A large informal sector, comprising inadequately trained or untrained providers (generally referred to as quacks) also exists, typically serving the poorer segments of population.

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For profit private sector also consists of Registered Medical Practitioner (RMP), Hakeems and Homoeopaths, traditional healers, dispensers and TBAs. There are about 520 small to medium general hospitals, 300 maternity centers and 8 teaching hospitals.58 43% of the pregnant women and 45% of women seeking post natal care visit private hospital/clinic whereas 8% and 21% respectively visit private TBA, doctor and LHV.59 Hakeems and homoeopaths have also been involved in the population program since the early 1980s, and about 13,000 of them are providing contraceptives and counseling. Evaluation of this segment was conducted in 2001 which found out that there is low interest on the part of these practitioners and low level of demand for their family planning services. 60
3. NGO/FOR NON PROFIT

Apart from this governmental infrastructure, a number of prominent NGOs maintain permanent clinics and operate community-based contraceptive distribution programs, which provide family planning and reproductive services. Although government has been encouraging the NGOs and has been reflecting this commitment in its policies but still there is lack of a comprehensive mechanism for NGO-Government partnership. The full extent of the work of the NGOs with respect to the provision of services and the conduct of RH-related activities is complex. The NGOs involved in RH are providing different types of services such as advocacy for womens rights, community mobilization, HRD, health education and communication and preventive and curative RH services. However, there is need for developing linkages among these isolated efforts.
4. SOCIAL MARKETING ORGANIZATIONS

The Government of Pakistan took a bold initiative in mid 1980s to involve the resources of the private sector to meet the goal of making family planning services and information widely available. This initiative generally known as Social Marketing of Contraceptives is an attempt to use marketing techniques and commercial distribution network to mange, distribute and sell the contraceptive products. The social marketing projects focus on four goals; i) establishment of skilled manpower for delivery of quality service; (ii) expansion of coverage of family planning services, especially in urban areas; (iii) availability of products to enhance choice and meet urgent unmet need of contraceptives, and (4) change attitudes for paying for family planning services. Two social marketing firms, Social Marketing Pakistan and Key Social Marketing, have been working in Pakistan.. Social Marketing Pakistan (SMP) - more widely known as Green Star Social Marketing (GSM) - is the result of a partnership between donors initiated by USAID, and continued
58

Situational analysis of health sector in Paki stan (1995) MOH PIHS survey 2001/02 Hakim, homeopaths and RH, population council 2001.

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by KfW, DFID and Population Services International (Washington D.C). SMP manages the largest FP/RH operation in the private sector, while GSM sells condoms and oral pills at subsidized prices through an incentive program to thousands of retailers around Pakistan. It is the second largest provider of family planning and RH services in Pakistan after the Government, providing over 20 percent in CYP and distributing over 58 percent of all condoms. The other organization, Key Social Marketing (KSM), solely supported by DFID is making its contribution by supporting local manufacturing initiative for pills. The two social marketing firms maintain a combined network of 12,400 doctors, 7,100 paramedics, 9,562 chemists and 47,500 retailers.
5. ISSUES

a) Regulatory issues
There are no explicit or effective regulatory mechanisms or laws governing the provision of health services by the private sector. Neither has there been any comprehensive national study done on the private health facilities and services. Lack of data in this area is also one of the reason for not having required regulatory mechanisms in place. It is interesting to note that, while one requires a license to establish and run a pharmacy or medical store, no such permission is required by a fresh medical graduate to run a private clinic or maternity home. The Pakistan Medical and Dental Council (PMDC) is not a regulatory body and its role is mostly limited to registering medical graduates. Pakistan Medical Association, the largest and most influential professional organization of medical doctors in Pakistan, is also not playing its role in regulating the practices of its members. A significant number of public sector medical care providers double as private practitioners in the evening. It is common to redirect patients from public hospitals to private clinics, which raises serious ethical issues and further deteriorates the quality of care in the public hospitals. A proposal for Ombudsman was conceived but still it is on papers only. Pakistan Nursing Council is the regulatory body for the nurses, LHV and midwives. Apart from registration of the above category of workers, it is also empowered to impose fine and rescind the licence of workers involved in mal-practice. A person can also be imprisoned for a period of six months if involved in the practice of above mentioned professions without being registered with PNC.61 However, the extent of implementation of these few regulatory mechanism is also a matter of concern. However, there are laws to curb quackery and executive district health officer can seal the clinic and get the person tried in the court of law but its implementation is lacking.

b) Linkages with public sector

Private sector, especially for-profit, sector has grown much faster than the not for profit sector and mainly without any support from the government. It is only few years ago that government established health foundations in the provinces to provide small to medium loans for the support and establishment of private health enterprise. At the district level, the health managers mostly do
61

Pakistan Nursing Council Act, 1973

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not have organized links with the private sector service providers. However, managers of the population welfare programme are relatively more involved with the private sector but this involvement is limited to supply of contraceptives and organizing out reach camps. Generally there is relatively more cooperation on ad-hoc basis between the NGOs and the health and population sector of the government. Recently, under the health sector reform initiative, the government is experimenting the public private partnership concept by handing over few first level care facilities to NGOs.

c) Affordability
In mid 1980s it was estimated that 80% of patients visited private provider (77% rural and 86% urban), national health survey from 1990-1995 reported a similar share of 81%.62 Private sector, in general, whether for profit or non-profit is considered to be efficient than the government sector for various reasons. One is the easy access to resources but it comes at a price and burden of which is passed on to the clients especially in the absence of regulatory mechanisms. There is no consistent fee structure or package costs for the interventions undertaken specially among the small to medium clinics and individuals. The linkage between household income and health outcomes is a well known fact. Considering the current poverty levels of 32%63 in the country, it is the low socio-economic class which compromises on expenditures on health, education, housing and transport64 as compared to expenses on food. As a result of which they try to seek health care from cheapest sources like traditional healers, paramedics, pharmacies and quacks. Per capita expenditure on health increased from Rs 3.52 monthly in 1978 to Rs. 160 in 1997-9865 against the average monthly income of around Rs. 2000 in 1996-7. However,15 percent of married women of ages 15-49 in the lowest expenditure quintile have ever used contraceptives, compared to 25 percent of those in the highest quintile66 Public sector facilities are accessed by the low socio-economic strata of the population who can not afford to pay for the private sector services. It is imperative to provide a safety net to this class through improving the quality and availability of services at the public sector facilities.

d) Support to NGO sector

Considering the tendency of the clients to access private sector for their majority health needs and the scarce resources with the public sector, it is time to harness and strengthen the potential of non-profit private sector in health and population service delivery. For discussion sake we shall limit ourselves to NGO sector here. Traditionally few NGOs have been successful in accessing financial resources from donors, however, a majority of small NGOs and CBOs have been raising funds from
62

Report by presidents task force on human development, jan 2002 IPRSP 2002 Pakistan poverty assessment 2002 National health Policy 1997 Pakistan poverty assessment 2002

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64

65

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their own sources. The large umbrella organizations which are mandated to build the capacity of small NGOs in accessing fund, providing services and organization have not been very successful leaving the small NGOs to fend for themselves. In the context of devolution and decentralization initiative of the government, it is now imperative that funding organizations strengthen this initiative of the government by establishing and strengthening decentralized funding at the district level to the small NGOs, CBOs and other non-profit organizations. Simultaneously the need to fund the large NGOs like social marketing which have substantial contribution in the reproductive health sector should not be ignored. Unfortunately these organizations are currently facing financial crunch and are considering de-scaling their operations if funding is not committed to them by the donors and the government. Considering the public-private concept of cooperation between the government and private sector, perhaps the way forward is enhanced cooperation between the government and social marketing.

III. AN INSUFFICIENT DEMAND FOR SERVICES

A . AN UNDERUTILIZED PUBLIC SECTORS

As mentioned earlier, the facilities of the public sector are underutilized for various reasons including availability, accessibility, affordability and quality of services.
B . LACK OF AWARENESS WITHIN THE COMMUNITY

As has been pointed out earlier, most of the peripheral health facilities including BHUs, RHCs and FWCs, are under utilized in Pakistan. Besides many reasons revolving around quality of care, poor health seeking behavior of people is also a contributor in the low demand and utilization of services. Various surveys suggest that awareness about issues such as maternal and child health, gender, correct use of family planning methods, communicable disease, STIs and STDs is low in Pakistan. Whereas the awareness about maternal and child healthcare and family planning is low in rural areas, the knowledge about danger signs of pregnancies and emergency obstetric care is also not very high even in urban areas. Maternal and infant mortality is unacceptably high in Pakistan and continues to pose challenges for public health professionals and planners. Only thirty five percent women receive any antenatal checkup from a doctor while 77 percent deliver their babies at home It is estimated that each year in Pakistan about 30,000 women die due to pregnancy related cause and about 360,000 infants fail to reach their first birthday ( PRHFPS 2000-01). For decreasing maternal and infant mortality, the foremost imperative action is referral for seeking essential obstetric care and neonatal services from the appropriate place. This could only occur if the adult population in communities is made aware of the warning signs of complications of pregnancy, child birth and reproductive health issues. While decision making about availing healthcare facilities is usually the prerogative of the males, men are not fully aware of their role in the management of emergency obstetric care. Male members are generally not involved at the time of the delivery as females take care of the whole process. They are only called when the matters get out of control of the supervising Dai, to shift the women to a hospital. Interventions in safe motherhood, therefore, should include intensive IEC and advocacy campaigns for men besides effective awareness programs for women and families.

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Awareness about sexually transmitted diseases is also low in Pakistan. There has been an increase in awareness level about HIV/AIDS which was recorded about 75% (Evaluation of NACP-2000). However, no credible data is available on the overall awareness level about Sexually Transmitted Diseases. According to PRHFPS-2000-01, 42 % ever married women had ever heard about AIDS. Knowledge about Hepatitis B/C was found low (46 %) even fewer women were able to correctly identify the mode of transmission of Hepatitis B/C. Awareness about family planning methods is reported to be as high as 96 %. However, most of the couples lack information about the correct use of contraceptives. Misperceptions about the side effects of contraceptives are also common. According to PRHFPS- 2000-01, 33 percent of all married women in reproductive age are not using family planning despite a desire of limiting/ spacing the number of births. Most of the reasons for this very high unmet need revolve around the information gap, pointing to the need for urgent attention to improve communication besides improving access to services ( Communication and Advocacy Strategy, MoPW). PRHFPS has also recorded a rising proportion of women dropping out of contraceptive use due to a number of reasons, which inter-alia included disinformation, lack of specific information, fears of side effects and contraindications. This is compounded by absence of effective and accessible source of receiving much needed information. In the public sector, MoPW taking stock of the situation has developed a comprehensive Communication and Advocacy Strategy focusing on three main areas: (a) capacity building of its staff in communication planning and evaluation; (b) focused IEC on unmet need for family planning, rural communities, male involvement and youth; (c) and advocacy for population issues with decision makers, planners and opinion leaders. The strategy is in the implementation phase. Ministry of Healths communication initiatives have remained focused on child health and family planning. Recently under the umbrella of the Women Health Project, health education campaigns have started to focus on safe motherhood. MoH, however, does not have a national communication strategy to create awareness about health issues and bring about behavior change among people for positive health practices.
C . SOCIAL AND CULTURAL FACTORS 1. GENDER

The available social indicators reveal gender imbalances in the society. Literacy among women is low as compared to men while malnutrition amongst women is higher when compared with men. Women and girls within the poorest and marginalized households bear a disproportionately high share of the burden of poverty. The traditional cultural values of Pakistan are important determining factors; women tend to be considered mostly as mothers, sisters, daughters or wives and many women often continue to bear children till they are able to produce a male heir. This is responsible for multiple pregnancies, thus increasing the risks of intra- and immediate post-partum complications and maternal death. Cultural factors limiting womens mobility and the lack of proper information contribute to low attendance of health services (ante- and pos-natal care) and very high prevalence of delivery at home with the support of a local Dai or family members. In many cases community members particularly men do

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not have the appropriate knowledge and information enabling them to recognize the danger signs of complicated pregnancy and to decide on timely transport to facilities taking care of obstetric emergencies. Despite significant steps undertaken by the Government, domestic violence continues to be reported. This phenomenon is the result of ignorance, lack of education of both men and women, should be further documented in order to be addressed adequately. The Governments commitment to the empowerment of women at the international level includes the ratification of the CEDAW, ILO Conventions on the employement of women, the ICPD programme of action, and the Beijing declaration. In the year 1987, the National Commission on the Status of Women was set up. It was reconstituted as a permanent body in 2000. More recently the government has also provided 33% quota to women at the lowest tier of local government system and 17% at the national and provincial legislature thereby increasing their representation at the grassroots level. This critical mass of local policy makers and political leaders should be sensitized to gender issues and provided data at a regular basis to advocate for social sector development. MoWD has taken steps to prevent gender discrimination. A code for gender justice has been put up to the cabinet for approval to check sexual harassment in the government offices. NGOs with the support of the MoWD have managed to make several private firms adopt this code as part of their anti sexual harassment policy. With the support of UNFPA the government is in the process of making a GMIS Gender Management Information System, which will ensure provision of gender, disaggregated data on four key sectors of health, education, violence against women and economic empowerment. A Social Audit on Abuse Against Women (SAAAW) has also been launched with the support of UNDP. This SAAAW will provide the community perception as well as the incidence and prevalence of violence cases at a national level. The MoWD has also started a Family Protection Program to provide shelter support and rehabilitation to the victims of violence. The above steps taken at various levels within the Government manifest a desire to address gender issues at the community and national level. Studies are however, needed to understand the exact nature and causes of gender discrimination along with effective plans to address the issue for bringing women at power with men and ending gender discrimination.
2. MALE INVOLVEMENT

Pakistani men are important decision-makers when it comes to practicing family planning and of utilizing health services during pregnancy and childbirth by their wives. Contrary to popular belief in the development circles, Pakistani men do recognize that they have a stake in the health and well-being of the family. A study in Karachi found that men took active part in childcare, especially when it came to the care of sick children. About 13% is the use condoms, rhythm or withdrawal methods, which require active male participation and initiative. The role of husbands in other reproductive health issues and decision-making has yet to be studied. Unpublished data from small qualitative studies suggest that husbands are concerned about their wives health, and recognize the potential threat to life that a pregnancy or delivery can impose. However, their knowledge and understanding of obstetric danger signs and the need for referral of obstetric emergencies are incomplete and should be explored. Mens own reproductive health is also a neglected aspect of health policy and planning in Pakistan. While explicit and elaborate interventions for improving maternal and child health are designed, little emphasis is put upon the needs of men (younger or older, married or unmarried). It is

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the men seeking advice and treatment for their sexual and psychological problems who contribute in large part to the booming businesses of faith healers, fake herbalists and quacks in the urban and rural areas of Pakistan. The focus on mens involvement in reproductive health is most marked in family planning. Several studies are available that document increased effectiveness of family planning programs when men are included in the interventions. The continued motivation system introduced in the earlier days of the Population Welfare Program in Pakistan depended significantly on male motivators. National Population Welfare Program included male (FWAs) to cater to the information needs of the male population of their communities. However, no empirical evidence is available of their effectiveness in motivating men about family planning methods. Worldwide, several studies have shown that involving men in the family planning programs has a positive impact on contraceptive use. Since husbands are key decision-makers when it comes to seeking medical care for obstetric complications, educating them about the dangers of these complications could greatly facilitate womens timely transfer to a hospital in emergencies. Research studies in Bolivia, Nigeria and India have found that husbands knowledge of obstetric danger signs, and their active involvement in safe motherhood interventions, are associated with high utilization of obstetric care services by women. In Pakistan, leading NGOs including Family Planning Association of Pakistan, The Asia Foundation and Marie Stopes Society have developed information, education and counseling materials on family planning and safe motherhood that are exclusively designed for use by husbands. These materials have been successfully tested in varied urban and rural settings. Further research is required to establish the most cost-effective methods for involving men in womens health interventions. Operations research is also required on how to train and motivate lady health workers for couple counseling. Additionally, there are large gaps in our knowledge of the prevalence and determinants of mens reproductive illnesses, and understanding is also lacking on why an overwhelming majority of men visit informal health care providers for sexual and psychosocial disorders. Research in these areas would guide policymakers in developing effective strategies to address mens reproductive health needs. In summary, there is a need to address each of the three aspects of the reproductive health issues related with men, as follows:
n

Men as Clients of the Health Care Delivery System: Men have their own reproductive health needs, including sexual education before marriage, and counseling regarding the all-too-common problems like erectile dysfunction syndrome, sexually transmitted infections and cancers of the male reproductive tract. Men as Clients of the Population Welfare Program: Men need advice, supplies and follow-up services just as women do. Recent increases in the use of condoms and natural methods of family planning call for a more direct involvement of men in community-based delivery of FP services and advice. Men as Decision-makers: Husbands play an important role in decision-making with regard to obtaining health care for women, particularly prenatal care, choice of birth attendant, place of delivery and seeking medical care in obstetric emergencies. As husbands and fathers, they also play a role in determining the dietary habits of pregnant and lactating wives as well as their young or adolescent daughters.

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It may be concluded that the status of male involvement in reproductive health in Pakistan is far from satisfactory. Huge gaps exist in our knowledge and understanding of mens reproductive health needs and behaviour; their part in decision-making to seek obstetric care for their wives; and their role in the promotion and persistence of existing child-bearing and child-rearing practices.
D. THE POTENTIAL ROLE OF CIVIL SOCIETY 1. COMMUNITY PARTICIPATION

At the center of the health systems stands community involvement/participation without which services will not reach their full potential. Communication involvement means that communities are able to organize themselves, address their needs. Community involvement in health takes many forms. It may simply mean the communitys compliance with requirements determined by the formal health system. It may focus on contribution, particularly in the form of payment for services; or on collaboration, through participation in the planning and management of services to be provided. Community involvement may also take the form of control, where the community has the authority to determine what is provided and how. Ideally, concerned communities should be in a position to own and operate the governments health and family planning facilities. This however, is not the case with Pakistan where the public sector facilities are run with little community involvement. Centralized management of health programs, lack of effective accountability and lack of skills of health providers in community participation techniques are some of the reasons for the prevailing situation. Several initiatives have been taken by leading NGOs such as Agha Khan Rural Support Program ( AKRSP), National Rural Support Program ( NRSP), Sarhad Rural Support Program ( SRSC), Balochistan Rural Support Program ( BRSP), Punjab Rural Support Program ( PRSP), Korangi Pilot Project etc to organize communities and bring them to a forum to be mobilized for a set of issues that the communities consider as their main problems.
The initiatives for community participation in the public sector are discussed earlier under the offer of services in the public sector. The present devolution initiative provides a favorable environment for community participation through elected councilors and district Nazims. However, it is not clear how the structural changes will develop over the coming years, especially after the new political governments are in place in the Centre and in the Provinces. The major issues pertaining to community participation in the planning and management of health and FP services include the following: (i) The governments line departments and the elected district representatives have been brought together under the devolution plan but it will take time for true synergy to develop between these. There is little coordination between public sector health organizations and various NGOs working with different communities throughout the country on social and development issues. Community participation and networking despite being part of the job description of Executive District Officers, Health and District Population Welfare Officers is not ensured. Both managers and field workers also lack skills in effective community mobilization techniques. There is hardly any mechanism for community input in program planning, while the government departments also lack mechanisms for quality assurance and consumer satisfaction. The

(ii) (ii)

(iii)

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devolution plan makes the line departments responsible to and accountable directly to the communities they serve. It has to be seen as to how this is put into practice now that the political governments and the grassroots representatives are in place. However, a problem area is that the newly-elected local representatives, serving on the district and union councils, lack knowledge and skills in the planning and management of social services in the public sector. (iv) There is a dearth of operations research studies that could help in determining the future course of action for involving communities in the planning and management of health and FP services. 2. DEVOLUTION AND LOCAL POLITICAL ENVIRONMENT

The Government of Pakistan embarked on a plan to establish Local Governments in all districts of the country from August 14, 2001. The proposed plan was based on five fundamentals:67 devolution of political power, decentralization of administrative authority, de-concentration of management functions, diffusion of the power authority nexus and distribution of resources to the district level. The devolution plan has major implications for all the social sectors including health, education and population. Devolution of authority and responsibility to the districts offers a renewed opportunity as well as a challenge for strengthening district systems for the delivery of quality social services that are accessible, efficient and equitable. There are several prerequisites for the success of the devolution process - clear redistribution of provincial and district authority and responsibilities; capacity development of the district managers; sensitization of the local political leaders about the importance of social sector concerns; user friendly rules and procedures; and a paradigm shift in the minds of the government functionaries to be accountable to the communities they serve. The district is the basic administrative unit in Pakistan. The districts are uniquely placed at the level where they are in a position to maintain a vertical relationship with higher management levels, horizontal relationship with other local departments and external relationship with communities and organizations they serve. Though the roles and responsibilities of district managers include a) provision of services to the entire population of the district and b) coordination with other sectors, for effective delivery of services. the performance of district managers is limited by their capacity to prepare district plans, use information for improved decision, provide supportive supervision, involve communities, and effectively function as a coherent management team.

A) Political Leadership:
Under the devolution plan, the political leadership at the district level h to play its role by as expressing their commitment to and advocating for the social sector concerns. This would foster for a district strategy enabling the managers to decentralize authority and responsibility together, suppression of administrative malaise in timely recruitment, transfer and posting; enhance funding and their timely utilization and effective monitoring and supervision system to ensure availability of quality services and material; and ensuring community participation for better utilization of social sector services.

67

Local Government Plan 2000. Government of Pakistan, Chief Executive Secretariat, National Reconstruction Bureau, August 2000.

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b) Devolution and its Implications on District Health Services

For the social sectors, the devolution initiative is potentially the most important organization and management reform to come around in many years. This initiative would imply a shift of responsibility for social services, from the provincial governments to the newly created district governments. A major challenge would be to ensure that local governments give priority to those types of services which are cost-effective and have the potential for effecting large improvements in the health status of the population.

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CHAPTER 4 MOBILIZATION OF FINANCIAL RESOURCES FOR POPULATION AND REPRODUCTIVE HEALTH PROGRAMMES
I. INTRODUCTION

The planning process of the Government of P akistan (GoP) starts with the development of various short and long-term plans. The Planning Division has defined a Plan as a package of economic and social policies expressed with quantified targets and objectives to be achieved during a laid down period. The GoP has established a hierarchy of stages for the development and review of plans, which consists involving the (a) Planning & Development Departments in the provinces, and (b) Planning Division/Planning Commission at the federal level. The concerned ministries and departments take part in the planning process by preparing a PC-1 for each proposed project/programme, in which the justification for and expected benefits of the components and anticipated costs (the planning budget) is given in a specific format. The projects and programmes proposed by a department/ministry have to pass through a process of scrutiny and approval for which governmental bodies have been established at appropriate levels. These include (a) the Departmental Development Working party (DDWP); (b) Provincial Development Working Parties, (c) the Central Development Working Party (CDWP), (d) the Economic Coordination Committee of the Cabinet (ECC); (e) Executive Committee of National Economic Council (ECNEC); and (f) National Economic Council (NEC). After approval, the projects/programmes become part of the GoPs macro development plan. Funds for the approved projects are allocated in the Governments Annual Development Programme (ADP) and the project becomes part of the Public Sector Development Programme (PSDP). The release of funds for approved projects is made on a quarterly basis against the ADP allocations and this release is linked with the liquidity position of the Government. The experience has been that there are often long delays in release of funds, especially at the provincial level, which occur when the liquidity position of the government is not favourable. In addition to the ADP, there is another budget in the public sector, which is termed Recurrent Budget or Non-Development Budget. This budget caters for the recurring expenditure of the regular administrative infrastructure of the government and mainly includes government staff salaries and non-salary expenditures of a regular nature.
II. PUBLIC SECTORS PLANNING, BUDGETING AND FINANCING STRUCTURE AND ITS RELATIONSHIP WITH THE POPULATION PROGRAMME

The Ministry of Population Welfare, which has the responsibility of population planning, has been funded since its inception through the ADP. Except for a small proportion of the overall expenditure, pertaining to the regular federal infrastructure, the whole programme is part of the PSDP and has constantly faced the danger of being reduced during the periods of serious financial crunches. This situation also has unfavourable implications on staff recruitment and development. Failure to integrate population staff into the regular services further limits opportunities to build cadre commitment towards population goals within the civil service, and discourages recruitment of well-qualified professionals.

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In line with the Government policy of decentralization and devolution, MOPW has defederalized Population Welfare Program with effect from 1 July 2002 and all the administrative and financial powers now vest in the Provincial Population Departments. Field activities too have been transferred to the provinces under an Ordinance issued in 2000. The transferred employees of the Population Welfare Programme have become provincial civil servants under full administrative control of the provinces.
III. A REVIEW OF SOCIAL SECTOR EXPENDITURES IN PAKISTAN AND ASSESSMENT OF REASONS FOR THESE BEING HISTORICALLY LOW

The economic growth rate of Pakistan has remained quite impressive during the first fifty years of its birth, on the average it was around 5.6 percent per annum but the trend has become erratic in recent years. There have been years when the rate rose higher than the average rate, and other years when it fell to less than even half, as it did in 1992/3 when it was a mere 2.27 percent. Despite an overall impressive economic growth record, Pakistans progress in the social sector has been unimpressive. The current Human Development Index (HDI) for Pakistan, has increased from 0.343 in 1975 to 0.552 in 1998. Social development in Pakistan has been subject to various constraining factors, of which some are generic while others are sectoral. One of the major reasons for little progress in the social sector has been the low level of resource allocation, coupled with policy and p rocedural issues that minimize the opportunities for taking optimum benefit of the meager resources which have been made available to the social sectors. The figure in Table 4.1 compares social sector expenditures with the overall public expenditures (Rs. 6,655.8 billion) during the last decade (financial years 1990-91 to 1999-2000). It shows that the ratio of social sector expenditure remained only at 8.2% against the overall public sector expenditure from both development and non-development budget. Further, the social sector experienced a rising trend in the expenditure in the range of 11 to 16 percent during the fiscal years 1990-91 to 1996-97, but thereafter the trend became erratic. The increase between 1996-97 and 1997-98 was 6% only. This rose to 19% in 1998-99, but dropped drastically to 0.04% in 1999-2000. Throughout this period there had been a regular trend of increase in the overall public expenditure. This situation indicates that the expenditure on social sectors has not increased in proportion with the general increase in public expenditure.

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Figure 4.1: A comparison of Social Sector Expenditure With Overall Public Expenditure
A comparison of Social Sector Expenditure with Overall Public Expenditure
1200

1000

800

600

400

Non-dev. Public exp. Dev. Public Exp. Interest Domestic Interest Foreign Social Sect. Exp. 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 199991 92 93 94 95 96 97 98 99 00 Total Expenses Social Sect. Exp. As % of total exp.

200

Source: ADB, April 2001, Draft Poverty Assessment for Pakistan.

The low expenditures of the social sector suggest that not only is resource allocation low but that existing social sector programmes are inefficient in terms of resource usage. They may be ineffective in terms of producing a measurable impact on intended beneficiaries and also inequitable in that they benefit the urban areas more than the poor rural areas. Some of the factors responsible for this inequity are as follows: Failure to involve the local community in project design and implementation, which is resulting in poor targeting, high costs and poor maintenance; Highly centralized administrative and financial systems which are resulting in resource leakage, as well as inadequate impact on intended beneficiaries and other stakeholders who have no voice in the use of funds and management of the programme; Funds being insufficient in the first instance are irrationally used more on brick and mortar and salary rather than on service delivery and quality; Non-observance of the policy of merit and transparency in recruitment, imprecise job descriptions and inadequate training plans for human resource development.

IV. RESOURCE ALLOCATIONS AND EXPENDITURE OF THE POPULATION AND REPRODUCTIVE HEALTH PROGRAMME AND THEIR RELATIONSHIP WITH THE POLICY RECOMMENDATIONS

Resource Allocation & Expenditure

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The population programme of Pakistan is predominantly funded by the GoP and international assistance. As can be seen in Table 4.3, public expenditure on the population welfare programme in Pakistan had initially been extremely modest, and it fluctuated in response to the variations in programme strategies and in political commitment. Until the 7th Five-year Plan, allocations remained between the range of 0.08 to 1.01 percent of the overall macro plan size. A noticeable change was observed in the Eighth Plan, in which the allocation increased by more than 157% over preceding plan allocations. The increase in allocations continued in the current 9th Five-year Plan, which indicates that the Government of Pakistan remains sensitive towards its population issues and was ready to allocate more resources for addressing the complex issue despite unfavourable economic conditions. Table 4.2 shows that except for the initial three Plans, when the allocation for population programme was substantially low, thereafter while there were relative increases in the social sectors, the overall implementation of the social-sector related programmes remained weak and allocated resources could not be fully utilized. Table-4.2: Ministry of Population Welfare Allocations and Expenditure (Rs. in million) % of Actual Plan ADP Actual % of ADP to Exp.to Five year Plans Allocation Allocation Expenditure Plan Allocation ADP Allocation 1st (1955-60) 0 0 0 0 0 2nd (1960-65) 9 9 9 100 100 3rd (1965-70) 145 168 168 115 100 Non plan period 990 1,029 834 103.9 81.0 (1970-78) 5th (1978-83) 1,800 824 9 617. 45.8 74 6th (1983-88) 7th (1988-93) 8th (1993-98) 9th (1998-03) * Upto November 2002. 2,300 3,535 9,100 15,625 2,184 3,039 7,654 *10,340 1,686 3,039 5,914 *6,933 88.9 86.0 84.1 *66.2 82.5 100 77.3 *67

Source: ADB TA-3387, Reproductive Health Project-Pakistan, Options, Datalines, 2000.

Policy Recommendations Following the ICPD there was a change in the Governments approach to the countrys reproductive health issues in the light of inherent socio-cultural issues that affect fertility. However the change has been quite gradual. As explained in Chapter 3, in the later y ears, especially in the current 9th Five-Year Plan, other elements of reproductive health, as defined in the ICPD Program of Action, were incorporated to provide a more comprehensive Reproductive Health Services Package. The expenditure trend (Table 4.3) of the Population Welfare Programme illustrates this change in the policy as not only more resources have been allocated to the Population Programme after the 1994 ICPD but also a change in the allocation mix is observed.

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Table 4.3:

EXPENDITURE TREND OF THE MINISTRY OF POPULATION WELFARE (93-94 to 99-2000) Share of Activities in Total Expenditure (%) Activities 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99 Administrative 26.9 22.1 23.3 21.8 22.8 20.9 Organisation Population Welfare 46.3 45.2 44.1 36.1 38.3 55.8 Services IEC Programme 11.8 7.4 5.7 4.9 5 5.7 Training 8 9.4 16.4 19 17 4.2 Research 2.2 2 2 2.4 1.4 1.4 Logistics and Supplies 2.2 11.3 6.8 15 14.1 11 Construction 2.6 1.7 1.7 0.6 0.7 1 Total Expenditure 710.5 1,133 1,181.2 1,256.9 1,194.3 1,401.6 (Rs.million) Total Allocation (Rs. 1,100 1,200.2 1,433 2,000 1,920.9 2,000 million) Expenditure/Allocation 64.6 94.4 82.4 62.8 62.17 70 (%)
Source: Ministry of Population Welfare

1999-00 15.8 46.4 1.8 3.2 1.2 31.6 0 2,144.9 2,172.5 98.7

Expenditure on reproductive health, as an integral part of total health expenditures, is not being reported separately. A World Bank study attempted to give a break down of the total cost of various health facilities, and this study noted that a sizeable portion of preventive health services incurred are those for services that are now covered by the RH definition. Brief details are reproduced in Table 4.4: Table 4.4: Cost Share of Preventive & Curative Services by Type of Facility BHU EPI MCh* Total Preventive Total Curative Total Facility Cost 25.0% 17.1% 42.1% 57.9% 100% RHC 9.8% 5.6% 15.4% 84.6% 100% THQ 5.3% 2.6% 7.9% 92.1% 100% DHQ 3.1% 1.1% 4.2% 95.8% 100%

*Includes antenatal care, tetanus toxoid vaccination, growth monitoring, and family planning Source: World Bank, 1998, Pakistan: Towards a Health Sector Strategy

The Netherlands Interdisciplinary Demographic Institute (NIDI), under the UNFPAs Resource Flows for Population Project, has been collecting data about Pakistans resource flows to its population sector for the last few years. A comparative analysis of the data for the last four years indicate that no noticeable change in the overall resource allocation for RH programme by the public sector has occurred during the four years studied. However, funding from international resources increased by about 18% in fiscal 1998-99 over the ratio in the fiscal year 1997-98.

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The Government of Pakistans allocations to the health and population sector in recent years do indicate that the share of resources provided to the Ministry of Health is improving and that this largely supports the National Programme for Primary Health Care and Family Planning. Table-4.5: Government budget for population activities in Pakistan and its distribution between implementing organisations (1996-97 to 1999-2000) (000s of Rupees) 1996-97 Total Government budget for Population Activities From International Resources
From National resources

1997-98 3,887.5 23.7% 76.3%

1998-99 3,934 28% 72%

1999-00 4,247 26% 74%

3,998.5 23% 77%

Percentage Going To: Ministry of Population Welfare Ministry of Health Ministry of Women Dev. Ministry of Education Ministry of Labor & Manpower Provincial Health Departments Total Budget NGOs From international Resources From Self generated Income 50% 22.7% 0.5% 0.01% 0.24% 26.6% 216 95.8% 4.2% 49.4% 23.1% 0.5% 0.13% 0.3% 26.6% 279 92.5% 7.5% 22% 529 91.9% 8.1% 23.6% 546 82.4% 17.6% 50.8% 26.3% 0.7% 0.1% 51.2% 24.8% 0.3% 0.1%

V.

THE ROLE OF EXTERNAL ASSISTANCE IN FINANCING THE POPULATION AND REPRODUCTIVE HEALTH PROGRAMME.

Pakistan, as with many other developing countries, is faced with widespread poverty. In the year 1998-99 around 28%of its population was living below the poverty line and this ratio in rural areas was 32 percent. [See Chapter 1.] For undertaking the plans that focus on poverty alleviation, one of the limiting factors is the resource crunch. At the end of 2002, the external debt burden was US$36.5 billion. In the fiscal year 2000-2001, the country paid $1.96 billion in debt servicing, which is 13.8% of its overall foreign exchange earnings. Given this situation, Pakistan cannot be expected to meet its essential targets without the availability of external financial assistance. Population planning is an important component of the social sector that is very closely related with poverty. A review of the Table 4.6 indicates that assistance in this sector from the

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international community continued at a reasonable level during the last decade despite an adverse political climate. Table-4.6: Donor funds for population Year Total $ in 000 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 15,519 14,092 18,771 15,028 12,670 15,761 33,508 15,967 28,561 28,144 % by Channel Bilateral 64% 57% 56% 66% 37% 60% 58% 50% 52% 42% Multilateral 19% 21% 16% 9% 44% 28% 36% 41% 27% 34% NGO 16% 22% 29% 25% 19% 12% 6% 9% 21% 25%

Source: UNFPA, New York, USA, Financial Resource Flows for Population Activities in 1999. Note that the NGO share actually reflects additional donor resources as most NGOs are donor dependent.

The 1994 ICPDs Programme of Action estimated that in the developing countries and the countries with economies in transition, the costs of the implementation of reproductive health programmes, including those related to family planning, maternal health and the prevention of sexually-transmitted diseases, as well as programmes that address the collection and analysis of population data, will cost $17 billion by the year 2000. Approximately two-thirds of the projected costs in developing countries will have to come from the international donor community. The international donor community has shown its commitment to achieve the goals and objectives of the conference, and there is an increasing flow of resources in the form of international assistance for population activities. As can be seen from Table 4.6, donor funding for population activities in Pakistan has fluctuated. Bilateral assistance has been the main channel, except for the year 1994 when the bilateral funding was only 37%. By the year 2000, the main international donors for population activities were UNFPA, the Asian Development Bank, World Bank/IDA, SAP-II. UNFPA is among the main donors for Pakistans population sector.

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Table 4.7: UNFPA Expenditure Trend Year Program Regular 1994 4,600,000 1995 5,000,000 1996 6,500,000 1997 5,000,000 1998 5,000,000 1999 5,000,000 2000 7,000,000 2001 7,000,000 2002 7,000,000 Average 94-02 5,788,889 Total estimated 57,888,889
Source: UNFPA-Pakistan, Islamabad

(1994-2002) in US$ Total Expenditure 3,400,000 4,600,000 6,400,000 4,600,000 2,100,000 3,000,000 600,000 4,200,000 4,500,000 3,711,111 37,111,111

VI. NGOS AND PRIVATE SECTORS ROLE IN FINANCING OF POPULATION AND REPRODUCTIVE HEALTH ACTIVITIES

In Pakistan, the NGO sector was almost non-existent at the time of independence. The All Pakistan Women Association (APWA) was t e first organisation and was founded in 1949. The h number of NGOs has steadily grown over time and rapidly expanded during the last two decades. According to an estimate, around 16,000 NGOs are currently working in Pakistan, a majority at the district level. Two types of NGOs are active in Pakistan: (a) international NGOs , and (b) national NGOs. Some of the international NGOs are the Pakistani affiliates of their international offices like Marie Stopes Society, Save the Children (US), The Asia Foundation, and the Population Council. Most of these NGOs implement their own social sector/population programmes for which funding is largely by international donors. The role of national NGOs in Pakistan has remained limited due to several reasons including those related to national security. The political environment in Pakistan is not congenial for local NGOs. Some of these NGOs have, however, have shown their potential to work in difficult sociopolitical conditions with a measure of success in achieving their objectives. Few examples are the Pakistan Association for Voluntary Health and Nutrition Activities (PAVHNA), the Marie Stopes Society (MSS) and the Family Planning Association of Pakistan. Efforts were made in the past to organise local NGOs for increasing their role in the social sector but there have been constraints. (See Chapter 3). The absorptive capacity of local NGOs is relatively low and constrained by the overall lack of funds. They tend to be dependent on funding from international sources. A glance through Table 4.86 reveals that most of the time 85% to 90% funding has come from international donors.
VII. THE FINANCIAL RESOURCE GAP OF PAKISTANS POPULATION WELFARE PROGRAMME

The MoPW has developed a Population Perspective Plan for a ten-year period (2001-2011) that seeks to convert the ICPD consensus recommendations into a programme of action, by taking a lead role in coordinating the implementation of a multisectoral programme. It also envisages the

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monitoring and devising of an appropriately consolidated reporting system by partnering with NGOs, elected representatives, academia and media. The goal of the Perspective Plan is to achieve replacement level fertility by the year 2020 through a restructured population programme, focusing on reaching and expanding services in rural areas, increasing investment from the private sector, timely availability of contraceptives for all contraceptive and RH delivery outlets, and increased expenditure on research, human resource development and advocacy. The total financial outlay for the Plan period has been proposed at Rs. 72 billion against which the PSDP commitments by the Government are estimated at Rs. 39 billion. This leaves a resource gap of Rs. 33 billion which needs to be met through external assistance. The breakdown of the Plan budget and resource gap is given below: Table 4.8: Ten-Year Perspective Plan Budget and Resource Gap Programme Location Population Welfare Programme-Federal Population Welfare Programme-Punjab Population Welfare Programme-Sindh Population Welfare Programme-NWFP Population Welfare Programme-Balochistan Total Proposed Budget Allocations Committed 25084 24686 11513 7191 3467 71,941 10671 14510 6638 4793 2568 39,180 (Rs in million) Resource Gap 14413 10176 4875 2398 899 32,761

Source: Planning Commission, Government of Pakistan

VIII. EXPENDITURE ON PAKISTANS POPULATION PLANNING PROGRAMME IN P R E - AND POST- ICPD PERIOD, AND A COMPARISON WITH COUNTRIES IN THE SOUTH ASIA REGION.

The 1994 ICPD recommended abandoning the concept of population control and for it be replaced with the more comprehensive concept of free choice in access to family planning and reproductive health care services. The ICPD emphasized the importance of education for women and girls and the need to decrease maternal mortality. Those governments which ratified the ICPD-POA agreed to increase their annual spending on population and health-related programmes. Among the most important changes in the policy environment brought out in Pakistan during the post-ICPD period were: The promulgation of a clear policy of expanded and improved reproductive health services in the Ninth Five-ear Plan (1998-2003);

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Incorporation of major elements regarding social sector planning, implementation, and funding under the Social Action Programme; Integration of the efforts of the Ministry of Population Welfare and the Ministry of Health at service delivery levels to jointly advance FP/RH agenda; Producing working definitions of reproductive health in both the Health and Population Welfare ministries, with ongoing efforts to forge common definitions; Establishment of a clear policy of shared inter-ministerial responsibility for implementation of population sector plans; and Promulgation of a national plan of action for the empowerment of women.

While the allocations of the international donor community funds encouraged a commitment of signatory countries to achieve ICPD objectives, their policies impacted significantly and positively on resource flows for population activities in the immediate post-ICPD period, their domestic policy objectives have now changed substantially. Table 4.9: External Resource Flows for Population Activities Pre & Post ICPD (million US$) Year Assistance Received Pakistan Sri Lanka Bangladesh India Iran Pre-ICPD: 1991 1992 1993 1994 Post-ICPD: 1995 1996 1997 1998 1999 15.8 33.5 16.0 28.6 28.1 2.0 4.6 2.2 3.9 2.8 65.4 87.3 93.1 87.6 89.4 60.2 44.6 45.6 58.1 57.2 3.0 2.6 1.8 2.1 1.2 14.1 18.8 15.0 12.7 2.8 3.7 1.9 1.6 75.1 74.6 39.6 100.9 25.6 31.9 21.9 33.7 1.5 0.3 2.1 1.8

Source: UNFPA, 1999, Financial Resource Flows for Population Activities in1999. Table 4.10 above, shows that developing countries should earmark more indigenous resources and undertake effective social mobilization for population and reproductive health programmes for the achievement of the ICPD goals and objectives.

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IX. DEVOLUTION OF AUTHOR ITY

The GoP introduced the Devolution Plan which restructured the district governments with a view to enhancing the participatory roles in planning and decision-making at the grassroots level. It was thought that devolution offers a unique opportunity to reverse the past trends and revitalize services in the key social sectors that matter at the grassroots level, with the decision-making and authority under this set-up be made closer to the people. Concurrently it poses new risks and challenges also, and it is necessary that proper rules of business, byelaws, systems and procedures are framed so that various components of the devolved set up could function smoothly and deliver efficiently. It is still too early to say anything about the efficacy of the new system especially so soon after the recent seating of a political government at the national and provincial levels.

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CHAPTER 5: RECOMMENDATIONS FOR STRATEGIC ACTIONS IN POPULATION, REPRODUCTIVE HEALTH AND GENDER
I. OVERVIEW

Chapters 1-4 confirm the relevance and vitality of population and reproductive health issues to development in Pakistan. Significant achievements on the one hand are softened by formidable tasks still ahead on the other. On this side, the balance sheet is a fertility transition in the making. There is a solid physical health and population welfare infrastructure with impressive national coverage. The policy commitment to population and reproductive health issues is strong. An open and pro-active approach to the threatening HIV/AIDS epidemic sets Pakistan apart from other countries, giving rise to the hope that mistakes committed elsewhere will be avoided in this country. Public awareness on reproductive health issues, particularly family planning is high. The stage would thus seem to be set for significant progress on such issues as fertility reduction and maternal health. On the other side, the balance sheet reveals several and multi-faceted features that lend a greyer shade to this picture begun above. There we find high unmet demand for family planning, still relatively low contraceptive prevalence, a high number of maternal deaths inconsistent availability of quality of care services and supplies, services inadequate to young people, and service delivery points with insufficient numbers of qualified staff. Because of financial and security constraints, a low national resource base for the social sector, including population welfare and health, stretch to the limit the capacity of responsible government institutions to deliver on their mandate. Educational disparities (girls/boys, urban/rural), despite much progress, are still considerable. Any package aiming to address this array of concerns and requirements could begin by contemplating a four-pronged approach: First, it could look at improving the offer or supply of services. Secondly, a combination of information and communication, social mobilization and enhanced counseling skills could entice better awareness and demand for quality services through better-informed choice. Thirdly, enhanced management and technical capacity at all levels of service delivery (federal, provincial and district) could strengthen service availability and quality of care delivered. Strengthened supervision of service delivery points could hold a key function in enabling this process. To make this possible, a broad coalition of key government institutions, reliable NGOs, community organizations, and the private corporate sector with clearly defined roles and responsibilities recommends itself. A systematic advocacy initiative for a common vision and strategy towards a substantive partnership for change is called for.
II. CHILD SPACING A NATIONAL CAUSE

The much heralded fertility transition in Pakistan is real. Reductions in total fertility rates and population growth underline this. But the road this way has been long and tough. This lends

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uncertainty about the ability to sustain the trend. There is evidence to suggest that with growth in contraceptive use tapering off, the transition could be jeopardized. Adjustments in policies and reorientation of advocacy efforts to safeguard this transition are necessary.
A . ADJUSTING EXISTING POLICIES 1. ACHIEVEMENTS

The policy framework for the ICPD agenda in Pakistan can be related to at least five major documents: The Interim Poverty Reduction Strategy paper, the national health policy 2001 entitle The way forward, agenda for health sector reform, the national plan of action for women, the population policy of Pakistan (July 2002), and the national policy on education. These documents elaborated by the Government of Pakistan constitute a remarkable and very comprehensive policy framework for the social sector. However, there is a need to bridge some gaps and orchestrate its implementation. The following suggestions try to address both.
2. RECOMMENDATIONS

A coordination mechanism with representatives of all stakeholders at the PM level would ensure that population and RH issues remain at the core of social development in Pakistan and addressed through multi-sectoral approach. Considering that people under 2 years of age constitute 63% per cent of the population, a 5 comprehensive youth and adolescent health/reproductive health policy is urgently required. Such a policy could at its core rest upon a structured and mutually supportive partnership of public and NGO sector. The development of a comprehensive national maternal health policy should be pursued together with a set of national intervention guidelines to reduce maternal mortality and morbidity. The Human development section of PRSP should look at fertility reduction as a first priority, to ensure that investments in other areas are not constantly undermined by an uncontrolled demand.

B . NATIONAL ADVOCACY AND COMMUNICATION STRATEGY 1. ACHIEVEMENTS

In the public sector, the Population Welfare Programme has always maintained a communication campaign to support its service delivery efforts. Past IEC campaigns have been relying on mass media for creating awareness and have also focused on increasing visibility of the sources of services. Similarly, people have been made aware of family planning choices through field workers. These efforts have been effective as is evident from findings of various household surveys. Awareness regarding family planning methods has been consistently rising since 1991 and is almost universal according to PRHFPS 2000-01. In view of the social cultural and religious constraints this is no mean achievement.

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MoPWs Communication and Advocacy Strategy 2012 fills the gap of behaviour change communication by defining clear strategic objectives, identifying key target audience, and setting up a road map for achieving the objectives. The strategy, if fully implemented, has the potential to narrow the gap between awareness and practice of family planning. Ministry of Health through its National AIDS Control Program has been able to create around 70 % awareness about HIV/AIDS.
2. RECOMMENDATIONS

Investment in capacity building should be made to allow the Ministry of Population Welfare to become the lead department on policy issues, advocacy, information, education, and monitoring of population aspects and to ensure effective support to the coordinating mechanism mentioned above. Political commitment should be harnessed to build a broad coalition for the policy and strategic integration of population issues and RH in all development sectors, for a sustained increase in resources for population and RH, and for an effective implementation of programs serving the most in need. This would be achieved though a nationwide advocacy and social mobilization program at all levels involving elected leaders (MNAs, MPAs, Nazims, male and female councilors), political leaders, religious leaders and scholars, community leaders, and members of communities. Complementary to population and reproductive health issues is girls education. The relationship of ideal small family norms and years of schooling is universally recognized. Advocacy for increased girls enrolment is indispensable to the success of any family planning campaign. Immediate attention has to be paid to capacity building in IEC and advocacy in order to have a pool of experts both in the public and private sector capable of designing effective IEC strategies. Socially and culturally acceptable long-term IEC and advocacy strategies with clear objectives, defined target audiences and focused messages should be made part of all population and reproductive health interventions.

III. SERVING AND MANAGING BETTER THE PATH TO IMPROVED SERVICE DELIVERY

A . SERVING BETTER AND REACHING OUT 1. ACHIEVEMENTS

Pakistans health and population welfare service system has a distinct advantage over many other developing countries, namely the presence of nation-wide physical service infrastructure. Launched, in 1994, to address the needs of rural and urban poor, specifically women, the National Programme for Family Planning and Primary Health Care is a success story and plans are underway to expand the Program, which now employs 70,000 Lady Health Workers, to 150,000 fully

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trained Lady Health Workers by mid-2003. This will allow the Programme to reach about 85 percent of Pakistans rural population. As mentioned in this document, ante- and post-natal care remain very low, this is due to several factors e.g ability to pay, accessibility, and to strong cultural barriers preventing pregnant women to attend health clinics. Covering womens needs therefore require at the same time the improvement of facilities, and the existence of outreach services. In addition to the LHW programme, there are other outreach mechanisms that exist like camps deployed by both Health and Population, and Mobile Service Units (MSUs) organized by Ministry of Population Welfare. However, as described in Chapter 3, there is room for improving the quality of these services and for making them more accessible, available, and attractive to women, men and young people, especially in rural and slums areas.

2.

RECOMMENDATIONS

Reproductive health through primary health care services provided by the Departments of Health and Population should be coordinated to avoid duplication, to enhance effectiveness, and to respond better to demand. Both Ministries should harmonize job descriptions, services, standards of quality, supplies, and equipment. This would include inter alia the definition of treatment regimen, drug range, equipment, training curricula, and capacity and skills enhancement, as well as procurement, storage and delivery of contraceptives. Beyond family planning and maternal health services, services should be expanded to include prevention, detection and treatment of sexually transmitted infections (STIs) including HIV/AIDs. Contraceptive should be procured and distributed through the Central Warehouse, and be provided to clients at a minimum fixed price, this charge being kept by the service provider as an incentive. In this connection, Ministries responsible for PHC services should allocate adequate funding for procurement and distribution of contraceptives. A Woman Friendly Initiative should be launched to guarantee proper, clean, and well maintained amenities for women, to ensure proper attention by staff, and to preserve confidentiality and privacy. Mobile service units should serve isolated communities which have restrained access to health care. They should therefore provide an integrated PHC/RH including FP service package, with appropriate equipment, appropriate staff including a medical officer, and appropriate CEC equipment. The role of FWAs ( male) should be studied for its effectiveness in informing males about reproductive health issues. In view of the findings, mechanisms for catering to the information needs of men, especially in the rural areas may be put in place. Existing health facilities should also cater to the RH needs of men..

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Training sessions should be arranged for health and reproductive healthcare providers to adequately respond to the needs of youth and adolescents, and to address gender related issues. Youth and adolescents services should be organized in a broader context e.g. youth centers, educational and recreational facilities in order to improve availability and accessibility. Civil society organizations and NGOs working with adolescents should be supported to establish specialized adolescent health centres and telephone help-lines to advise and guide the youngsters, and to advocate special legislation to protect the rights of youth and adolescents. This should be supported by an information campaign to increase awareness about those services.

B . SAVING MOTHERS 1. ACHIEVEMENTS

To decrease maternal mortality, the Government has taken critical steps in the area of safe motherhood; infrastructure has been improved in many districts, staff have been retrained, and some of the undeserved areas have been staffed. Currently two loans from the Asian Development Bank are under negotiation: the Women Health project (75MUS$) covering 20 districts, and the Reproductive Health project (40MUS$) covering 34 districts. These loans are investments made in addition to those of the LHWs national program. In parallel to these positive developments, the launching of pilot community midwives projects, and initiatives like the Safe motherhood program in NWFP will have an impact on MMR.
2. RECOMMENDATIONS

Staffing should comply with minimum standards especially providing for female staff at Primary Health Centres. For instance 2 female obstetricians should be posted in each District Headquarters Hospital. These staff would have the responsibility for outpatients, counseling, and EmoC, and the supervision and training of EmoC staff at Tehsil Headquarters Hospitals. Appropriate infrastructure, facilities, should be available at Tehsil and District level. Delivery rooms should comply with basic standards (e.g. water and electricity supply, size, ventilation, stable room temperature). Compliance with these standards should be regularly monitored. Community midwives with adequate supervision and training should provide ante- and post-natal care, including safe basic obstetric care. A comprehensive Emergency Obstetric Care (EmoC) program should be implemented nationwide, addressing the critical issues of equipment and supply, staffing, referral, communication, and transport. Routine training of service providers s ould include a module on dealing with cases of domestic h violence. IEC and counselling materials should be made available at service delivery points.

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IV. FAMILY HEALTH FOR HUMAN WEALTH A.

BUILDING ALLIANCES A ND SUPPORTING COMMUNIT I E S ACHIEVEMENTS

1.

The NGOs constitute a large community, which as with social marketing, perform an important function in RH service delivery. However few, usually the larger ones, have the capacity to deliver sustained services. Even these often rely on donor assistance. Smaller NGOs could benefit from structured support and backstopping through an umbrella body on throng decentralized mechanisms at district level. The corporate sector (private and public) in Pakistan has a long tradition of providing quality health care services to its workers. Referred to as the Target Group Institutions (TGIs) this sector has earlier been part of the MoPWs efforts to reach out to workers/employees of large enterprises and industrial organizations. UNFPA has financially supported two such projects in close collaboration with the Directorate of Workers Education of the Ministry of Labour alongwith technical assistance from the International Labour Organization. The TGIs offer an opportunity that should be further explored, as workers and their families form a concentration of almost 6 to 7 million people who can be approached through the umbrella of management and labour unions, labour colonies, schools and mosques established in the housing colonies of large industrial units and lastly a large migrant seasonal workforce associated with several industries.

2.

RECOMMENDATIONS

District officers skills in community mobilization should be enhanced in order to ensure effective involvement of all stakeholders in reproductive health initiatives. The community mobilization expertise of relevant NGOs should be harnessed for effective utilization of reproductive health services offered by the public sector. The capacity building of the medical and para-medical staff of private companies to deliver a comprehensive RH/FP package would ensure uninterrupted supply of contraceptives, enhance counselling skills and that these be supplemented through the provision of visual materials to undertake these tasks. Advocacy for support to RH and family planning should be undertaken with the Board Members of private companies, higher management and relevant operational levels with a view to enlisting their political support and commitment for RH/FP in their organizations. Advocacy and information of labour unions, collective bargaining agents and office bearers should be undertaken to encourage workers to improve their RH status.

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V. KNOWING BETTER

A . ENHANCING NATIONAL EXPERTISE 1. ACHIEVEMENTS

Aiming for a better understanding of population and development calls for strengthened capacity in population and RH data collection and dissemination. Follow up and monitoring of ICPD indicators could build on the valuable experiences of the National Institute of Population Studies (NIPS). NIPS, over the years, has had its professionals trained abroad but has seen attrition too as several of them have left for better opportunities. At the same time, NIPSs contribution in carrying out various studies, surveys and researches has been significant. Among the numerous reports, mention may be made of The State of Pakistans Population, 1987; Pakistan Demographic and Health Survey, 1991; Pakistan Fertility and Family Planning Survey, 1998; and Pakistan Reproductive Health and Family Planning Survey, 2001. These studies are widely quoted by the researchers. Currently two reports are in the final stages: District Profiles of Pakistan and AJK, 2002 (118 individual reports); and Reproductive Health of Youth: Perceptions, Attitude and Practices, 2002. Here, recognition may also be made of other agencies and persons in the area. These include Pakistan Institute of Development Economic, The Agha Khan University, Population Cells in some of the universities where demographic research is carried out, though sporadically. Of late, several independent consultants have come forward in the RH field, they have carried out studies and researches after having been commissioned by various international and donor agencies.
2. RECOMMENDATIONS

The capacity of the National Institute for Population Studies should be further enhanced by training the existing personnel, inducting new on a permanent basis, and, raising its expertise at international level. There is a lack of expertise in population in the country. Creation of an in-country academic centre of excellence for training of population specialists is required. Such a centre could have exchange of researchers, and twinning arrangements, with various international demographic research institutes. Pakistan Census Organization conducts decennial census every ten years with a long slack period in between. PCO is short of trained staff and the existing personnel are not always abreast with the modern data collection and analysis techniques. This organization, which is being merged with FBS, should be strengthened personnel-wise with a defined agenda for the inter-censal period.

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B . POPULATION AND RH MONITORING 1. ACHIEVEMENTS

The need for relevant information for planning, policy making and monitoring the impact of health and population programs is imperative. Realizing this, in the early 1990s, the health management information system (HMIS) was initiated. Currently the system is operational in all the districts. The MoPW in 1987 developed a contraceptive logistics MIS reporting on stock balances and supply statistics. This was further strengthened in 1994 and 1998 through UNFPAs assistance. Currently, under the recent initiatives by Ministry of Health, the HMIS system is being evaluated for up gradation with the assistance from UNICEF and UNFPA. The federal HMIS has also produced a number of reports on various health issues by using the data generated by the HMIS with the technical assistance of WHO. The National Programme is piloting integration of facility based HMIS with the LHWs- HMIS and building capacity of the district managers in data analysis and its use for decision making in selected districts. The MOPW and MOH are working towards a common RH information system at the district level, where information on RH and contraceptives can be shared. Both the ministries through the assistance of UNFPA have also initiated the mapping of health, population and NGO facilities for a compute based Geographical Information System (GIS) in selected districts.
2. RECOMMENDATIONS

A district HMIS cell under the EDO office for monitoring the indicators and building capacity of the facility staff and LHWs in information collection and use should be established, which will also include the development of a common interface between the population MIS and the HMIS at the district level. The information from these systems should be used to monitor the RH and contraceptive logistics status at the district levels. The reporting regularity from facility to district and above should be further strengthened by regular monitoring of the facilities and districts. The district health and population departments should establish a mechanism for providing regular feedback to the service providers and facilities. The capacity of the district staff of MOPW and MOH in collection, analysis, dissemination and use of information should be enhanced. Especially the use of information technology should be institutionalized in the district health management systems for knowledge sharing. Information generated from the HMIS and Population MIS should be used in Advocacy issues particularly at the district levels and linked with the Gender Management Information System (GMIS).

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VI. MANAGING BETTER TOWARDS A RELIABLE SUP PLY AND OPTIMAL USE OF RESOURCES

A . DEVOLUTION, AN IMPORTANT STEP 1. ACHIEVEMENTS

A very important administrative step of far reaching consequence has been the Devolution Plan. Now, the planning and implementation of the development schemes as well as carrying out of normal activities will be done at the district level instead of being directed from the provincial level. To fully involve the communities, local councils have been established through elections. The head of district council, called the Nazim will be incharge of all the activities to carry out which 11 groups of departments have been created in each district. Since, the inception of the district governments in mid 2001, the provinces are placing funds at the disposal of the district governments. The main challenge now is that of planning and implementation capacity, both on the part of the elected representatives and the officials of district hierarchy.
2. RECOMMENDATIONS

An awareness and training programme of the elected representatives at district level is required. It should not only be comprehensive but repeated periodically. The official hierarchy may be assisted in providing them data on a disaggregated basis which is relevant to the district. Elected representatives-official hierarchy joint working should be institutionalized by encouraging work through mechanism such as establishment of joint committee and a system of mutual consultation.
B . ENHANCING DISTRICT MANAGEMENT CAPACITY 1. ACHIEVEMENTS

Decentralization holds enormous promise. But it also contains significant challenges. Districts find themselves having to plan, program and implement activities at an unprecedented scale. Considerable enthusiasm and goodwill should be reinforced through a coherent and extensive capacity building effort. Aside from technical skills, management and supervisory skills require strengthening. Physical capacity in the form of equipment, supplies and even infrastructure is needed.

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2.

RECOMMENDATIONS

There should be continued technical support in policy monitoring, planning, operationalizing MIS and enhancing management capacity; Social sector allocations and expenditures at the district level should be enhanced.

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